Meyers' Dynamic Radiology of the Abdomen: Normal and Pathologic Anatomy

425 Pages·2011·44.61 MB·English

by  Morton A. Meyers MD

Meyers’ Dynamic Radiology
of the Abdomen
S E
IXTH DITION
Morton A. Meyers
Chusilp Charnsangavej
Michael Oliphant
Meyers’ Dynamic Radiology
of the Abdomen
Normal and Pathologic Anatomy
S E
IXTH DITION
With531Figures,in729Parts,22inColor
1 3
MortonA.Meyers,MD,FACR,FACG
ProfessorEmeritusofRadiologyandMedicine
DistinguishedUniversityProfessor
StateUniversityofNewYork
StonyBrook,NY11794-8460
USA
ChusilpCharnsangavej,MD,FSIR
ProfessorofRadiology
RobertD.MoretonDistinguished
ChairinDiagnosticRadiology
TheUniversityofTexas
M.D.AndersonCancerCenter
Houston,TX77030
USA
MichaelOliphant,MD,FACR
ProfessorofRadiology
DepartmentofRadiology
WakeForestUniversity
SchoolofMedicine
Winston-Salem,NC27157-1088
USA
ISBN978-1-4419-5938-6 e-ISBN978-1-4419-5939-3
DOI10.1007/978-1-4419-5939-3
SpringerNewYorkDordrechtHeidelbergLondon
LibraryofCongressControlNumber:2010932339
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To Bea, Amy,
Richard, Karen,
Sarah, and Sam
I couldn’t wish for a more loving family
Morton A. Meyers
To my teachers: Professor Milton Elkin who encouraged me to use
multimodality approach and to apply physiology and pathology
in Diagnostic Imaging, and to Professor Sidney Wallace who taught me
how to be a clinician
To my wife and children: Tanitra, Chutapom, Tonyamas, Nalinda,
Sirynda, and Larissa who endured my long hours at work
To my parents: Chow and Usa who would like their children
to be successful and secure a better life
Chusilp Charnsangavej
To Phyllis, Melissa,
Jason, Bradley, and Ella
All my love always.
In memory of Molly Sara
Michael Oliphant
Therearesomethingswhichcannotbelearnedquickly,andtime,
whichisallwehave,mustbepaidheavilyfortheiracquiring.Theyare
theverysimplestthings;and,becauseittakesaman’slifetoknow
them,thelittlenewthateachmangetsfromlifeisverycostlyandthe
onlyheritagehehastoleave.
Ernest Hemingway
Death in the Afternoon
Preface to the Sixth
Edition
The preface to the first edition of Meyers’ Dynamic In the pursuit of comprehending the pattern, all
Radiology of the Abdomen: Normal and Pathologic methods of investigation have been used, including
Anatomystatedthatthisbookintroducesasystematic (a) anatomic cross-sectioning of cadavers frozen to
applicationofanatomicanddynamicprinciplestothe maintainrelationships;(b)cadaverinjectionsanddis-
practicalunderstandinganddiagnosisofintraabdom- sectionsperformedtodeterminepreferentialplanesof
inaldiseases.Theclinicalinsightsandrationalsystem spreadalong ligaments,mesenteries,and extraperito-
ofdiagnosticanalysisstimulatedbyanappreciationof neal fascial compartments; (c) selected clinical cases
thedynamicintraabdominalrelationshipsoutlinedin withthefullestrangeofimagingstudies;(d)peritoneo-
previous editions have been universally adopted. scopy and peritoneography; and (e) surgical opera-
Literally thousands of scientific articles in the litera- tions,surgicalpathology,andautopsies.
ture have attested to their basic precepts. Formula- Thebasicaimsinwritingthisbookhavenotchan-
tions and analytic approaches introduced in the first ged from the first edition, and it is produced in the
editionarenowwidelyappliedinclinicalmedicineso samespiritasitspredecessors.Thequestofsciencehas
that many of the terminologies, definitions, and con- always sought the identification of a pattern of cir-
ceptsofpathogenesishavesolidlyenteredthescientific cumstances. With this recognition, there follows
domain.Theseinsightsleadtotheuncoveringofclini- insight and understanding into the nature and
callydeceptivediseases,theevaluationoftheeffectsof dynamics of events and thereby their predictability,
disease, the anticipation of complications, and the management, and consequences. This book estab-
determinationoftheappropriatediagnosticandther- lishes that the spread and localization of diseases
apeutic approaches. Spanish, Italian, Japanese, and throughout the abdomen and pelvis are not random,
Portuguese editions have encouraged more wide- irrationaloccurrencesbutratheraregovernedbylaws
spread application of the principles, which in turn ofstructuralanddynamicfactors.
hasledtofurthercontributionstoourunderstanding In the past, radiology books have traditionally
of the features of spread and localization of intraab- dealtwithhighlyfocusedtopicslimitedtoaparticular
dominal diseases. These principles have been applied organorimagingmodality.Often,thesehavetypically
to the full range of imaging modalities – from plain been collections of cases illustrating the range of dis-
films and conventional contrast studies to CT, US in eases affecting that organ or the advantages and lim-
all its modes (endoscopic, laparoscopic, and intra- itations offered by a particular imaging technique.
operative), MRI, and PET-CT – leading to this sixth However, in a clinical setting, patients often present
editionafter34years. in a manner challenging the physician’s thinking
viii (cid:2) Preface to theSixth Edition
patterns: to determine not only ‘‘what?’’ but ‘‘how?’’ explainwhathaslongbeenthoughtofasillogicaland
and‘‘why?’’and‘‘where?’’ mysterious circumstances. On this basis, the role of
Thefirsteditionwashailedas‘‘thebookthatrevo- diagnosticimagingisvastlyextended.
lutionized abdominal radiology.’’ One reviewer Manynewchaptersmeticulouslydetailthepattern
enthused:‘‘Inliteraturetherearefavorite64thousand oflymphaticspreadofcancerfromprimaryorgansin
dollar questions, namely, which three books would a theabdomenandpelvis.ChusilpCharnsangavejillus-
manchooseifhehadtolivealoneonadesertedisland. trates exquisitely precise identification based on ana-
If one narrows the field to radiological abdominal lysis of huge clinical material at the M.D. Anderson
texts, I wouldn’t hesitate to take Meyers’ Dynamic CancerCenterinHouston.
Radiology of the Abdomen...The book would be an With a known primary lesion, it may be critical to
intellectual challenge that would make the loneliness anticipatethelikelysitesofspread.Ontheotherhand,
bearable.’’Anauthor’spridethatcriticalinsightshad apatientmaypresentwithalesionataremotesite,in
been formulated was furthered by another reviewer’s whichcaseitbecomesimportanttothinkbackwardin
tribute: ‘‘MortonMeyershasopenedupawholenew ordertorevealtheoccultprimarysite.Charnsangavej
worldformanyofus...Meyersontheabdomenislike shows that an intimate knowledge of the vascular
Armstrongonthemoon.’’ distributions characteristic of each organ provides
Whilehewingtothefundamentaltheme, thissixth the template for identifying its lymphatic pathways.
editionisnotsimplyarevision,notmerelyacompen- He emphasizesthat the benefitsof understandingthe
diumoftheobservationsandexperiencesreportedby pathways of lymphatic drainage of each individual
others.Rather,itisdecidedlyavirtuallynewpresenta- organ are threefold. First, when the primary site of
tion. Its authorship has been enlarged by two inter- thetumorisknown,itallowspreciseidentificationof
national authorities who have pioneered ground- theexpectedsitesofnodalmetastasesbyfollowingthe
breaking perspectives in the precise recognition of a arterial supply or venous drainage in the ligaments,
wide spectrum of intraabdominal disease processes. mesentery,ormesocolonattachedtothatorgan.Sec-
To satisfy these aims, completely new chapters have ond, when the primary site of tumor is not clinically
beenaddedandothershavebeenextensivelyupdated known, identifying abnormal nodes allows tracking
andenlarged.Thiseditionincludesmorethan680new the arterial supply or venous drainage in that region
imagesandillustrations. totheprimarysource.Third,italsoallowsidentifica-
The insights introduced by Morton Meyers in the tion ofthe expected site ofrecurrentdiseaseor nodal
first edition and developed over the subsequent edi- metastasis or the pattern of disease progression after
tionsensuredthecriticalpositionoftheradiologistin treatment bylooking at the nodal station beyondthe
establishingthediagnosis,oftenredirectingthecourse treated site. Accurate assessment is crucial for plan-
of investigation, and in indicating the prognosis and ning treatment regarding neoadjuvant therapy and
determining the management. Clearly established are surgeryandmayimpacttheoutcomeoftreatment.
thedynamicsandpathwaysofspreadandlocalization Additional value is occasionally encountered. An
ofintraperitonealinfectionsandmalignancies,andthe incidentally noted abnormal-appearing lymph node
anatomic–pathologic delineation of the three extra- not in the expected pathway from a known primary
peritoneal spaces. What had been woefully described sitemaybediscountedtorepresentametastasis.And
as a ‘‘hinterland of straggling mesenchyme with its today, with increased patient longevity achieved fol-
shadowy fascial boundaries’’ is now seen as clearly lowingtreatmentofaprimarycancer,secondandeven
demarcated compartments with pathognomonic third primaries may arise. In this setting, if a lymph
features. node metastasis is identified at a distant site, knowl-
Asusefulasthesehavebeen,muchhasbeengained edgeofthepathwaysofspreadmayhelpinaccurately
bybroadeningavisiontoencompassglobalanatomic determiningtheparticularprimarysitefromwhichthe
continuitythroughouttheabdomenandpelvis:justas recurrencehastakenorigin.
aloopofribbontwistedonceorseveraltimes,asina As in previous editions, great care has been taken
Mo¨bius strip, yields a structure with continuity of withthelayouttogiveprominencetoselectedillustra-
planes. The unifying concept of the subperitoneal tionsand,mostimportantly,topositionthefiguresas
space of the abdomen and pelvis devised and refined closely as possible to their citation in the text so that
by Michael Oliphant and colleagues in the scientific thereader’stimeandeffortarenotwastedreferringto
literature, including the fifth edition, is here now ele- pagessomedistanceapart.
gantly elaborated for clinical applications. It serves The color images detail anatomic features of clin-
bothtoilluminatethepotentialofbidirectionalspread icalsignificance.
of disease – predominantly cancer but also benign Thereferenceshavebeenexpandedandcontinueto
conditions, e.g., inflammation and trauma – and to includebothclassicarticlesandrecentcitations.They
Preface to theSixth Edition (cid:2) ix
are not restricted to the English language and, when (cid:2) Drs. Maarten S. van Leeuwen and Michiel A.M.
pertinent,refertotheoriginaldescriptions.Alengthy Feldberg of the University Medical Center,
indexwithcross-referencesprovidesimmediateaccess Utrecht, The Netherlands, who contributed the
tothedetailedmaterialpresented. section on Compartmentalization of the Anterior
We wish to express our gratitude to the contribut- PararenalSpaceinChapter6.
ingauthorswhohaveaddedlustertothisedition:
We also wish to thank Dr. Jae Hoon Lim for his
(cid:2) Drs. Yong Ho Auh of the Weill Cornell Medical generouscooperationinprovidingmanystate-of-the-
College – New York Presbyterian Hospital, New art images depicting extraperitoneal anatomy and
York City; Jae Hoon Lim of the Sungkyunkwan pathology.
UniversitySchoolofMedicine,SamsungMedical We have submitted this manuscript to Springer,
Center, Seoul, Korea; and Sophia T. Kung of confidentthattheirskillshaveproducedanotheredi-
the Weill Cornell Medical College – New York tionofhightechnicalquality.
Presbyterian Hospital, who contributed Chapter
7onTheExtraperitonealPelvicCompartments;
MortonA.Meyers,M.D.,F.A.C.R,F.A.C.G.
StonyBrook,NewYork
ChusilpCharnsangavej,M.D.,F.S.I.R.
Houston,Texas
MichaelOliphant,M.D.,F.A.C.R.
Winston-Salem,NorthCarolina
Contents
PrefacetotheSixthEdition .................................................................. vii
1 ANewParadigm ................................................................... 1
References........................................................................ 7
2 ClinicalEmbryologyoftheAbdomen.................................................... 9
Introduction....................................................................... 9
EarlyEmbryonicDevelopment......................................................... 9
ThoracoabdominalContinuum......................................................... 10
SubperitonealSpace................................................................. 12
VentralMesenterySpecialization .................................................... 13
DorsalMesenterySpecialization..................................................... 14
PelvicSpecialization .............................................................. 18
EmbryologyofSpecificOrgans ........................................................ 19
EmbryologicRotationandFixationoftheGut......................................... 19
HepatobiliarySystem ............................................................. 20
Pancreas ....................................................................... 21
Spleen ......................................................................... 21
AdrenalGlands.................................................................. 21
UrinarySystem.................................................................. 21
References........................................................................ 22
3 ClinicalAnatomyoftheAbdomen ...................................................... 23
Introduction....................................................................... 23
TheFundamentalConceptoftheSubperitonealSpace....................................... 23
TheSubperitonealSpace ............................................................. 23
xii (cid:2) Contents
VentralMesogastricDerivatives..................................................... 24
DorsalMesogastricDerivatives ..................................................... 25
DorsalMesenteryDerivatives....................................................... 26
ContinuitywiththeFemaleOrgans .................................................. 29
CentralandLateralContinuity...................................................... 29
AnteriorContinuity .............................................................. 30
PelvicContinuity................................................................. 30
ThoracoabdominalContinuum......................................................... 31
ImagingFeatures................................................................... 32
ThePeritonealCavity ............................................................... 32
References........................................................................ 40
4 MechanismsofSpreadofDiseaseintheAbdomenandPelvis ................................. 41
Introduction....................................................................... 41
DistinguishingIntraperitonealSpreadfromSubperitonealSpread.............................. 42
SubperitonealSpreadAlongMesentericPlanes............................................ 44
SubperitonealSpreadbyLymphaticsandLymphNodeMetastasis............................. 55
SubperitonealSpreadbyPeriarterialandPerineuralSpread.................................. 55
SubperitonealSpreadbyTransvenousSpread ............................................. 55
SubperitonealSpreadbyIntraductalSpread .............................................. 66
Summary......................................................................... 67
References........................................................................ 67
5 IntraperitonealSpreadofInfectionsandSeededMetastases .................................. 69
IntraperitonealInfections:PathwaysofSpreadandLocalization .............................. 69
AnatomicConsiderations............................................................. 69
ThePosteriorPeritonealAttachments ................................................ 69
TheRightSubhepaticSpace......................................................... 71
TheRightSubphrenicSpace......................................................... 72
TheLeftSubphrenicSpace.......................................................... 72
TheLesserSac.................................................................... 73
RadiologicFeatures................................................................. 76
TheSpreadandLocalizationofIntraperitonealAbscesses ................................ 76
PelvicAbscesses .................................................................. 77
RightSubhepaticandSubphrenicAbscesses ............................................ 77
HydrostaticConsideration......................................................... 82
LesserSacAbscesses............................................................... 83
LeftSubphrenicAbscesses .......................................................... 83
SummaryofPathways............................................................. 87
IntraperitonealSeeding:PathwaysofSpreadandLocalization................................ 87
PathwaysofAsciticFlow............................................................. 88
SeededSites....................................................................... 89
PouchofDouglas(RectosigmoidJunction):RadiologicFeatures........................... 89
LowerSmallBowelMesentery(TerminalIleumandCecum):RadiologicFeatures ............. 91
SigmoidColon:RadiologicFeatures ................................................. 92
RightParacolicGutter(CecumandAscendingColon)andMorison’sPouch:
RadiologicFeatures .............................................................. 96
SeededPerihepaticandSubdiaphragmaticMetastases.................................... 96
Contents (cid:2) xiii
SeededMetastasesontheGreaterOmentum........................................... 103
TwoUnusualSitesofPeritonealCarcinomatosis........................................ 103
SisterMaryJoseph’sNodule ........................................................ 103
KrukenbergTumors............................................................... 104
MimicryofCarcinomatosis......................................................... 105
Instrumental,Operative,andNeedleTrackSeeding ..................................... 105
References........................................................................ 105
6 TheExtraperitonealSpaces:NormalandPathologicAnatomy ................................ 109
Introduction....................................................................... 109
AnatomicConsiderations............................................................. 110
TheThreeExtraperitonealCompartmentsandPerirenalFasciae ........................... 110
ThePsoasMuscle ................................................................ 125
TheHepaticandSplenicAngles..................................................... 128
AnteriorPararenalSpace ............................................................ 128
RoentgenAnatomyofDistributionandLocalizationofCollections......................... 128
SourcesofEffusions .............................................................. 128
ExtraperitonealPerforationsoftheColonandAppendix.................................. 130
PerforationoftheDuodenum........................................................ 131
RetroduodenalandIntramuralDuodenalHematoma..................................... 132
Pancreatitis ...................................................................... 132
BleedingfromBareAreaofSpleen,SplenicArtery,orHepaticArtery........................ 147
PelvicandMesentericContinuities.................................................... 151
CompartmentalizationoftheAnteriorPararenalSpace...................................... 151
MaartenS.vanLeeuwen,M.D.,Ph.D.,MichielA.M.Feldberg,M.D.,Ph.D
FusionalFasciae ................................................................. 151
NormalImagingFeatures.......................................................... 152
AbnormalImagingFeatures........................................................ 152
PerirenalSpace .................................................................... 158
RoentgenAnatomyofDistributionandLocalizationofCollections......................... 158
SourcesofEffusions............................................................... 158
PerirenalGas-ProducingInfection.................................................... 160
PerirenalAbscess ................................................................. 165
UriniferousPerirenalPseudocyst(Urinoma)............................................ 169
EtiologyandPathogenesis......................................................... 169
ClinicalSignsandSymptoms....................................................... 170
RadiologicFindings.............................................................. 170
Treatment ..................................................................... 172
DistinctionBetweenPerirenalandSubcapsularCollections ................................ 172
AnatomicConsiderations.......................................................... 175
EtiologyandPathogenesis......................................................... 175
ClinicalSignsandSymptoms....................................................... 176
RadiologicFindings.............................................................. 177
BridgingRenalSepta............................................................. 179
Treatment ..................................................................... 179
PerirenalLymphoma .............................................................. 181
PerirenalRetroperitonealFibrosis.................................................... 182
PerirenalExtramedullaryHematopoiesis............................................... 182
PerirenalMetastases............................................................... 182
PosteriorPararenalSpace............................................................ 183
RoentgenAnatomyofDistributionandLocalizationofCollections......................... 183