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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3679_Библиотеки_им_академика_М_И_Перельмана
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Fig. 22.6 Interposition of left hepatic lobe separating the heart from the stomach. The left lobe of
the liver is positioned beneath the heart on the rest images ( a ). There is pronounced gastric refl ux
on the stress images ( b ), providing an opportunity to discern that the left hepatic lobe buffers this
source of potential artifact from the inferior myocardial wall ( c ). Note biliary prominence ( c ) and
absent gallbladder (known cholecystectomy) ( a , b ).
( a ) Rest raw projection images (Video 22.6a, frame 1),
99m
Tc sestamibi. ( b ) Stress raw projection
images (Video 22.6b, frame 1),
99m
Tc sestamibi. ( c ) Stress raw projection image (Video 22.6c,
frame 21),
99m
Tc sestamibi, left lobe of the liver ( orange box ), left bile duct ( green lines ), stomach
( yellow circle ), and heart for reference ( red oval ). ( d ) Coronal CT image through left lobe of the
liver ( orange box ), stomach ( yellow circle ), and heart ( red oval )
ab
See Video 22.6a See Video 22.6b
c d
See Video 22.6c
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ab
c
d
See Video 22.7a See Video 22.7b
See Video 22.7b
Fig. 22.7 Diffusely “hot” stomach wall characteristic of cirrhotic gastropathy. A 48-year-old
male presents with shortness of breath during pre-transplant evaluation. Note the “hot” gastric wall
with a relatively “cold” center; the gallbladder fi lls and there is splenomegaly ( a – c ). By CT, the
liver is shrunken but there is no ascites ( d ). The heart is normal.
( a ) Stress raw projection images (Video 22.7a, frame 1),
99m
Tc sestamibi. ( b ) Stress raw projection
image (Video 22.7b, frame 15),
99m
Tc sestamibi, stomach ( green outline ), gallbladder ( yellow box ),
heart for reference ( red oval ). ( c ) Stress raw projection image (Video 22.7b, frame 29),
99m
Tc ses-
tamibi, stomach ( green outline ), spleen ( blue box ), heart for reference ( red oval ). ( d ) Coronal CT
image through the liver and stomach ( green oval ), gallbladder ( yellow box ), and inferior tip of the
spleen ( blue box )
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Fig. 22.8 Diffusely “hot” stomach wall in cirrhotic gastropathy. Note how the intensity of gastric
activity exceeds that of the myocardium on both the rest ( a ) and the stress ( b , c ) raw data.
Interestingly, there is no signifi cant processing artifact on the adjacent myocardium; the heart is
normal ( d – f ). The 67-year-old male has a small liver, splenomegaly, and “cold” ascites ( a – c ).
( a ) Rest raw projection images (Video 22.8a, frame 1),
99m
Tc sestamibi. ( b ) Stress raw projection
images (Video 22.8b, frame 1),
99m
Tc sestamibi. ( c ) Stress raw projection image (Video 22.8c,
frame 18),
99m
Tc sestamibi, stomach ( green outline ), ascites ( pink lines ). ( d ) Stress/rest processed
SPECT images (SA, VLA, HLA). ( e ) Stress/rest processed SPECT images (SA), gastric activity
( green boxes ) on selected stress and rest images. ( f ) Stress and rest gated SPECT images
(Video 22.8d, frame 1) (SA, VLA, HLA)
ab
c
d
See Video 22.8a
See Video 22.8c
See Video 22.8b
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e
f
See Video 22.8d
Fig. 22.8 (continued)
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Fig. 22.9 “Railroad track” pattern of gastric wall uptake in cirrhosis. A 52-year-old male’s raw
data ( a , b ) show gastric wall uptake. There is separation of the “hot” gastric walls with a “cold”
central lumen ( a , b ); this pattern resembles railroad tracks ( c ). In contradistinction, intraluminal
duodenogastric refl ux would have a “hot” lumen. Note the distance between the heart and the “hot”
stomach; despite the markedly abnormal stomach, there is no artifactual effect on the normal processed and gated images ( e , f ). Note splenomegaly and a prominent left kidney ( a , b ); renal activity
may be prominent in the setting of liver disease (refer to Chap.
25 ).
( a ) Rest raw projection images (Video 22.9a, frame 1),
99m
Tc sestamibi. ( b ) Stress raw projection
images (Video 22.9b, frame 1),
99m
Tc sestamibi. ( c ) Stress raw projection image (Video 22.9c,
frame 16),
99m
Tc sestamibi, gastric walls ( blue lines ). ( d ) Stress raw projection image (Video 22.9c,
frame 42),
99m
Tc sestamibi, stomach ( blue outline ), distance between the heart and stomach
( red lines ). ( e ) Stress/rest processed SPECT images (SA, HLA, VLA) (without and with AC).
( f ) Stress and rest gated SPECT images (Video 22.9d, frame 1) (SA, VLA, HLA)
ab
cd
See Video 22.9a
See Video 22.9c See Video 22.9c
See Video 22.9b
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e
f
See Video 22.9d
Fig. 22.9 (continued)
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Fig. 22.10 Horizontal “hot” stomach. This patient has cirrhotic gastropathy. The “hot” stomach has
a horizontal lie ( a – d ). On careful inspection, the stomach activity is more related to the inferior wall
on the rest processed images but more closely related to the inferolateral wall on stress processed
images ( e , f ). Thus, slight differences in patient position during image acquisition can result in inter-
pretative challenges. The gastric activity creates a fi xed defect in the adjacent inferior myocardial
wall ( e , f ). Note that the liver is faintly perceptible, yet the gallbladder is well visualized ( a , c ).
( a ) Rest raw projection images (Video 22.10a, frame 1),
99m
Tc sestamibi. ( b ) Rest raw projection
image (Video 22.10b, frame 40),
99m
Tc sestamibi, stomach ( green box ), heart for reference ( red
oval ). ( c ) Stress raw projection images (Video 22.10c, frame 1),
99m
Tc sestamibi. ( d ) Stress raw
projection image (Video 22.10d, frame 45),
99m
Tc sestamibi, stomach ( green box ), heart for refer-
ence ( red oval ). ( e ) Stress/rest processed SPECT images (SA, HLA, VLA) (without and with AC),
gastric activity with adjacent inferior wall defect ( blue boxes on representative SA and VLA
images). ( f ) Stress and rest gated SPECT images (Video 22.10e, frame 1) (SA, VLA, HLA)
ab
cd
See Video 22.10a
See Video 22.10c See Video 22.10d
See Video 22.10b
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e
f
See Video 22.10e
Fig. 22.10 (continued)
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ab
c
d
e
f
See Video 22.11a See Video 22.11b
See Video 22.11c
See Video 22.11e
See Video 22.11d
See Video 22.11f
Fig. 22.11 Cirrhotic gastropathy with variable stomach distension. The “hot” stomach is collapsed on rest images (closely approximated “hot” walls with no discernible lumen) ( a – c ) yet quite
distended on stress images (“hot” walls widely separated by a “cold” center) ( d – g ). Note how
the ascites causes a well-demarcated “cold” region overlying the liver; this is better appreciated on
the “white-on-black” raw data ( c , f ). MRI ( h ) demonstrates ascites.
( a ) Rest “black-on-white” raw projection images (Video 22.11a, frame 1),
99m
Tc sestamibi. ( b ) Rest
“black-on-white” raw projection image (Video 22.11b, frame 37),
99m
Tc sestamibi, stomach ( green
outline ). ( c ) Rest “white-on- black” raw projection images (Video 22.11c, frame 1),
99m
Tc sesta-
mibi. ( d ) Stress “black-on-white” raw projection images (Video 22.11d, frame 1),
99m
Tc sestamibi.
( e ) Stress “black-on-white” raw projection image (Video 22.11e, frame 36),
99m
Tc sestamibi, stom-
ach ( green outline ). ( f ) Stress “white-on-black” raw projection images (Video 22.11f, frame 1),
99m
Tc sestamibi. ( g ) Stress “white-on-black” raw projection image (Video 22.11g, frame 27),
99m
Tc
sestamibi, stomach ( green outline ), ascites ( pink outlines ). ( h ) Coronal MRI through the liver,
ascites ( yellow ovals )
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ab
cd
See Video 22.12a See Video 22.12b
See Video 22.12c See Video 22.12d
Fig. 22.12 Collapsed “hot” stomach on rest, distended “cold” stomach on stress. In this fasting
patient, the “hot” stomach is collapsed at rest ( a , b ); the activity is more fundal in location, sug-
gesting duodenogastric refl ux as the etiology. On stress images ( c , d ), the stomach – from antrum
to fundus – appears quite distended and “cold” due to water ingestion; the “hot” activity at rest has
cleared with minimal residual gastric wall uptake evident. Note that the stomach appears “folded
on itself” in the distended state ( c , d ). On the processed images ( e ), gastric activity is problematic
only on rest images; there is an associated small inferior wall defect; since this region is normal on
the stress images, it is of no clinical consequence.
( a ) Rest raw projection images (Video 22.12a, frame 1),
99m
Tc sestamibi. ( b ) Rest raw projection
image (Video 22.12b, frame 31),
99m
Tc sestamibi, stomach activity ( green oval ), heart for reference
( red oval ). ( c ) Stress raw projection images (Video 22.12c, frame 1),
99m
Tc sestamibi. ( d ) Stress
raw projection image (Video 22.12d, frame 30),
99m
Tc sestamibi, stomach antrum ( blue outline ),
stomach fundus ( green outline ), overlapping stomach wall due to fold ( pink line ), heart for refer-
ence ( red oval ). ( e ) Stress/rest processed SPECT images (SA, HLA, VLA) (without and with AC)
Fig. 22.11 (continued)
gh
See Video 22.11g
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