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INTERVENTIONAL AND OTHER TECHNIQUES 269 PV RPV MPV c(i) c(ii) Figure 11.15 cont’d (C) i, Before contrast injection, portal vein thrombosis is suspected in a patient with alcoholic liver disease; ii, after injection, the main portal vein is confirmed as thrombosed. Forward flow is seen in the right portal vein (presumably due to collateral circulation), and increased hepatic arterial flow is clearly demonstrated. of life and an overall 5-year survival of 20–45%, and up to 60% in unifocal disease. Without surgery the 5-year survival in this patient group is effectively zero. However, not all patients with liver metastases are deemed suitable for resection, being poor surgical risks or having lesions which are either too large or affect too many hepatic segments. Percutaneous ablation of liver tumours is now a viable and rapidly developing option for control of liver metastases, prolonging survival time after initial diagnosis and, in some cases, shrinking tumours to enable future curative resection. Various methods have been investigated, using ultrasound guidance. ● ● Alcohol injection has proved highly effective for hepatocellular carcinoma (HCC), 32,33 shrinking tumours over a period of time and causing necrosis within them, but has not proved as effective for metastatic liver disease. This is thought to reflect the fact that HCC is a ‘soft’ tumour and so the alcohol can be instilled effectively into the tumour whereas metastases are ‘hard’ lesions and often the alcohol seeps out of the lesion. Radiofrequency (RF) thermal ablation and laser ablation are also developing as minimally invasive percutaneous therapeutic techniques and are becoming increasingly popular. Ablation of liver metastases using RF is a recent method of ultrasound-guided therapy for liver metastases and HCC in which RF, applied to monopolar electrodes either individually or with multiprobe arrays, is guided into the lesion to be treated. RF tissue ablation through an 18G needle uses fewer probes than laser. It is an outpatient procedure: 1–4 sessions has been reported to achieve complete necrosis of liver metastases in 67% of lesions. 34 It is a simple, safe and potentially effective treatment for liver metastases, associated with a low rate of complications (in one study only one small area of haemorrhage was observed in 75 sessions) 35 together with a significant rate of shrinking or stabilization of the metastases. ENDOSCOPIC ULTRASOUND Some of the limitations of conventional ultrasonography in biliary and pancreatic imaging can be overcome by the use of endoscopic probes and miniprobes. Endoscopic probes are either radial or linear arrays which are incorporated into the end of an endoscope. They have a frequency of 7.5–12 MHz and are used to image the pancreas, biliary tract, portal vein and adjacent structures
270 ABDOMINAL ULTRASOUND A B C D Figure 11.16 (A) Conventional ultrasound of the liver showing no abnormality. (B) Pulse inversion mode following intravenous Levovist injection showing a focal lesion (arrow) i.e. metastasis in the same patient as Fig. 16a. (C) Conventional grey-scale scan of the liver. A number of metastases were seen throughout the liver. One in the left lobe has been arrowed. (D) Pulse inversion mode with intravenous Levovist in the same patient as (C). The metastasis seen on the unenhanced grey-scale image can still be seen (arrow); however, easily discernible additional lesions are now also appreciated. within 5–6 cm of the probe. Radial probes may be used in the preoperative staging of a number of diseases, including oesophageal, gastric, pancreatic and lung cancer, whilst linear array probes are used for interventional procedures such as fineneedle aspiration analysis of mediastinal lymph nodes, solid organ assessment, for example pancreas, occasionally liver, adrenals, pseudocyst drainage and coeliac plexus neurolysis. Endoscopic ultrasound is more sensitive and specific than spiral CT, MRI or transabdominal ultrasound in the detection of small pancreatic masses and its diagnostic ability can be further enhanced by the use of endoscopic ultrasonically guided fineneedle aspiration cytology 36 and biopsy. It may also detect early changes of pancreatitis which are not visible on endoscopic netrograde cholangiopancreatography (ERCP), and one of its
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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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Chapter 9 215 The paediatric abdome
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THE PAEDIATRIC ABDOMEN 217 A B SPLE
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Page 288 and 289: 275 Bibliography and further readin
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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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