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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
19.2 Abnormal Findings
Schmidt, Ultrasound © 2007 Thieme
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ab
Fig. 640a, b a Parotid mixed tumor (TU). MAX = maxilla b Cystadenolymphoma
(Whartin tumor, cursors). Diagnosed by FNAB
n
Pleomorphic adenoma : may undergo malignant transformation
x
Smooth margins
x
Homogeneous
n
Cystadenolymphoma (Whartin tumor, Fig. 640b): more common entity; like
oncocytoma, is classified as a sialoma
x
Markedly hypoechoic, nonhomogeneous echo pattern
x
Smooth margins
x
Small cysts, may contain fine septations
n
Oncocytoma: rare
x
Uniformly hypoechoic
x
Smooth margins
n
Mucoepidermoid carcinoma: low-grade malignancy, the most common malig-
nant tumor in adults (approximately 50 % of malignant salivary gland tumors)
x
Very hypoechoic
x
Smooth margins
x
May contain cystic areas
n
Adenoid cystic carcinoma (older term: cylindroma): high-grade malignancy
marked by early infiltration of the facial nerve
x
Usually hypoechoic. Some lesions are heterogeneous or anechoic
x
Ill-defined margins
n
Metastases, malignant lymphoma (Fig. 641):
x
Hypoechoic round or scalloped mass
19
19
19
Major Salivary Glands
Major Salivary Glands
Major Salivary Glands
Fig. 641 Lymph node metastases (LN)
from bronchial carcinoma: very hypoechoic mass in the parotid gland (P).
MAN = mandibular echo with acoustic
shadow
429
19.2 Abnormal Findings
Schmidt, Ultrasound © 2007 Thieme
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19
19
19
Hyperechoic Changes
..............................................................................................................
n
Sialadenosis:
x
Frequently hyperechoic (due to diffuse fatty infiltration)
x
Bilateral symmetry
x
Painless enlargement
n
Lipoma, hemangioma, lymphangioma:
x
Hyperechoic
x
Lipoma with a feathery pattern; lymphangioma may have a cystic appearance
n
Sialolithiasis (salivary stone, Fig. 642) : presents clinically with swelling and acute
Major Salivary Glands
Major Salivary Glands
Major Salivary Glands
pain
x
Round or oval hyperechoic mass with an acoustic shadow, projected over the
duct
x
Duct obstruction; anechoic duct structure at least 1 mm wide
x
Rarely intraglandular, usually extraglandular with anteromedial extension into
the buccal mucosa
ab
Fig. 642a, b Sialolithiasis. a Abnormal anechoic duct structure. b Magnified view
with the scan plane positioned for greatest clarity: microliths (arrow) with a distal
acoustic shadow (S)
Evaluation and Further Testing
..............................................................................................................
n
Sonography: Diffuse and circumscribed salivary gland lesions can be clearly
visualized with a high-resolution transducer. Most lesions (benign tumors)
occur in the parotid gland.
x
Isoechoic diffuse swelling: usually viral parotitis
x
Hypoechoic swelling: usually bacterial sialadenitis
x
Circumscribed hypoechoic tumors: Ultrasound is of limited value for benign–
malignant differentiation
n
Further testing :
x
Circumscribed hypoechoic masses: fine-needle aspiration cytology and histology
x
Adenoid cystic carcinoma and carcinomas in adenomas: These malignancies
often present clinically with rapid growth and facial nerve palsy
– Critical: FNAB, surgical diagnosis
– Infiltrative growth is clearly demonstrated by CT.
– MRI cannot differentiate between benign and malignant lesions (but is
useful in the diagnosis of pleomorphic adenoma).
430
20.1 Normal Postoperative Changes
Schmidt, Ultrasound © 2007 Thieme
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20 Postoperative Ultrasound
20.1 Normal Postoperative Changes
n
The prior history (anamnesis) and follow-up history (catamnesis) can account for
almost all postoperative findings.
n
Therefore, always ask about previous operations, especially involving the abdomen (it is easy to overlook scars in the darkened ultrasound room).
n
The absence of organs should be noted and documented (e.g., previous cholecystectomy, Figs.
implant materials (Fig.
a
643 and 644). It is also easy to miss an aortic prosthesis and other
645).
20
20
20
Postoperative Ultrasound
Postoperative Ultrasound
Postoperative Ultrasound
Fig. 643a, b Status postcholecystectomy. a Hyperechoic mass in the gallbladder bed = normal postoperati ve
finding. b Anechoic mass (cursors) = postoperative seroma
Fig. 644 Metal clip following a cholecystectomy: high-amplitude echo
(arrow) with reverberations. Posterior
to the clip is the bile duct (BD).
PV = portal vein, VC = vena cava
Examples of Postoperative Anatomical Changes
..............................................................................................................
n
Scars and scar-tissue bands (Fig. 646): Surgical procedures on the liver, kidney,
and other organs leave scars. Scar tissue following ablative tumor surgery is particularly easy to recognize in a large parenchymatous organ like the liver. A scartissue band that is present for years or decades may cause significant local ana-
b
Fig. 645 Prosthesis in the iliac artery
(AIS-P)
431
20.1 Normal Postoperative Changes
Schmidt, Ultrasound © 2007 Thieme
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20
20
20
ab
Postoperative Ultrasound
Postoperative Ultrasound
Postoperative Ultrasound
Fig. 646a, b Postoperative scars. a Scars following laser-inducted tumor ablation
(LIT) of the liver: echogenic mass (arrows) with a hypoechoic halo and acoustic
shadow. b Scar-tissue band with an acoustic shadow (S) following a herniotomy.
P = peritoneal echo
tomic changes. An example is the displacement of the upper abdominal visceral
“packet” toward the left side that typically occurs after a partial gastrectomy or
other extensive upper abdominal surgery (nonvisualization of the displaced gallbladder or of the pancreas because of adhesions with overlying bowel).
n
Thoracic surgical procedures : Thoracic operations may also produce changes in
upper abdominal anatomy. Examples are upward displacement of the liver due
to right-sided phrenic nerve palsy and the impairment of respiratory organ mobility (e.g., by basal pleural adhesions). Generally in these cases the liver and pancreas cannot be visualized by ultrasound.
n
Scanning tips :
x
Define the liver and gallbladder in a high intercostal scan on the right side.
x
Define the pancreas after filling the stomach with fluid.
n
Organ transplants: typical pelvic location of the renal allograft with a denervated
and ectatic pyelocalyceal system (Fig.
!
Caution: Do not misinterpret as urinary obstruction.
647.).
Fig. 647 Renal allograft (K) in the right
lower abdomen. Arrows: ectatic fluidfilled pyelocalyceal system. C = renal
columns, MP = hypoechoic medullary
pyramids
n
Pneumobilia (Fig. 648): Air in the bile ducts is consistently present after the sur-
gical creation of a biliary–enteric anastomosis and is frequently present after
endoscopic papillotomy (complete sphincterotomy). It is considered a normal
finding in these settings.
432
20.1 Normal Postoperative Changes
Schmidt, Ultrasound © 2007 Thieme
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ab
Fig. 648a, b Pneumobilia. a Supine position: A hyperechoic air echo (arrows)
is visible in the most anterior portion of the bile duct (BD). b When the patient
is moved to left lateral decubitus, the air echo moves into the liver (arrow).
PV = portal vein
n
Cholangiectasis (asymptomatic dilatation confined to the extrahepatic bile ducts,
649): May result from cholecystectomy but is more commonly an age-related
Fig.
finding.
Fig. 649 Cholangiectasis: local variations in the caliber of the bile duct
(cursors, 12.2 and 4.8 mm), common
after cholecystectomy or with aging.
This pattern is not consistent with an
obstructive dilatation
20
20
20
Postoperative Ultrasound
Postoperative Ultrasound
Postoperative Ultrasound
n
Intestinal anastomoses and resections (Fig. 650): Accessible to ultrasound
evaluation only in selected cases, e.g., the restenosis of ileocolic anastomoses in
Crohn disease, hepato(choledocho)jejunostomy for carcinoma
Fig. 650 Hepaticojejunostomy. Notable postoperative findings: cutoff of the
anechoic hepatic duct (arrow) at the site
of the biliary–enteric anastomosis.
Chyme and bowel gas in the jejunal loop
produce a complex echo pattern
433
20.2 Postoperative Complications
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20
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20.2 Postoperative Complications
Abnormal Accumulations of Fluid (Fig. 651)
..............................................................................................................
n
The most effective role of ultrasound in the follow-up of abdominal operations is
for the detection or exclusion of abnormal accumulations of fluid.
n
Peripheral accumulations of fluid around parenchymatous organs, mesenteric collections, and fluid in the cul-de-sac are considered normal findings. Larger accumulations associated with clinical manifestations arouse suspicions of ascites,
intraperitoneal hemorrhage, pus, or leaks (bile, gastrointestinal, pancreas).
!
Caution: Avoid mistaking a harmless hematoma or seroma for an abscess.
Postoperative Ultrasound
Postoperative Ultrasound
Postoperative Ultrasound
b
a
cd
Fig. 651a–c Postoperative hematoma and hemorrhage. a, b Extraperitoneal and
intraperitoneal hematomas (cursors). The boundary line of the peritoneum (P) aids
in assessing their location. c, d Hematoma/hemorrhage following cholecystectomy: mass with low-level peripheral echoes (cursors) and a peripancreatic mass
(arrows)
Obstructed Tubular Systems
..............................................................................................................
n
The sonographic features of postoperative obstructions are the same as those of
other types. When a detailed history is taken (and with meticulous scanning technique), the cause of the obstruction can usually be identified. Some cases may
require investigation by ultrasound-guided percutaneous biopsy.
434
20.2 Postoperative Complications
Schmidt, Ultrasound © 2007 Thieme
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n
Biliary tract obstruction: presenting clinically with jaundice. Despite unfavorable
postoperative conditions, the course of the obstructed bile duct can usually be
traced with ultrasound. Scanning tip: intercosta l scans are helpful.
x
Possible causes:
– Postoperative pancreatitis
– Iatrogenic bile duct ligation
– Residual duct stone
x
Differentiation: can be differentiated from obstructive drug-induced jaundice or
toxic-septic jaundice by noting the presence or absence of obstructed intrahepatic bile ducts.
x
Signs suggestive of postoperative obstructive cholestasis :
– Double-walled, anechoic intrahepatic duct systems (bile ducts, portal venous
branches)
– Extrahepatic bile duct dilated to i 7mm
– Detection of the obstructing lesion
n
Ureteral obstruction (Fig. 652): most commonly results from urinary stas is (often
unilateral). May occur after tumor operations in the lower abdomen, or may be
secondary to retroperitoneal lymphadenopathy. In most cases the cause cannot
be established by ultrasound and the patient should be referred for CT scans.
Therapeutic options include stenting and drainage.
ab
Fig. 652a, b Postoperative ureteral stricture (U, arrow). a Loss of ureteral delineation in an area of echogenic scar tissue. AI = iliac artery, VI = iliac vein. b Ureteral
occlusion by an echogenic band (clip and suture material from previous intestinal
tumor surgery)
20
20
20
Postoperative Ultrasound
Postoperative Ultrasound
Postoperative Ultrasound
n
Bowel obstruction (partial or complete): Ultrasound is the simplest and best
modality for the early postoperative diagnosis of bowel obstruction. Generally
the cause is determined intraoperatively.
Abscess Formation (Circumscribed, Diffuse, Loculated, Fig. 653)
..............................................................................................................
n
The most common problem in postoperative patients is to determine the presence
or absence of a postoperative abscess. It is easy to make a sonographic diagnosis in
cases that present with local swelling, redness, pain, and a circumscribed liquid
mass. A more difficult problem is to detect or exclude an intra-abdominal abscess.
n
A diffuse or uncircumscribed abscess is difficult to distinguish from ascites or leakage. Many of these cases can be evaluated by ultrasound-guided needle aspiration
or drainage (see Fig.
73, p. 54).
435
20.2 Postoperative Complications
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20
20
20
Postoperative Ultrasound
Postoperative Ultrasound
Postoperative Ultrasound
ab
Fig. 653a–c Postoperative suppuration
and abscess formation. a After cholecystectomy: echogenic mass in the
gallbladder bed (GB-B) and hypoechoic
purulent fluid tracking around the
pancreas (FL, arrows). P = visceral
peritoneum. b Concomitant seepage
pleuropneumonia (same patient as in a).
c
Arterial and Venous Perfusion Disorders
..............................................................................................................
n
These conditions are difficult to assess with ultrasound, but CDS is rewarding in
some cases. The best modality is conventional angiography.
Foreign Bodies (Figs. 654 and 655)
..............................................................................................................
n
These include “forgotten” foreign objects, devices that have been implanted for
functional maintenance (e.g., drains), and endogenous bodies that are lost during
an operation and have to be located with ultrasound.
c After appendectomy: complex mass
(arrows, FL). HB = hepatic border
Fig. 654 Obstruction of the bile duct
by a tumor (T). Biliary drain (arrows):
typical pattern of echogenic double
walls with an anechoic lumen
436
Fig. 655 Gallstone lost at operation
(cholesterol stone, ST) and located by
ultrasound (lodged between the liver
and diaphragm). Treatment: endoscopic
cholecystectomy. B = bilioma, L = liver,
S = shadow
21.1 Principal Signs and Symptoms
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21 Search for Occult Tumors
21.1 Principal Signs and Symptoms
Overview (Table 78):
..............................................................................................................
Table 78.Clinical manifestations of tumors
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Weight loss
Pain
Fever, night sweats
Acute abdomen, bowel obstruction
Ascites, pleural effusion
Diarrhea, constipation
Thrombosis
Abnormal laboratory values (anemia, lymphocytosis, thrombocytosis, hemoblastosis,
hypercalcemia, elevated ESR)
Weight Loss
..............................................................................................................
n
Definition: unexplained loss of 10 % of the body weight in 6 months, often caused
by complex processes associated with a previously unknown neoplasm (metabolism, mass effects, obstructive stenosis, malnutrition, tumor metabolic products)
n
Occurrence:
x
Esophageal, gastric and duodenal tumors: weight loss due to eating difficulties
or impaired alimentary transit (Fig.
656; see also Fig. 537, p. 365)
21
21
21
Search for Occult Tumors
Search for Occult Tumors
Search for Occult Tumors
Fig. 656 Massive prestenotic dilatation
of the duodenal bulb and stomach.
Malignancy is evidenced by lymph node
metastases and small bowel wall thickening (see Fig. 538b, p. 366). The
patient presented clinically with vomiting and weight loss. Horizontal arrows:
peristaltic wave, vertical arrow: pylorus
x
Bowel tumors: weight loss usually due to advanced (hepatic) metastases
x
Gallbladder tumors: locally advanced tumor growth
x
Pancreatic carcinoma (Fig. 657): due to displacement, compression, or other
mass effects in the upper abdomen and maldigestion (ductal carcinoma with
duct obstruction in i 90 % of cases; see Fig.
x
High-grade non-Hodgkin lymphoma: disseminated disease (Fig. 658)
443, p. 305)
437
21.1 Principal Signs and Symptoms
Schmidt, Ultrasound © 2007 Thieme
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21
21
21
Fig. 658 High-grade non-Hodgkin
lymphoma. Lymph node metastases (L)
Search for Occult Tumors
Search for Occult Tumors
Search for Occult Tumors
Fig. 657 Malignant tumor (carcinoma, T) of the pancreas infiltrating
the hepatic artery. CT = celiac trunk,
BD = obstructed common bile duct
x
Hodgkin lymphoma, sarcoma: advanced tumor stage (Ann Arbor stage IIIB
are scattered throughout the upper abdomen, compressing (but not infiltrating)
the celiac vessels. The patient presented
clinically with severe weight loss,
cachexia
[subphrenic involvement or Stage IVB [disseminated disease])
x
Neuroendocrine tumors: advanced tumor stage
x
Metastatizing urologic or gynecologic tumors
Pain
..............................................................................................................
n
Definition: Tumors are most likely to cause visceral pain, which is dull, poorly
localized, and associated with autonomic effects (vasospasms, stretching of the
organ capsule, displacement and pressure via a viscerocutaneous or viscerovisceral reflex arc).
n
Occurrence:
x
Pancreatic carcinoma (Fig. 658)
x
Hepatic metastases
x
High-grade lymphoma (stage IE or IVB)
x
Retroperitoneal tumor (sarcoma)
Fever and Night Sweats
..............................................................................................................
n
Definition: Fever is a rise in body temperature above the normal range (i 37.5 h C,
or rectal temperature i 38.3 h C in children) lasting at least 3 weeks. Tumors are
associated with an undulating febrile pattern (see Unexplained Fever, p. 92).
n
Occurrence:
x
Abdominal or retroperitoneal tumors
x
Metastases
x
Malignant lymphoma, Hodgkin disease (see Fig. 658, p. 438; Fig. 132, p. 101)
Acute Abdomen, Bowel Obstruction
..............................................................................................................
n
Definition: Symptom complex that includes abdominal pain, muscular guarding,
and altered intestinal peristalsis
n
Occurrence:
x
Obstruction of the small or large intestine
x
Tumor hemorrhage
x
Peritoneal carcinomatosis
x
Acute portal vein thrombosis (neoplastic or paraneoplastic, see Fig. 116, p. 85)
438