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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_540_Библиотеки_им_академика_М_И_Перельмана
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22.3.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 759
22.3.5 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 759
22.3.6 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 760
22.3.7 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 760
22.4 Intestinal Perforation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 760
22.4.1 Intestinal Endometriosis. . . . . . . . . . . . . . . . . . . . . 761
22.4.2 Bowel Perforation . . . . . . . . . . . . . . . . . . . . . . . . . 764
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 767
23 Bariatric Surgery Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . 775
23.1 Bariatric Surgery and Pregnancy . . . . . . . . . . . . . . . . . . . . . 775
23.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775
23.1.2 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775
23.1.3 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776
23.2 Intussusception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777
23.2.1 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777
23.2.2 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . 777
23.2.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 778
23.2.4 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 778
23.2.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 778
23.2.6 Gastroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 779
23.2.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 779
23.2.8 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 781
23.3 Incarcerated Internal Hernia . . . . . . . . . . . . . . . . . . . . . . . . 781
23.3.1 Classication and Pathophysiology . . . . . . . . . . . . 781
23.3.2 Incidence and Risk Factors . . . . . . . . . . . . . . . . . . 782
23.3.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 783
23.3.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 783
23.3.5 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 785
23.3.6 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 785
23.3.7 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 788
23.4 Gastric Band Slippage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 788
23.4.1 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 788
23.4.2 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . 788
23.4.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 788
23.4.4 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 788
23.4.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 788
23.4.6 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 788
23.4.7 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 789
23.5 Gastric Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 789
23.6 Acute Cholecystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 789
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 789
Contents
24 Splenic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 793
24.1 Splenic Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 793
24.1.1 Denition and Historical Perspective . . . . . . . . . . 793
24.1.2 Classication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 794
24.1.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 797
24.1.4 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 798
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24.1.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 798
24.1.6 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800
24.1.7 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801
24.2 Primary Splenic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . 802
24.2.1 Denition and Classication . . . . . . . . . . . . . . . . . 802
24.2.2 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
24.2.3 Risk Factors and Pathophysiology . . . . . . . . . . . . . 802
24.2.4 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 803
24.2.5 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 804
24.2.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 804
24.2.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 804
24.2.8 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 809
24.3 Spontaneous Splenic Artery (Aneurysm) Rupture . . . . . . . . 809
24.3.1 Historical Perspective . . . . . . . . . . . . . . . . . . . . . . 809
24.3.2 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 810
24.3.3 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 811
24.3.4 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . 811
24.3.5 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 812
24.3.6 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 813
24.3.7 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 813
24.3.8 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 813
24.3.9 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 815
24.4 Spontaneous Splenic Vein (Aneurysm) Rupture . . . . . . . . . 816
24.4.1 Historical Perspective and Incidence . . . . . . . . . . . 816
24.4.2 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816
24.4.3 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 817
24.4.4 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . 817
24.4.5 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 818
24.4.6 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 818
24.4.7 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 818
24.4.8 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 818
24.4.9 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 819
24.5 Splenic Torsion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 819
24.5.1 Historical Perspective and Incidence . . . . . . . . . . . 819
24.5.2 Etiopathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . 819
24.5.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 819
24.5.4 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 819
24.5.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 820
24.5.6 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 820
24.5.7 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 821
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 821
25 Maternal Abdominal Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . 827
25.1 General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827
25.1.1 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827
25.1.2 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 828
25.1.3 Maternal Changes Relevant to Trauma . . . . . . . . . 829
25.1.4 Prehospital Management . . . . . . . . . . . . . . . . . . . . 833
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25.2 Anesthetic Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 835
25.3 Blunt Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 835
25.3.1 Historical Perspective . . . . . . . . . . . . . . . . . . . . . . 835
25.3.2 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 835
25.3.3 Motor Vehicle Accidents . . . . . . . . . . . . . . . . . . . . 836
25.3.4 Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 847
25.3.5 Social and Domestic Violence . . . . . . . . . . . . . . . . 848
25.3.6 Obstetric Complications. . . . . . . . . . . . . . . . . . . . . 850
25.3.7 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 861
25.3.8 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 867
25.3.9 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 879
25.4 Penetrating Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 882
25.4.1 Incidence and Pathophysiology . . . . . . . . . . . . . . . 882
25.4.2 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 883
25.4.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 884
25.4.4 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 886
25.4.5 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 892
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 893
26 Miscellaneous Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 905
26.1 Spontaneous Liver Rupture . . . . . . . . . . . . . . . . . . . . . . . . . 905
26.1.1 Historical Perspective . . . . . . . . . . . . . . . . . . . . . . 905
26.1.2 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 906
26.1.3 Etiopathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . 906
26.1.4 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 908
26.1.5 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 908
26.1.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 909
26.1.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 910
26.1.8 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 914
26.2 Bleeding Peptic Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 914
26.2.1 Historical Perspective . . . . . . . . . . . . . . . . . . . . . . 914
26.2.2 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 914
26.2.3 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 915
26.2.4 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 915
26.2.5 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 915
26.2.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 915
26.2.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 915
26.2.8 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 916
26.3 Mesenteric Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 916
26.3.1 Mesenteric Vein/Portal Vein Thrombosis . . . . . . . . 916
26.4 Rectus Sheath Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . 921
26.4.1 Historical Perspective . . . . . . . . . . . . . . . . . . . . . . 921
26.4.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 922
26.4.3 Incidence and Risk Factors . . . . . . . . . . . . . . . . . . 922
26.4.4 Mechanism of Injury . . . . . . . . . . . . . . . . . . . . . . . 922
26.4.5 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 923
26.4.6 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 925
26.4.7 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 925
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26.4.8 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 926
26.4.9 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 928
26.5 Omental Infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 928
26.5.1 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 928
26.5.2 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 928
26.5.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 929
26.5.4 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 929
26.5.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 929
26.5.6 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 930
26.5.7 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 930
26.6 Gastrointestinal-Genital Communications . . . . . . . . . . . . . . 931
26.6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 931
26.6.2 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 931
26.6.3 Etiopathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . 931
26.6.4 Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 932
26.6.5 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 933
26.6.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 933
26.6.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 934
26.6.8 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 934
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 935
Part IV Urology
27 Complicated Urinary Tract Infections . . . . . . . . . . . . . . . . . . . . 945
27.1 Anatomic and Functional Changes of the
Urinary Tract During Pregnancy . . . . . . . . . . . . . . . . . . . . . 946
27.1.1 Upper Urinary Tract . . . . . . . . . . . . . . . . . . . . . . . . 946
27.1.2 Lower Urinary Tract . . . . . . . . . . . . . . . . . . . . . . . 946
27.1.3 Composition of the Urine. . . . . . . . . . . . . . . . . . . . 948
27.2 Symptomatic Urinary Tract Stones . . . . . . . . . . . . . . . . . . . 949
27.2.1 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 949
27.2.2 Etiopathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . 949
27.2.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 949
27.2.4 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 949
27.2.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 949
27.2.6 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 951
27.2.7 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 953
27.3 Acute Pyelonephritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 953
27.3.1 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 953
27.3.2 Etiopathogenesis and Risk Factors . . . . . . . . . . . . 954
27.3.3 Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 954
27.3.4 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 955
27.3.5 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 955
27.3.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 955
27.3.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 956
27.3.8 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 957
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 958
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28 Urinary Tract Obstruction or Rupture . . . . . . . . . . . . . . . . . . . . 963
28.1 Acute Urinary Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . 963
28.1.1 Historical Perspective . . . . . . . . . . . . . . . . . . . . . . 963
28.1.2 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 964
28.1.3 Etiopathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . 965
28.1.5 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 968
28.1.6 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 968
28.1.7 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 968
28.1.8 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 970
28.1.9 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 974
28.2 Renal Collecting System or Parenchymal Rupture . . . . . . . 974
28.2.1 Incidence and Etiopathogenesis . . . . . . . . . . . . . . . 974
28.2.2 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 976
28.2.3 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 976
28.2.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 976
28.2.5 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 979
28.2.6 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 981
28.3 Urinary Bladder Injury or Rupture . . . . . . . . . . . . . . . . . . . 982
28.3.1 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 982
28.3.2 Etiopathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . 982
28.3.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 985
28.3.4 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 986
28.3.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 986
28.3.6 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 989
28.3.7 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 991
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 991
Contents
29 Urinary Tract Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 997
29.1 Traumatic Renal Injury/Rupture . . . . . . . . . . . . . . . . . . . . . 997
29.1.1 Incidence and Risk Factors . . . . . . . . . . . . . . . . . . 997
29.1.2 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 998
29.1.3 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 998
29.1.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 998
29.1.5 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 998
29.1.6 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 998
29.2 Renal Artery Aneurysm Rupture . . . . . . . . . . . . . . . . . . . . . 999
29.2.1 Historical Perspective and Incidence . . . . . . . . . . . 999
29.2.2 Etiopathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . 1000
29.2.3 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 1000
29.2.4 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 1001
29.2.5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1001
29.2.6 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1003
29.2.7 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1007
29.3 Ruptured Renal Angiomyolipoma . . . . . . . . . . . . . . . . . . . . 1007
29.3.1 Historical Perspective . . . . . . . . . . . . . . . . . . . . . . 1007
29.3.2 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1007
29.3.3 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . 1007
29.3.4 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . 1008
Contents
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xxxvii
29.3.5 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . 1008
29.3.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1008
29.3.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1010
29.3.8 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1012
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1012
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1015
Part I
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General Considerations
Radiology
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1
Abstract
Imaging studies are necessary for accurate
preoperative diagnosis of acute abdominal
conditions during pregnancy. However, confusion about the safety of these modalities
for pregnant and lactating women and their
infants often results in unnecessary avoidance of useful diagnostic tests or interruption of breastfeeding. Ultrasonography and
magnetic resonance imaging are not associated with risks. They are the imaging techniques of choice for pregnant patients.
However, they should be used prudently and
only when their use will answer a relevant
clinical question or otherwise provide medical benet to the patient. With few exceptions, radiation exposure through
radiography, computed tomography, or
nuclear medicine imaging techniques is at a
dose much lower than the exposure associated with fetal harm. If these techniques are
necessary after inconclusive ultrasonography or magnetic resonance imaging or are
more readily available, they should not be
withheld from a pregnant patient.
Terminating pregnancy at fetal doses of less
than 100mGy is not justied based on radiation risk. Breastfeeding should not be interrupted after gadolinium administration.
1.1 General Considerations
Clinicians may not be well informed of the facts
of diagnostic radiological studies in pregnancy.
Lack of understanding of radiation effects on the
fetus causes unnecessary anxiety in pregnant
patients exposed to diagnostic radiation and may
lead to unnecessary pregnancy termination.
Physicians may be reluctant to order a radiological examination due to the potential teratogenic
risks to the fetus and the medicolegal implications of the radiation dose, causing birth defects.
For acute indications, the benets for the mother
usually outweigh the small risk to the fetus. The
indications for diagnostic imaging modalities are
presented in the corresponding chapters.
The greatest radiation effects occur during
rapid cell proliferation (2–25 weeks of pregnancy). The recommended total dose of radiation
is less than 5rad. During the rst 2–3weeks of
pregnancy, while cells are not yet specialized and
radiation injury will cause implantation failure or
undetectable death of the embryo. After that, the
injury usually occurs in the organs under development during exposure.
Patients and physicians are commonly concerned about fetal radiation exposure, but adverse
effects are unlikely at less than 5–10 radiationabsorbed doses (rads) [1, 2]. Less than 1% of
trauma patients are exposed to more than 3rads
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
G. Augustin, Acute Abdomen During Pregnancy, https://doi.org/10.1007/978-3-031-26021-6_1
3
4
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1 Radiology
(Table1.1) [1, 3, 4]. However, the risk to the fetus
of a 1 rad exposure, approximately 0.003%, is
>1000 times smaller than the spontaneous risks
of malformations, abortions, or genetic disease.
Intrauterine exposure to 10rad does not cause a
signicant increase in congenital malformations,
intrauterine growth retardation, or miscarriages.
However, it is associated with a small increase in
childhood cancers. Poor growth, mental retardation, central nervous system defects, and microcephaly are the most common adverse events
related to large fetal radiation doses [2]. The relative risk (RR) of childhood cancers is greatest
when a fetus is exposed to radiation in the rst
trimester (RR 3.19) and is high when exposure
occurs before 8weeks of gestation (RR 4.60) [4].
The overall RR of in utero radiation was not statistically different from that of the general population [4]. After 15weeks of gestation, fetuses are
unlikely to be affected by radiation [4]. Fetal
doses from identical procedures vary among
pregnant women and are lower in obese women
[5].
1.1.1 Examinations That Do Not
Require Verication
ofPregnancy Status
In general, X-ray-based examinations that do not
directly expose the pelvis or gravid uterus to the
X-ray beam do not require verifying pregnancy status. Such studies include but are not limited to [7]:
• Chest radiography,
• Extremity radiography,
• Any diagnostic examination of the head or
neck,
• Mammography,
• Any CT imaging outside of the abdomen or
pelvis (except for the hip),
• Nuclear medicine examinations.
1.1.2 Examinations That May
Require Verication
ofPregnancy Status
Examinations in this group include [7]:
No single diagnostic procedure results in a
radiation dose that threatens the wellbeing of the developing embryo and fetus.
(American College of Radiology [7])
The fetal risk is considered to be negligible
at 5 rad or less when compared with the
other risks of pregnancy, and the risk of
malformations is signicantly increased
above control levels only at doses above 15
rad. (National Council on Radiation
Protection [8])
• Interventional uoroscopic procedures of the
abdomen or pelvis,
• Diagnostic angiography of the abdomen or
pelvis,
• Hysterosalpingography [13],
• Standard-dose CT protocols of the abdomen
or pelvis,
• Diagnostic Nuclear Medicine PET/CT.
A refused pregnancy test by the patient should
be documented in the patient’s medical record,
and the radiologist should be notied. When pregnancy is discovered after undergoing an imaging
procedure using ionizing radiation, counseling
should provide her with information to objectively assess the possible risk to the conceptus [7].
1.1 General Considerations
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5
Table 1.1
Radiation exposure for the unshielded uterus/fetus in various imaging studies
Estimated fetal dose per
Estimated fetal exposure for plain
X-rays
Examination type
Skull <0.0005
Dental 0.001
examination (mGy = mSv)
Cervical spine 0.02
Upper or lower extremity 0.01
Chest 2–7/104
Abdominal 1.4–4.2
Thoracic spine 0.09
Lumbosacral spine 1.7–10
Pelvis 1.1–4
Mammogram 0.2–0.7
Intravenous pyelogram 10–40
Retrograde pyelography 6
Estimated fetal exposure for
uoroscopic studies
Upper GI series 0.56–1
Barium swallow 1.1–5.8
Barium enema 6.8–10
Cerebral angiography <0.1
Cardiac angiography 0.85
GI = gastrointestinal
Estimated fetal exposure for
computed tomography
Head <0.005
Chest 0.06–0.16
Chest angiography 0.0035–0.131
Abdomen 8–30
Lumbar spine 0.9–7.5
Pelvis 25–79
Pelvimetry 0.2–0.4
Estimated fetal
Estimated activity
Study
administered per study
Brain 20 mCi
Hepatobiliary 5 mCi
5 mCi
Renal 20 mCi
99m
Tc DTPA 7–8.8
99m
Tc sulfur colloid 0.45
99m
Tc HIDA 1.5
99m
Tc DTPA 8.8
Dose to uterus/embryo
(mGy = mSv)
exposure for nuclear
medicine studies
V-Plung scanning 0.1–0.37
Perfusion portion 3 mCi
Ventilation portion 10 mCi
Thyroid scanning 0.1 mCi
99m
Tc MAA
133
Xe gas
131
I
Whole body (2–6 weeks) 0.15
Whole body (12–13 weeks) 1.6
Whole body (20 weeks) 3
Fetal thyroid (12–13 weeks) 1300
Fetal thyroid (20 weeks) 5900
Reproduced with permission from [6]
DTPA diethylenetriaminepentaacetic acid, HIDA hepatobiliary iminodiacetic acid,
99m
Tc MAA technetium macro-aggregated albumin plus, V-P ventilation-perfusion
131
I iodine-131, mCi millicuries,
Average environmental background radiation (cumulative dose over 9months): 0.5–1.633,34
The accepted background cumulative dose of ionizing radiation during pregnancy is 5rad (50mGy), which is much
more than the exposure dose of most of the radiological diagnostic examinations
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