Ultrasound Diagnosis of Digestive Diseases

735 Pages·1996·48.8 MB·English

by  Francis S. Weill (auth.)

F. S. Weill· Ultrasound Diagnosis of Digestive Diseases
Springer
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Francis S. Weill
Ultrasound Diagnosis
of Digestive Diseases
With Contributions by
J.
M. Lafortune Y. Menu G. R. Schmutz P. Valette
Fourth Revised Edition
with 969 Figures in 2651 Separate Illustrations,
Some in Color and 27 Tables
Springer
Francis S. Weill
Professor of Radiology (Emeritus)
La Combe d' AroUes
35, rue du Comte de Montbeliard, 25660 Montfaucon, France
Michel Lafortune, M. D. Yves Menu, M. D.
Professor of Radiology Professor of Radiology
Dept. of Radiology, Hospital St. Luc Dept. of Radiology, Hospital Beaujon
1058, rue St. Denis, 100, Boulevard du General Leclerc,
Montreal, H2X3J4, Canada 92118 Clichy, France
Gerard R. Schmutz, M. D. Pierre Jean Valette, M. D.
Professor of Radiology Professor of Radiology
Dept. of Diagnostic Radiology, C. H. U. S. Dept. of Radiology, Hospital Ed. Herriot
3001, 12th Avenue North, Place d' Arsonval, 69003 Lyon, France
Sherbrooke, Quebec, JIH5N4, Canada
Library of Congress Cataloging-in-Publication Data
Weill, Francis S., 1933-. [Ultrasonographie en pathologie digestive. English] Ultrasound diagnosis of
digestive diseases / Francis S. Weill ; with contributions by M. Lafortune ... [et al.]. - 4th rev. ed.
p. cm. Includes bibliographical references and index.
ISBN-13: 978-3-642-64669-0 e-ISBN-13: 978-3-642-61045-5
DOl: 10.1007/978-3-642-61045-5
1. Digestive organs - Ultrasonic imaging. 2. Digestive organs - Diseases - Diagnosis. I. Title. [DNLM:
1.Digestive System Diseases - ultrasonography. WI 141 W422u 1996a) RC804.U4W4413 1996.
616.3'07543 - dc20. DNML/DLC 95-39184
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© Springer-Verlag Berlin Heidelberg 1990, 1996
Softcover reprint of the hardcover 4st edition 1990
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SPIN 10484840 21/3135-543210 - Printed on acid-free paper
The first edition of this work contained the following dedication:
"To my everloving wife, who said that if I ever dared
write another book, she would fly to Honolulu.
That was a mistake: I will."
Alas! Neither of us will, or, as you might pun in English
"Oh, no, Lulu!"
Preface
The 18 years which have elapsed since the first edition of this book was published
in 1978 have indeed been a long and eventful period in the life of the still young and
rapidly evolving imaging procedure of ultrasonography. Eighteen years ago real
time ultrasonography was only a few years old, and employed in few institutions;
most at that time were still faithful to the primary technique of manual scanning, of
which the reader will find some historical examples in the following pages of this
book. Doppler ultrasonography was not an imaging procedure and represented a
speciality within a speciality; the quality of images was far from the high standard
currently achieved. Even during the process of preparing this fourth edition, new
developments were becoming available, some still needing extensive clinical evalu
ation - this will be for the fifth edition. Improved signal processing, angle nonde
pendent flow display, and sensitive color Doppler imaging are new advances in the
quality of conventional and flow images; ultrasonic contrast media will improve the
specificity of lesional images and enhance Doppler imaging; three-dimensional
imaging, and the new endoscopic probes designed for intradigestive or intravascu
lar use are already producing good diagnostic results. Interventional ultrasonogra
phy is being developed in parallel, enabling one not only to carry out biopsies, but
also to place therapeutic agents within lesions.
Thus the need for general and specialized training and for technical and clinical
teaching is greater than ever, in sophisticated institutions and in the modest facil
ities of developing countries, where ultrasonography has become an essential diag
nostic modality.
Moreover, diagnostic ultrasonography is facing competition from other high-tech
procedures, such as computed tomography (CT) and magnetic resonance imaging
(MRI), which are themselves a undergoing phase of accelerated technical evolu
tion. The results of such procedures are superior to those of ultrasonography in
some abdominal applications. However, I remain convinced that neither CT nor
MRI can be used rationally in an environment devoid of ultrasound. A physical
examination extended by the use of ultrasound should remain the first step in the
patient's management, particularly in the emergency room - and often no other
step will be necessary. Many specialized ultrasound techniques are currently with
out competition - endoscopic ultrasound in the diagnosis of choledochal lithiasis,
or peroperative and endoscopic ultrasound in the diagnosis of pancreatic endo
crine tumors, for instance.
Ultimately the aim of this book remains what is was in 1978: to facilitate the training
of new sonologists; their long period of training can be shortened by use of a clear
methodology and an adequate array of pathologic examples which practice does
not necessarily offer during a limited period of training, sometimes far distant from
a specialized teaching center. I also hope to make ultrasound images more familiar
to radiologists, internists, gastroenterologists, surgeons, and other interested spe
cialists; whether or not they use sonography directly, they should at least be familiar
with diagnostic images.
VIII Preface
It is obvious that, if the future of diagnostic ultrasonography is to be guaranteed,
we must also be mindful of its past. This means that, as before, we must pay re
spectful tribute to the clinical pioneers: Dr. John Wild, to whom I had the honor
and privilege, as acting president at the time, of presenting an award on behalf of
the World Federation of Societies for Ultrasound in Medicine and Biology, on the
occasion of the 1991 World Congress in Copenhagen; to Dr. Joseph Holmes of
Denver, and to Dr. Ian Donald of Glasgow, both now no longer with us.
April 1996 Francis S. Weill
Contents
Part 1 Chapter 3. Examination Methods
General Principles and Positioning ....................... 41
Preparation of the Patient ............... 41
Chapter 1. Principles of Ultrasonography Positions and Scanning Planes ........... 41
and Types of Ultrasound Imaging ........ 3 Ultrasonically Guided Biopsy and Drainage 42
Choice of Ultrasound Equipment ........ 44
Principles of Ultrasound Laminagraphy ... 3
Documentation ....................... 44
Static Scanning (Contact) ............... 5
Who Should Conduct the Examination? ... 45
Dynamic Real-Time hpaging ............ 8
References and Further Reading ......... 45
Mechanical Scanners ................. 8
Arrays (Linear, Curved, Phased) ....... 8
Contact Scanning and Real-Time Scanning. 12
Interventional Sonology .............. 12 Chapter 4. An Anatomic Guide
Spatial Resolution ................... 12 in the Examination of the Upper Abdomen:
Contrast Resolution ................. 16 Echoangiography ..................... 47
Three-Dimensional Imaging ............ 18
The Aorta ............................ 47
Doppler Imaging
Branches of the Aorta ................ 51
(Pulsed Doppler, Duplex-Doppler) ........ 19
The Vena Cava ........................ 60
Color Doppler Scanning .............. 21
Branches of the Vena Cava ............ 67
Color Coding Without Doppler ........ 21
The Portal System ..................... 71
Expected Improvements in
References and Further Reading ......... 79
Doppler Imaging .................... 21
References and Further Reading ......... 22
Part 2
Chapter 2. Types of Tissue Echo Pattern
The Liver
and Artifacts ......................... 23
Contour Images ....................... 23 Chapter 5. Examination Techniques 83
Tissue Images ......................... 23
Choice of Techniques ................... 83
Liquid and Solid Regions ............. 23
Failures ............................ 83
Semisolid (or "Complex") Echotexture .. 26
Views and Patient Positions ............. 83
Tissue Identification or Characterization
Preparation of the Patient ............... 90
with Contrast Agents. . . . . . . . . . . . . . . . . . . . 27
Doppler Examination .................. 90
Tubular Images ........................ 28
Perendoscopic and
Artifacts ............................. 28
Laparoscopic Ultrasound ............... 90
Acoustic Shadowing ................. 30
Ultrasonographically Guided Biopsy . . . . . . 90
Other Artifacts ...................... 33
References and Further Reading ......... 91
Artifacts in Doppler ................. 37
References and Further Reading ......... 39
X Contents
Chapter 6. Sonoanatomy of the Liver 93 Chapter 9. Primary Tumors of the Liver
and Ultrasonographic Follow-up
General Shape and Contours ........... . 93
of Liver Transplantation ............... . 157
Contours .......................... . 93
Size .............................. . 106 Section 1. Primary Tumors of the Liver ... . 157
Hepatic Parenchyma .................. . 107
Malignant Tumors .................... . 157
Tubular Structures .................... . 107
Hepatocellular Carcinomas and
Sectorial and Segmental Anatomy ....... . 110
Fibrolamellar Hepatocarcinomas ..... . 157
Ultrasonographic Anatomic Relations ... . 117
Pathology ....................... . 157
Conclusion .......................... . 117
Diagnosis of Spread and Screening .. . 163
References and Further Reading ........ . 118
Rare Malignant Tumors ............. . 166
Interventional Sonology and Radiology
Chapter 7. Hepatomegaly and in Hepatocarcinoma ................ . 166
Benign Tumors ....................... . 166
Diffuse Liver Diseases ................. . 119
Adenoma ......................... . 167
The Criteria for Hepatomegaly .......... . 119 Focal Nodular Hyperplasia ........... . 170
Relations of the Liver to the Costal Hamartomas ...................... . 171
Margin; Angle and Tangent Signs ..... . 119 Cystadenomas ..................... . 171
Nonspecific Hepatomegaly ............. . 121 Lipomas and Angiomyolipomas ...... . 171
Cardiac Liver ...................... . 121 Vascular Tumors ................... . 172
Hepatitis .......................... . 124
Congenital Fibrosis ................. . 125
Section 2. Ultrasonographic Follow-up
Other Nonspecific Hepatomegalies .... . 126
of Transplanted Livers ................. . 178
Storage Diseases ................... . 126
References and Further Reading ........ . 129 Morphologic Evaluation ............... . 179
Parenchyma and Bile Ducts .......... . 179
Vessels ............................ . 182
Chapter 8. Metastases ................. . 131
References and Further Reading ........ . 186
Technical Data ....................... . 131
Elementary Signs ..................... . 131
Contour Abnormalities .............. . 131
Chapter 10. Cirrhosis and
Changes in Echotexture ..... , ....... . 133
Portal Hypertension .................. . 191
Nodules ........................ . 133
Ductal Abnormalities ............. . 142 Section 1. Morphologic Changes
Discussion of the Elementary Signs ...... . 142 of Cirrhosis and Portal Hypertension .... . 191
The Bump Sign ..................... . 142
Morphologic Appearances of Cirrhosis ... . 191
The Margin Sign ................... . 142
Hepatomegaly and the Bright Liver .... . 191
Hypoechoic Regions ................ . 142
Steatosis, Fibrosis, and
Hyperechoic Regions ............... . 144
Hepatic Retraction ................. . 192
Global Ultrasound Features
Associated Abnormalities .............. . 201
of Hepatic Metastases ................. . 146
Splenomegaly ...................... . 201
Solitary Nodules ................... . 146
Ascites ............................ . 201
Multiple Nodules ................... . 147
Jaundice .......................... . 201
Histologic Correlations ................ . 148
Hepatocarcinoma .................. . 203
Lymphomas ......................... . 149
Portal Hypertension .................. . 203
Hepatic Signs ...................... . 149
Etiologic Factors in Portal Thrombosis .. 206
Associated Signs ................... . 149
Budd -Chiari -Syndrome
Metastases and Chemotherapy .......... . 152
and Veno-Occlusive Disease .......... . 206
Interventional Sonology ............... . 152
Differential Diagnosis ................. . 208
Differential Diagnosis ................. . 152
Reliability of Ultrasound -
Association with Other Procedures ...... . 153
References and Further Reading ........ . 154
Contents XI
Section 2. Doppler Ultrasound and Chapter 13. The Postoperative Liver ...... 269
the Portal Venous System
References and Further Reading ......... 275
(M. Lafortune) ........................ 208
Introduction .......................... 208
Anatomy of the Portal Venous System ..... 208
Chapter 14. Juxtahepatic Liquid Collections
Physiology of the Portal Circulation ...... 209
and Ascites;
Portal Hypertension ................... 210
Sonoanatomy of the Peritoneum ......... 277
Definition .......................... 210
Pathophysiology .................... 210 Juxtahepatic Collections ................ 277
Technique of Doppler Examination. . .. . .. 211 Subcapsular Collections .............. 277
Doppler Flow Volume Measurements ... 214 Subdiaphragmatic Collections ......... 279
Normal Doppler Patterns ............. 214 Supradiaphragmatic Collections ....... 284
Doppler in Portal Hypertension .......... 214 Peritoneal Effusions .................... 284
Prehepatic Portal Hypertension. . . . . . .. 214 Small Effusions and the Anatomy of
Portal Hypertension of Hepatic Origin .. 217 the Ligaments and Peritoneal Recesses .. 284
Posthepatic Portal Hypertension ....... 219 Peritoneal Anatomy: Comparison of
Surgical Porto systemic Shunts ........... 219 Ultrasound and Computed Tomography 305
Nonsurgical Porto systemic Shunts ....... 221 Abundant Ascites .................... 305
References and Further Reading ......... 222 Rare (and Less Rare) Types of Ascites ... 312
Pneumoperitoneum ................. 312
Other Autonomous Peritoneal Diseases 313
References and Further Reading ......... 314
Chapter 11. Abscesses, Cysts,
and Parasitoses ....................... 227
Abscesses ............................ 227
Bacterial Abscesses .................. 227
Part 3
Amebic Abscesses ................... 233
The Bile Ducts
Mycotic (Aspergillic) Abscesses ........ 233
Tuberculous Abscesses ............... 235
Chapter 15. The Bile Ducts: Examination
Congenital Cysts and Biliary Cysts ........ 235
Techniques and Sonoanatomy ........... 319
Parasitic Cysts ...................... 243
The Common Hydatid Cyst ........... 243 Examination Techniques ................ 319
Multilocular Echinococcosis .......... 251 Gallbladder ......................... 319
Other Parasitoses of the Liver ......... 256 Main Bile Duct ...................... 320
References and Further Reading ......... 257 Intrahepatic Bile Ducts ............ 320
c. ••
Interventional Sonology ................ 321
Perendoscopic Ultrasonography (PERUS) 321
Sonoanatomy ......................... 321
Chapter 12. Differential Diagnosis ....... 259
Gallbladder ......................... 321
Confusing Juxtahepatic Images .......... 259 Main Bile Duct ...................... 335
Hypoechoic Images .................. 259 Biliary Convergence
HyperechoicImages ................. 259 and Intrahepatic Bile Ducts ........... 337
Confusing Anatomic Intrahepatic Images 259 References and Further Reading ......... 338
Hypoechoic Anatomic Images ......... 259
Hyperechoic Anatomic Images ........ 262
Contour Images ..................... 263
Chapter 16. Biliary Lithiasis and
Diagnosis of Liver Diseases ............. 263
Cholecystitis .......................... 341
Characterization of a Hepatic Mass
(M. Lafortune) ........................ 265 Gallstones ............................ 341
Benign Lesions ...................... 266 Direct Sign ......................... 341
Malignant Tumors ................... 266 Indirect Sign. . . . . . . . . . . . . . . . . . . . . . .. 351
References and Further Reading ......... 267 Differential Diagnosis and Pitfalls ...... 352