Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3645_Библиотеки_им_академика_М_И_Перельмана
.pdf
Case 40 Lower Gastrointestinal Bleed
https://t.me/med1917
Figure 40.3
Figure 40.4
Figure 40.5
Findings
▶ Figures 40.2 and 40.3 demonstrate intraluminal contrast in the right colon representing active bleeding
(white arrow).
▶ Superior mesenteric angiogram (Fig. 40.4) demonstrates active bleeding originating from a branch of the right
colic artery corresponding to the nding on computed tomography (CT) (black arrow).
▶ Postembolization angiogram (Fig. 40.5) shows successful coil embolization (black arrow) of the distal
oending arterial branch.
Teaching Points
▶ Common causes of lower gastrointestinal bleeding include diverticulosis, angiodysplasia, and cancer/
polyps.
▶ When patients are stable and the site of bleeding is in question, radionuclide scintigraphy (
blood cell scan) or CT angiography may be helpful. Lower gastrointestinal bleeding is intermittent and oen
self-limited, and tagged red cell scans that are more sensitive than angiography at detecting hemorrhage can
be very useful.
118
99
Tc-labeled red
▶ CT angiography can identify potential cause of lower gastrointestinal bleeding with ~90% accuracy.
https://t.me/med1917
▶ When patients are hypotensive and have transfusion requirements of more than 5 units, the likelihood of a
positive angiogram is high and immediate angiography or colonoscopy (without tagged red cell scan or CT)
should be performed.
▶ e use of provocative angiography, injection of a thrombolytic agent, heparin, or vasodilators into the target
vessel of suspicion to identify lesions not seen with standard angiography is controversial.
Management
▶ Transarterial embolization with microcoils, gelfoam, or polyvinyl alcohol particles is very eective in
controlling acute bleeding.
▶ Selective embolization at the level of the vasa recta should be performed to decrease the risk of bowel
ischemia.
▶ While embolization can be eective in controlling acute bleeding, the risk of recurrent bleeding in the setting
of angiodysplasia or arteriovenous malformations is high, and resection should be considered.
Further Reading
Marti M, Artigas JM, Garzon G, etal. Acute lower intestinal bleeding:feasibility and diagnostic performance of CT
angiography. Radiology. 2012; 262:109–116.
Strate LL, Naumann CR. e role of colonoscopy and radiological procedures in the management of acute lower intestinal
bleeding. Clin Gastroenterol Hepatol. 2010; 8:333–343.
119
History
https://t.me/med1917
▶ A13-Year-Old Boy with Recurrent Nosebleeds
Case 41
Figure 41.1
Figure 41.2
120
Case 41 Juvenile Nasal Angiofibroma
https://t.me/med1917
Figure 41.3
Figure 41.4
Figure 41.5
Figure 41.6
Findings
▶ Precontrast T1-weighted magnetic resonance (MR) (Fig. 41.3) demonstrates a heterogenous right-sided
nasopharyngeal mass (arrowheads) that exerts mass eect on the nasopharyngeal space and is associated with
bone erosion of the sphenoid sinus.
▶ e mass enhances intensely with contrast (Fig. 41.4). Note the large ow voids within the mass (arrows).
▶ Right external carotid arteriography (Fig. 41.5) shows the hypervascular mass (hollow arrows) arising from
the maxillary artery (arrow).
▶ Aer distal embolization with polyvinyl alcohol particles (Fig. 41.6), there is stasis within the branches of the
maxillary artery previously seen to supply the tumor.
Teaching Points
▶ Juvenile nasal angiobroma occurs in the second decade almost exclusively in males and is the most common
benign nasopharyngeal tumor.
▶ While histologically benign, these tumors are locally destructive and have a tendency to erode bone, typically
into the sinuses or orbit.
▶ Patients commonly present with recurrent epistaxis, which may be severe, and/or signs of nasal obstruction.
Management
▶ Preoperative embolization may be performed to decrease intraoperative blood loss. Tumors are typically
supplied by branches of the ipsilateral external carotid artery, but large tumors may also derive supply from
the ipsilateral internal carotid artery and also occasionally by branches of the contralateral carotid arteries.
121
▶ Ideally, surgery should occur within 3 days following the procedure to prevent revascularization of the tumor
https://t.me/med1917
by collateral vessels.
▶ Prior to embolization of a target artery, careful study is imperative to ensure there are no ophthalmic artery
branches to avoid nontarget embolization that could result in vision loss.
Further Reading
Wu AW, Mowry SE, Vinuela F, etal. Bilateral vascular supply in juvenile nasopharyngeal angiobromas. Laryngoscope. 2011;
121(3):639–643.
122
History
https://t.me/med1917
▶ A12-Year-Old Boy with Painful, Swollen Le Testicle
What is the diagnosis and what are the treatment options?
Figure 42.1
Case 42
123
Case 42 Male Varicocele Embolized with Coils and Sclerosant
https://t.me/med1917
Figure 42.2
Figure 42.3
Findings
▶ Ultrasound demonstrates dilatation of venous sinuses of the pampiniform plexus (Fig. 42.2, arrows).
▶ e le internal spermatic vein (ISV) has been catheterized from the le renal vein (Fig. 42.3). Distal coils are
seen at the level of the sacroiliac joint. Aer the distal coils were placed, sodium tetradecyl sulfate was injected,
and a second level of coils was placed approximately 2cm from the conuence of the internal spermatic vein
with the le renal vein (Fig. 42.4), which is marked by arrows.
Teaching Points
▶ Doppler ultrasound is the modality of choice for diagnosing varicoceles. In addition to dilation of the
pampiniform plexus, ndings include continuous reux and high peak retrograde ow in the ISV.
▶ e majority (>80%) of primary varicoceles are either le sided or bilateral, due to the relatively high
impedence of the le renal vein compared to the inferior vena cava (into which the right internal spermatic
vein drains).
▶ For this reason, unilateral right-sided varicoceles are uncommon and warrant further evaluation for
mechanical obstruction by retroperitoneal or abdominal tumors (i.e. secondary varicocele).
124
Figure 42.4
▶ In standard anatomy, the right ISV drains directly into the inferior vena cava just below the renal vein,
https://t.me/med1917
and the le drains into the le renal vein. Variations are common; they are seen in approximately 20% of
patients.
▶ Ιndications for treatment of varicoceles include pain, infertility, and/or testicular atrophy.
Management
▶ Valsalva maneuver or reverse Trendelenberg position may help document incompetent valves during
venography.
▶ Treatment options include surgery (open, laparoscopic, or microsurgery) or transcatheter embolization.
Both are generally performed as outpatient procedures, with comparable success and rates of recurrence.
Recurrence aer surgery may be treated with transcatheter embolization and vice versa.
▶ Transcatheter embolization can be performed utilizing a combination of coils and/or a sclerosant such as
sodium tetradecyl sulfate made into a foam by mixture with sterile saline or Ethiodol and air.
▶ When a sclerosant is used, care must be taken to prevent reux into the le renal vein. e most distal
coils are placed just above inguinal ligament or pubic symphysis and the most proximal in the ISV 1–2cm
from the conuence with the renal vein to prevent recannalization from parallel, capsular, and colic
collaterals. Additional coils may be placed in between to prevent recanalization from pelvic collaterals.
▶ Some patients may experience temporary scrotal swelling and pain aer embolization. Treatment includes
oral nonsteroidal antiinammatory drugs.
▶ Because the treatment is usually performed on children or men being treated for infertility, minimizing
radiation exposure is important. Use of “last-image hold” or “uoro-store” images rather than photospot
imaging can decrease exposure up to 25-fold.
Further Reading
Iaccarino V, Venetucci P. Interventional radiology of mal varicocele:current status. Cardiovasc Intervent Radiol. 2012;
35(6):1263–1280.
Masson P, Brannigan RE. e varicocele. Urol Clin North Am. 2014; 41(1):129–144.
125
Case 43
https://t.me/med1917
History
▶ A30year-old male patient with known history of paroxysmal nocturnal haemoglobinuria (PNH) and
symptomatic cholelithiasis was scheduled for an elective laparoscopic cholecystectomy. Why is this procedure
being performed?
Figure 43.1
Figure 43.2
126
Case 43 Partial Splenic Embolization
https://t.me/med1917
Figure 43.3
Figure 43.5
Figure 43.4
Figure 43.6
L LL
Figure 43.7
127
Соседние файлы в папке Библиотека им академика М.И. Перельмана