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THE ACUTE ABDOMEN 247 LIVER LS GB STENT RUQ A B C D Figure 10.3 (A) An acutely tender, inflamed gallbladder containing stones and debris. (B) A patient with known carcinoma of the head of the pancreas has presented acutely with obstructive jaundice. Her stent (arrow) is blocked, causing intrahepatic biliary duct dilatation with cholangitis (C). (D) Large liver abscess in an acutely ill patient. frequently cause bile duct wall thickening and may introduce gas into the biliary tree. These will prevent the diagnosis of cholangitis or ductal calculi with ultrasound, and may impede detailed Doppler investigation of, for example, the portal vein. If urgent biliary drainage is required, particularly when the bile is infected, this can quickly be effected by endoscopic stent placement or sphincterotomy. 11 These less invasive methods are replacing surgery as the treatment of choice in this situation, having a lower mortality rate. Endoscopic sphincterotomy and stone extraction have been found to be preferable to surgery, particularly in cases of severe gallstone pancreatitis where patients may be poor operative risks 12 and in cases of stone-related cholangitis. Ultrasound-guided bed-side cholecystostomy may also be useful in high-risk patients with infected gallbladders and is an effective treatment for acalculous cholecystitis brought on by prolonged postoperative fasting. The liver itself may be acutely tender in systemic venous congestion due to cardiac failure, acute hepatitis, or the presence of an intrahepatic abscess. The management of liver abscesses is determined by their size, number and cause. Ultrasound is used to guide diagnostic aspiration and drainage procedures, and most types of hepatic
248 ABDOMINAL ULTRASOUND abscess can be treated successfully using these techniques combined with appropriate antibiotic therapy. THE ACUTE PANCREAS (See also Chapter 5.) Most cases of acute pancreatitis are suspected clinically, with raised amylase levels and often a history of recurrent epigastric pain pointing to the diagnosis of acute pancreatitis (Fig. 10.4). Although pancreatitis may be due to abdominal trauma, it is more frequently due to gallstone obstruction or alcohol abuse. The pancreas often appears normal even when acutely inflamed, so ultrasound examination should focus on the possible causes (such as gallstones, biliary dilatation or evidence of alcoholic liver disease) and complications (pseudocysts, portal or splenic vein thrombosis). Many pancreatic pseudocysts are now managed successfully by endoscopic ultrasoundguided transgastric drainage. 13 RENAL TRACT EMERGENCIES (See also Chapter 7.) Ultrasound is usually the firstline investigation in the assessment of acute loin pain, which in the absence of trauma is commonly due to acute urinary tract obstruction and/or renal infection (Fig. 10.5). Less common acute presentations include renal vein thrombosis or spontaneous haemorrhage, usually from a renal tumour or cyst. Until recently, ultrasound and/or intravenous urography (IVU) have been the investigations of choice in acute renal colic due to suspected ureteric calculus, and in most UK centres the IVU is currently the method of choice for demonstrating ureteric obstruction (Fig. 10.5E). Low-dose unenhanced multislice CT is increasingly being recommended as a replacement for these two modalities, 14 but even with this technique diagnostic pitfalls exist. 15 Abdominal ultrasound with or without plain radiography may still provide comparable accuracy where CT resources are limited. 16,17 The main limitation of ultrasound in acute ureteric obstruction is that obstruction may be present in the early stages without collecting system dilatation. But the minimally dilated renal pelvis, which would normally be dismissed as unremarkable in a patient with a full bladder, should raise the operator’s suspicion in the patient with acute loin pain. Doppler ultrasound of the kidneys shows a higher resistance index in the obstructed kidney than in the normal side. 18 Upper tract obstruction can be relieved via cystoscopy-guided ureteric stent placement. Ultrasound-guided percutaneous nephrostomy may be required if this is not practicable, or if there is evidence of infection. Renal infection with parenchymal involvement (acute pyelonephritis) may be the cause of severe acute loin pain with fever, but ultrasound examination mostly shows no abnormality. Occasionally the skilled operator using high-specification equipment may be able to identify segmental areas of high reflectivity, showing decreased blood flow with power Doppler. The diagnosis of this condition is usually based on clinical criteria, but these segments can be demonstrated with CT if necessary. Figure 10.4 Pancreatitis with a large pseudocyst. The patient was acutely tender, and the cyst was drained under ultrasound guidance. OTHER RETROPERITONEAL EMERGENCIES (See also Chapter 8.) Ultrasound has an established role in identifying the presence of an abdominal aortic aneurysm, but should not be used to assess subacute leakage or rupture. However, where rupture is suspected, and no previous imaging results
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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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Chapter 8 195 The retroperitoneum a
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Page 294 and 295: INDEX 281 Intravenous urography (IV
Page 296 and 297: INDEX 283 Phrygian cap, 29 Pneumobi
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