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THE ACUTE ABDOMEN 245 scan of the pelvis where possible. Gynaecological masses may rupture or haemorrhage, presenting acutely, and in women of childbearing age, ectopic pregnancy should be included in the list of differential diagnoses. When visceral trauma is treated conservatively, follow-up ultrasound may be used to monitor the resolution of any fluid collections or haematoma. GASTROINTESTINAL TRACT Most acute presentations of gastrointestinal tract pathology are due to obstruction or inflammation, and the ultrasound appearances of these conditions are discussed more fully in Chapter 8. Appendicitis, and its possible complications, is one of the most common reasons for referral (Fig. 10.2). Ultrasound A B C D Figure 10.1 (A) The presence of free fluid in a trauma patient implies organ injury, even if this cannot be successfully demonstrated on ultrasound. CT on this patient demonstrated perforation of the bowel. (B) A patient who has been stabbed on the right side has injury to the liver causing a subcapsular haematoma. Blood is also present in the right chest. (C) Laceration of the spleen following a road traffic accident. Free fluid was also present in the abdomen. (D) Splenic lacerations are more obvious several hours after injury. This large splenic haematoma resolved following conservative treatment. (Continued)
246 ABDOMINAL ULTRASOUND E Figure 10.1 cont’d (E) CT demonstrating pancreatic fracture (arrow) in the tail of the pancreas following a road traffic accident. Ultrasound was not able to demonstrate the fracture but did demonstrate free fluid following the accident and also diagnosed devascularization of the left kidney (no Doppler flow within the kidney) following a severed left renal artery. This is also confirmed on CT. linear probe, many useful indicators can be found with the basic curvilinear or sector abdominal scan. The presence of fluid-filled bowel segments, which may also show ‘overactive’ peristalsis, should alert the operator to the possibility of acute intestinal obstruction. Such segments frequently lie proximal to the obstructing lesion, and so the point at which they appear to end should be the subject of detailed examination. Ultrasound is highly accurate in demonstrating obstruction. However, it is less successful in finding its cause and contrast CT or other bowel studies are usually undertaken when obstruction is diagnosed. With both intestinal obstruction and focal pain it may be necessary to examine the hernial orifices. A small but symptomatic epigastric hernia often goes unnoticed unless a detailed scan of the abdominal wall is performed. Fluid collections such as abscesses may also point to the diseased segment, for example in Crohn’s disease or acute diverticulitis. Such inflammatory bowel conditions may well present with an established history which helps the operator to focus the ultrasound examination accordingly. Perforation of an abdominal viscus can produce small amounts of ascites. This is usually ‘mucky’, i.e. containing particulate or gas bubble echoes, and may be localized close to the perforation site, around the duodenum or within the lesser sac. Although gas is usually regarded as an obstacle to ultrasound diagnosis, recent studies have shown that specific patterns of gas echoes can make ultrasound more sensitive than plain radiography in the diagnosis of pneumoperitoneum. 10 Figure 10.2 Appendicitis abscess. has a high sensitivity for acute appendicitis, particularly in children. Although the detailed assessment of the primary gastrointestinal pathology usually requires evaluation by an experienced operator with a high-frequency HEPATOBILIARY EMERGENCIES Ultrasound scanning is invariably the first-line investigation for suspected biliary tract emergencies. These include inflammatory conditions causing right upper quadrant and epigastric pain, mostly acute cholecystitis or gallstone pancreatitis, and the various causes of obstructive jaundice (Fig. 10.3). If possible, interventional treatment should be delayed until a detailed imaging assessment of the cause of biliary obstruction has been made, since the presence of a biliary stent can compromise subsequent imaging by CT, MRI or endoscopic ultrasound. Similarly, biliary stents
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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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Chapter 4 79 Pathology of the liver
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PATHOLOGY OF THE LIVER AND PORTAL V
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Chapter 5 121 The pancreas CHAPTER
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THE PANCREAS 123 the patient’s le
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THE PANCREAS 125 Acute pancreatitis
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THE PANCREAS 127 E F G Figure 5.3 c
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A C DISTANCE = 3.43 CM 5%. 13 Over
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THE PANCREAS 131 G H I Figure 5.5 c
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THE PANCREAS 133 head of pancreas.
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THE PANCREAS 135 pancreatic juice i
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Chapter 6 137 The spleen and lympha
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THE SPLEEN AND LYMPHATIC SYSTEM 139
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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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Page 294 and 295: INDEX 281 Intravenous urography (IV
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