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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3627_Библиотеки_им_академика_М_И_Перельмана
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42
https://t.me/med1917
RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Selected axial image from a contrast-enhanced CT scan of the abdomen showing a rounded, calcied, well-dened uid collection within the spleen.
There is air/uid level sign within the cavity. (B) Spot lm obtained after percutaneous drainage of the calcied uid collection.
■ Dierential Diagnosis
• Pyogenic splenic abscess: The uid collection was
drained percutaneously. Purulent material was obtained.
The bacteria was Salmonella agbeni. This patient did not
respond to antibiotic therapy and percutaneous drainage,
and he required a splenectomy.
• Splenic echinococcal cyst: This is a good option. The
patient did not have any history of travel outside of the
United States.
• Calcied splenic pseudoaneurysm: This patient had
no history of trauma, biopsies, or percutaneous
interventions, making this possibility low on the list.
■ Essential Facts
• Splenic abscess is a rare condition; the incidence is
estimated to be 0.4%.
• Most common risk factors include HIV, leukemia, and
diabetes.
• If identied promptly, most patients recover.
• Percutaneous drainage of splenic abscesses has been
proved to be safe.
Pearls and Pitfalls
ü Splenic abscesses are more common in
immunosuppressed individuals.
ü Percutaneous drainage has gained popularity to
complement treatment. It may avoid splenectomy.
ü The combination of percutaneous drainage and
antibiotics is successful in 70 to 90% of cases.
ü Surgery is indicated when noninvasive treatment fails.
ü Splenic abscesses are potentially fatal if not treated.
Case 22
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43
A
■ Clinical Presentation
A 62-year-old woman with morbid obesity and a history of cholecystectomy and gastric bypass with Roux-en-Y presents
with abdominal pain.
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
C D
(A) Spot lm from a percutaneous cholangiogram. This shows two relatively large lling defects within the common bile duct, consistent with stones.
(B) Spot lm obtained during stone manipulation. An angioplasty balloon was used to dilate the ampulla to allow passage of the stones. (C) Spot lm
obtained during stone manipulation. The image shows an occlusion balloon (arrow) being advanced through a 10-Fr, 23-cm-long sheath during the stone
pushing maneuver. (D) Spot lm obtained 2 weeks after stone manipulation; no residual stones are shown.
■ Dierential Diagnosis
• Recurrent common bile duct (CBD) stones: The image is
characteristic for stones. The importance of this case is
the minimally invasive management of CBD stones using
a percutaneous approach.
• Common bile duct clots: This is a possibility, but usually
clots are more extensive and of irregular shape.
• Fungal balls: Very unusual nding; mainly seen in
immunosuppressed patients.
■ Essential Facts
• Patients with gastric bypass and Roux-en-Y surgery are
not good candidates for endoscopic stone management.
• Percutaneous stone manipulation is eective in the
management of residual or recurrent CBD stones.
• The incidence of residual and recurrent CBD stones is
reported to be 1 to 3%.
• Surgery is usually avoided because it is invasive and
technically complex.
Pearls and Pitfalls
ü Stone pushing is simple and eective. The steps
required are as follows: 1) Percutaneous drain and
infection control. 2) Follow-up procedure 4 to 6 weeks
after initial drain with stone manipulation, which
includes angioplasty of the ampulla with a 7- or 8-mm
balloon (a cutting balloon can also be used) followed by
stone pushing using an occlusion balloon (8 or 11 mm
diameter) over a long 10–12 Fr sheath. The entire
system is pushed over a super-sti wire to force stones
through the ampulla into the duodenum. 3) Follow-up
cholangiogram to conrm the absence of residual
stones or stone fragments.
ü Percutaneous drain should not be removed until
the absence of stones is conrmed with a follow-up
cholangiogram.
Case 23
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45
BA
■ Clinical Presentation
A 68-year-old man who underwent an elective laparoscopic cholecystectomy presents 10 days after surgery with fever,
jaundice, and abdominal pain.
46
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
C D
(A) Spot lm obtained during endoscopic retrograde cholangiopancreatography. There is extravasation of contrast through the remnant of the cystic duct,
consistent with a bile leak. (B) Selected image from a hepatobiliary (HIDA) scan; the image conrms the presence of a large bile leak. (C) Spot lm after
coiling of the cystic duct. (D) Selected image of a HIDA scan done after cystic duct coiling. The leak is no longer identied.
■ Dierential Diagnosis
• Bile leak after laparoscopic cholecystectomy: Both
the endoscopic retrograde cholangiopancreatography
(ERCP) and hepatobiliary (HIDA) scan are diagnostic
of a large leak after cholecystectomy originating from
the cystic duct. Tracer spill into the peritoneal cavity is
demonstrated in the HIDA scan.
• Abscess of gallbladder fossa: Excellent option because
the leaking bile may be infected as well.
• Bleeding into gallbladder fossa/vascular injury: This
is also a possibility; however, there is no mention of
decreasing hemoglobin levels.
■ Essential Facts
• Bile duct injuries after laparoscopic cholecystectomy are
dicult to manage.
• Bile duct injuries may be in the intrahepatic ducts, cystic
duct, and common bile duct.
• Biliary leaks may cause bile peritonitis and a severe
infectious complication.
• Management with endoscopic stent placement is the
rst line of treatment.
• Interventional options are used in patients after failure
of endoscopic management.
Pearls and Pitfalls
ü In patients with bile leaks secondary to cystic duct
injuries, the catheterization of the cystic duct followed
by microcoil embolization is feasible and controls the
leak eectively.
ü Surgeons will not request this procedure. It needs to be
oered by the interventional radiologist.
ü Careful technique is essential. Coiling of the common
bile duct during this procedure is possible and should
be avoided.
ü Failure to identify the problem may lead to bile
peritonitis, sepsis, and death.
Case 24
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■ Clinical Presentation
A 46-year-old woman presents with fever, chills, and lower abdominal pain.
BA
48
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A C
(A) Selected axial image of a contrast-enhanced CT scan of the pelvis. This shows a complex multilobulated uid collection posterior to the uterus, con-
sistent with a pelvic abscess. (B) Selected axial image from a CT-guided drainage procedure using a transgluteal approach. (C) Spot lm obtained during
a follow-up abscessogram. This shows an enlarged fallopian tube and communication to the uterine cavity and vagina.
■ Dierential Diagnosis
• Tubo-ovarian abscess: The diagnosis was established
with the follow-up abscessogram that demonstrated the
enlarged fallopian tube and its communication with the
uterus.
• Diverticular abscess: Good option; these abscesses usually
present peripheral to the sigmoid, but this is high in the
dierential.
• Peri-appendiceal abscess: Good option as well, and
probably these three entities are indistinguishable from
each other in the absence of more clinical information or
further imaging evaluation.
■ Essential Facts
• Tubo-ovarian abscess is a complication of pelvic
inammatory disease.
• Risk factors include younger age, multiple sexual partners,
and the lack of use of protective barrier contraception.
• Most common symptoms include fever and chills, nausea,
and vaginal discharge.
B
Pearls and Pitfalls
ü CT is an excellent imaging option for diagnosis and
shows thick-walled, rim-enhancing adnexal masses.
ü Treatment is mainly with antibiotics and either
percutaneous or laparoscopic drainage.
ü Look for the ovarian vein associated with the pelvic
abscess. Ovarian vein entering the abscess had 100%
specicity and 94% sensitivity to detect tubo-ovarian
abscess in a large series.
ü Tubal rupture may result in severe infection with
peritonitis.
Case 25
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A
■ Clinical Presentation
A 50-year-old man presents with an abnormal chest x-ray.
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RadCases.thieme.com RadCases Interventional Radiology
■
Imaging Findings
A B
(A) Selected axial image from a noncontrast CT scan of the chest. It shows a soft tissue mass that appears to be adjacent to the pericardium, in the anterior
mediastinum. (B) Selected axial image obtained during a CT-guided biopsy. The needle is seen to be within the soft tissue mass.
■ Dierential Diagnosis
• Thymoma: This was the diagnosis obtained from the
ne needle aspirate. This mass is challenging from the
imaging standpoint.
• Lung carcinoma: The mass is well dened, not spiculated,
and appears to be adjacent to the pericardium, which
makes this possibility less likely.
• Pericardial cyst: Also a good possibility. Hounseld units
were not shown, but in this case, the Hounseld units
were in the solid tissue range.
■ Essential Facts
• Thymomas are uncommon tumors.
• Lung masses may be dicult to assess from an imaging
standpoint.
• Relationship to other structures, such as pleura or
pericardium, is important.
• Fine needle biopsy is safe and useful for diagnosis of lung
masses.
Pearls and Pitfalls
ü The most important factor for a successful lung biopsy
is procedure planning.
ü The shortest pathway to the mass is usually selected.
ü Avoid crossing pleural ssures if possible.
ü Having a pathologist in the procedure room to review
the ne needle aspirate increases the diagnostic yield of
percutaneous biopsies.
ü Pneumothorax is a frequent complication of lung
biopsy, reaching 20% of cases.
Case 26
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A
■ Clinical Presentation
A 94-year-old woman presents to the emergency department with left ank pain.
B
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