Exercises in Diagnostic Ultrasonography of the Abdomen

128 Pages·1983·5.63 MB·English

by  Francis S. Weill M.D.

F. S. Weill A. Le MoueI
Exercises in
Diagnostic Ultrasonography
of the Abdomen
Translated by R. Chambers
With 361 Figures
Springer-Verlag
Berlin Heidelberg New York Tokyo 1983
FRANCIS S. WEILL, M.D.
Professor of Radiology, University of Besan~n, Head Department
of Radiology, University Hospital, 2, Place Saint-Jacques,
F-25000 Besan~on
ARLETTE LE MOUEL, M.D.
Senior Radiologist, Head Department of Radiology, University Hospital,
2, Place Saint-Jacques, F-25000 Besan~on
Translator:
RICHARD CHAMBERS, 9 bis rue de la Grette, F-25000 Besan~on
Title of the original French edition:
Exercices de diagnostic abdominal by R S. Weill, A Le MouiH
© Editions Vigot Freres, Paris, 1982
ISBN-13: 978-3-540-12228-9 e-ISBN-13: 978-3-642-68986-4
DOl: 10.1007/978-3-642-68986-4
Library ofC ongress Cataloging in Publication Data. Weill, Francis Samuel, 1933-Exercises
in diagnostic ultrasonography of the abdomen. Translation of: Exercices de diagnostic
abdominal. l. Abdomen-Radiography-Problems, exercises, etc. 2. Diagnosis, Ultrasonic
Problems, exercises, etc. I. Le Mouel, A (Arlette) II. Title. RC944.W38131983 617'.5507543
83-4658
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Contents
Introduction 1
Chapter 1
In Which the Reader is Invited to Clean His Glasses 3
Chapter 2
Six Painful Hepatomegalies . . . . . . . . . . . . . . . .. 11
Chapter 3
Two Additional Cases of Hepatomegaly . . . . . . . . .. 27
Chapter 4
A Geological Chapter . . . . . . . . . . . . . . . . . . .. 35
Chapter 5
In Which it is Shown that the Ways of the Lord are
Unfathomable ........................ 51
Chapter 6
A Few Strange, Strange Cases ............... 61
Chapter 7
Postoperative Complications ................ 71
Chapter 8
The Yellow Peril ...................... 85
Chapter 9
Several Acute Situations 107
Conclusions ......................... 125
Introduction
This book of diagnostic exercises cannot be used to good advantage without a
good grasp of elementary sonoanatomy and the most common pathologic
imagesl. We have tried to follow a pedagogical progression from the simple to the
complicated for each group of clinical situations. We recommend that the
sonograms at the beginning of each case study be thoroughly analysed before
proceeding to the commentaries which explain the grounds for the final diagnosis.
These explanatory remarks are accompanied by the same sonograms, but with
arrows and letters added so as to pinpoint the details referred to as the diagnosis
progresses. In reading the commentaries it will therefore be a good idea to cover
over the figures in which the details are picked out for you, uncovering them one
by one as required.
1 Which the reader may obtain from our previous books:
Ultrasonography of Digestive Diseases (Mosby Publ., 2nd Ed., 1982)
Renal Sonography (Springer Verlag, 1981)
1
Chapter 1
In Which the Reader is Invited to Clean His Glasses
1.1. Mrs. Beech, 75 years, has the complexion of a young girl, but she is losing
weight and complains of epigastric pain. She has undergone a whole series of
conventional radiological procedures; this may be good news for the film
manufacturers, but it has not aided in the diagnosis. Finally, she is referred for an
ultrasound examination.
Look first at ultrasonic cuts 1.1a, b (transverse), then LId (sagittal).
a b
c d
Fig. 1.1
3
Fig. LIe
There is a large abnormality here. If you haven't discovered it, it will become
obvious if you compare these pathologic images with the normal image in
Fig. LIe, which is from another individual.
What is this abnormality?
It is clearly a deep sonolucent mass, with smooth limits and a small central
(1
echogenic zone below).
a
b
Fig. 1.1
C1
The mass is also seen in sagittal section Fig. LId, below)
Fig. LId
4
a b
Fig. 1.1
What is its relationship to the pancreas?
The comma shaped reflective echotexture (!) of the latter is well marked (see
above, Fig. l.la, b). It is underlined along its posterior aspect by the transparency
(t
of the splenic vein Fig. LIb).
In this case, we are confronted with a mass located anterior to the large vessels
(a = aorta) and within the posterior part of the pancreatic head. It forces part of
the pancreatic tissue forward.
Before we continue our discussion of the nature of this mass, carefully study Fig.
1.la (above). As good internists we now want to know the condition of a
particular anatomic structure. What should we assess?
Fig. 1.la
We assess the common bile duct and find the beginning of a "gun sign" (white
arrow and crossed arrow above). The diameter of the bile duct (white arrow),
anterior to the portal vein (i), is half the diameter of the latter. This is the upper
normal limit for the relationship between these two diameters. Most likely, Mrs.
Beech will soon be losing her young girl's complexion in exchange for one more
Asiatic in appearance.
5
Now, carefully study Fig. 1.lb below. You have thirty seconds to try to extend the
list of Mrs. Beech's problems. You note ...
Fig.1.1b
... You note, posterior to the liver, a sonotransparent, comma-shaped fluid
collection (white arrowheads).
It corresponds to? ...
. . . to a pleural effusion. A small ascitic strip would be in an anterior or lateral
position in relation to the liver. This image is also visible in Fig. 1.1a below
(arrowheads) .
Fig. 1.1a
If you're not convinced look at Fig. 1.1c (p. 3, then next page).
6
Fig. 1.ic
The figure is a sagittal section of the right upper quadrant. It disctinctly shows a
fluid collection above the diaphragm (black arrows). Due to this liquid contrast,
the posterior thoracic wall is visualized (white arrows). Normally, no echo
appears above the dome of the liver and the diaphragm.
A puncture will show that this effusion is hemorrhagic.
For the moment we can conclude that there is a mass of the cephalic pancreatic
region, which is beginning to compress the common bile duct and is accompanied
by a hemorrhagic pleural effusion, most likely metastatic.
Logically, this image of a retroperitoneal mass should be caused by an
adenopathy, since it forces the splenic vein as well as the pancreatic tissue
forward. Can a pancreatic carcinoma cause the same type of anterior bulging? It
seems improbable since the branches of the-portal system are retropancreatic:
logically they should be forced backward. In fact, pancreatic tumors as they
progress deeper usually do compress these portal branches posteriorly. However,
when the tumor develops in the uncinate process, which is posterior to the
mesenteric vein, then like an adenopathy it forces the pancreas forward (see also
Fig. 1.lf-h, below).
fig h
CD
Fig. 1.1. f, g Transverse pancreatic section s = Uncinate process is retrovenous Csp = splenic vein,
m = superior mesenteric artery, c = vena cava, a = aorta), h sagittal section: the uncinate process CD
appears posterior to the mesenteric vein (m)
7