Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5789_Библиотеки_им_академика_М_И_Перельмана.pdf
ANSWERS
CASE 27
Pulmonary Sequestration
1. A, B, C, and D
2. D
pleural effusions are also known complications. Differential
diagnoses include an intrathoracic mass such as congenital cystic adenomatoid malformation and congenital diaphragmatic
hernia.
3. D
4. A
References
Dhingsa R, Coakley FV, Albanese CT, et al: Prenatal sonography and MR
imaging of pulmonary sequestration. AJR Am J Roentgenol 2003; 180(2).
443-437.
http://www.ncbi.nlm.nih.gov/pubmed/12540448 (Accessed on June 5,
2012.)
Hernanz-Schulman M, Stein SM, Neblett WW, et al: Pulmonary sequestra-
tion: diagnosis with color Doppler sonography and new theory of associ-
ated hydrothorax. Radiology 1991; 180(3):817-821.
http://www.ncbi.nlm.nih.gov/pubmed/1871300 (Accessed on June 5, 2012.)
Felker RE, Tonkin IL: Imaging of pulmonary sequestration. AJR Am J Roent-
genol 1990; 154(2):241-249.
http://www.ncbi.nlm.nih.gov/pubmed/2105007 (Accessed on June 5, 2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, p 426.
Comment
Differential Diagnosis
Pulmonary sequestration is diagnosed when a portion of the
lung receives systemic rather than pulmonary arterial supply
and is separated from the tracheobronchial tree. There are two
subtypes:
1. Intralobar—sequestration is contained within normal
pleura. Because this type of sequestration is normally
found in infants older than 2 months, some authors believe
that it is an acquired entity. It is associated with brosis and
chronic inammation.
2. Extralobar—sequestration is contained within its own
pleura. Usually this condition is diagnosed prenatally. Infection and congestive heart failure are the most common
associations with this disorder.
Sequestration should be included in the differential diagnosis of any infant with congestive heart failure and suspected
pneumonia or atelectasis. Lobar emphysema, hemothorax, and
Ultrasound Findings
Prenatal ultrasound shows a supradiaphragmatic or infradiaphragmatic hyperechoic mass, usually on the left side (Figures
A and B). Mediastinal and cardiac shift results if the sequestration is large. In some cases, as the fetus grows, the sequestration
becomes relatively smaller. The diagnosis should be suspected
in any fetus with a lung mass, especially when hydrothorax is
present. Blood ow may be evident on color Doppler imaging,
and in some cases the systemic arterial supply may be visible
from the aorta, which is the usual supply (Figures A and B).
MRI may be useful to dene better the location of the mass,
any associated pleural effusions, and systemic arterial supply
(Figure C).
Extralobar sequestrations may be diagnosed prenatally
between the lower lobe and the hemidiaphragm, surrounding the diaphragm or lung in the pleural or pericardial space,
and in the retroperitoneum. Most occur on the left side. More
recently, there have been cases of pulmonary sequestration
with elements of cystic adenomatoid malformation or congenital pulmonary airway malformation. These have been called
hybrid lesions.
Prognosis and Management
Perinatal mortality of a fetus with an extralobar sequestration
is rare. These cases have an excellent prognosis, frequently
with spontaneous regression. However, tension hydrothorax
can develop secondarily from uid secreted by the mass. This
condition can cause vena caval obstruction or cardiac compression leading to hydrops fetalis. Postnatal surgery is usually
necessary for treatment of sequestration.
Acknowledgment
Special thanks are extended to Jonathan Kuo, MD, for his contribution to preparing this case.
56
CASE 28
A
D
History: A 30-year-old woman with a previously inserted
T-shaped intrauterine contraceptive device (IUCD) presents
with heavy menstrual ow.
1. What is the most likely cause of the patient’s heavy menstrual ow?
A. Endometrial cancer
B. T-shaped IUCD embedded in the uterine wall
C. Endometritis
D. Submucosal broid
2. What is the role of ultrasound in the evaluation of an
IUCD?
A. To evaluate the endometrial cavity for the correct size
IUCD
B
B. To evaluate the length of the cervix for the correct size
IUCD
C. To evaluate for the presence and location of an IUCD
D. To measure the endometrial lining
3. If the string of an IUCD is not identied on physical exami-
nation, which of the following is not a serious consideration?
A. The string has just pulled back into the cervical or uter-
ine canal.
B. The IUCD has been expelled with the string.
C. The IUCD has perforated the wall, and the string
has been pulled up into the uterine canal or into the
myometrium.
D. The string fell off the IUCD.
4. What is the most common complication of an IUCD?
A. Infection
B. Pregnancy
C. Hemorrhage
C
D. Urinary frequency
57
ANSWERS
CASE 28
Intrauterine Contraceptive Device
1. B
2. C
3. D
4. A
References
Boortz HE, Margolis DJA, Ragavendra M, et al: Migration of intrauterine
devices: radiologic ndings and implications for patient care. Radiographics 2012; 32:335-352.
http://www.ncbi.nlm.nih.gov/pubmed/22411936 (Accessed on June 27,
2012.)
Grimes DA, Jones KP, Knutson CC, et al: New developments in intrauterine
contraception. Association of Reproductive Health Professionals ARHP
Clinical Proceedings September 2004, pp 1-20.
Shipp TD, Bromley B, Benacerraf BR: The width of the uterine cavity is nar-
rower in patients with an embedded intrauterine device (IUD) compared
to a normally positioned IUD. J Ultrasound Med 2010; 29(10):1453-1456.
http://www.ncbi.nlm.nih.gov/pubmed/20876899 (Accessed on June 5,
2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 544-549.
Comment
General Background of Intrauterine
Contraceptive Devices
IUCDs have been used since the early 1900s to prevent pregnancy (Figures A to D). Since then, the devices have been
steadily rened, and today many types are available. The two
most common types of IUCD in the United States are the
ParaGard IUCD and the Mirena IUCD. Visualization of the
newer Mirena IUCD is most challenging. Three-dimensional
ultrasound imaging is most helpful. IUCDs are better suited
for older women who have already been pregnant. Younger
users of IUCDs experience higher pregnancy rates and more
expulsions, and they have the devices removed more frequently for medical reasons. Contraindications to use of an
IUCD include pregnancy, a history of pelvic inammatory
disease, undiagnosed vaginal bleeding, uterine anomalies, and
large broid tumors. IUCDs have undergone a resurgence in
the United States because they are being used for contraception and the treatment of menorrhagia.
combination of both. A Copper 7 IUCD has a long arm of
wrapped copper and a small arm of plastic in transaxial view in
the upper body. The metal wrapping exhibits a “reverberation
artifact”—a series of parallel lines that become weaker from
the IUCD posteriorly when the IUCD is parallel to the ultrasound beam. The plastic tubing appears as two parallel lines,
entrance and exit echos.
Ultrasound Imaging of Intrauterine Contraceptive
Device Position
Ultrasound is very accurate in detecting an IUCD when it is
correctly positioned. When the uterus is normal and there is
no distortion of the endometrial canal, the IUCD has a midline position. Fibroids may change the position of the uterine
cavity so that the IUCD appears to be partially perforating
the uterine wall. Perforations have been more common when
the cavity is thinner. One of the most common clinical uses
of ultrasound in the evaluation of IUCDs is to determine
whether the IUCD is still present within the uterus when the
string is no longer present on pelvic examination. Because of
the potential for expulsion and for perforation (Figure A), failure to detect a string within the vagina or seeing too much
string (Figure B) often leads to an ultrasound examination.
When clinical symptoms make perforation likely, a negative
uterine study does not entirely rule out perforation, and a plain
anteroposterior radiograph of the pelvis may be obtained to
detect the perforated radiopaque IUCD.
Complications of Intrauterine Contraceptive
Devices
IUCDs are associated with complications. Infections are the
most common complications (Figures C and D); unexpected
pregnancies also occur. Although infections typically are bacterial, they may be fungal, such as actinomycosis. Expulsion
may also occur. If a pregnancy occurs after implantation of
an IUCD, ultrasound is indicated to detect whether it is still
present. The IUCD does not create a risk to the pregnancy
because it is in the endometrial cavity and is not within the
chorionic sac. However, if on physical examination the string
is still projecting into the vagina, the cervical plug will not
form, and there is a potential for an ascending infection. The
IUCD should be removed, often under ultrasound guidance.
Ultrasound Imaging Characteristics
of Intrauterine Contraceptive Devices
IUCDs have many different appearances on ultrasound. They
are composed of thin plastic tubing, metal wrapping, or a
58
CASE 29
History: A patient has a routine second-trimester ultrasound scan with a question of a cystic structure in the fetal
abdomen.
1. What are potential causes of upper abdominal cystic struc-
tures in the fetus? (Choose all that apply.)
A. Enlarged fetal stomach
B. Enlarged duodenum
C. Gastric duplication cyst
D. Esophageal duplication cyst
E. Pericardial cyst
2. What is a potential cause for not identifying the fetal
stomach?
A. Esophageal atresia
B. Duodenal atresia
C. Jejunal atresia
D. Ileal atresia
3. If an echogenic structure is identied within the lumen,
what could this indicate?
A. Pseudomass
B. Choledochal cyst
C. Duodenal atresia
D. Annular pancreas
4. At what gestational age can the fetal stomach rst be
identied?
A. 9 weeks
B. 15 weeks
C. 19 weeks
D. 21 weeks
59
ANSWERS
CASE 29
Enlarged Fetal Stomach
1. A, B, and C
2. A
3. A
4. A
References
Bonin B, Gruslin A, Simpson NA, et al: Second trimester prenatal diag-
nosis of congenital gastric outlet obstruction. J Ultrasound Med 1998;
17(6):403-406.
http://www.ncbi.nlm.nih.gov/pubmed/9623481 (Accessed on June 5, 2012.)
Wax JR, Hamilton T, Cartin A, et al: Congenital jejunal and ileal atresia: natu-
ral prenatal sonographic history and association with neonatal outcome.
J Ultrasound Med 2006; 25(3):337-342.
http://www.ncbi.nlm.nih.gov/pubmed/16495494 (Accessed on June 5,
2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 433-440.
Comment
Differential Diagnosis
The differential diagnosis of an anechoic cystic structure in the
upper abdomen includes a normal or enlarged fetal stomach,
gastric duplication cyst, choledochal cyst, and ovarian cyst. An
enlarged stomach is seen with duodenal atresia or any potential
obstruction of the duodenum such as Ladd bands or annular
pancreas. The fetal stomach can be identied on ultrasound at
9 weeks’ gestation. The characteristic morphology is shown at
14 weeks.
Ultrasound Findings
The stomach is usually identied in the left upper quadrant as
a uid-lled anechoic structure. If the position of the stomach
is difcult to determine or obviously on the right, a search for
other anatomic anomalies should be undertaken, specically,
cardiac anomalies because of the high association with cardiac
disorders. If the stomach is midline, this may be associated
with heterotaxia syndrome and major cardiac malformation.
If the stomach appears to be residing in the chest, this likely
represents a congenital diaphragmatic hernia.
Absence of the fetal stomach may be secondary to a multitude of causes, including but not limited to oligohydramnios,
problems with swallowing (neurogenic), or tracheoesophageal
stula. Most commonly with a tracheoesophageal stula, there
is a distal communication between the trachea and the distal
esophagus that connects to the stomach and as such a small
stomach may be identied with this entity. If no stomach is
identied and esophageal atresia is suspected, a search for
other abnormalities or other syndromes should be undertaken.
Finally, the fetal stomach may be displaced by an enlarged
abdominal mass, and in such cases the mass is the primary
abnormality and not absence of the fetal stomach.
Prognosis and Management
Enlargement of the fetal stomach (see Figure) has been associated with duodenal atresia when occurring with an enlarged
duodenum; however, it was also shown to be present in 5 of 15
cases of jejunal or jejunoileal atresia in a single-center, 10-year
retrospective review. There have been a few case reports of
enlarged fetal stomach manifesting as the only abnormality on
fetal ultrasound associated with a postnatal diagnosis of pyloric
stenosis. If duodenal atresia is associated with a chromosomal
abnormality, such as trisomy 21 (which has the highest association), a comprehensive fetal ultrasound survey should be
undertaken and genetic karyotyping should be considered.
Acknowledgment
Special thanks are extended to Vishal Sidhar, MD, and Simran
Sekhon, MD, for their contribution to preparing this case.
60
History: An asymptomatic woman with a second-trimester
pregnancy undergoes ultrasound.
1. What is the most likely diagnosis of the images of the right
foot?
A. Osteogenesis imperfecta
B. Clubfoot
C. Rocker-bottom foot
D. Pes planus
2. What is an extrinsic cause of this abnormal ankle-foot
relationship?
A. Amniotic sheet
B. Polyhydramnios
C. Oligohydramnios
D. Cytomegalovirus infection
A
B
3. What percentage of cases are bilateral?
A. Slightly more than 50%
B. Slightly more than 10%
C. Slightly more than 85%
D. Less than 5%
4. What is the most common cause of the abnormal relationship of the foot to the lower leg?
A. Trisomy 18
B. Trisomy 13
C. Idiopathic
D. Pierre Robin syndrome
ANSWERS
1. B
2. C
3. A
4. C
References
Hashimoto BE, Filly RA, Callen PW: Sonographic diagnosis of clubfoot in
utero. J Ultrasound Med 5 1986; 2:81-83.
http://www.ncbi.nlm.nih.gov/pubmed/3514941 (Accessed on June 5, 2012.)
Mammen L, Benson C: Outcome of fetuses with clubfeet diagnosed by
prenatal sonography. J Ultrasound Med 2004; 23(4):497-500.
http://www.ncbi.nlm.nih.gov/pubmed/15098867 (Accessed on June 5,
2012.)
Shipp TD, Benacerraf BR: The signicance of prenatally identied
isolated clubfoot: is amniocentesis indicated? Am J Obstet Gynecol 1998;
178(3):600-602.
http://www.ncbi.nlm.nih.gov/pubmed/9539532 (Accessed on June 5, 2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 480-482.
Comment
Incidence of Clubfoot
Clubfoot is a common congenital anomaly that occurs bilaterally in slightly more than 50% of cases. Many cases are familial,
and the risk is 25% for the fetus if the parent has a clubfoot.
Although the most common cause is idiopathic, possible associated abnormalities warrant a careful search with prenatal
ultrasound when clubfoot is detected.
fails to detect other malformations, the incidence of a karyotype abnormality is 6%. The rates for aneuploidy have been
found to be similar whether clubfoot is unilateral or bilateral.
Clubfoot and Other Associated Anomalies
In addition to chromosomal anomalies, clubfoot deformity is
associated with other malformations in 10% of cases. Cleft lip
and palate, micrognathia, facial deformities, congenital heart
disease, and hip dislocations are among the associated anomalies. Neurologic abnormalities associated with clubfoot include
meningomyelocele and hydrocephalus. Numerous congenital
syndromes and musculoskeletal disorders include clubfoot in
their spectrum of anomalies: Gordon syndrome (camptodactyly and cleft palate), distal arthrogryposis (xated hands and
feet), nail-patella syndrome, muscular dystrophies, and Pierre
Robin syndrome (congenital heart disease). Musculoskeletal
anomalies besides clubbed feet, neural tube defects, and cardiovascular anomalies have been found to be more common in
fetuses with bilateral clubbed feet than in fetuses with unilateral
deformity. Extrinsic causes can also lead to clubfoot deformity,
including oligohydramnios and amniotic band syndrome.
Ultrasound Appearance of Clubfoot
The ultrasound appearance relies on an unusual conguration
between the foot and the lower leg (Figures A and B). Once
this is seen, the other extremities should be carefully evaluated
for bilaterality and clubhands. The more the limbs are affected,
the greater is the possibility of the presence of a congenital
syndrome or a musculoskeletal disorder.
Clubfoot and Chromosomal Anomalies
Clubfoot is associated with chromosomal anomalies such as
trisomy 13 and trisomy 18. Even if the prenatal ultrasound scan
CASE 31
D
A
fetus undergoes imaging (Figures A and B).
1. What should be included in the differential diagnosis of
the abdominal anterior cysts in the two presented fetuses?
(Choose all that apply.)
A. Mesenteric cyst
B. Ovarian cyst
C. Omental cyst
D. Enteric duplication cyst
2. How is a meconium pseudocyst formed?
A. From walled-off complicated ascites
B. From walled-off simple ascites
C. From a ruptured mesenteric cyst
D. From a ruptured duplication cyst
3. Which of the following is not a genitourinary cyst seen in a
fetus?
History: An asymptomatic patient with a third-trimester
B
A. Urachal cyst
B. Bladder outlet obstruction
C. Urinoma
D. Medullary sponge kidney
4. What fetal abdominopelvic masses typically have both cystic and solid components?
A. Ovarian cyst
B. Teratoma
C. Multicystic dysplastic kidneys
D. Obstruction of the vagina
C
63
ANSWERS
CASE 31
Cystic Abdominal Mass
1. A, B, C, and D
2. A
3. D
4. B
References
Bryant AE, Laufer MR: Fetal ovarian cysts: incidence, diagnosis and manage-
ment. J Reprod Med 2004; 49(5):329-337.
http://www.ncbi.nlm.nih.gov/pubmed/15214704 (Accessed on June 8,
2012.)
Foster MA, Nyberg DA, Mahoney BS, et al: Meconium peritonitis: prenatal
sonographic ndings and their clinical signicance. Radiology 1987;
165(3):661-665.
http://www.ncbi.nlm.nih.gov/pubmed/3317498 (Accessed on June 8, 2012.)
Richards DS, Langham MR, Anderson CD: The prenatal sonographic
appearance of enteric duplication cysts. Ultrasound Obstet Gynecol 1996;
7(1):17-20.
http://www.ncbi.nlm.nih.gov/pubmed/8932626 (Accessed on June 8, 2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 447, 464.
Comment
Differential Diagnosis of Cystic Abdominal
or Pelvic Mass
The list of differential diagnoses for a cystic abdominal or pelvic mass in a fetus is long. Identication of associated ndings
may aid in determining the precise etiology. In the two cases
presented, the cystic masses do not extend back to the spine
and are not related to the kidney, so renal and retroperitoneal
masses do not need to be considered.
greater numbers of ovarian cysts are being diagnosed. The
risks of acute and long-term complications must be weighed
against the possibility of cyst regression. Cyst size is important.
Simple cysts (Figures A to D) and teratomas can arise from the
ovary. Obstruction of the vagina or uterus may appear as a
cystic mass in the pelvic midline.
Meconium Pseudocysts and Bowel-Related Cysts
A meconium pseudocyst forms from walled-off complicated
ascites secondary to meconium peritonitis. The cyst typically
contains internal echoes. Dilation of the small bowel, peritoneal calcications, and polyhydramnios can be seen. The
obstructed bowel loop in bowel atresia can also manifest as an
abdominal cystic mass, usually with hyperperistalsis. A simple
cyst may represent a mesenteric or omental cyst; additionally,
enteric duplication cysts are located in the mesentery. Enteric
duplication cysts are directly contiguous with the bowel and
may communicate with the bowel lumen. Approximately 30%
of fetuses with enteric duplication cysts have associated anomalies. Spinal or gastrointestinal malformations may be present
with foregut or hindgut duplications.
Genitourinary Cysts
Genitourinary cysts can arise from several sites. Renal causes
such as multicystic dysplastic kidney have been eliminated in
this case. However, posterior urethral valve obstruction can
result in urinoma formation. An obstructed bladder in posterior urethral valve and other types of bladder outlet obstruction
appears as a large cystic abdominopelvic mass. The existence
of a urachal cyst is an additional possibility.
Ovarian Cysts and Pathology of the Uterus
and Vagina
Ovarian cysts are among the most common cystic abdominal
masses in female patients. With improved neonatal imaging,
64
CASE 32
A
B
History: A woman with a rst-trimester pregnancy presents
with pelvic pain.
1. What should be included in the differential diagnosis for
the ultrasound image shown in Figure A? (Choose all that
apply.)
A. Early intrauterine pregnancy
B. Tubal ectopic pregnancy
C. Cornual ectopic pregnancy
2. What is the intradecidual sign?
A. Intrauterine pseudogestational sac
B. Corpus luteum
C. Early intrauterine sac located adjacent to the endome-
trium and embedded in the decidua
3. What is double decidual reaction?
A. Two concentric hyperechoic rings that surround the
early intrauterine gestational sac
B. Twin gestational sacs
C. Corpus luteum
D. Decidual cysts
4. What is the nding in Figure B?
A. Cervical ectopic pregnancy
B. Ruptured tubal ectopic pregnancy
C. Ectopic pregnancy in a cesarean section scar
65