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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5802_Библиотеки_им_академика_М_И_Перельмана.pdf
Genital tract
106
Uterus (transvaginal sonography)
PREPARATION
Empty bladder prior to the examination.
POSITION
Lithotomy position on adapted examination couch.
TRANSDUCER
8.4 MHz curved transvaginal transducer.
METHOD
Mid-sagittal section of the uterus is taken. The total uterine length (L)
is measured from the top of the fundus to the external cervical os. The
maximum anterior-posterior (AP) diameter is measured perpendicular
to the maximum L. The transducer is then rotated 90° to obtain maximum transverse (TRV) diameter in a transverse section.
APPEARANCE
Uniform pattern of medium-strength echoes with a highly reective
central stripe called the endometrial stripe.
Mid-sagittal section of the uterus. The endometrial stripe is seen as a highly reective stripe
(arrow) and the cursors indicate the uterine length (L) and anteroposterior (AP) diameter.
MEASUREMENT
Uterus (transvaginal sonography)
107
Age Mean length
(L)
Mean
anteroposterior
Mean width
(TRV)
(AP)
Reproductive age group
Nulliparous (P = 0) 7.3 cm 3.2 cm 4.0 cm
Primiparous (P = 1) 8.3 cm 3.9 cm 4.6 cm
Multiparous (P > = 2) 9.2 cm 4.3 cm 5.1 cm
Postmenopausal
Early(< 5 years) 6.7 cm 3.1 cm 3.6 cm
Late (> 5 years) 5.6 cm 2.5 cm 3.1 cm
FURTHER READING
Merz E, Miric-Tesanic D, Bahlmann F, Weber G, Wellek
S. Sonographic size of uterus and ovaries in pre- and
postmenopausal women. Ultrasound Obst Gynaecol. 1996;
7:38– 42.
Platt JF, Bree RL, Davidson D. Ultrasound of the normal non-
gravid uterus: Correlation with gross and histopathology. J Clin
Ultrasound. 1990; 18:15–19.
Genital tract
108
Endometrial stripe thickness
(transvaginal sonography)
PREPARATION
Empty bladder prior to the examination.
POSITION
Lithotomy position on adapted examination couch.
TRANSDUCER
8.4 MHz curved transvaginal transducer.
METHOD
Endometrial thickness is taken in the sagittal plane of the uterus at the
thickest part near the fundus, including both endometrial layers, from
basal layer of the anterior wall to the basal layer of the posterior uterine wall, excluding any intracavitatory uid.
APPEARANCE
During menstruation: The endometrium appears as a thin echogenic
line.
Proliferative phase (days 6–14): The endometrium becomes thicker
and more echogenic relative to the myometrium, reecting the development of glands, blood vessels, and stroma.
Late proliferative (periovulatory) phase: The endometrium develops a
multilayered appearance with an echogenic basal layer and hypoechoic
inner functional layer, separated by a thin echogenic median layer arising from the central interface or luminal content.
Secretory phase: The endometrium becomes even thicker and more
echogenic. It reaches a maximum thickness during the mid-secretory
phase.
Postmenopausal: The endometrium appears thin, homogeneous, and
echogenic.
Endometrial stripe thickness (transvaginal sonography)
During the proliferative
phase, the endometrium
(between cursors)
measures 6 mm.
During the secretory
phase, the endometrium
(between cursors)
measures 16 mm.
109
MEASUREMENT
Age group Maximum thickness
(range, mean ± 2 SD)
Reproductive age group
Phase of cycle Menstrual 4 mm (1–4 mm)
Proliferative 7 mm (mean 7.63 ±
3.82 mm)
Secretory 16 mm (mean 8.65 ±
4.21 mm)
Postmenopausal Symptomatic 4 mm
Asymptomatic 5 mm
Genital tract
110
Focal heterogeneity or eccentric thickening of the endometrium
detected should always be further investigated irrespective of endometrial thickness.
The value of endometrial thickness in reproductive age group women
is less important because it may vary widely depending on the phase
of the menstrual cycle. The examination should ideally be performed
during the early proliferative phase (day 6–10) of the menstrual cycle,
after the endometrium has sloughed.
Imaging should be performed on a postmenopausal woman on hormonal replacement, at the beginning or end of a cycle of treatment,
when the endometrium is at its thinnest as any pathologic thickening
will be more prominent at this stage.
FURTHER READING
Bennett GL, Andreotti RF, Lee SI, Dejesus Allison SO, Brown
DL, Dubinsky T, Glanc P, Mitchell DG, Podrasky AE, Shipp
TD, Siegel CL, Wong-You-Cheong JJ, Zelop CM. ACR
appropriateness criteria (R) on abnormal vaginal bleeding. J Am
Coll Radiol. 2011; 8:460– 468.
Nalaboff KM, Pellerito JS, Ben-Levi E. Imaging the endometrium:
Disease and normal variants. Radiographics. 2001;
21:1409–1424.
Ozdemir S, Celik C, Gezginc K, Kiresi D, Esen H. Evaluation of
endometrial thickness with transvaginal ultrasonography and
histopathology in premenopausal women with abnormal vaginal
bleeding. Arch Gynecol Obstet. 2010; 282:395–399.
Saatli B, Yildirim N, Olgan S, Koyuncuoglu M, Emekci O, Saygili
U. The role of endometrial thickness for detecting endometrial
pathologies in asymptomatic postmenopausal women. Aust NZ
JObstet Gynaecol. 2014; 54:36–40.
GASTROINTESTINAL
5
TRACT
Anu E. Obaro and Suzanne M. Ryan
Appendix 112
Upper gastrointestinal tract wall
(endoscopic ultrasound) 114
Gastrointestinal tract wall
(transabdominal ultrasound) 118
Anal endosonography 122
Gastrointestinal tract
112
Appendix
PREPARATION
Full bladder. After a 10-minute search for the appendix on full bladder, if the search is negative, ask the patient to empty the bladder and
continue the search.
POSITION
Supine and left lateral decubitus position if retrocecal appendix is suspected.
TRANSDUCER
5.0–10.0 MHz linear array transducer or a 3.0–7.0 MHz curvilinear
transducer.
METHOD
Place transducer transversely below the edge of the right hepatic lobe,
in front of the right kidney, and slowly move down to the right iliac
fossa along the line of the ascending colon. Identify the cecum and then
trace the appendix; it is draped over the right iliac vessels anterior to
the iliopsoas muscle.
APPEARANCE
Features of a normal appendix include:
1. A compressible blind-ended tubular structure
2. Surrounded by normal-appearing fat
3. Wall thickness < 3 mm, measured from the serosa to the lumen, and
diameter measurement of < 6 mm, measured from serosa to serosa.
Caution: In normal appendices nonexpressible inspissated feces may
result in an outer diameter > 6 mm; therefore, mural thickness is a
more sensitive indicator of inammation.
MEASUREMENTS
Typically, appendicitis is characterized by a wall thickness > 3 mm and
a diameter > 6 mm. Since a maximal diameter > 6 mm may be seen
in the absence of appendicitis, the following must also be considered:
intraluminal content, periappendiceal change, hypervascular mural
ow with color Doppler, or loss of wall layers.
Variation in age is only marginally signicant. Acute appendicitis in
the pediatric population is diagnosed if the appendiceal diameter is
>5.7 mm and wall thickness is > 2.2 mm.
Appendix
The tubular structure (between cursors) is the inamed appendix with free uid (arrow).
Note the presence of inamed increased hyperechoic fat (arrowhead), so that the appendix
“stands out.”
113
FURTHER READING
Je BK, Kim SB, Lee SH, Lee KY, Cha SH. Diagnostic value of
maximal-outer-diameter and maximal-mural-thickness in
use of ultrasound for acute appendicitis in children. World J
Gastroenterol. 2009; 15: 2900–2903.
Park NH, Park CS, Lee EJ, Kim MS, Ryu JA, Bae JM, Song JS.
Ultrasonographic ndings identifying the fecal-impacted
appendix: Differential ndings with acute appendicitis. Br J
Radiol. 2007; 80: 872–877.
Simonovský V. Normal appendix: Is there any signicant difference
in the maximal mural thickness at US between pediatric and
adult populations? Radiology. 2002; 224:333–337.
Simonovsky V. Sonographic detection of normal and abnormal
appendix. Clin Rad. 1999; 54; 533–539.
Gastrointestinal tract
114
Upper gastrointestinal tract wall
(endoscopic ultrasound)*
PREPARATION
The patient is sedated and given pharyngeal local anesthesia.
POSITION
Left lateral position.
TRANSDUCER
An ultrasonic endoscope consisting of a 7.5 MHz ultrasound mechanical sector-scan transducer housed in an oil-lled chamber at the tip of
a specially adapted ber-optic endoscope.
METHOD
After introduction of the endoscope to the desired position under
direct vision, intraluminal gas is aspirated.
Three methods are available for exploration of the upper GI tract wall:
1. Direct apposition of the transducer on the mucosa: used for the
esophagus.
2. Contact of a small balloon lled with water over the tip of the
ultrasonic transducer: used for the esophagus, and gastric and
duodenal walls.
3. Direct instillation of deaerated water, usually about 500 ml: for
gastric and duodenal walls.
APPEARANCE
The ultrasound beam passing through the gastrointestinal wall will
potentially encounter six interfaces between tissue layers, which allow
the visualization of ve separate layers. These layers have their respective histological correlates.
*This is a specialized procedure and is conducted in a similar manner to stan-
dard upper gastrointestinal endoscopy.
Upper gastrointestinal tract wall (endoscopic ultrasound)
The gastrointestinal wall is visualized as six interfaces between tissue layers, which result in
the depiction of ve separate layers: layer 1, luminal/mucosa; layer 2, deep mucosa; layer 3,
submucosa; layer 4, muscularis propria; layer 5, adventitia/serosa.
115
Layer 1 High reective line Luminal/mucosa
Layer 2 Low reectivity Deep mucosa
Layer 3 High reectivity Submucosa
Layer 4 Low reectivity Muscularis propria
Layer 5 High reectivity Adventitia/serosa
MEASUREMENT
The accuracy of endoscopic ultrasound measurements is affected by
physiological peristalsis, with a wide variation in normal wall thickness. Measurements are also affected by interobserver variability, differences in the frequency of transducer, and differences in pressure
application. Esophageal wall thickness is 2.4 mm in normal controls,
which is statistically lower than in patients with a histological grade of
Barrett’s esophagus.