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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
16.4 Female Genital Tract
Schmidt, Ultrasound © 2007 Thieme
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x
Endometriosis externa (endometriotic cysts of the ovary or fallopian tubes):
– Nonhomogeneous anechoic/hyperechoic mass due to intralesional hemor-
rhage
– CDS: absence of internal vessels
Evaluation and Further Testing
..............................................................................................................
n
Further testing : Additional gynecologic studies:
n
Note: Every indeterminate cystic ovarian mass warrants further investigation.
x
Transvaginal sonography
x
Fine-needle aspiration or surgery, if needed
16
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16
Urogenital Tract
Urogenital Tract
Urogenital Tract
399
17.1 Examination
Schmidt, Ultrasound © 2007 Thieme
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17 Thorax
Thorax
Thorax
Thorax
17.1 Examination
Scan Planes
..............................................................................................................
n
Two main scanning techniques are used in thoracic ultrasound: subcostal and
intercostal (Fig.
Fig. 596a, b a Subcostal scan: The liver serves as an acoustic window for the
transducer. b Intercostal scan. The transducer is oriented parallel to the ribs
n
Specific scan planes:
x
Transthoracic with intercostal transducer placement
x
Right and left subcostal
x
Supraclavicular and suprasternal
x
Substernal
x
High right and left flank scans
Sonographic Anatomy and Normal Findings
..............................................................................................................
n
Because ultrasound cannot penetrate aerated lung or the bony thorax, it can only
demonstrate lesions that are in direct contact with the pleura or chest wall (see
Figs.
605–608, p. 408, 409).
n
Interpretive criteria (Table 70):
596).
400
17.1 Examination
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Table 70.Criteria for evaluating lesions of the chest wall, pleura, and
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Chest wall Echogenicity (anechoic, hypoechoic, hyperechoic)
yyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyy
Pleura
yyyyyyyyyyyyyyyyyyyyyy
Lung parenchyma
Scanning tips
..............................................................................................................
n
lung parenchyma
Margins (smooth, irregular)
Shape (round, oval, changing)
Moving internal echoes on real-time observation
Presence or absence of intralesional vascularity by CDS
yyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Extent of effusion
Echogenicity (anechoic, hyperechoic)
Septations, fibrin strands
Pleural thickening, lung involvement
Pleural tumors
Moving internal echoes on real-time observation
yyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Echogenicity (hypoechoic, hyperechoic)
Internal echo pattern, echo texture (homogeneous, nonhomogeneous)
Margins (smooth, irregular)
Shape (round, oval, wedge-shaped)
Moving internal echoes on real-time observation
Presence or absence of intralesional vascularity by CDS
Examine the patient in the sitting position to supplement supine or semiupright
scans.
n
A 5.0 MHz transducer is generally best for defining chest wall lesions.
n
Position the transducer parallel to the ribs to avoid interference from rib shadows.
n
Use respiratory maneuvers to improve the visualization of peripheral areas.
n
Raise the arms to obtain a clear projection of lesions located below the scapulae.
Overview and Classification of Findings
..............................................................................................................
n
Pleura: The most common finding is pleural effusion. Sonography is the simplest
and most effective method for the detection of pleural effusion. It also permits the
further differentiation of epidiaphragmatic liquid masses.
n
Lung parenchyma: The most important sonographic finding is the presence of
nonaerated lung tissue.
n
Classification and overview:
x
Chest wall: see Table 71.
x
Pleura: see Table 72, p. 403.
x
Lung parenchyma: see Table 74, p. 408.
Thorax
Thorax
Thorax
401
17.2 Chest Wall
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17.2 Chest Wall
Overview (Table 71):
Thorax
Thorax
Thorax
..............................................................................................................
Table 71.Abnormal findings in the chest wall
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Hematoma (see below)
Abscess (see below)
Metastasis (see below)
Tumor infiltration (see below and p. 403)
Lipoma (see below)
Abnormal Findings
..............................................................................................................
n
Hematoma:
x
Variable echogenicity
x
Usually has smooth margins
x
Variable shape
x
May contain moving internal echoes
x
CDS: absence of vascularity
n
Abscess (Fig. 597):
x
Variable echogenicity, margins, and shape
x
Moving internal echoes may be seen in response to compression
x
CDS: absence of vascularity
Fig. 597 Hypoechoic confluent foci (A)
in the parasternal intercostal muscles.
Identified cytologically as a tuberculous
abscess.
C = cartilaginous rib, D = diaphragm
n
Metastases:
x
Usually hypoechoic
x
Smooth margins
x
Usually round
x
CDS: vascularity
n
Tumor infiltration (Fig. 598):
x
Usually hypoechoic
x
Irregular margins
x
Changes in shape
x
Transgresses organ boundaries
x
402
CDS: vascularity
17.3 Pleura
Schmidt, Ultrasound © 2007 Thieme
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Fig. 598 Hypoechoic tumor mass (TU)
with sites of rib destruction (arrows) and
soft-tissue infiltration. Plasmacytoma
n
Lipoma:
x
Hyperechoic
x
Smooth margins
x
Usually oval
x
CDS: sparse vascularity
Evaluation and Further Testing
..............................................................................................................
n
Clinical findings : frequently suggest the correct diagnosis, e.g. :
x
Hematoma p trauma
x
Abscess p inflammatory signs
x
Metastases p primary tumor
x
Lipoma p often an asymptomatic incidental finding
n
Further testing : Chest radiographs should always be obtained. Doubtful cases
should be investigated by ultrasound-guided fine-needle aspiration histology
and if necessary by CT.
x
With an abscess: eradicate by repetitive percutaneous drainage (see also p. 53)
and if necessary by catheter drainage
x
With hematomas and metastases: ultrasound follow-ups
17
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Thorax
Thorax
Thorax
17.3 Pleura
Overview (Table 72):
..............................................................................................................
Table 72.Abnormal findings in the pleura
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Transsudative effusion (p. 403)
Benign exudative effusion (p. 404)
Malignant exudative effusion (p. 404)
Pleural tumors (p. 405)
Abnormal Findings
..............................................................................................................
n
Transsudative effusion (Fig. 599):
x
Anechoic
x
Variable extent, usually small
x
Fine pleural line
403
17.3 Pleura
Schmidt, Ultrasound © 2007 Thieme
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Thorax
Thorax
Thorax
n
Benign exudative effusion (Figs. 600 and 601):
x
Anechoic, echogenic, or with fibrin strands
x
Frequent septations (Fig. 601)
x
Possible pleural thickening and concomitant lung involvement
x
Possible moving echoes
Fig. 600 Echogenic pleural effusion
with moving echoes in the real-time
examination. Thoracentesis yielded a
hemorrhagic exudate
n
Malignant exudative effusion (Figs. 602 and 603):
x
Like a benign exudative effusion (see above)
x
Detectable pleural tumors
Fig. 599 Anechoic pleural effusion (PE)
with associated compression atelectasis
(AT) and visualization of air-filled
bronchi (arrows) in a patient with heart
failure. LU = lung, L = liver
Fig. 601 Pleural effusion loculated by
fibrin strands, creating a honeycomb-like
appearance. Percutaneous needle aspiration is often unproductive with this type
of effusion. H = heart, L = liver
Fig. 602 Plaque-like tumor (TU) growing along the parietal pleura in a patient
with bronchial carcinoma. PE = pleural
404
effusion
17.3 Pleura
Schmidt, Ultrasound © 2007 Thieme
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Fig. 603 Nodular tumor mass (M)
abutting the visceral pleura in a patient
with bronchial carcinoma. PE = pleural
effusion, LU = lung, SP = spleen
n
Pleural tumors:
x
Variable shape (plaque-like, nodular)
x
Usually hypoechoic
x
Variable sites of occurrence (diaphragmatic, visceral, parietal)
x
Tumors i 1 cm in size or thickness are most likely malignant.
Evaluation and Further Testing
..............................................................................................................
n
Clinical features of pleural effusion: frequently suggest the correct diagnosis:
x
With a transsudative effusion: symptoms (dyspnea) depend on the extent of the
effusion
x
With an inflammatory etiology: signs of inflammation, pain with respiratory
excursions (pleurisy)
x
With a malignant etiology: frequent copious effusion with significant dyspnea
n
Types of pleural effusion (Table 73):
Table 73.Causes and types of pleural effusion
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Transsudate Exudate
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Inflammatory effusion
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Hemorrhagic effusion
Analysis of aspirate
Protein I 3g/dl Protein i 3 g/dl Protein j 3 g/dl
Hypocellular Hypercellular aspirate Bloody
LDH I 200 U/L Cholesterol i 60 mg/dl
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Causes (examples)
Heart failure Pleuropneumonia Hematothorax
Hepatic cirrhosis Pulmonary infarction Tumor hemorrhage
Hypoalbuminemia Collagen disease
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Characteristic sonographic findings
Anechoic Anechoic or internal echoes Hypoechoic with internal echoes
Fine pleural lines Septations, fibrin strands Possible sediment echoes
(snowstorm pattern)
Frequent bilateral
Accentuated pleural lines
parenchymal lesions
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Thorax
Thorax
Thorax
405
17.3 Pleura
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Table 73.Causes and types of pleural effusion – continued
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Exudate, continued
Thorax
Thorax
Thorax
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Chylous effusion
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Purulent effusion
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Malignant effusion
Analysis of aspirate
Protein i 3 g/dL Protein i 3 g/dL Protein i 3 g/dL
Milky, turbid Debris Possible tumor cells
Triglycerides i 110mg/dL
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Causes (examples)
Thoracic trauma Pleural empyema Peritoneal carcinomatosis
Malignant lymphoma Pyothorax Malignant mesothelioma
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Malignant lymphoma
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Characteristic sonographic findings
Hyperechoic with highamplitude internal echoes
Variable, may be
hyperechoic
Anechoic or internal echoes
(snowstorm pattern)
Absence of pleural
Septation, fibrin strands
movements
Pleural tumors
Parenchymal lesions
n
Further testing :
x
Chest radiographs should always be obtained.
x
Pleural effusion (Fig. 604): ultrasound-guided diagnostic aspiration of the
effusion. Diagnostic and therapeutic drainage, see p. 58
x
Suspected pleural tumor : may be investigated by pleural biopsy, ultrasoundguided percutaneous biopsy of the lesion, or thoracoscopy
406
Pleural effusion
Schmidt, Ultrasound © 2007 Thieme
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Cause unknown Probable known cause
17.3 Pleura
17
17
17
Thorax
Thorax
Thorax
Thoracic ultrasound with
pleural aspiration
Inconclusive
Ultrasound-guided
FNAB or
pleural punch biopsy
Inconclusive
Thoracoscopy with
biopsy
Inconclusive
Fig. 604 Diagnostic algorithm for pleural effusion (after Schwerk and Görg)
Unresponsive
to treatment
Observation
Operative treatment
if needed
Resolves with
treatment
407
17.4 Lung Parenchyma
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17.4 Lung Parenchyma
Overview (Table 74):
Thorax
Thorax
Thorax
..............................................................................................................
Table 74.Abnormal findings in the lung parenchyma
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Pulmonary tumors (p. 408)
Pulmonary metastases (p. 408)
Pulmonary abscess (p. 409)
Pneumonia (p. 409)
Compression atelectasis (p. 409)
Obstructive atelectasis (p. 410)
Pulmonary infarction (p. 410)
Abnormal Findings
..............................................................................................................
n
Lung tumors (Fig. 605):
x
Usually hypoechoic
x
Variable echo pattern
x
Variable shape and margins
x
Frequently transgress organ boundaries
x
CDS: vascularity
n
Pulmonary metastases (Fig. 606):
x
Usually hypoechoic
x
Homogeneous
x
Round with smooth margins
x
Not fixed to the chest wall on real-time observation
x
CDS: vascularity
Fig. 605 Peripheral hypoechoic bronchial carcinoma with irregular margins.
The tumor (TU) has infiltrated the
pleura (arrow) and chest wall. LU = lung
Fig. 606 Hypoechoic peripheral pulmonary metastases (M), which move
with respiratory excursions (patient had a
malignant pulmonary blastoma)
408