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PATHOLOGY OF THE LIVER AND PORTAL VENOUS SYSTEM 95 Table 4.2 diagnoses Common solid focal liver lesions: differential E Figure 4.18 cont’d (E) Tumour thrombus almost occluding the PV in a patient with multifocal HCC. Increasingly, contrast ultrasound is used to detect and characterize HCCs in patients with a background of liver disease. HCCs tend to demonstrate an early enhancement of tortuous vessels, followed by a ‘blush’ of arterial enhancement compared to normal liver. Cholangiocarcinoma This primary carcinoma of the bile ducts is discussed more fully in Chapter 3. Most commonly seen affecting the main biliary ducts, it also occurs in the intrahepatic biliary tree where it infiltrates the surrounding liver parenchyma, having the appearance of a solid mass. It may be solitary or multifocal and a clue to its location is often the focal dilatation of ducts proximal to the obstructing mass. For a summary of solid focal liver lesions, see Table 4.2. DIFFUSE LIVER CONDITIONS Lesion Benign Haemangioma Adenoma Focal fatty change Focal nodular hyperplasia Granuloma Regenerating nodules Abscess Infarct Malignant Metastasis Hepatocellular carcinoma Cholangiocarcinoma Characteristics Diseases which diffusely affect the liver may have very non-specific ultrasound appearances. Suspicion is usually raised following altered LFTs (see Chapter 1) and the diagnosis made histologically. A number of diffuse liver conditions can cause hepatocellular (or non-obstructive) jaundice which is associated with increased levels of unconjugated bile in the blood. Many of these can be demonstrated with ultrasound, others cannot. The main role of ultrasound in the jaundiced patient is to exclude any obstructive cause (by the presence or absence of biliary duct dilatation) and to search for liver metastases or signs of a diffuse liver condition (Table 4.3). Fatty infiltration (steatosis) Usually hyperechoic. Common incidental finding Associated with oral contraceptive pill No mass effect Uncommon, usually asymptomatic lesion, often found in young women Associated with PBC or TB. May calcify Associated with cirrhosis. Multiple lesions May appear solid in the early stages. Look for posterior enhancement. Fever and pain Associated with HA thrombosis in liver transplant Wide spectrum of possible acoustic appearances Associated with cirrhosis Associated with PBC. Proximal biliary dilatation PBC = primary biliary cirrhosis; TB = tuberculosis. The process of accumulation of fat within the hepatic cells may be either focal (see above) or diffuse. Related to various conditions such as alcoholism, obesity and diabetes, it is associated with any process which alters liver metabolism and it is reversible in many circumstances. The acoustic properties of fat differ from those of normal liver tissue. The liver appears hyperechoic as the fat globules provide interfaces which are highly
96 ABDOMINAL ULTRASOUND Table 4.3 jaundice Condition Haemolysis Haematoma Gilbert’s disease Viral hepatitis, cirrhosis of all types, alcoholic or drug-induced liver disease Abscess, intrahepatic malignancy Causes of non-obstructive (‘medical’) Aetiology In which red cells are destroyed, releasing the haemoglobin (from which bilirubin is derived) into the surrounding tissue Haemolytic process A defect in the hepatic uptake of bilirubin Destruction of the liver cells by these diseases prevents the mechanism of hepatic uptake and excretion of bilirubin. Both conjugated and unconjugated bilirubin are present Multiple and/or large lesions prevent the take-up and excretion of bilirubin by the liver cells reflective. As the level of fat deposition increases, the level of echogenicity may reach that of the highly reflective portal tract walls. This has the effect of reducing the prominence of the portal tracts (Fig. 4.19) and making the liver appear smooth and homogeneous, with closely packed, fine echoes. The contrast between the liver and parenchyma of the right kidney is therefore increased (a particularly useful sign confirming that the correct gain settings have been used). Hepatomegaly is also a feature, though not invariably. Finally, the attenuation of fat is greater than that of normal liver tissue; this has the effect of reduced penetration in the far field, rather as if the time gain compensation (TGC) paddles or slope control had been incorrectly set. In severe cases of infiltration, most of the sound is reflected back to the transducer in the first few centimetres, creating a highly reflective near-field band through which the sound is unable to penetrate. Fatty infiltration itself is not usually a significant finding; however it often occurs in conjunction with other significant diffuse processes such as cirrhosis. Its increased attenuation reduces the ability of ultrasound to exclude other disease or A B Figure 4.19 (A) Fatty infiltration increases the hepato-renal contrast. The portal tracts are reduced in prominence, giving a more homogeneous appearance. (B) Attenuation of the beam by fat prevents demonstration of far-field structures.
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Abdominal Ultrasound
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Abdominal Ultrasound How, Why and W
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v Contents Contributors Preface ix
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vii Contributors Rosemary Arthur FR
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ix Preface Ultrasound continues to
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ABBREVIATIONS xi MHA MHV MI MPV MRA
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Chapter 1 1 Optimizing the diagnost
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OPTIMIZING THE DIAGNOSTIC INFORMATI
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Chapter 2 17 The normal hepatobilia
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THE NORMAL HEPATOBILIARY SYSTEM 19
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Chapter 3 41 Pathology of the gallb
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PATHOLOGY OF THE GALLBLADDER AND BI
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Page 92 and 93: Chapter 4 79 Pathology of the liver
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Page 134 and 135: Chapter 5 121 The pancreas CHAPTER
Page 136 and 137: THE PANCREAS 123 the patient’s le
Page 138 and 139: THE PANCREAS 125 Acute pancreatitis
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Page 142 and 143: A C DISTANCE = 3.43 CM 5%. 13 Over
Page 144 and 145: THE PANCREAS 131 G H I Figure 5.5 c
Page 146 and 147: THE PANCREAS 133 head of pancreas.
Page 148 and 149: THE PANCREAS 135 pancreatic juice i
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THE SPLEEN AND LYMPHATIC SYSTEM 145
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Chapter 7 153 The renal tract CHAPT
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THE RENAL TRACT 155 As with any oth
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THE RENAL TRACT 157 A B q 0 LRA AO
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THE RENAL TRACT 159 junctions of or
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THE RENAL TRACT 161 A B Figure 7.5
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THE RENAL TRACT 163 carcinomas, the
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THE RENAL TRACT 165 the vesicourete
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THE RENAL TRACT 167 Table 7.1 Sourc
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THE RENAL TRACT 169 A B Figure 7.13
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THE RENAL TRACT 171 Table 7.2 Diffe
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THE RENAL TRACT 173 Ultrasound stil
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THE RENAL TRACT 175 CT is useful fo
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THE RENAL TRACT 177 Xanthogranuloma
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THE RENAL TRACT 179 As with acute t
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THE RENAL TRACT 181 der with increa
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THE RENAL TRACT 183 ● ● Morphol
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THE RENAL TRACT 185 ● ● hydrone
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THE RENAL TRACT 187 A Figure 7.27 A
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THE RENAL TRACT 189 vascular reject
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THE RENAL TRACT 191 B A C Figure 7.
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THE RENAL TRACT 193 computerised ul
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Chapter 8 195 The retroperitoneum a
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THE RETROPERITONEUM AND GASTROINTES
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Chapter 9 215 The paediatric abdome
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THE PAEDIATRIC ABDOMEN 217 A B SPLE
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THE PAEDIATRIC ABDOMEN 219 B A B Fi
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THE PAEDIATRIC ABDOMEN 221 probe de
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THE PAEDIATRIC ABDOMEN 223 When the
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THE PAEDIATRIC ABDOMEN 225 + 78 A 2
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THE PAEDIATRIC ABDOMEN 227 A B C D
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THE PAEDIATRIC ABDOMEN 229 Table 9.
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THE PAEDIATRIC ABDOMEN 231 A LT B C
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THE PAEDIATRIC ABDOMEN 237 mesenter
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THE PAEDIATRIC ABDOMEN 239 E F G Fi
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THE PAEDIATRIC ABDOMEN 241 system i
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Chapter 10 The acute abdomen 243 CH
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THE ACUTE ABDOMEN 245 scan of the p
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THE ACUTE ABDOMEN 247 LIVER LS GB S
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THE ACUTE ABDOMEN 249 D A RT B C E
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THE ACUTE ABDOMEN 251 17. Patlas M,
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Chapter 11 253 Interventional and o
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INTERVENTIONAL AND OTHER TECHNIQUES
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275 Bibliography and further readin
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277 Index A Abdomen, acute gastroin
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INDEX 279 Continuous ambulatory per
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INDEX 281 Intravenous urography (IV
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INDEX 283 Phrygian cap, 29 Pneumobi
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