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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
6.2 Lower Abdominal Pain
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
n
Accuracy of sonographic diagnosis: Selective intestinal scanning with a high-
resolution probe can demonstrate typical bowel wall changes in up to 90 % of
patients. These changes, combined with the clinical presentation, can establish
the diagnosis.
Epiploic Appendagitis (Fig. 104)
..............................................................................................................
n
Fat necrosis of an epiploic appendix:
x
Biconvex, incompressible mass of high echogenicity
x
Surrounding rim of low echogenicity
ab
Fig. 104a, b Epiploic appendagitis. a Inflammatory matting and necrosis of the
epiploic appendix (arrows) on the peritoneum (P). b Endoscopic appearance
Hernia (Fig. 105)
..............................................................................................................
n
See also Palpable Masses, p. 105.
n
Clinical manifestations: Pain is localized to the hernia site and is constant if
the hernia has become incarcerated. Most patients present with a palpable
mass, and many have a palpable hernial ring. The mass enlarges on coughing or
straining.
n
Diagnosis:
x
History
x
Clinical examination with inspection, auscultation, and selective palpation
x
Sonography
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
ab
Fig. 105 a, b Inguinal hernias. a Echogenic omentum in the hernial sac.
b Herniated small bowel. With an incarcerated hernia, the sac always contains fluid
77
6.2 Lower Abdominal Pain
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
6
6
n
Sonographic findings :
x
Signs of mechanical bowel obstruction (see p. 82).
x
Gap in the peritoneal line (detectable with a 5 MHz or 7 MHz transducer).
x
Bowel loops with thickened walls or omentum can be detected in the hernial
sac. The contents are easier to identify if peristalsis is still present.
x
Indirect hernia = hernial sac that is lateral to the epigastric vessels and passes
obliquely through the abdominal wall.
x
Direct hernia = medial hernial sac that passes directly through the abdominal
wall.
Urinary Retention (Fig. 106)
..............................................................................................................
n
Clinical manifestations: retention of urine, increasing pain in the lower abdomen
n
Diagnosis: history (onset of pain, location of pain, last voiding); urinalysis; sono-
Principal Signs and Symptoms
Principal Signs and Symptoms
graphy; urethral catheter
n
Sonographic findings :
x
Markedly distended bladder
x
The renal pelvis is often dilated and anechoic as a result of bladder tamponade
and reflux
x
High-level internal echoes (blood clots) may be seen.
ab
Fig. 106a–c Urinary retention.
a Strongly distended bladder, tender
c
to pressure, with faint internal echoes
(clotted blood). The patient, taking
300 mg/day of aspirin, presented
clinically with hemorrhagic cystitis.
b Dilated, obstructed, anechoic renal
pelvis. c Following bladder irrigation
(to clear blood clots causing bladder
tamponade), ultrasound demonstrates
intravesical air (echogenic crescent
along the bladder roof). Bright swirling echoes (blood) can be seen during irrigation
Adnexitis (Fig. 107)
..............................................................................................................
n
Clinical manifesta tions : acute or slowly progressive lower abdominal pain, often
bilateral; frequently begins after menses; fever; palpable tender mass.
n
Diagnosis:
x
History, physical examination
x
Laboratory findings : leukocytosis, elevated ESR
x
Sonography
x
Transvaginal sonography may be used if needed; diagnostic laparotomy is
78
rarely indicated.
6.2 Lower Abdominal Pain
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Fig. 107 Adnexitis. Behind the bladder
(B) is a mass with irregular echogenic
margins and a hypoechoic center (T).
Hypoechoic free fluid is visible above the
mass. May be mistaken for an ovarian
tumor in patients with elevated tumor
markers (diagnosis established by
histologic examination)
n
Sonographic findings :
x
Mixed cystic/solid mass (hypoechoic, echogenic) caused by wall thickening and
the accumulation of pus
x
Tenderness to probe pressure
n
Accuracy of sonographic diagnosis: The sonographic findings are diagnostic in
approximately 80 % of all cases. This accuracy rate can be increased somewhat
by transvaginal scanning. More pronounced forms may be indistinguishable
from a tumor.
Tubal Rupture (Fig. 108)
..............................................................................................................
n
Clinical manifestations: lower abdominal pain; signs and symptoms may mimic
hemorrhagic shock
n
Diagnosis:
x
History: menstrual history, including information on the intensity of menstrual
bleeding. (Most tubal ruptures are caused by an unrecognized ectopic pregnancy in adolescents and young women.)
x
Sonography
x
Laboratory findings, pregnancy index
x
Laparoscopy, followed if necessary by laparotomy
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
ab
Fig. 108a, b Tubal rupture in a patient with ectopic pregnancy and periadnexitis.
a Uterus (UT) with proliferative endometrium, left adnexa enlarged with a marginal
discontinuity (arrows) and retrouterine effusion (E). b Enlarged adnexa (cursors)
with an irregular internal echo pattern and a conspicuous hypoechoic mass
(possible an old gestational sac). A fluid rim (FL) surrounds the adnexa. With a
presumptive diagnosis of abscess, laparoscopy was performed to exclude ovarian
cancer, followed by laparotomy. Histologic diagnosis: periadnexitis following an old
tubal abortion
79
6.2 Lower Abdominal Pain
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
6
6
n
Sonographic findings : uterine changes like those seen in pregnancy (enlarged
uterus, proliferative endometrial changes with or without a pseudogestational
sac). Free fluid around the uterus. A conceptus can often be detected.
n
Accuracy of sonographic diagnosis: An acute tubal rupture can be diagnosed
sonographically in conjunction with the clinical findings and b-HCG. Small,
older ruptures are difficult to evaluate with ultrasound. The detection of an ectopic sac establishes an extrauterine pregnancy. In the absence of this finding, ectopic
pregnancy can be sonographically confirmed in 80 % of cases.
Torsion of an Ovarian Cyst (Fig. 109)
..............................................................................................................
n
Clinical manifestations: colicky pain of sudden onset, increasing in intensity,
sometimes beginning after an abrupt twisting of the body
n
Diagnosis:
n
Principal Signs and Symptoms
Principal Signs and Symptoms
Note: It is essential not to overlook this diagnosis.
x
Rectal or vaginal examination: very tender mass
x
Sonography, transvaginal sonography
x
Laparoscopy with preparations for laparotomy
n
Sonographic findings :
x
Unilateral ovarian enlargement with an associated cystic mass.
x
In many cases the twisted pedicle can be visualized as an echogenic band.
n
Accuracy of sonographic diagnosis: The cyst can be detected with high confi-
dence, but it may be difficult to classify. The diagnosis can be made sonographically in conjunction with clinical findings and the exclusion of pregnancy.
ab
Fig. 109a, b Torsion of an ovarian cyst: anechoic cyst (C) adjacent to the bladder
(B). The pedicle (P) appears as an echogenic band
Testicular Torsion
..............................................................................................................
n
Clinical manifestations : excruciating pain of sudden onset; swelling and redness
of the scrotum; nausea, vomiting
n
Diagnosis:
x
History: age
x
Laboratory tests to differentiate from orchitis and epididymitis
x
Sonography
Sonographic findings :
x
Enlarged testis
x
80
Testis decreases in size over a period of days, may become atrophic
6.3 Diffuse Abdominal Pain
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
x
Affected testis is isoechoic to unaffected testis
x
Hypoechoic to anechoic areas increase over a period of days, signifying necrosis
x
Enlarged epididymis
x
Hydrocele
x
Absence of vascularity by CDS
n
Accuracy of sonographic diagnosis: Testicular torsion may be mistaken for a
tumor or inflammation. CDS can confirm the diagnosis in 100 % of cases by showing an absence of blood flow.
!
Caution: This diagnosis is an indication for immediate surgery.
6.3 Diffuse Abdominal Pain
Basic Principles
..............................................................................................................
n
Principal signs and symptoms: see p. 62.
n
Differential diagnosis: see Table 11.
Table 11.Differential diagnosis of diffuse abdominal pain
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Diagnosis Sonographic signs
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Common
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Gastroenteritis (p. 361)
Coprostasis Distended colon loops with tense, air-filled haustra
Mechanical ileus (p. 82) Bidirectional peristalsis, dilated bowel loops containing
Paralytic ileus (p. 83) Absence of peristalsis, dilated bowel loops
Peritonitis (p. 83) Thickened peritoneum, dilated bowel without wall swelling,
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Less common
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Mesenteric vascular
occlusion (p. 84)
Dissecting aortic aneurysm
(p. 71, 205)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Rare
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Intra-abdominal bleeding
(p. 86)
For conditions that cannot be diagnosed with ultrasound, see Table 9, p. 62.
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Accentuated bowel walls, increased intraintestinal fluid,
possible small hypoechoic mesenteric lymph nodes
increased amounts of fluid
free fluid
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Long segmental thickening of bowel walls, acute luminal
narrowing, decreased peristalsis
Aortic dilatation, floating anechoic band in aortic lumen,
double lumen
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Essentially anechoic fluid surrounding the organs;
capsular discontinuity is seen with an organ rupture
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
81
6.3 Diffuse Abdominal Pain
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
6
6
Mechanical Bowel Obstruction (Figs. 110–113)
..............................................................................................................
n
See also Small Intestine, p. 361.
n
Clinical manifestations :
x
Intermittent colicky pain : The pain from a strangulated bowel does not have this
colicky aspect. An obstruction of the small bowel is more painful than an
obstruction of the large bowel.
x
Vomiting with retention of stool and flatus: The higher the site of the obstruction, the greater the frequency and severity of vomiting.
x
Distended abdomen
n
Diagnosis: History, auscultation, palpation; ultrasound, plain abdominal radio-
graph, endoscopy
n
Sonographic findings :
x
Circumscribed bidirectional peristalsis
Principal Signs and Symptoms
Principal Signs and Symptoms
x
Dilated bowel loops containing an increased amount of fluid and stool
x
Detectable causes:
– Gallstone (rapidly enlarges after entering the duodenum or colon following a
confined gallbladder perforation): Typical echogenic crescent, generally
casting a complete acoustic shadow
– Adhesive band: Echogenic constricting band associated with thickening of
the bowel wall due to venous stasis
– Tumor: Circumscribed swelling of the bowel wall with an abnormal target
pattern
– Intussusception: Target pattern with a hypoechoic inner and outer ring
(bowel wall) separated by an hyperechoic middle ring (bowel lumen between the telescoped wall segments)
– Bezoar: Foreign body obstructing the bowel lumen (hyper- or hypoechoic
structure, often with an irregular surface). Frequently casts an acoustic shadow. May cause intermittent signs of bowel obstruction, and may migrate
initially. Marked symptoms usually appear when the foreign body becomes
lodged at the ileocecal valve.
n
Accuracy of ultrasound diagnosis : Very high, up to 100 %. More sensitive than
radiographs in early cases.
Fig. 110 Mechanical obstruction by a
circumferential antral tumor causing
high-grade stenosis of the bowel
lumen. Ultrasound shows that the wall
thickness (W) is increased to 17 mm
(cursors). The patient presented clini-
82
cally with intractable vomiting
Fig. 111 Adhesive bowel obstruction.
Midabdominal transverse scan shows an
abnormal target pattern with a markedly
thickened bowel wall that is tapered
inferiorly (adhesive band). The acoustic
shadow is from intraluminal air
6.3 Diffuse Abdominal Pain
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
a
b
Fig. 112a, b Gallstone ileus of the small bowel. a Gas in an intrahepatic bile duct
(arrows) following the perforation of a calculus into the duodenum. b Gallstone
obstructing the bowel lumen. The stone can be identified by its echogenic crescent
and complete acoustic shadow (S). D = dilated bowel loop
ab
Fig. 113a, b Intussusception and bezoar obstruction of the small bowel.
a Intussusception (bowel wall in bowel). Arrows: hypoechoic bowel walls.
b Bezoar obstruction : fluid-filled bowel (B), nonhomogeneous foreign body with
an acoustic shadow (S)
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
Paralytic Ileus (Fig. 114)
..............................................................................................................
n
See also Small Bowel, p. 362.
n
Clinical manifestations : see Mechanical Bowel Obstruction, p. 82, 361.
n
Diagnosis: History, including possible precipitating causes. Absent bowel sounds.
See also Mechanical Bowel Obstruction, p. 82, 361.
n
Sonographic findings :
x
Absence of peristalsis, usually affecting the entire bowel.
x
Dilated bowel loops.
x
Toxic megacolon: Gas-distended bowel loops with thinning of the anterior wall
x
The posterior bowel walls cannot be evaluated because of extensive intraluminal gas and associated shadowing.
n
Accuracy of ultrasound diagnosis: Same as in mechanical bowel obstruction.
Peritonitis (Fig. 114)
..............................................................................................................
n
Clinical manifestations: Severe clinical picture that may include shock, heart fail-
ure, or impaired renal function; tense abdomen, diffuse or localized pain; retention of stool, nausea, vomiting, fever.
83
6.3 Diffuse Abdominal Pain
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
6
6
Fig. 114 Inflammatory peritonitis with
paralytic ileus in Crohn disease. Bowel
loops (B) are crowded together, dilated,
and filled with stool. No evidence of wall
thickening or bowel motility. The large
psoas muscle (M) is visible posteriorly
n
Diagnosis:
x
History and clinical course : Appendicitis; perforated diverticulitis, ulcer disease
Principal Signs and Symptoms
Principal Signs and Symptoms
or gallbladder; previous cholecystectomy or common duct surgery; gangrenous
bowel obstruction due to adhesions (prior surgery) or an incarcerated hernia.
x
Laboratory findings : Inflammatory signs, marked leukocytosis
x
Ultrasound
x
Rarely, diagnostic lavage to identify the causative organism
x
Peritoneal biopsy
n
Sonographic findings :
x
Thickened peritoneum
x
Inflammatory peritonitis may cause the matting of bowel loops by adhesions.
The bowel loops cannot be separated from one another by digital palpation.
x
Dilatation of the bowel (due to deficient absorption) with no wall swelling and
decreased or absent peristalsis. Paralytic ileus may result.
x
Peritonitis is usually marked by a very cellular exudate, and free fluid in the abdomen often contains high-level internal echoes.
n
Accuracy of ultrasound diagnosis : Ultrasound can rarely demonstrate the perito-
nitis itself, but can detect the associated changes. The detection of infected ascites
(by percutaneous aspiration) confirms the diagnosis.
Mesenteric Vascular Occlusion (Figs. 115–117)
..............................................................................................................
n
Clinical manifestations: Colicky pain of very sudden onset, circumscribed and
later diffuse. The pain subsides as the condition worsens. Intestinal gangrene
develops with peritonitis and abdominal rigidity, sepsis, and shock. Vomiting,
nausea, diarrhea, and constipation may occur.
n
Cause is often cardiogenic: Absolute arrhythmia with atrial fibrillation, dilatative
cardiomyopathy, or a ventricular aneurysm after myocardial infarction.
n
Course: Embolism develops more rapidly than thrombosis.
n
Diagnosis:
x
Laboratory findings : Include acidosis, elevated serum lactate, and leukocytosis
x
Ultrasound imaging and Doppler sonography of the mesenteric vessels (superior and inferior mesenteric arteries)
x
Radiography: Contrast enema with a water-soluble contrast medium to check
for edematous thickening (“thumbprinting”) of the bowel wall
x
Celiacography and mesentericography
x
Look for the source of the embolus and/or signs of atherosclerosis.
n
Sonographic findings :
x
Significant, hypoechoic wall thickening affecting a long bowel segment, becom-
84
ing less pronounced over time
6.3 Diffuse Abdominal Pain
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Fig. 115 Mesenteric infarction: Segmental thickening of hypoechoic bowel
wall (BW) with absence of peristalsis.
The bowel lumen appears as an echogenic band
Fig. 116 Acute portal vein thrombosis.
Mass in the portal vein (VP) is isoechoic
to liver tissue (arrows). Doppler scanning
shows no evidence of flow
ab
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
Fig. 117a–c a Stenosis of the superior
mesenteric artery: Echogenic plaques at
the origin of the superior mesenteric
artery, initially difficult to identify. b CDS
shows bright color pixels (aliasing) indicating turbulence and high flow velocities. c Spectral curve in a pulsed Doppler
c
scan shows flow acceleration to 4 m/s
x
Acute luminal narrowing, progressing to dilatation due to ischemic malabsorption
x
Decreased peristalsis progressing to aperistalsis
x
Doppler sonography: atherosclerosis of the mesenteric vessels, occasionally
with demonstrable stenosis of the celiac trunk or superior mesenteric artery
(Fig.
n
117)
Accuracy of ultrasound diagnosis: Typical ultrasound findings narrow the differ-
ential diagnosis, but mesenteric vascular occlusion cannot be diagnosed by exclusion. The definitive diagnosis is made at operation, since an arterial stenotic occlusion and a thrombotic venous occlusion are often indistinguishable by ultrasound.
85
6.3 Diffuse Abdominal Pain
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
6
6
Intra-Abdominal Bleeding (Fig. 118)
..............................................................................................................
n
Clinical manifestations: Acute pain, which may be local or diffuse. Significant
bleeding can lead to shock, abdominal distention and rigidity.
n
Diagnosis:
x
History: Previous painful traumatic episode (vehicular accide nt, kick, fall, etc.)
or neoplasia (bleeding metastasis)
x
Ultrasound: Ultrasound follow-ups are advised because of the possibility of a
delayed organ rupture.
x
Laboratory findings : Hematocrit and hemoglobin tests are mandatory.
x
Paracentesis: This is warranted in doubtful cases or in patients with copious
intra-abdominal fluid.
x
Exploratory laparotomy (diagnostic)
n
Sonographic findings :
Principal Signs and Symptoms
Principal Signs and Symptoms
– Essentially anechoic fluid surrounding the organs
– Older organized hematomas are usually nonhomogeneous and more echo-
genic.
– Blood may be localized or distributed throughout the abdominal cavity.
– Capsular discontinuity is seen with an organ rupture (kidney, spleen, liver,
etc.).
n
Accuracy of ultrasound diagnosis: Ultrasound can detect an intra-abdominal
fluid volume as small as 10–15 mL. The nature of the fluid can be determined
by guided needle aspiration. Rarely, tumors and metastases may rupture and
bleed profusely.
ab
Fig. 118a, b Intra-abdominal bleeding. a Echogenic clots (HAE; 2 days) in the right
lower abdomen. b Arterial hemorrhage in progress, almost anechoic. Skiing injury
86