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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
9.4 Changes in the Portal Venous System
Schmidt, Ultrasound © 2007 Thieme
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n
Compression or occlusion of a tributary vein (Fig. 367) : segmental portal hyper-
tension
x
Usually encased by tumor masses
x
With splenic vein involvement, also inflammatory obliteration or thrombosis
due to chronic pancreatitis.
ab
Fig. 367a, b Segmental portal hypertension resulting from superior mesenteric
lymph node metastasis (T). Tumor stenosis with dilated portal tributaries.
a Superior mesenteric vein (SMV) dilated to 12.4 mm (cursors). b Splenic vein (SV)
dilated to 17.6 mm (cursors). PV = portal vein
Flow Changes and Collaterals
..............................................................................................................
n
Flow changes (Fig. 368):
x
Flow velocity is slowed to I 10 cm/s (normal = 15–20 cm/s) (Fig. 368a)
x
Luminal diameter i 15 mm, does not vary with respirations
x
Bidirectional, absent or reverse flow in the portal vein or its tributaries
(Fig.
n
368b)
Collaterals (Fig. 369): detection of portosystemic collaterals
9
Liver9Liver9Liver
ab
Fig. 368a, b Portal hypertension in liver cirrhosis. CDS: decreased flow velocity
with absence of flow in the portal vein. a Flow is in the normal hepatopetal
direction (encoded in red), but its velocity is slowed to 9 cm/s. b Absence of flow in
the portal vein (PV). Additional sign: large-caliber hepatic artery (A), arterial
waveform
259
9.4 Changes in the Portal Venous System
Schmidt, Ultrasound © 2007 Thieme
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9
Liver9Liver9Liver
Fig. 369 Portosystemic collaterals: 1 = fundal and esophageal varices,
2 = recanalized paraumbilical and umbilical veins, 3 = hemorrhoidal venous
collaterals, 4 = splenic hilar collaterals
Intraluminal Changes
..............................................................................................................
n
Acute portal or mesenteric vein thrombosis (see Fig. 116, p. 85) :
x
Echogenic filling defect
x
Vascular dilatation
x
Absence of color Doppler flow signals
n
Note: Clinical picture of acute abdomen.
n
Chronic portal vein thrombosis (Fig. 370):
x
Little or no luminal dilatation
x
Echogenic intraluminal thrombus
x
No measurable flow by Doppler ultrasound, resulting in collateral formation
and recanalization (cavernous transformation of the portal vein, see Fig.
260
371)
9.4 Changes in the Portal Venous System
Schmidt, Ultrasound © 2007 Thieme
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Fig. 370 Chronic portal vein thrombosis (PVT) in the setting of a paraneoplastic syndrome. Hepatic metastases:
very little increase in luminal diameter,
intraluminal echoes in thrombosed portal vein segments. Intrahepatic portal
vein (PV) is clear
Fig. 371 Cavernous transformation of
the portal vein. Tortuous vessels resulting from tumor infiltration of the portal
vein (patchy red/blue vessels representing tortuous collaterals) and portal vein
occlusion (arrows). PV = intrahepatic
portal vein with normal course,
VC = inferior vena cava
Associated Effects
..............................................................................................................
n
Displacement, compression:
x
Intrahepatic due to cirrhosis or tumors
x
Extrahepatic due to chronic pancreatitis or pancreatic tumors
n
Infiltration (Fig. 371):
x
Faint, irregular vascularity
x
The causative malignancy can usually be detected (see Search for Occult
Tumors, p. 447)
Interpretation and Further Testing
..............................................................................................................
n
Sonography: CDS with the analysis of spectral indices has become the standard
method of choice for evaluating the portal venous system.
n
Pressure measurements and splenoportography: These are no longer used in
routine examinations.
n
Esophagoscopy and conventional esophagography: Gastroscopy or esophago-
graphy is essential for the detection of esophageal varices in patients with hepatic
cirrhosis.
9
Liver9Liver9Liver
261
10.1 Examination
Schmidt, Ultrasound © 2007 Thieme
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10
10
10
10 Kidney and Adrenal Gland
10.1 Examination
Kidney
..............................................................................................................
n
Scan planes :
x
Flank scan (see p. 25, 26)
x
Upper abdominal transverse scan (see p. 22)
x
Lateral upper abdominal longitudinal scan (see p. 24)
n
Sonographic anatomy and normal findings (Figs. 372 and 373):
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
x
The kidneys are located in the retroperitoneum on the iliopsoas muscles. Their
longitudinal axes point laterally downward at a divergent angle. They are tilted
laterally, and their lower poles are directed forward.
x
An imaginary line joining the bases of the medullary pyramids separates the
cortical substance of the kidney from the medulla.
x
The center of the renal ellipse (central echo complex, CEC) appears hyperechoic
and consists of vessels, connective tissue, renal sinus fat, and the actual renal
pelvis.
Fig. 372 Section through the kidney
n
Normal values:
x
Length 100–115 mm, width 50–70 mm, thickness 30–50 mm.
x
Parenchyma: The parenchymal–pelvic ratio (ratio of the combined anterior and
posterior parenchymal thickness to the CEC) is 1.7 up to 60 years of age and 1.1
after age 60.
n
Note: Because of the position of the kidneys (see above), their size cannot be
accurately determined. It tends to be underestimated, and their sonographically
262
determined size is approximately 20 mm below the normal value. Unless the
10.1 Examination
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
a b
Fig. 373a, b Normal right kidney (K). L = liver, MP = hypoechoic
medullary pyramids, C = renal columns
longest renal dimension is accurately visualized, ultrasound measurements will
be too low.
n
Scanning protocol:
x
Transducer: 3.5–5.0 MHz
x
Patient generally supine. Left lateral decubitus occasionally used
x
Right kidney: The right liver provides a good acoustic window for scanning the
right kidney. The lower pole is occasionally obscured by the right colic flexure
but is accessible to scanning from the posterior side.
x
Left kidney : An acoustic window is not available for the left kidney. Scanning
from the posterolateral side is advantageous as it avoids overlying gas in the
colon and gastric fornix.
x
Always scan the kidneys during inspiration and expiration to ensure that they
are completely visualized (rib shadows and bowel gas are often troublesome)
and move normally with respiration (i.e., are not fixed by perirenal abscesses).
x
Both kidneys are systematically surveyed in longitudinal and transverse planes.
n
Scanning tips :
x
If a kidney is not visualized, think of agenesis or nephrectomy. An ectopic kidney is often located in the lesser pelvis anterior to the iliac vessels. The possible
causes of nonvisualization are listed below.
n
Note: Take measurements to determine renal size. A visual estimate is often
incorrect.
n
Causes of large or small kidneys (see also Table 47, p. 267):
x
Small kidneys: May be constitutional or may result from hypoplasia or ectopia,
making the organs difficult to locate (Fig.
374).
10
10
10
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
ab
Fig. 374a, b a Renal hypoplasia. The “absent left kidney” is probably a tiny
hypoplastic kidney (cursors). b Malrotated kidney at a slightly ectopic location
(cursors). The renal hilum is directed anteriorly
263
10.1 Examination
Schmidt, Ultrasound © 2007 Thieme
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10
10
10
ab
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Fig. 375a, b Large kidneys. a Duplex kidney (K, cursors 132.5 mm) with
a parenchymal band, b Acromegaly (cursors 138.1 mm)
x
Large kidneys: May be constitutional or may result from duplex kidneys, unilateral aplasia, acromegaly, or compensatory enlargement of the remaining kidney
after nephrectomy (Fig.
n
Causes of difficult visualization or nonvisualization:
x
Ectopic kidney: Located along the path of its normal ascent, usually in the lesser
pelvis near the iliac vessels; “lower abdominal mass” (see Fig.
x
Unilateral renal agenesis: Characterized by enlargement of the contralateral kidney
x
Hypoplastic kidney: Careful inspection of the renal fossa in a close-up view
should reveal a small kidney with normal-appearing parenchyma.
x
Atrophic kidney: Shrunken kidney that displays abnormalities in its contours,
internal echo pattern, or both
x
Renal fusion anomaly: A bilateral “horseshoe kidney” initially appears as two
normal kidneys, but the lower poles are found to be fused across the midline
in the lesser pelvis.
375).
376)
ab
Fig. 376a, b Empty right renal fossa, caused by a partial horseshoe kidney on the
left side (K). AO = aorta, V = compressed vena cava, M = lumbar muscle, L = liver
Adrenal Glands
..............................................................................................................
n
Scan planes :
x
Upper abdominal transverse scan (right adrenal gland)
x
264
Upper abdominal oblique scan (right adrenal gland)
10.1 Examination
Schmidt, Ultrasound © 2007 Thieme
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x
High flank scan (left adrenal gland)
x
High upper abdominal transverse scan (left adrenal gland)
n
Sonographic anatomy and normal findings (Figs. 377 and 378):
x
The normal adrenal glands have a variety of ultrasound appearances, usually
presenting a forked, Y, or triangular shape.
x
The right adrenal gland is located between the upper pole of the kidney and the
inferior vena cava. The left adrenal gland lies between the upper pole of the kidney and the aorta.
10
10
10
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Fig. 377 Topography of the adrenal glands
a b
Fig. 378a, b Normal right adrenal gland (arrows, AG) located between the kidney
(K) and vena cava (VC)
265
10.1 Examination
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
10
10
10
n
Scanning protocol:
n
Note: Normal adrenal glands can be identified only by prolonged scanning with
high-resolution equipment. They are easier to image when they are enlarged
(see Fig.
x
422a–d, p. 292).
Right adrenal gland : High lateral upper abdominal transverse or oblique scan
defining the renal upper pole and the inferior vena cava (the adrenal gland
should be between them), and an upper abdominal longitudinal scan in the
midclavicular line or anterior axillary line demonstrating the vena cava
x
Left adrenal gland : High flank scan through the lower pole of the spleen and the
upper pole of the kidney, with the transducer angled medially toward the aorta.
As on the right side, the gland can be identified between the aorta and renal
upper pole in a high upper abdominal transverse scan.
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Overview and Classification of Findings
..............................................................................................................
n
Size changes: Acute diffuse diseases are generally associated with renal enlarge-
ment due to inflammatory edematous swelling, whereas chronic diseases are
marked by a decrease in renal size caused by loss of parenchyma. In chronic glomerulonephritis and diabetic nephropathy, the kidneys do not shrink in size until
the disease has progressed to the dialysis stage.
n
Echogenicity changes: Increased or decreased echogenicity reflects tissue
changes at the histologic level (see Table
Table 46.Relationship between histologic change and renal echogenicity
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Decreased echogenicity Increased echogenicity
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Interstitial edema
yyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyy
Leukocytic or tumor-cell infiltration
Hyaline or crystalline deposition
Tubular atrophy
Fibrosis or sclerosis
46).
n
Diffuse renal changes with or without a change in size: see p. 267 and Table 47.
n
Circumscribed changes in the renal parenchyma: see p. 272 and Table 48.
n
Circumscribed changes in the renal pelvis or renal sinus: see p. 283 and Table 49.
n
Perirenal masses : see p. 292.
n
Adrenal glands : see p. 292.
266
10.2 Diffuse Renal Changes
Schmidt, Ultrasound © 2007 Thieme
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10.2 Diffuse Renal Changes
Overview (Table 47):
..............................................................................................................
Table 47.Diffuse renal changes
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Hypoechoic Hyperechoic
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Enlarged or normal-sized kidneys
Acute renal failure, transient renal
insufficiency
Acute bacterial interstitial nephritis
(pyelonephritis, p. 268)
Renal vein thrombosis (p. 268) Acute glomerulonephritis (p. 269)
Small or normal-sized kidneys
Hypoplastic kidney (p. 269) Chronic glomerulonephritis (p. 270)
Renal atrophy due to vascular
occlusive disease (p. 270)
Enlarged or Normal-Sized Kidneys with Decreased Echogenicity
..............................................................................................................
n
Acute renal failure or transient renal insufficiency (Fig. 379): Prerenal–cardio-
vascular or postrenal.
x
Sonographic findings:
– Parenchymal thickening with associated thinning of the CEC; renal sinus
echo
– Decreased echogenicity
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyy
Acute renal failure (hyperuricemia, sepsis, p. 268)
Diabetic nephropathy, early stage (see p. 269)
Renal myeloma, adrenal amyloidosis (p. 269),
gouty nephropathy
Diabetic nephropathy (p. 270)
Chronic pyelonephritis (p. 271)
Analgesic nephropathy (p. 271)
10
10
10
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Fig. 379 Transient renal insufficiency in
a patient with alcohol-related disease
and diarrhea: Enlarged hypoechoic kidneys with swollen parenchyma and loss
of corticomedullary differentiation.
Length = 170 mm!
267
10.2 Diffuse Renal Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
10
10
10
n
Acute bacterial interstitial nephritis = pyelonephritis (Fig. 380; emphysematous
pyelonephritis, see Fig.
x
Thickened, hypoechoic, hazy parenchyma with a thinned sinus echo. A rim of
fluid is often visible in the renal pelvis. Incipient abscess appears as a hypoechoic zone.
x
CDS: Perfusion defect with an increase in surrounding vascularity
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
n
Renal vein thrombosis (Fig. 381a, b):
x
Hazy, hypoechoic renal echo pattern
x
Evidence of venous thrombosis
x
Tumor thrombosis is common (see Fig. 393e, p. 275)
x
CDS: Veins not visualized. Absence of flow in the renal vein, reverse flow in
arteries with a high RI; see Table
397, p. 278; acute suppurative pyelitis, see Fig. 412, p. 286)
Fig. 380 Acute pyelonephritis: Large,
hypoechoic kidney with an obliterated
sinus echo and a rim of fluid in the renal
pelvis
30, p. 193.
b
a
Fig. 381a, b Renal vein thrombosis. a Acute renal vein thrombosis in septic
pyelonephritis: Enlarged kidney (K, cursors) with a hazy, hypoechoic structure
and patchy-streaky hypoechoic transformation of the central echo complex.
C = atypical cyst. b Spectral analysis shows an extremely high RI of 0.96
Enlarged or Normal-Sized Kidneys with Increased Echogenicity
..............................................................................................................
n
Acute renal failure:
x
With massive hyperuricemia (Fig. 280): echogenic parenchyma
x
With sepsis: large, echogenic kidneys
x
With diabetic nephropathy (Fig. 382a):
– Enlargement, sometimes massive
– Hyperechoic parenchyma
– Hypoechoic medullary pyramids
268