Therapeutic Aspiration and Drainage

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5.1 Fine-Needle Aspiration Biopsy (FNAB)

Kidney:

Indications: Suspected tumor, parenchymal disease.

Caution: If hypernephroma is suspected, a preoperative needle biopsy is not

advised because of the risk of bleeding and inoculation metastasis.

Thyroid gland:

Indications: Cold nodule, cyst

Note: Often there is no need for local anesthesia.

Accumulations of fluid:

Indications: Pleural effusion, pericardial effusion, ascites, cyst, pseudocyst, hematoma, abscess.

Note: Percutaneous aspiration may be diagno stic or therapeutic.

In the therapeutic aspiration of a pleural effusion, no more than 1.5 L should be evacuated in one sitting. If the effusion is under negative pressure, aspirating even a small volume may cause a significant shift of the mediastinum (common with malignant effusions), and the procedure should therefore be terminated if the patient manifests chest pressure or a dry cough.

Other indications: Lesions of the retroperitoneum, chest wall, subpleural lung,

mediastinum, bone, gastrointestinal tract, soft tissues, etc.

Contraindications

..............................................................................................................

Refusal of informed consent or lack of patient cooperation

Severe coagulation disorder

Noninvasive diagnostic alternatives

Lack of therapeutic implications

Caution: Be careful when dealing with very vascular superficial lesions.

Interpretation

..............................................................................................................

General:

Focal lesions (i 2 cm in diameter) in parenchymal organs (e.g., liver, pancreas, retroperitoneum, adrenal gland) are diagnosed with approximately 90 % sensitivity and 100 % specificity.

Complications (excessive pain, peritoneal irritation, bleeding, infection, inoculation metastasis, bile leak, pneumothorax, death) are extremely rare when the puncture route is carefully selected and contraindications are noted.

Specific risks:

Liver: With superficial lesions, a hemangioma should be excluded with very high confidence because of the risk of bleeding.

Pancreas: Confirm a safe puncture route because of the risk of bowel injury.

Kidney: Apply rigorous patient selection criteria.

Pleura: When draining an effusion, discontinue at once if the patient complains of chest pressure or tightness or develops a dry cough, because of the risk of mediastinal displacement.

Interventional Ultrasound

5.2 Therapeutic Aspiration and Drainage

Preparations and Technique

..............................................................................................................

Prerequisites: Quick PT i 70 %, platelets i 100 000/mm

tor XIII) may be indicated in patients with a hematologic systemic disease. Obtain informed consent.

Setup (Fig. 77):

Skin prep, sterile drapes, local anesthesia, razor, scalpel blade

Drainage materials: Small-gauge catheters (F 8) are often adequate for cyst aspiration. Abscess drainage requires a larger (double-lumen) suction-irrigation catheter (F 14).

Interventional Ultrasound

Suture material (plus scissors and needle holder)

Dressing materials

. Factor analysis (e.g., fac-

Fig. 77 Materials for Seldinger drainage. 1a–c Puncture needle (a), stylet (b), and depth-setting lock screw (c). 2 Guidewire,

3 dilators, 4 pigtail catheter, F 8

(e.g., for cyst drainage)

Procedure for percutaneous drainage (Seldinger technique):

Define the target lesion and puncture route, and measure as for a diagnostic aspiration (Figs

Insert the needle, remove the stylet, and check the position of the needle tip

78, 79a). Make a stab incision with a scalpel blade.

echo (may be necessary to aspirate and instill saline solution). Introduce the guidewire and remove the puncture needle. Dilate the tract with graded dila-

abc

Fig. 78a–c Diagnostic and therapeutic aspiration. a B-mode image shows an anechoic pancreatic pseudocyst anterior to the pancreas (P). AO = aorta. b Longitudinal scan of the pseudocyst (Cy). c The angle of the puncture is carefully planned to bypass the stomach (arrow heads). Large arrow: needle tip echo

5.2 Therapeutic Aspiration and Drainage

abc

Fig. 79a–c Therapeutic catheter drainage. a Large, rounded, sharply circumscribed, intrasplenic cystic mass with fluctuating internal echoes on real-time examination. b The liquid mass was drained externally using Seldinger technique. The arrows indicate the catheter in place. c Follow-up scan several months after catheter drainage shows complete resolution of the cystic lesion, leaving a calcified scar. SP = spleen, CY = cystic lesion, S = acoustic shadow

tors, and introduce the drainage catheter (Fig. 79b). Remove the guidewire and check catheter position (may be done radiographically). Secure the catheter with sutures and apply a dressing.

Indications and Guidelines for Specific Lesions

..............................................................................................................

Pseudocysts (e.g., of the pancreas):

Therapeutic procedure: See Fig. 80).

Technique: See Figs. 78 and 81.

Interventional Ultrasound

Fig. 80a–c Algorithm for the management of pancreatic pseudocysts (after Schwerk)

5.2 Therapeutic Aspiration and Drainage

Fig. 81a–c Ultrasound-guided percutaneous external drainage of pancreatic pseudocysts (after Schwerk). a Transhepatic (or transgastric) fine-needle

Interventional Ultrasound

aspiration. AO = aorta, L = liver, P = pancreas. b External catheter drainage using Seldinger technique. The guidewire is advanced into the pseudocyst under sonographic guidance, avoiding the perforation of internal organs. c Transgastric external catheter drainage

Abscesses (of the liver or spleen, intra- or retroperitoneal, subphrenic):

The treatment of choice is repeated percutaneous drainage (Fig. 76) or therapeutic catheter drainage (Fig.

Note: Irrigate the abscess cavity with saline solution. Drains should be flushed

79).

once or twice daily to prevent clogging.

Primary symptomatic cysts:

By definition, these lesions are lined with potentially secretory epithelium.

If the contents reaccumulate after percutaneous drainage, the cyst should be surgically extirpated or evacuated by catheter drainage followed by the injection of pure alcohol (99.5 %). Catheter placement should be checked radiographically.

Percutaneous drainage may be combined with sclerotherapy for cysts of the liver, spleen, kidney, etc.

Empyema: Intrathoracic, gallbladder, ascites, pleural effusion, pericardial effusion.

Contraindications

..............................................................................................................

Refusal of informed consent or lack of patient cooperation

Coagulation disorder

Unsafe drainage route

Specific Types of Therapeutic Drainage

..............................................................................................................

Alcohol instillation:

Indications: Malignant tumors (e.g., malignant primary or secondary hepatic tumors), thyroid adenoma.

Prerequisites: Good visualization, solitary lesion, tumor I 5 cm.

Suprapubic bladder catheter:

Indication: Incontinence that necessitates long-term urinary diversion. Possible causes include outflow obstruction due to inoperable prostatic carcinoma.

In principle, suprapubic aspiration of a full bladder can be carried out after clinical palpation and percussion. Ultrasound-guided aspiration is recommended only when the bladder volume is small.

Percutaneous nephrostomy:

Indication: Ultrasound-guided puncture aided by fluoroscopy is appropriate for

renal pelvic dilatation that is clearly demonstrated by sonography.

5.2 Therapeutic Aspiration and Drainage

Technique: Using the Seldinger technique, a needle is passed into the dilated calyx under continuous sonographic guidance from a posterolateral approach, avoiding the vascularized renal medulla. The tract is dilated, and a pigtail catheter (F 5–8) is introduced.

Interpretation

..............................................................................................................

Pancreatic pseudocysts:

Success rate: 60–90 % depending on the location, size, and consistency of the pseudocyst (see Figs

Complications: Bleeding, septicemia, organ injuries in 5–10 % of cases. The com-

78 and 81).

plication rate can be lowered by finding a safe drainage route that avoids parenchymatous organs, gastrointestinal structures (Fig.

78c), and the costophrenic

angle.

Abscesses:

Success rate: 80–95 %

Complications: With a safe access route and proper instrumentation, the complication rate is approximately 10 % (sepsis, bleeding, pleural empyema, fistula formation).

Primary symptomatic cysts:

Success rate: i 95 %

Complication rate: I 5 % (infection, bleeding)

Empyema:

Success rate: 72–88 % with early diagnosis of pleural empyema

Complication rate: Low (bleeding from intercostal vessels)

Nephrostomy:

Success rate: 95 %

Complication rate: 5 % (bleeding, infection)

Interventional Ultrasound

6.1 Upper Abdominal Pain

6 Principal Signs and Symptoms

6.1 Upper Abdominal Pain

Basic Principles

..............................................................................................................

Principal signs and symptoms: Pain, fever, vomit ing, circulatory depression,

hematologic changes, muscular guarding (rigidity), occasional retention of stool

The differential diagno sis is reviewed in Table 9, where the possible diagnoses are listed in order of their frequency in the general hospital setting.

Table 9.Differential diagnosis of upper abdominal pain

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Principal Signs and Symptoms

Diagnosis Sonographic signs

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Common

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Acute cholecystitis (p. 63)

Biliary colic (p. 64) Stone echo, acoustic shadow, obstructed duct

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Less common

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Acute pancreatitis (p. 65)

Impaired gastric emptying (p. 70)

Myocardial infarction Echocardiography: circumscribed abnormality of wall motion

Pulmonary embolism (p. 67) Peripheral embolism: wedge-shaped hypoechoic area

Renal colic (p. 65) Obstructed, anechoic pyelocalyceal system; stone echo with

Hernia (p. 77) Hernia sac, gap in peritoneum, possible thickening of bowel

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Rare

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Perforated gastric or duodenal ulcer (p. 68)

Perforated gallbladder (p. 69)

Splenic infarction (p. 74) Usually wedge-shaped, hypoechoic parenchymal lesion

Renal vein thrombosis (p. 74)

Subphrenic abscess (p. 71) Nonhomogeneous mass with ill-defined margins located

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Thickened, three-layered wall; possible gallbladder hydrops

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Pancreatic enlargement; hypoechoic, hazy internal echo pattern, circumscribed hypoechoic lesions

Greatly distended, fluid-filled stomach with internal echoes

(thoracic sonography)

twinkling artifact

wall

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Detectable free air, possible wall thickening at the ulcer site

Wedge-shaped parenchymal lesion, absence of flow by CDS

Kidneys initially enlarged, then small; dilated veins

between the diaphragm and the liver or spleen

6.1 Upper Abdominal Pain

Table 9.Differential diagnosis of upper abdominal pain – continued

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Diagnosis Sonographic signs

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Cholangitis (p. 304, 331)

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Hypoechoic wall thickness, hypoechoic intraductal mass

Intraorgan bleeding (p. 72) Hypoechoic mass, usually with associated organ enlargement

Conditions that cannot be diagnosed with ultrasound

Common: Gastroenteritis, pleurisy Less common: Diabetic coma with pseudoperitonitis, uremia, thyrotoxicosis, Meckel diver-

ticulum, Boerhave syndrome Rare: Hemolytic crisis, hepatic porphyria (e.g., acute intermittent porphyria), Addisonian crisis, intoxication (lead, arsenic, mushroom, thallium), type I hypertriglyceridemia

Acute Cholecystitis (Figs. 82 and 83)

..............................................................................................................

See also Gallbladder, p. 334.

Clinical manifestations: Right upper abdominal pain radiating to the right

shoulder, fever, possible jaundice (if the edematous inflammatory changes involve the biliary tract). Anorexia; nausea; enlarged, tense, painful gallbladder that may be palpable (Murphy’s sign). Localized rigidity, meteorism, or diminished bowel sounds due to paralytic ileus may be noted.

Diagnosis:

History and physical examination

Laboratory findings: Leukocytosis, g-glutamate transferase (GGT) and alkaline phosphatase (AP) o, possible elevation of direct serum bilirubin, C-reactive protein (CRP) o

Sonography

Radiography: Plain abdominal radiograph for suspected emphysematous cholecystitis

Biliary scintigraphy if the gallbladder cannot be visualized.

Sonographic findings :

Tenderness to probe pressure over the gallbladder

Gallbladder wall is thickened, and three distinct layers are visible as a result of edema

Borders may be poorly demarcated from surroundings as a result of pericholecystitis

Gallbladder hydrops may occur with a painful, enlarged, incompressible gallbladder

Principal Signs and Symptoms

Fig. 82a, b Acute cholecystitis. The edematous wall of the gallbladder (GB) appears thickened and shows a distinct layered structure. L = liver

6.1 Upper Abdominal Pain

Fig. 83a, b Gallbladder hydrops in acute cholecystitis. The gallbladder (GB) is enlarged, tender to pressure, and is incompressible with the ultrasound probe.

Principal Signs and Symptoms

Arrows: shadowing stones (S). L = liver

Calculi can be detected in up to 95 % of cases.

Accuracy of sonographic diagnosis: Very high, especially when combined with

the clinical presentation and history, laboratory findings, and sonographic follow-ups. There is no need for additional imaging studies.

Biliary Colic (Fig. 84)

..............................................................................................................

Clinical manifestations: Episodes of severe, colicky pain due to gallbladder con-

tractions. The cause is a stone obstructing the bile ducts and raising the pressure within the gallbladder. The pain often occurs after meals and lasts for 1–4 hours (residual complaints may persist for 24 hours). Vomiting is common, and jaundice may occur with duct occlusion. Fever signifies a complication.

Diagnosis:

History: Many patients have a prior history of gallstones.

Laboratory tests may show signs of cholestasis with elevated bilirubin, GGT, and AP.

Sonography.

Sonographic findings :

Stone: Hyperechoic with an associated acoustic shadow.

Often difficult to define a stone within the bile duct.

Acoustic shadow may indicate the presence of a stone.

With an obstructed duct, look for a stone: – Common duct stone leads to ductal dilatation – Infundibular or cystic duct stone leads to gallbladder hydrops (marked gall-

bladder enlargement and tenderness).

– Prepapillary stones may obstruct the pancreatic duct and incite pancreatitis.

Fig. 84 Duct stone. The bile duct (BD) is obstructed. An acoustic shadow (S) indicates the presence of the intraductal stone (cursors). GB = gallbladder,

VC = vena cava

6.1 Upper Abdominal Pain

Accuracy of sonographic diagnosis: The cause of biliary colic can be diagnosed

sonographically with i 90 % accuracy. With atypical findings (small gallbladder), the diagnostic accuracy falls to 65 %. Additional imaging modalities are necessary only in exceptional cases (e.g., radiographs for distinguishing a porcelain gallbladder from gallstones).

Renal Colic (Figs. 85 and 86)

..............................................................................................................

Clinical manifestations : Unilateral pain that comes in characteristic waves, often

radiating to the groin. Nausea and vomiting. Reflex ileus may occur. Hematuria

Diagnosis: Sonography and urinalysis; may be supplemented by urography

Sonographic findings :

Obstructed, anechoic pyelocalyceal system.

The proximal ureter may be dilated, depending on the site of the outflow obstruction (stone, tumor, lymphadenopathy).

The twinkling artifact (see p. 283, 382) is helpful in detecting intrauteral stones and differentiating them from bowel gas.

Accuracy of sonographic diagnosis : The obstruction can be detected sonographi-

cally in up to 100 % of cases, and the obstructing lesion can be identified in approximately 85 % of cases. Additional imaging studies may be ordered as adjuncts.

Principal Signs and Symptoms

Fig. 85 Renal pelvic stone. The renal pelvis is hypoechoic and dilated. A stone with a high-amplitude echo (arrow) and posterior acoustic shadow

Fig. 86 Ureteral stone. The ureter (U) is occluded by a prevesical stone (arrow). An acoustic shadow (S) indicates the

presence of the stone. B = bladder (S) is visible at the ureteropelvic junction. K = kidney

Acute Pancreatitis (Figs. 87–89)

..............................................................................................................