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INTERVENTIONAL AND OTHER TECHNIQUES 261 A full scan of the kidney is first performed to highlight potential problems, for example perirenal fluid collections, and to establish the safest and most effective route. The transplanted kidney lies in an extraperitoneal position and the chosen route should avoid puncturing the peritoneum, to minimize the risk of infection. Unlike the native kidney, the upper pole of the transplanted kidney is usually chosen to avoid major blood vessels and the ureter, which pass close to the lower pole. The biopsy aims to harvest glomeruli, and the chosen route should therefore target the renal cortex. An angle is chosen to include the maximum thickness of cortex and, where possible, avoid the renal hilum (Fig. 11.10). Upper pole A Proposed route Lower pole Complications of ultrasound-guided biopsy Postprocedure complications such as haematoma requiring blood transfusion and trauma to adjacent viscera occur very infrequently when ultrasound guidance is used. As expected, the risk of complications is less in fine-needle biopsy than with larger needles; 4 however, there is no significant difference in complication rate between a standard 18G Tru- Cut needle and a 22G Chiba needle. 5 The mortality and major complication rates vary but using a standard 18G needle these are approximately 0.018–0.038% and 0.18–0.187% respectively, mortality being due to haemorrhage in 70%. As a working figure this means the mortality is approximately 1 in 3300–5400 and morbidity 1 in 530 biopsies (Table 11.1). 4,6,7 The risk of haemorrhage is increased in patients with coexistent cirrhosis and is more likely to occur with malignant than benign lesions, 8,9 although large haemangiomas also can carry a significant risk of bleeding. As with any procedure of this nature, there is a very small risk of infection, which can be minimized by using an aseptic technique. Tumour seeding of the biopsy tract is an uncommon complication of biopsy and reports of tumour seeding are associated with repeated passes into the mass using large needles. Although much talked about, tumour track seeding is in fact rare, occurring in approximately 1 in 20 000 biopsies. 7,10 The bestknown tumours for this are mesothelioma and hepatoma. B Figure 11.10 (A) The transplanted kidney lies in the iliac fossa and is biopsied with the patient supine. (B) The needle is seen entering a transplanted kidney (arrowheads). Complications following abdominal biopsy are increased with multiple passes and are at least in part related to the skill and experience of the operator. If the biopsy result is negative or unexpected then a number of scenarios should be considered and include sampling error, poor histological specimen, sonographic or pathological misinterpretation or indeed a true negative finding. A repeat biopsy is sometimes justified. ULTRASOUND-GUIDED DRAINAGE Many fluid collections are the result of surgical intervention and often cannot be differentiated on ultrasound alone. Diagnostic aspiration of
262 ABDOMINAL ULTRASOUND Table 11.1 biopsy fluid collections is used to establish their exact nature: this may include haematoma, lymphocoele, urinoma, biloma, pseudocysts and others. Postoperative haematomas are normally treated conservatively and tend to resolve spontaneously. Insertion of a drain into such a collection is at high risk of converting the collection into an abscess. Abscess drainage Complications of ultrasound-guided Major Number compliof Mortality cation Author Year biopsies rate rate Fornari et al 4 1989 10 800 1:5400 1:530 Nolsoe et al 6 1990 8000 1:2700 1:540 Smith 7 1991 16 400 1:3300 — Ultrasound-guided drainage of abscesses is now the preferred treatment when the collection can be visualized on ultrasound and a safe route chosen. These may result from postoperative infection, inflammatory bowel conditions, such as Crohn’s disease or appendicitis, or other sources of infection, particularly in immunosuppressed patients. Drains come in different sizes and generally the thicker the pus, the larger the bore of drain that is required. Whilst aspiration is initially performed to confirm the nature of the collection, very often a drain is left in situ; together with appropriate antibiotic therapy this is usually effective. At the very least it normally leads to an improvement in the overall clinical condition to allow definitive treatment and can in itself be a definitive cure. Ultrasound is particularly useful in cases of hepatic abscesses and in draining the subphrenic, pericolic and subhepatic areas. Superficial collections, usually associated with wound sites, are also readily accessible to ultrasound. Collections obscured by bowel gas are best drained under CT guidance. Gallbladder drainage Gallbladder drainage under ultrasound control is a temporary, palliative procedure which tends to be reserved for particularly ill patients with septicaemia, as a method of stabilizing their condition prior to surgery. Drainage of, for example, a gallbladder empyema buys useful time, reducing the risk of perforation and subsequent peritonitis and improving clinical status prior to surgical removal. Although the portable nature of ultrasound allows a bedside procedure to be performed (which is particularly useful in patients under intensive therapy who cannot be moved), these procedures carry a high risk to the patient and full anaesthetic, nursing and medical support is required. Nephrostomy Renal obstruction in which the pelvicalyceal system is dilated may be alleviated by the percutaneous introduction of a nephrostomy tube under ultrasound guidance. This procedure relieves pressure in the renal collecting system and avoids potential irreversible damage to the renal parenchyma (Fig. 11.11). Although the procedure may be carried out completely under ultrasound control, it is normally performed in a screening room where a combination of ultrasound and X-ray screening can be used to maximal effect. Cyst drainage The percutaneous treatment of renal and hepatic cysts by simple aspiration may afford only temporary relief as they frequently recur, but a more permanent result may be achieved by injecting a sclerosant, for example absolute alcohol or tetracycline into the cyst. In addition, percutaneous treatment of hydatid liver disease (traditionally avoided because of the risk of spreading parasites along the needle track and causing further infection) has been successfully performed by injecting of a scolicidal agent, 11 avoiding the need for surgical removal. Other applications include draining of pancreatic pseudocysts and inserting a cystogastrostomy tube with combined fluoroscopy and ultrasound guidance; the cyst is allowed to drain through this
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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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THE RETROPERITONEUM AND GASTROINTES
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Page 288 and 289: 275 Bibliography and further readin
Page 290 and 291: 277 Index A Abdomen, acute gastroin
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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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