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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5790_Библиотеки_им_академика_М_И_Перельмана.pdf
6.6 Lung Pathology
ab
Fig. 6.14 Atelectasis: ( a ) Axial transhepatic view: atelectatic, echogenic, concave-shaped lung –
compressed by pleural effusion. ( b ) Sagital view: peripherally collapsed lung – minimal atelectasis
of dorsolateral lung with secondary effusion
205
NOTE : These and pneumonic changes only visible when pathology reaches lung
periphery, becoming accessible for US.
6.6.4 Respiratory Distress Syndrome (RDS)/Hyaline
Membrane Syndrome
Defi nition : Surfactant defi ciency, typically in preterm neonates due to immature
lung or secondary to surfactant consumption - results in secondary collapse of
alveolus. NOTE : Possibly prediction of bronchopulmonary dysplasia (BPD) by
lung US: incomplete resolution of retrodiaphragmatic hyperechogenicity by the
second or third week = high probability for BPD.
US fi ndings : More or less inhomogeneous echogenicity from reduced ventilation –
varying degree of sound penetration, potentially changing with respiration allows
some grading as well as assessment during follow-up:
• Higher echogenicity than in pneumonia or atelectasis, sometimes (mild RDS)
only surface echo visible
• Potentially atelectasis-like appearance
• Other appearances: confl uent B-lines, pleural line and subpleural abnormalities
without spared areas
206
a
6 Ultrasound of the Chest
bb
Fig. 6.15 Sequestration and lung malformations: ( a ) Schematic demonstration of the range
of foregut malformations, graded depending upon amount of tissue and/or vessel alteration.
( b ) Typical sagittal US image of in this case an infradiaphragmatic echogenic sequestration in a
neonate with right-sided diaphragmatic hernia. NOTE : intrathoracic liver and slight effusion, as
well as preserved part of diaphragm covering sequestration. ( c ) CDS reveals the systemic vascular
supply, in this case deriving from a thoracic artery (chest wall vessel)
c
6.6.5 Sequestration
Defi nition : Lung tissue without function, usually without connecxion to tracheo-
bronchial system. Part of spectrum of various congenital lung/foregut malformations (Fig. 6.15a ).
Usually atypical vascular supply:
• Commonly from aorta, potentially draining into systemic vein
• Typically positioned in lower lobes, particularly left sided
US fi ndings : Usually best seen from abdominal approach (Fig. 6.15b ):
• More or less homogeneous, slightly echoic, space-occupying lesions
• May have complex inhomogeneous appearance with cysts (hybrid lesion)
• Large tubular structures often seen represent vessels
• Displaces lung, rarely also intraabdominal
6.6 Lung Pathology
Fig. 6.16 CCAM: CCAM type I (large macrocysts, + +) – diffi cult to differentiate from other
fl uid fi lled/cystic mass (bronchogenic, cystic sequestration, etc.)
CDS : Commonly large-supplying artery deriving from abdominal aorta
(Fig. 6.15c ):
• Draining vein depictable if drains into abdominal inferior cava; allows
differentiation of intra- versus extralobar sequestration
NOTE : Sequestration may also occur infradiaphragmatically.
Duplex Findings :
• If waveform resembles aorta/systemic veins, indicates systemic vascular supply
– extralobar sequestration
• If fl ow pattern resembles pulmonary artery/pulmonary vein, indicates vascular
supply from pulmonary circulation – intralobar sequestration
207
6.6.6 Congenital Cystic Adenomatoid Malformation (CCAM)
Defi nition : Part of spectrum of foregut malformations (see Fig. 6.15a ). Typically
three types differentiated, depending on cyst size:
• Type 1 = large cyst(s) > 2 cm
• Type 2 = multiple medium-sized cysts around 1 cm
• Type 3 = pseudosolid mass with multiple microcysts not resolvable by US
US fi ndings : More or less echoic, complex mass (Fig. 6.16 ):
• Varying number and size of cysts depending on type
• Between cysts there can be echogenic septae
CDS : No large vessels, some vascular supply sometimes seen
DDx : Atypical form of sequestration, hybrid lesion, bronchial atresia with
non- aerated malformed lung tissue, if more homogenous - thoracic kidney (usually
in the dorsal paramedian basal part of the chest)
208
a bc
Fig. 6.17 Cyst: ( a ) Fluid fi lled bronchial cyst - could be any kind of chest cyst adjacent to medi-
astinum. ( b ) Air-fi lled bronchogenic cyst. ( c ) Huge bronchial cyst connected to bronchial system
– air-fl uid level
6 Ultrasound of the Chest
6.6.7 Cysts
Defi nition : Fluid- or (if connected to tracheobronchial system) air-containing
lesions:
• Seen only if positioned close to lung surface
US fi ndings : Simple cyst(s) of varying size (Fig. 6.17a ):
• Posterior acoustic enhancement, smooth surface
• Separation from other entities diffi cult
• If fi lled with air, bright reverberation echoes without change during respiratory
cycle, thus distinguishable from normal lung (Fig. 6.17b )
• Bronchial cysts – potentially air-fl uid levels (may be diffi cult to depict)
(Fig. 6.17c )
DDx : Echinococcus/hydatid cyst (focus on typical wall appearance):
• Complicated cysts (echoes within lumen, aetiology not defi nable by US)
• Pericardial/pleural cysts
• Postinfl ammatory cysts, abscess, AV-malformation (use CDS)
6.6.8 Infarction
Defi nition : Pulmonary artery embolism PAE
US fi ndings : Pneumonia-like subpleural triangular areas without perfusion
• Usually hypoechoic, liver-like appearance, often relatively homogeneous:
– Beginning – some ventilation possible
– Later stage – completely resemble pneumonia, but no pulmonary vessels
depicetd by (a) CDS
CDS : No central vascularisation/fl ow, no pulmonary vascular supply (Fig. 6.18 ):
• Some pleural vessels may be depicted.
6.6 Lung Pathology
ab
cd
e
209
Fig. 6.18 PAE and pulmonary perfusion defi cit: ( a ) Axial view, infant after Glen procedure – with
peripheral pneumonia-like oedematous lung. ( b ) Same child as in ( a ): note severe postoperative
perfusion defi cit of one lung. ( c ) Axial view through liver: Large infarction, no air sonobroncho-
gram as would be seen with infection. ( d ) Dorsal scan through intercostals space: triangular sub-
pleural pneumonia-like lung area, typical for infarction induced pneumonia. ( e ) CDS demonstrates
lack of perfusion in the peripheral triangular subpleural consolidation
NOTE : Perfusion defi cit for other reasons (cardiac, postoperative, etc.) sometimes
diffi cult to distinguish, but tends to be more global, with less pronounced changes
of the lung echotexture.
210
6 Ultrasound of the Chest
Fig. 6.19 Lung tumour. Axial view: chest fi lled with partially cystic tumour that turned out to be
a pulmonary blastoma
6.6.9 Tumours and Space-Occupying Lesions
Defi nition : Lung tumours rare in children. US has limited role:
• One may visualise tumours if reaches lung surface
US fi ndings : US fi ndings vary depending on tumour and composition (Fig. 6.19 ):
• More or less echogenic, potentially necrotic areas or calcifi cations
• Sometimes origin depictable – allows speculation on aetiology
CDS : Evaluate vascularisation, depict necrosis, asses supplying/draining vessels:
• Pneumonia, atelectasis: CDS helpful for showing normal vascular supply
allowing differentiation from infarction or depiction of necrotic area before
typical abscess formations manifest
• Superfi cial/pleural/soft tissue arteriovenous malformation: CDS irreplaceable
for diagnosis
DDx : Any other cause of non-aerated lung, particularly CCAM, sequestration,
pneumonia, abscess, complicated cysts and hernia:
• In medial/mediastinal aspect: thymus versus lymphoma, etc.
• Extremely rare intrathoracic kidney (normal kidney in atypical location):
– Typical renal vascularisation pattern – undisputable diagnosis
6.7 Other Miscellaneous and Rare Applications
Many More Partially Rare Applications Reported: Most Relevant Ones
6.7.1 US for Interstitial Lung Disease
Increased extravascular lung water creates “B-line” on lung US; a few B-lines can be
found in a healthy population:
6.8 Additional Imaging
211
• B -lines are vertical, sharply de ned hyperechoic lines and structures without
decrease in brightness with depth (ring-down artefact)
• Low-frequency convex transducer detects more B-lines than high-frequency lin-
ear transducers
• Multiple B-lines suggest interstitial lung syndrome
• Non-speci c in terms of aetiology – wide variety of conditions (pulmonary
oedema, ARDS, pulmonary contusion, pneumonia, pulmonary brosis, etc.)
• B -lines correlate with CT abnormalities (e.g. thickened interlobular septa and
ground-glass opacities – closely packed B-lines)
6.7.2 US for Pneumothorax
Detection by US is possible and bene cial for patients in the emergency department
(ER) and on ventilation support (NICU, ICU, etc.)
US fi ndings:
• To-and-fro motion during respiration in real-time US with B-mode (visceral
pleura or parietal pleura) “gliding” or “sliding” sign and M-mode “seashore” sign
• Additional findings: lung point, absence of B-lines and absence of lung
pul s e
• Pneumothorax directly beneath the US transducer: no sliding sign in B-mode
and “stratosphere” sign on M-mode
NOTE: False-positive ndings from hyperextended hyperin ated lung (COPD,
severe asthma, aspiration with focal emphysema/hyperin ation, etc.)
6.8 Additional Imaging
Plain fi lm, CT, sometimes (and increasingly) MRI:
• Rarely angiography (vascular malformations) or fl uoroscopy
• Role/value of US exquisite for follow-up of effusions or diaphragmatic
palsy:
– Image-guided interventions: diagnostic or therapeutic puncture (in effusions,
abscess, chylothorax, haematothorax, tumour biopsy, etc.)
NOTE : US has limitations in the chest – complementary imaging tool. Plain fi lm
often initially compulsory. US often used in equivocal fi ndings (e.g. white haemithorax) (Fig. 6.20 ). Always include assessment of lung base in upper abdominal US
and FAST examinations.
212
6 Ultrasound of the Chest
ba
cd
Fig. 6.20 Case examples where US was helpful to further defi ne the cause of equivocal chest fi lm
fi ndings: ( a , b ) White haemithorax on chest fi lm ( a ): US ( b ) reveals a partially atelectatic, partially
pneumonic lung with elevated position of the diaphragm. The pulmonary vessels are well
perfused on CDS, no sign of tumour, only slight effusion. ( c ) Atypical opacifi cation of right
lower lung on plain fi lm: US ( d ) demonstrates collapsed lung with secondary pneumonic changes
in a child after aspiration
Liver and Bile System
Michael Riccabona
Contents
7.1 Requisites and Investigation............................................................................................ 214
7.1.1 Preparation......................................................................................................... 214
7.1.2 Positioning ......................................................................................................... 214
7.1.3 Transducers ........................................................................................................ 214
7.1.4 Course of Investigation ...................................................................................... 215
7.1.5 Standard Planes ................................................................................................. 215
7.2 Normal Findings ............................................................................................................. 216
7.2.1 Structure ............................................................................................................ 216
7.2.2 Ligaments .......................................................................................................... 217
7.2.3 Hepatic Veins (HV) ........................................................................................... 217
7.2.4 Portal Vein (PV) ................................................................................................ 217
7.2.5 Hepatic Artery (HA) .......................................................................................... 218
7.2.6 Gall Bladder ...................................................................................................... 218
7.2.7 Common Bile Duct (Commonly Addressed as Hepato- Choledochal Duct) ..... 218
7.2.8 Intrahepatic Bile Ducts ...................................................................................... 219
7.2.9 Doppler Findings ............................................................................................... 219
7.2.10 Special Aspects of Newborns and Infants ......................................................... 220
7.3 Pathology of the Liver ..................................................................................................... 222
7.3.1 Congenital Changes and Normal Variance ........................................................ 222
7.3.2 Infl ammatory Conditions ................................................................................... 223
7.3.3 Other Parenchymal Liver Disease ..................................................................... 225
7.3.4 Portal Hypertension and Vascular Problems ..................................................... 230
7.3.5 Liver Trauma ..................................................................................................... 234
7.3.6 Space-Occupying Liver Lesions ........................................................................ 237
7
M. Riccabona
Division of Pediatric Radiology, Department of Radiology,
University Hospital Graz, Auenbruggerplatz 3,
Graz 8036, Austria
michael.riccabona@klinikum-graz.at
e-mail:
M. Riccabona, Pediatric Ultrasound,
DOI 10.1007/978-3-642-39156-9_7, © Springer Berlin Heidelberg 2014
213
214
7.4 Biliary Tract and Gall Bladder ........................................................................................ 245
7.4.1 General Findings ............................................................................................... 245
7.4.2 Congenital Conditions and Normal Variants of Biliary Tract ........................... 245
7.4.3 Biliary Tract Diseases ........................................................................................ 248
7.4.4 Tumour-Like Conditions ................................................................................... 251
7.4.5 Role of US ......................................................................................................... 252
7.4.6 US-Guided Biopsy (See also Entry Interventional US, Chap. 2) ...................... 253
7.4.7 Additional Imaging............................................................................................ 253
7.5 US in Liver Transplantation ............................................................................................ 254
7.5.1 Pretransplant US ................................................................................................ 254
7.5.2 Intraoperative US ............................................................................................... 254
7.5.3 Postoperative Assessment ................................................................................. 254
7.5.4 Typical Complications ....................................................................................... 255
7 Liver and Bile System
7.1 Requisites and Investigation
7.1.1 Preparation
Fasting helpful for suffi cient fi lling of gall bladder and bile duct assessment.
Additional provocation by feeding during investigation helpful to enhance visualisation of intrahepatic and extrahepatic bile ducts and allows for assessment of
gall bladder emptying.
For quantitative assessment of liver perfusion (portal vein velocity and hepatic
artery fl ow), child must be fasted to avoid fl ow alterations from increased splanchnic fl ow mimicking pathology or masking disease.
TIP : Fasted means no food, no drink, no chewing gum, no sweets, no smoking, etc.
7.1.2 Positioning
Conventionally supine position
• In small children positioning manoeuvres diffi cult
• Potentially intercostal access necessary
• In older children manoeuvres can be attempted, instructing child “to show a big
tummy” or similar child-adapted wording
7.1.3 Transducers
Usually curved arrays of age-adapted frequencies used, but may not work well for
intercostal access (children do not like pressure on ribs) – for these applications and