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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
12.2 Sonographic Findings
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Fig. 470 Multiple rounded, echogenic
splenic foci (S) due to diffuse metastasis
from a carcinoid
– Usually round with smooth margins
– Occasional intralesional calcifications
– CDS: usually sparse vascularity
x
Clinical findings: usually asymptomatic, often detected incidentally on ultrasound
n
Splenic calcification (Fig. 471):
x
Sonographic criteria:
– Predominantly echogenic focus
– Variable size, smooth margins; variable shape
– Posterior acoustic shadowing
– CDS: absence of vascularity
x
Clinical findings: usually asymptomatic. May result from or accompany inflammations, abscesses, infarctions, cysts, and metabolic diseases (calcification of
the splenic artery)
12
12
12
Spleen
Spleen
Spleen
Fig. 471 Multiple intrasplenic
calcifications in an asymptomatic
patient. S = acoustic shadows
Further Testing
..............................................................................................................
n
Splenomegaly: A complete workup may require laboratory tests, lymph node
histology, bone marrow histology, and liver histology.
n
Small spleen: laboratory parameters, Howell–Jolly bodies in stained blood,
99m
Tc colloid scintigraphy
n
Splenic cyst : see Fig. 472).
n
Splenic abscess :
x
Diagnostic fine-needle aspiration (see p. 53), repetitive percutaneous drainage,
catheter drainage (see p. 58), surgical options
319
12.2 Sonographic Findings
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
12
12
12
Spleen
Spleen
Spleen
Fig. 472 Therapeutic algorithm for a splenic cyst
x
With microabscesses (Fig. 462, p. 316): antimycotic therapy with sonographic
follow-up
n
Splenic lymphoma: sonographic follow-up. Isolated splenic lymphoma can be
evaluated by percutaneous biopsy, but the sonographic course is usually enough
to make a benign–malignant differentiation.
n
Splenic infarction: requires sonographic follow-up. Most cases undergo complete
resolution. Surgery may be necessary if complications arise (e.g., increasing liquefaction of the infarction, lack of regression, splenic rupture, infection) (Fig.
n
Splenic trauma :
x
CT is more reliable than ultrasound for grading the splenic injury.
x
Sonographic follow-up or surgery, depending on imaging findings and especially on clinical status
!
Caution: Look out for two-stage splenic rupture with subcapsular hemorrhage.
n
Splenic metastases:
x
Sonographic follow-up is usually sufficient, because of the presence of an inoperable tumor or end-stage disease.
x
With isolated splenic infiltration : fine-needle aspiration (see p. 53) or surgical
diagnosis
n
Hemangioma, splenoma: CT may be required. Sonographic follow-ups or surgical
diagnosis may be advised, depending on clinical findings. Often a definitive diagnosis is not made if the lesion remains unchanged over time.
n
Splenic calcification: Sonographic follow-up may be advised. If ultrasound con-
firms the diagnosis, there is no need for additional tests.
473).
320
12.2 Sonographic Findings
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Fig. 473 Sonographic manifestations, course, and complications of splenic
infarction (after Görg)
12
12
12
Spleen
Spleen
Spleen
321
13.1 Examination
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
13
13
13
13 Bile Ducts
13.1 Examination
Bile Ducts
Bile Ducts
Bile Ducts
Scan Planes
..............................................................................................................
n
Intercostal scan, extended right intercostal scan, porta hepatis scan (see p. 33)
n
Subcostal oblique scan on the right side (see p. 22).
Sonographic Anatomy and Normal Findings
..............................................................................................................
n
With careful scrutiny, the intrahepatic bile ducts can be identified as fine anechoic
bands running anterior to the portal venous branches (except the left anterior segmental branch). The hepatic artery runs between or posterior to the intrahepatic
ducts.
n
The right and left hepatic ducts unite at the porta hepatis to form the common
hepatic duct.
n
The cystic duct is very difficult to visualize because of its tortuous course.
n
In most cases the common bile duct and pancreatic duct empty into the duodenum by a common opening. (Since the termination of the cystic duct generally
cannot be identified with ultrasound, the common hepatic duct and common
bile duct are usually referred to collectively as “the bile duct,” Figs
n
Normal dimensions : The extrahepatic duct is I 7 mm in diameter, depending on
age.
474 and 475.)
Fig. 474a Topographic anatomy of the gallbladder and biliary tract
322
13.1 Examination
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Fig. 474b Topographic anatomy of the gallbladder and biliary tract
Fig. 475 ERCP demonstrates the descending, prepapillary (common) course
of the bile duct and pancreatic duct in
the head of the pancreas
13
13
13
Bile Ducts
Bile Ducts
Bile Ducts
Scanning Protocol
..............................................................................................................
n
Transducer: 3.5–5.0 MHz.
n
The patient is scanned early in the morning in a fasting state.
n
Use the supine position for scanning the prepapillary bile duct; use left lateral
decubitus and deep inspiration for scanning the upper two-thirds of the bile duct.
n
A parasagittal upper abdominal longitudinal scan is best for evaluating the prepapillary segment of the bile duct (see Fig.
n
A semiupright position is occasionally helpful in the detection of prepapillary
stones.
n
Scanning tip: Carefully controlled compression of the abdominal fat and bowel
gas with a small-footprint transducer will generally permit good imaging of the
distal bile duct and its termination in the duodenum (Fig.
84, p. 64).
476).
323
13.1 Examination
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
13
13
13
a b
Bile Ducts
Bile Ducts
Bile Ducts
c
Fig. 476a–c Intra- and extrahepatic
course of the bile duct (BD) anterior to
the proper hepatic artery (A, arrow, cut
transversely by the scan), the portal vein
(PV, cut obliquely by the scan), and the
inferior vena cava (VC, cut longitudinally
by the scan). Paramedian upper abdominal longitudinal scan on the right
side. a B-mode image. b Correlative
diagram. c CDS. L = liver, P = pancreas
Overview and Classification of Findings
..............................................................................................................
n
Incidental findings in the biliary tract are rare because clinical manifestations will
usually prompt a specific ultrasound examination of that region. Thus, the sonograms in this chapter do not illustrate findings that correlate with a clinical presentation of “jaundice” or “cholestasis” (jaundice is reviewed on pp. 139–149).
n
Most abnormal findings are characterized by circumscribed or diffuse biliary stasis. It is rare to encounter a nonobstructive biliary tract lesion.
n
Echogenic structures projected into the liver or biliary tract may represent stones,
calcifications, vascular calcification, abscesses, clots, or an echogenic ligamentum
teres. Biliary sludge is apt to be mistaken for an intraluminal tumor.
n
Classification and overview:
x
Intrahepatic duct changes: see Table 55, p. 325.
x
Extrahepatic duct changes: see Table 56, p. 330.
n
Typical duct changes in:
x
Biliary cysts, liver cysts: Biliary cysts communicate with the biliary system. They
contain biliary fluid and are therefore susceptible to stone formation (see
Fig.
478a–c, p. 326). “Liver cysts” usually originate from the biliary tract but
do not communicate with the bile ducts and therefore contain serous fluid
rather than bile.
Sclerosing cholangitis, biliary cirrhosis : Despite cholestasis, primary biliary
cirrhosis is not associated with bile duct changes (unlike primary sclerosing
cholangitis, it affects only canaliculi and does not affect larger bile ducts).
x
Duct stones : Intraductal stones are not necessarily associated with cholestasis
or ductal dilatation.
324
13.2 Intrahepatic Ductal Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
13.2 Intrahepatic Ductal Changes
Overview (Table 55):
..............................................................................................................
Table 55.Intrahepatic duct changes
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Anechoic or hypoechoic Echogenic or sonodense
yyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyy
Biliary cysts, Caroli syndrome (p. 326)
Sclerosing cholangitis (p. 327) Pneumobilia (p. 330)
Parasites (p. 328)
Papillomatosis, papillomatous carcinoma (p. 328)
Intrahepatic bile duct carcinoma (p. 328)
Compression or infiltration by metastases (p. 329)
Anechoic or Hypoechoic Changes
..............................................................................................................
n
Ductal dilatation: The dilated duct and associated portal vein branch appear as
anechoic tramlines. Generally the bile duct lies anterior and the portal vein branch
is posterior.
x
Exception: With the anterior and posterior branches of the left main branch of
the portal vein, the bile duct is posterior to the anterior branch and anterior to
the posterior branch. Doubts can be resolved by CDS (Fig.
yyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyy
Duct stones (p. 330)
477).
13
13
13
Bile Ducts
Bile Ducts
Bile Ducts
ab
Fig. 477a, b Intrahepatic bile duct dilatation secondary to a long-standing
elevation of biliary pressure. a B-mode image: dilated intrahepatic duct branch in
segment II and an accompanying anterior portal vessel, also an expanded bile duct
branch in segment III. b CDS: The left main branch of the portal vein is encoded in
red. CDS (with spectral analysis if necessary) can positively distinguish between a
portal venous branch, an artery, and a bile duct (BD)
325
13.2 Intrahepatic Ductal Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
13
13
13
n
Biliary cysts (Caroli syndrome, Fig. 478):
x
Circumscribed anechoic ductal dilatation
x
Possible hyperechoic stone with a distal acoustic shadow
Bile Ducts
Bile Ducts
Bile Ducts
ab
Fig. 478a–c Caroli syndrome (detected
incidentally in a patient with iritis).
a Cystic dilatation of intrahepatic bile
duct with a peripheral echogenic zone
and distal acoustic shadowing.
b Scan after operative treatment shows
regression of cholestasis with a persistent echogenic stone casting a partial
shadow. c ERC image: cystic dilatation
of bile ducts including the cystic duct,
with partial filling defects caused by
c
intraductal stones
326
13.2 Intrahepatic Ductal Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
n
Sclerosing cholangitis (Fig. 479):
x
Irregularly dilated bile ducts with caliber variations
x
Stenoses
x
Broadened, fragmented portal tracts extending toward the periphery
x
Accentuated arteries (between the portal branch and bile duct)
b
a
13
13
13
Bile Ducts
Bile Ducts
Bile Ducts
Fig. 479a–c Chronic sclerosing
cholangitis. a Wall-thickened common
bile duct (1). b Caliber irregularities in
intrahepatic bile ducts (2) and sludge (3).
c Corresponding retrograde cholangiogram: segmental stenoses and prestenotic dilatation
c
327
13.2 Intrahepatic Ductal Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
13
13
13
n
Parasites (in order of frequency) : ascarids, Echinococcus alveolaris, liver fluke
n
Note: The overall incidence of biliary parasites is very low.
n
Biliary papillomatosis, papillomatous carcinoma (Fig. 480):
x
Lobular, polypoid intraluminal mass
x
Dilated intrahepatic (and extrahepatic) bile ducts
Bile Ducts
Bile Ducts
Bile Ducts
n
Note: Papillomatosis is rare. The prognosis is poor because of the high potential
for recurrence and malignant change. Liver transplantation may be required.
ab
Fig. 480a, b Papillomatous bile duct carcinoma. a Tumor mass in the left
hepatic duct (LHD), appearing isoechoic to liver parenchyma. Arrow: biliary drain.
b CDS: tumor ingrowth into the bile duct (BD). There are practically no intratumoral vessels. PV = portal vein, GB = gallbladder
n
Intrahepatic bile duct carcinoma (Fig. 481):
x
Circumscribed, anechoic area of ductal dilatation
x
Contour cutoff
x
Often a tumor is not directly visualized but is evidenced by the hypoechoic
transformation of proximal liver segments
x
Pericanalicular tumor spread
328