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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3645_Библиотеки_им_академика_М_И_Перельмана
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Case 13 Autoimmune Pancreatitis with Biliary Tract Involvement
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Figure 13.3
Figure 13.4
Figure 13.5
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Findings
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▶ Contrast-enhanced computed tomography (CT) (Fig. 13.3) shows an enlarged featureless pancreas without
pancreatic duct dilation. ere is a “halo” of low density at the periphery of the gland. Finally, a low-density
lesion is seen in the right renal cortex (arrow).
▶ Percutaneous cholangiogram (Fig. 13.4) in a dierent patient with the same disease process shows multiple
intrahepatic biliary strictures (arrows) extending to the common duct (hollow arrow), which has a more
normal appearance.
▶ Aer a course of oral steroid therapy (Fig. 13.5), the stenoses at the conuence are improved and the drainage
catheter is removed.
Teaching Points
▶ Imaging ndings of an edematous, featureless pancreas without ductal dilation should raise the possibilty of
autoimmune pancreatitis. A“halo” of inammatory changes is commonly seen at the periphery of the gland.
▶ Focal autoimmune pancreatitis can mimic pancreatic cancer. Typical symptoms include obstructive jaundice,
abdominal pain, and type II diabetes.
▶ Extrahepatic manifestations of autoimmune pancreatitis (AIP) include biliary involvement and renal deposits,
as in this case. Renal disease represents foci of cortical lymphoplasmocytic inltrates. Retroperitoneal disease,
salivary glands, and enlarged lymph nodes, as well as lesions in the lung and gastrointestinal tract, may also be
present.
Management
▶ AIP is usually, but not always, associated with elevated serum IgG4. is, in combination with response to
immune suppression, clinches the diagnosis.
▶ AIP is most commonly diuse but may be focal. When AIP is considered in the dierential of a pancreatic
mass, immunohistochemistry stains for IgG4 can help dierentiate a lesion from a neoplasm.
▶ e imaging appearance and function of the pancreas usually normalize 4–6 weeks into treatment.
Further Reading
Vlachou PA, Khalili K, Jang HJ, etal. IgG4 related sclerosing disease:Autoimmune pancreatitis and extrapancreatic
manifestations. Radiographics. 2011; 31:1379–1402.
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Case 14
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History
▶ Post Bone Marrow Transplant, rombocytopenia with Elevated Liver Function Tests
Pressure measured with the catheter in Fig.14.1 was 10mmHg and in Fig.14.2 was 24mmHg. Right atrial
pressure was 6–8mmHg.
Figure 14.1
Figure 14.3
Figure 14.2
Figure 14.4
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Case 14 Transjugular Liver Biopsy
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Figure 14.5 Figure 14.6
Figure 14.7 Figure 14.8
Findings
▶ Transjugular access of the right hepatic vein has been achieved via the right internal jugular vein approach
(Fig. 14.5).
▶ In Figure 14.5 the end-hole catheter is positioned freely in the hepatic vein; in Figure 14.6 it is wedged in a
small branch of the hepatic vein. Contrast opacication of the right portal vein branches (arrow) with the
hepatic catheter conrms wedged position.
▶ An 18-gauge side-notch biopsy needle has been advanced through the metallic sheath (arrow, Fig. 14.8) to
obtain a random core of liver tissue.
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Teaching Points
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▶ Transjugular (vs. percutaneous) liver biopsy is indicated when a nontarget sample is required in patients with
ascites or coagulopathy. It may also be performed in conjunction with other procedures requiring venous
access, including hepatic venography or pressure measurements.
▶ e hepatic venous pressure gradient (HVPG) is calculated by subtracting the free hepatic vein pressure from
the wedge pressure measurement which provides an indirect measurement of portal vein pressure. Anormal
value is less than 5mmHg. In cirrhotic patients, varices typically develop at an HVPG over 10mmHg.
▶ In Figure 14.7 an Amplatz wire has been advanced deep into the right hepatic vein so that the oppy tip is
coiled distally. is provides a sti wire along the entire course of access to facilitate placement of the metal
cannula of the biopsy set.
▶ Because the central hepatic veins are posterior relative to the bulk of liver parenchyma, the metal sheath
is rotated anteriorly to direct the biopsy needle into the parenchyma and to minimize the risk of capsular
perforation.
▶ Multiple cores should be obtained and sent for appropriate studies. In the evaluation of cirrhosis, evaluation of
fewer than three cores may underestimate stage. In select cases, specimens may be obtained for culture and/or
quantitative iron analysis.
Management
▶ Repeated measurement of hepatic venous pressure gradient may be used to evaluate for response of portal
pressure to beta blockade in patients with cirrhosis.
Further Reading
McAfee JH, Keee EB, Lee RG, etal. Transjugular liver biopsy. J Hepatol. 1992; 15(4):726–732.
Transjugular liver biopsy. In:Mauro MA, Murphy KPJ, omson KR, Venbrux AC, Zollikofer CL, eds. Image-Guided
Interventions. Philadelphia, PA:Saunders; 2008:762–767.
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History
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▶ A76-Year-Old Male with Hematuria and Pain 3 Days aer Nontarget Kidney Biopsy
What is the most likely diagnosis and the appropriate management?
Figure 15.1
Case 15
Figure 15.2
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Case 15 Renal Pseudoaneurysm
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Figure 15.3 Figure 15.4
Figure 15.5
Figure 15.6
Figure 15.7
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Findings
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▶ Noncontrast computed tomography (CT) 3days aer biopsy (Figs. 15.3 and 15.4) demonstrates a large le
perinephric hematoma (arrows) and dense clot within the bladder (hollow arrow).
▶ Le renal angiogram (Fig. 15.5) demonstrates a pseudoaneurysm (arrow) arising from the lower pole renal
artery in the area that was biopsied (not shown).
▶ Aer subselective coil embolization (Fig. 15.6), the pseudoaneurysm is no longer opacied and the majority of
the renal arteries are preserved (Fig. 15.7).
Teaching Points
▶ Pseudoaneurysms of the renal arteries are commonly the sequela of trauma, most oen iatrogenic following
renal biopsy, nephrostomy placement, or partial nephrectomy.
▶ e constellation of persistent hematuria and bleeding around the catheter following nephrostomy should
raise the possibility of pseudoaneurysm.
Management
▶ Most iatrogenic pseudoaneuryms involve distal subsegmental branches of the renal artery. e classic teaching
for embolization of pseudoaneurysms is to embolize with permanent agent (e.g., coils) both proximal and
distal to the injury to prevent collateral reperfusion. In these very distal arteries this is not usually possible,
and proximal embolization suces.
▶ Unlike in a true aneurysm, in which packing the aneurysm to preserve the native vessel is eective treatment,
packing of a pseudoaneurysm, for example with coils, should be avoided because pseudoaneurysms represent
contained ruptures and packing can increase pressure and promote free rupture.
▶ Permanent embolic agents, including thrombin, coils, glue, and particles, have been used to treat these lesions.
Occasionally pseudoaneurysms are seen in association with renal arterio-venous stula. In such cases particles
should not be used because of the risk of shunting to the pulmonary arteries.
▶ Patients may experience a postembolization syndrome consisting of pain, nausea, and fever. Adverse eect on
renal function or hypertension is uncommon.
Further Reading
Sildiroglu O, Saad WE, Hagspiel KD, etal. Endovascular management of iatrogenic native renal arterial pseudoaneurysms.
Cardiovasc Intervent Radiol. 2012; 35(6):1340–1345.
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Case 16
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History
▶ Retroperitoneal sarcoma was resected 2years ago. New perineal mass is suspicious for recurrence. Biopsy was
requested.
Figure 16.1
Figure 16.2
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Case 16 Transperineal Magnetic Resonance–Guided Biopsy
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Figure 16.3 Figure 16.4
Figure 16.5 Figure 16.6
Findings
▶ Contrast-enhanced computed tomography (CT) shows an enhancing mass in the ishiorectal fossa (Fig. 16.3).
Prebiopsy sagittal T2-weighted proton density magnetic resonance (MR) also shows the mass (Fig. 16.4).
▶ T1- and T2-weighted sagittal MR images (Figs. 16.5 and 16.6) show an MR-compatible biopsy needle within
the mass from a transperineal approach.
Teaching Points
▶ Advantages of MR guidance for select biopsies include its superior so tissue contrast (e.g., bone marrow
lesions) and multiplanar capabilities allowing a biopsy trajectory in almost any plane.
▶ Several factors contribute to needle visualization, including sequence, eld strength, needle composition, and
direction of the frequency encoding direction. In general, artifact is increased with faster sequences, higher
eld strength, and imaging perpendicular to the frequency encoding direction. Blooming artifact at the needle
tip (Fig. 16.4, arrowhead) occurs when the needle is parallel to the static magnetic eld.
▶ Biopsy approach to potentially resectable bone and so tissue tumors (sarcoma) should be discussed with
the surgeon. Because of the high incidence of tract seeding from these tumors, resection is planned so as to
include the needle tract with the tumor en bloc. Transperineal biopsy in this case was based on the anticipated
transperineal resection.
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