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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
6.5 Unexplained Fever
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
n
Sonographic findings :
x
Hypoechoic mass, appearing on the right side between the vena cava and
superior renal pole (where it may easily cause a vena cava compression syndrome) or on the left side between the aorta and superior renal pole
n
Accuracy of sonographic diagnosis: Adrenal carcinomas are rarely I 3 cm, and
adenomas are usually I 6 cm. An adrenal tumor as small as 2–3 cm is very likely
to be detected sonographically when a specific search is undertaken. Benign–
malignant differentiation relies on ultrasound-guided percutaneous biopsy.
Malignant Lymphoma
..............................................................................................................
n
See Hepatosplenomegaly, High-Grade Lymphoma, p. 150, 316; Palpable Masses,
High-Grade Lymphoma, p. 101; Enlarged Lymph Nodes, Malignant Lymphoma,
p. 113.
Breast Carcinoma (Fig. 128)
..............................................................................................................
n
Clinical manifestations : nonspecific; ESR may be elevated; palpable breast mass
n
Diagnosis:
x
Inspection: cutaneous erythema, nipple retraction, possible abnormal nipple
discharge, orange-peel appearance of skin
x
Palpation: firm, relatively fixed breast mass
x
Sonography
x
Mammography: Local excision is indicated in doubtful cases.
n
Sonographic findings :
x
Exclusion of breast cyst
x
Usually, indistinct margins with spiculations
x
Echo pattern is usually nonhomogeneous
x
Extremely variable echogenicity
n
Accuracy of sonographic diagnosis : Breast nodules can be clearly visualized with
ultrasound. Benign–malignant differentiation is uncertain, however, and additional studies are needed. Ultrasound-guided percutaneous biopsy can establish
the diagnosis.
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
Fig. 128 Hypoechoic breast mass
with ill-defined margins (69-year-old
woman). The patient presented clinically
with a firm, immobile, painless nodule in
the right breast
Sarcoma
..............................................................................................................
n
See Fig. 167a, b), (p. 122).
n
Note: Sarcoma becomes symptomatic because of its complications, usually con-
sisting of mass effects (gastric sarcomas frequently ulcerate and bleed). Sarcomas
are clearly demonstrated by ultrasound. Histologic confirmation is mandatory.
97
6.5 Unexplained Fever
Schmidt, Ultrasound © 2007 Thieme
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6
6
Atrial Myxoma
..............................................................................................................
n
Clinical manifestations : nonspecific signs and symptoms, fever, weight loss, pos-
sible cardiac murmur
n
Diagnosis: First it is essential to consider this entity in the differential diagnosis.
An elevated ESR, anemia, and lethargy are suggestive signs. The diagnosis is
advanced by transthoracic and transesophageal echocardiography.
n
Sonographic findings :
x
Intracavitary echogenic mass, usually very mobile.
x
Rapid tumor enlargement may occur.
n
Accuracy of sonographic diagnosis: The diagnosis remains uncertain, and differ-
entiation from an intracavitary thrombus is difficult. A thrombus should shrink in
response to thrombolytic therapy.
Principal Signs and Symptoms
Principal Signs and Symptoms
Endocarditis (Figs. 129 and 130)
..............................................................................................................
n
Clinical manifestations : significant general malaise
n
Diagnosis:
x
Known history of valvular heart disease. Do not overlook this diagnosis, especially in patients with artificial valves.
x
Repeated blood cultures; echocardiography; TEE
n
Sonographic findings :
x
Transthoracic echocardiography (TTE): valvular incompetence; thickened, echogenic valves, possibly with mobile vegetations (difficult to detect by TTE
because they are on the side away from the transducer)
x
Transesophageal echocardiography (TEE): thickened valves, echogenic mobile
vegetations on the valves. Aortic valve vegetations are usually on the aortic
side, mitral valve vegetations are usually on the atrial side. It is rare to find
vegetations on the tricuspid valve (most common after catheterization and in
drug addicts) or pulmonary valve.
n
Accuracy of sonographic diagnosis: Valvular vegetations in endocarditis are
clearly visualized by TEE but are easily mistaken for fibrotic or thrombotic depos-
Fig. 129 Mitral valve endocarditis
following a mitral valve replacement.
The valve displays echogenic margins
and club-like expansion (arrow). Note
Fig. 130 Mitral valve endocarditis (same
patient as in Fig. 129). CDS demonstrates
a paravalvular leak (arrow) causing
regurgitation into the left atrium (LA)
the homogeneous, slightly echogenic
internal echo pattern (spontaneous
echoes) in the left atrium (LA) due to mitral
insufficiency. Fluttering motions of the
endocarditic vegetation can be seen with
98
real-time ultrasound. LV = left ventricle
6.6 Palpable Masses
Schmidt, Ultrasound © 2007 Thieme
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its. A definitive diagnosis relies on multiple positive blood cultures. Follow-ups
showing a regression of the changes in response to antibiotic therapy confirm
the diagnosis.
6.6 Palpable Masses
Basic Principles
..............................................................................................................
n
Principal signs and symptoms : palpable, enlarged lymph nodes, painful or pain-
less (see also p. 107); palpable masses of indeterminate nature. Enlarged lymph
nodes may reflect a distant disease process (tumor, infection). The lymphatic
pathways shown in Fig.
131 are helpful in locating the source of an infection.
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
Fig. 131 Lymphatic pathways
99
6.6 Palpable Masses
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
6
6
n
The differential diagnosis is reviewed in Table 15, where the possible diagnoses
are listed in order of their frequency in the general hospital setting.
Table 15.Differential diagnosis of palpable masses
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Diagnosis Sonographic signs
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Generalized
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Common
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
High-grade non-Hodgkin
lymphoma (p. 101),
lymphogranulomatous Hodgkin
Principal Signs and Symptoms
Principal Signs and Symptoms
disease (p. 113)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Multiple hypoechoic masses (p. 113, 114), enlarged
lymph nodes, sandwich signs, multifocal involvement
Conditions that cannot be diagnosed with ultrasound
Common: Leukosis (CLL)
Rare: Infections (acute infectious lymphocytosis, toxoplasmosis, infectious mononucleosis,
AIDS, rubella, histoplasmosis, tropical diseases), systemic diseases (lupus erythematosus,
juvenile rheumatoid arthritis, Waldenström macroglobulinemia, lymphosarcomatosis, Felty
syndrome, generalized exfoliative dermatitis, reticuloendotheliosis), hereditary diseases
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Regional
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Common
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
High-grade lymphoma (p. 101)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Conditions that cannot be diagnosed with ultrasound
Common: Erysipelas
Less common: Lymphangitis
Rare: Infections (cat-scratch disease, tropical diseases, syphilis, primary focus, anthrax)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Local
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Common
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Goitrous nodule (p. 102)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Inguinal, femoral or abdominal
hernia (p. 105)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Inflamed lymph nodes (p. 110)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Variable echogenicity, possible peristaltic motion
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Enlarged, hypoechoic lymph nodes, elliptical
100
6.6 Palpable Masses
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Table 15.Differential diagnosis of palpable masses – continued
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Diagnosis Sonographic signs
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Less common
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Breast tumor (p. 97)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Suppurative thyroiditis (p. 103)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Salivary gland swelling (p. 103)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Metastases (p. 105)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Nodular varix (p. 106)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Rare
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Neck cyst (p. 104)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Malignant lymphoma (p. 97),
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Nonhomogeneous, hypoechoic
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Nonhomogeneous, hypoechoic/echogenic
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Usually hypoechoic, elliptical foci
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Round lesions of varying echogenicity, depending on the
primary tumor and stage
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Compressible, anechoic nodule, shows blood flow by CDS
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Anechoic mass
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Enlarged lymph nodes, sandwich sign
lymphogranulomatous Hodgkin
disease
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Lipoma, fibroma (p. 107)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Round or elliptical, well-circumscribed mass; fibroma is
hypoechoic, lipoma is echogenic
Conditions that cannot be diagnosed with ultrasound
Less common: Infections (erysipelas, infectious mononucleosis, tonsillitis), systemic diseases
(lymphatic leukemia)
Rare: Infections (lymphangitis, vaccination reaction, otitis media, Plaut–Vincent tonsillitis,
pseudocroup, pediatric diseases, ulcerative stomatitis, actinomycosis, venereal diseases,
tropical diseases), systemic diseases (Waldenström macroglobulinemia, Pancoast tumor,
lymphangioma, malignant reticulosis)
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
High-Grade Lymphoma, Lymphogranulomatous Hodgkin Disease
(Figs. 132 and 133)
..............................................................................................................
n
See Enlarged Lymph Nodes, p. 107; Hepatosplenomegaly, p. 148.
n
Note: Malignant lymphoma is typically characterized by multifocal involvement
and the “sandwich sign” of enlarged lymph nodes.
Fig. 132 High-grade lymphoma:
hypoechoic, sharply circumscribed
rounded mass with an echogenic center
(LN). The patient presented clinically
with palpable inguinal lymph nodes
101
6.6 Palpable Masses
Schmidt, Ultrasound © 2007 Thieme
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6
6
Fig. 133 High-grade lymphoma (same
patient as in Fig. 132). CDS shows irregular central blood vessels. The patient
presented clinically with a palpable axillary lymph node
Goitrous Nodule (Figs. 134–137)
..............................................................................................................
Principal Signs and Symptoms
Principal Signs and Symptoms
n
See also Thyroid Gland, p. 412, and Goiter, Hyper- and Hypothyroidism, p. 179.
n
Note: A patient with a goiter may be in such poor general health that the signs
and symptoms suggest neoplasia. New swelling may signify a fast-growing thyroid carcinoma, intrathyroid hemorrhage, or the rapid growth of a thyroid nodule.
Rapid progression of dyspnea may indicate bleeding into a thyroid carcinoma.
n
Clinical manifestations: palpable, nontender swelling in the neck, often visible.
There may be dyspnea with stridor serious enough to require intubation. If dyspnea is of long standing, the patient may be in a debilitated condition.
n
Diagnosis: History, sonography. If intubation is required, it should be followed by
tracheoscopy.
n
Sonographic findings :
x
Enlarged thyroid gland, with or without a discrete nodule
x
The trachea may be narrowed or obstructed.
Fig. 134 Goiter with internal bleeding:
enlarged, nonhomogeneous thyroid
gland (TG) with an irregular anechoic
area (arrow, identified as a fresh hemorrhage by CDS). The trachea (TR) is
narrowed by the goitrous nodule
(arrows). Presumptive diagnosis:
thyroid carcinoma. Clinically, there
was rapid progression of dyspnea
requiring emergency intubation
Fig. 135 Endoscopy demonstrates
tracheal narrowing by the tumor
(same patient as in Fig. 134). A nodule
has narrowed the trachea at the end of
the endotracheal tube (arrows), preventing successful extubation. Histology
p simple goiter with internal bleeding
(possibly iatrogenic following catheter
placement in the internal jugular vein)
102
a
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Fig. 136a–c Thyroid nodule.
a Panoramic scan shows an asym-
metrical thyroid gland with a hypoplastic
left lobe and a large, palpable, solitary
nodule in the right lobe.
b Solitary nodule (cursors) with
regressive changes.
c CDS identifies the hypoechoic rim
as peripheral vascularity
6.6 Palpable Masses
b
c
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
Fig. 137 Thyroid nodule with cystic
degeneration and internal bleeding. The
patient presented clinically with a new,
firm, palpable swelling in the neck
n
Accuracy of sonographic diagnosis: The sonographic findings are diagnostic in
many cases. Additional laboratory parameters are often needed but are not yet
available in an emergency setting, making the diagnosis uncertain.
Suppurative Thyroiditis
..............................................................................................................
n
See Goiter, Hyper- and Hypothyroidism, p. 179.; Thyroid Gland, Abscess, p. 419.
Salivary Gland Swelling
..............................................................................................................
n
See also Chapter 19, Major Salivary Glands.
n
Classification:
x
Parotitis:
– Acute bacterial, viral, or allergic
– Chronic in systemic diseases, radiation-induced
103
6.6 Palpable Masses
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6
6
x
Tumor:
– Benign: e.g., adenoma, cystadenolymphoma
– Malignant: e.g., acinar cell tumor, mucoepidermoid tumor, carcinoma, malig-
nant lymphoma, metastases (locoregional bronchial carcinoma, melanoma)
x
Duct stone
x
Trauma
x
Cysts
n
Clinical manifestations: swelling, fever, hematologic changes. Signs suspicious for
a malignant tumor are rapid growth, pain, facial nerve paralysis, cervical lymph
node metastases, firm infiltration, skin ulceration, and very limited mobility.
n
Diagnosis:
x
History
x
Palpation: consistency, mobility
x
Sonography, FNAB
Principal Signs and Symptoms
Principal Signs and Symptoms
n
Sonographic findings :
x
Anechoic: cyst
x
Echogenic: duct stone
x
Elliptical foci, usually hypoechoic:
– Malignant: ill-defined, infiltrating margins; lesions are often multiple
– Benign: well-defined margins
n
Accuracy of sonographic diagnosis: The sonographic signs are easily recognized,
but an accurate benign–malignant differentiation requires histologic examination.
Thus, any salivary gland swelling that is not definitely referable to a known viral
infection should be investigated by FNAB, and the aspirate should be sent for both
cytologic and histologic evaluation.
Neck Cyst (Fig. 138)
..............................................................................................................
n
Clinical manifestations: Neck cysts become symptomatic only when infected,
producing a painful neck swelling associated with palpable lymph nodes, fever,
and dysphagia.
ab
Fig. 138a, b Infected neck cyst (C) and enlarged cervical lymph nodes (L).
a B-mode image before percutaneous aspiration. b CDS shows color pixels in
the carotid artery (AC) and jugular vein (V). The cyst was aspirated.
P = parotid gland
104
6.6 Palpable Masses
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
n
Diagnosis:
x
History, palpation
x
Sonography
x
FNAB: The aspirate is examined cytologically and bacteriologically to identify
the infecting organism and determine its antibiotic sensitivity.
n
Sonographic findings :
x
Anechoic mass at the border of the sternocleidomastoid muscle
x
Cyst: rubbery, compressible; with abscess formation, the contents become
more echogenic
n
Accuracy of sonographic diagnosis: The cyst is easily detected by sonography,
and CDS can positively distinguish it from blood vessels. Neck cysts are rare,
and when infected by bacteria they are virtually indistinguishable from a parotid
abscess. In these cases the diagnosis can be advanced by aspiration cytology.
Inguinal, Femoral or Abdominal Hernia (Fig. 139)
..............................................................................................................
n
See also Lower Abdominal Pain, Hernia, p. 75.
n
Clinical manifestations: soft, painless bulge of variable size. An incarcerated
hernia is painful.
n
Diagnosis:
x
History
x
Palpation: soft consistency, can usually be pressed down to skin level
x
Auscultation: bowel sounds
n
Sonographic findings :
x
Structure close to the transducer
x
Variable echogenicity, depending on the contents
x
May have detectable peristalsis
x
With an abdominal hernia, a gap can be seen in the peritoneum.
n
Accuracy of sonographic diagnosis: When accessible to ultrasound scanning, the
hernia itself can be clearly visualized. In the absence of peristalsis, hernias may
be mistaken for lymph nodes or tumors, but the clinical findings will suggest
the correct diagnosis.
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
Fig. 139 Abdominal hernia: hypoechoic, palpable rounded mass (cursors,
marking the gap in the peritoneum)
Metastases (Fig. 140)
..............................................................................................................
n
Clinical manifestations: complaints relating to the primary tumor. Symptoms
may be caused by mass effects such as superior and inferior vena cava syndrome
(see p. 122).
n
Diagnosis: sonography; FNAB: cytology aids in locating the primary tumor. Other
modalities that can aid the search for an occult primary tumor are chest radiography and fluoroscopy, thoracic and/or abdominal CT, pelvic CT, and endoscopy.
105
6.6 Palpable Masses
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6
6
Fig. 140 Lymph node metastasis :
large tumor mass in the left inguinal
region; metastasis from an ovarial
carcinoma. May be confused with a
hernia. The punctate vascularization
in the CDS suggests the tumor
genesis
n
Sonographic findings: Round lesions of varying echogenicity, depending on the
primary tumor; in the CDS tumor vascularisation
Principal Signs and Symptoms
Principal Signs and Symptoms
n
Accuracy of sonographic diagnosis: Sonography alone cannot positively distin-
guish a benign lymph node from a metastasis. Suggestive criteria are illustrated
in Figs.
144 and 145 (p. 109) and Table 16 (p. 108).
Nodular Varix (Fig. 141)
..............................................................................................................
n
Clinical manifestations :
x
Livid, localized nodular swelling
x
An infected varix is hard, extremely tender, and surrounded by erythematous
skin.
n
Diagnosis: compression sonography of the veins of the lower extremity; conven-
tional venography is rarely necessary (see p. 212).
n
Sonographic findings :
x
Easily compressible, anechoic nodule
x
CDS demonstrates blood flow. A normal flow velocity excludes thrombosis
and an arteriovenous fistula (following left-heart catheterization or dilatation
therapy).
n
Accuracy of sonographic diagnosis: A varix located close to the transducer can be
positively identified.
ab
Fig. 141a, b Recanalized umbilical vein, CDS. a The vessel is easily traced to the
abdominal wall. b The palpable, nodular mass beneath the abdominal wall is
identified as a varix by CDS. The patient presented clinically with alcoholic cirrhosis
of the liver
106