Ebook Diagnostic medical sonography - Abdomen and superficial structures (3rd edition): Part 1

(BQ) Part 1 book Diagnostic medical sonography - Abdomen and superficial structures presents the following contents: The abdominal wall and diaphragm, the peritoneal cavity, vascular structures, the gallbladder and biliary system, the pancreas, the gastrointestinal tract, the lower urinary system, the prostate gland,...

Diagnostic Medical Sonography ABDOMEN AND SUPERFICIAL STRUCTURES Diagnostic Medical Sonography ABDOMEN AND SUPERFICIAL STRUCTURES Third Edition Diane M Kawamura, PhD, RT(R), RDMS Professor, Radiologic Sciences, Weber State University Ogden, UT Bridgette M Lunsford, MAEd, RVT, RDMS GE Healthcare - Ultrasound Arlington, VA Publisher: Julie K Stegman Senior Product Manager: Heather Rybacki Product Manager: Kristin Royer Marketing Manager: Shauna Kelley Design Coordinator: Joan Wendt Art Director: Jennifer Clements Manufacturing Coordinator: Margie Orzech Production Services: Absolute Service, Inc Copyright © 2012 by Lippincott Williams & Wilkins, a Wolters Kluwer business 351 West Camden Street Baltimore, MD 21201 Two Commerce Square 2001 Market Street Philadelphia, PA 19103 Third Edition All rights reserved This book is protected by copyright No part of it may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in the book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright Printed in China Library of Congress Cataloging-in-Publication Data Diagnostic medical sonography Abdomen and superficial structures / edited by Diane M Kawamura, Bridgette M Lunsford 3rd ed p ; cm Abdomen and superficial structures Rev ed of: Abdomen and superficial structures / edited by Diane M Kawamura 2nd ed c1997 Includes bibliographical references and index ISBN 978-1-60547-995-8 (alk paper) I Kawamura, Diane M II Lunsford, Bridgette M III Title: Abdomen and superficial structures [DNLM: Abdomen ultrasonography Digestive System ultrasonography Ultrasonography methods Urogenital System ultrasonography WI 900] 617.5’5075 dc23 2011045980 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect to the contents of the publication Application of the information in a particular situation remains the professional responsibility of the practitioner The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This is particularly important when the recommended agent is a new or infrequently employed drug Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings It is the responsibility of the health care providers to ascertain the FDA status of each drug or device planned for use in their clinical practice To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320 International customers should call (301) 223-2300 Visit Lippincott Williams & Wilkins on the Internet at LWW.com Lippincott Williams & Wilkins customer service representatives are available from 8:30 AM to 6:00 PM, EST 10 To my husband, Bryan, for providing me with confidence, for supporting my professional endeavors, for giving of himself to help me, and for being my favorite companion and best friend To our wonderful children, Stephanie and Nathan, who continue to inspire me to appreciate how important it is to learn new things To all my colleagues on campus and in the profession who provide encouragement, support, and stimulating new challenges Diane M Kawamura To my husband, James, with love and gratitude for his constant support, encouragement, patience, and understanding without which I would not have had the courage to take on this task To my family for instilling a love of learning and supporting me in all of my endeavors To my colleagues at GE from whom I have learned so much and who continue to inspire me on a daily basis to expand my knowledge and take on new challenges Bridgette M Lunsford And to students and professionals who will use this book: “Any piece of knowledge I acquire today has a value at this moment exactly proportioned to my skill to deal with it Tomorrow, when I know more, I recall that piece of knowledge and use it better.” —Mark Van Doren, Liberal Education (1960) DMK, BML Contents Introduction Diane M Kawamura PART • ABDOMINAL SONOGRAPHY The Abdominal Wall and Diaphragm 13 Terri L Jurkiewicz The Peritoneal Cavity 39 Joie Burns Vascular Structures .57 Kathleen Marie Hannon The Liver 101 Joyce A Grube The Gallbladder and Biliary System 165 Teresa M Bieker The Pancreas 207 Julia A Drose The Spleen 225 Tanya D Nolan The Gastrointestinal Tract 243 John F Trombly 10 The Kidneys .265 Cathie Scholl 11 The Lower Urinary System 341 Bridgette M Lunsford • Christine Schara 12 The Prostate Gland 367 George M Kennedy 13 The Adrenal Glands 389 Kari E Boyce 14 The Retroperitoneum 419 Joie Burns PART • SUPERFICIAL STRUCTURE SONOGRAPHY 15 The Thyroid Gland, Parathyroid Glands, and Neck 435 Diane M Kawamura • Janice L McGinnis 16 The Breast 471 Catherine Carr-Hoefer vii viii CONTENTS 17 The Scrotum 529 Wayne C Leonhardt • Zulfikarali H Lalani 18 The Musculoskeletal System 571 Patrick R Meyers PART • NEONATAL AND PEDIATRIC SONOGRAPHY 19 The Pediatric Abdomen 633 Bridgette M Lunsford • Regina K Swearengin 20 The Pediatric Urinary System and Adrenal Glands 677 Bridgette M Lunsford • Heidi S Barrett 21 The Neonatal Brain 707 Monica M Bacani 22 The Infant Spine .735 Rechelle A Nguyen 23 The Infant Hip Joint 749 Charlotte Henningsen PART • SPECIAL STUDY SONOGRAPHY 24 Organ Transplantation .759 Kevin D Evans 25 Emergency Sonography 777 J P Moreland • Michelle Wilson 26 Foreign Bodies 791 Tim S Gibbs 27 Sonography-Guided Interventional Procedures 807 Aubrey J Rybyinski Index 825 13 — The Adrenal Glands information regarding presence of adrenal masses, adjacent lymphadenopathy, and for staging lung cancers, which commonly metastasize to the adrenal glands.5,69 Gastric and duodenal windows are used to image with to 7.5 MHz radial, linear, and/or curvilinear transducers.5,69 This technique can place the transducer as close as to cm from gland As a result, the acoustic appearance of a normal adrenal gland is that of seagullshaped hyperechoic medullary echoes against the hypoechoic cortical echoes and the hyperechoic halo of fatty tissue.17,69 Guidance of fine needle aspiration of adrenal lesions can also be performed using this endoscopic approach (EUS-FNA).69,72 EUS-FNA is used to differentiate benign adrenal masses from metastases or primary adrenal malignancies This is particularly important for preoperative staging of patients with known malignancies, since adrenal glands are common metastatic sites.5,69,72 EUS visualization of the left adrenal from a transgastric approach reaches 98%, while it has been reported that imaging the right adrenal gland from a transduodenal window is only successful 30% of the time with a mechanical radial transducer.73 Others have had improved the success for visualizing and performing EUSFNA on the right adrenal by instead using a curvilinear transducer.69,74 EUS is minimally invasive and has minimal complications for the patient.5,69,72,74,75 Limitations of EUS for adrenal imaging rests with the experience and motivation of the specialists who use this technology.5,17,69,72,74 INTRAOPERATIVE ULTRASOUND High-frequency IOUS is also used with a variety of laparoscopic (LIOUS) and open surgery settings.4,75,76 Benefits of LIOUS concurrent with laparoscopic adrenalectomies are numerous These include improved localization and guidance of complete and partial adrenalectomies, reduced blood loss due to improved vascular visualization, identification of adjacent tumor infiltration, metastases and lymphadenopathy, fewer complications, and shorter time to recovery.4,58,75,76 Drawbacks to laparoscopic adrenalectomies with LIOUS are an increase in procedure duration, steep learning curve for physicians, and an increase in patient cost for adding LIOUS.4,58,76 SUMMARY • The adrenal cortex and medulla develop from different embryonic tissues and are therefore two functionally distinct endocrine glands within one organ • The adrenal cortex comprises 90% of the gland and produces corticoids including cortisol, aldosterone, estrogen, and androgen 415 • The medulla produces the catecholamines epinephrine and norepinephrine responsible for the body’s fight-or-flight response to stress • The adrenal glands are retroperitoneal and are located anterior, medial, and superior to the kidneys • The right adrenal gland is triangular in shape and is located posterior and lateral to the inferior vena cava, medial to the right lobe of the liver, and lateral to the crus of the diaphragm; the left adrenal gland is larger than the right and is more crescent or semilunar in shape • Adrenal cysts are infrequent and usually asymptomatic, whereas most adrenal cysts are benign, and adrenal cysts with a “ring” calcification are more often malignant • Hemorrhage of the adrenal gland is seen most often in newborns, especially after a difficult delivery but can also be precipitated by adrenal trauma, surgery, stress, anticoagulant therapy, adrenal vein thrombosis, adrenal neoplasms, metastases, or septicemia The right side is involved more often than the left • Addison disease is a condition caused by hyposecretion of adrenocortical hormones and is characterized by fever, fatigue, muscle weakness, hypotension, and gastrointestinal distress such as nausea, vomiting, weight loss, and diarrhea • Cushing syndrome is caused by hypersecretion of the adrenocortical hormone cortisol, which triggers an increase in gluconeogenesis and results in elevated serum glucose levels, protein loss, and hypertension • Conn syndrome is caused by hyperaldosteronism and in 80% to 90% of patients, it results from a benign aldosterone-producing adrenal adenoma • Adrenal adenomas are typically benign, poorly encapsulated tumors to cm in diameter, and consist of lipid-filled cells that not secrete hormones Adenomas greater than cm in size are more likely to be functional and may cause Cushing syndrome • Adrenal myelolipoma is a rare benign tumor of the adrenal cortex composed of fatty tissue that sonographically appears as a well-defined and markedly hyperechoic mass • Adrenal adenocarcinoma occur in the adrenal cortex, often produce steroids, and are usually associated with one of the hyperadrenal syndromes, those that are nonfunctioning are highly malignant • Adenocarcinomas are solid masses larger than most adrenal masses, to cm for hyperfunctioning tumors and Ͼ6 cm for nonfunctioning lesions with a variable echogenicity depending on the degree of hemorrhage and necrosis Nonfunctioning neoplasms appear more complex and hyperechoic, whereas hyperfunctioning masses are more likely to be uniformly hypoechoic 416 PART — ABDOMINAL SONOGRAPHY Critical Thinking Questions A 40-year-old woman presents with right upper quadrant pain after eating for an ultrasound of the abdomen to rule out gallstones You notice a 2-cm, round, homogeneous, solid mass superior to the upper pole of the right kidney This mass appears separate from the kidney The patient has no other complaints What is the most likely diagnosis? Which hormones are secreted by the adrenal cortex and which are secreted by the adrenal medulla? What • Benign and malignant pheochromocytomas arise from the adrenal medulla and have similar sonographic and biochemical characteristics Patients with pheochromocytomas typically present with mild to marked hypertension, headache, sweating, and tachycardia and most have a history of a hereditary endocrine tumor syndrome such as MEN or Von Hippel-Lindau • Pheochromocytomas are usually well encapsulated, ovoid to round, and may be palpable They are highly vascular masses, and if rupture occurs, massive hemorrhage can be fatal They have a highly variable echogenicity ranging from cystic or complex to echogenic with calcifications • Adrenal metastases occur from squamous cell carcinoma of the lung, breast carcinoma, lymphoma, leukemia, melanoma; carcinoma of the gastrointestinal tract, thyroid, pancreas, and kidney; and tend to be bilateral • CT is the modality of choice for evaluating the adrenal glands, but MRI, radionuclide studies, endoscopic ultrasound, and intraoperative ultrasound are also utilized REFERENCES Little AF Adrenal gland and renal sonography World J Surg 2000;24:171–182 Suzuki Y, Sasagawa I, Suzuki H, et al The role of ultrasonography in the detection of adrenal masses: comparison with computed tomography and magnetic resonance imaging Int Urol Nephrol 2001;32:302–306 Wan YL Ultrasonography of the adrenal gland: a review J Med Ultrasound 2007;15(4):213–227 Heniford BT, Iannitti DA, Hale J, et al The role of intraoperative ultrasonography during laparascopic adrenalectomy Surgery 1997;122(6):1068–1074 Kann PH Endoscopic ultrasound imaging of the adrenals Endoscopy 2005;37(3):244–253 Saftoiu A, Vilman P Endoscopic ultrasound elastography–a new imaging technique for the visualization of tissue elasticity distribution J Gastrointestin Liv Dis 2006;15(2):161–165 Slapa RZ, Kasperlik-Zaluska AA, Polanski JA, et al Threedimensional sonography in diagnosis of retroperitoneal type of symptoms would occur with hypersecretion of the cortical hormones? What can cause adrenal hemorrhage in an adult? A 45-year-old male presents for an abdominal ultrasound with severe hypertension, headaches, and a rapid heart rate When examining his left upper quadrant you notice a 5-cm complex mass with internal calcifications that is highly vascular The mass is located superior and medial to the left kidney What are the differential diagnoses for this mass? 10 11 12 13 14 15 16 17 18 19 20 21 hemorrhage from adrenocortical carcinoma J Ultrasound Med 2004;23:1369–1373 Nawar R, Aron D Adrenal incidentalomas—a continuing management dilemma Endoc Relat Cancer 2005;12:585–598 Barwick TD, Malhotra A, Webb JA Embryology of the adrenal glands and its relevance to diagnostic imaging Clin Radiol 2005;60:953–959 Mangray S, DeLellis RA Adrenal embryology and pathology In: Blake MA, Boland G, eds Adrenal Imaging Totowa, NJ: Humana Press; 2009:1–34 Brunt LM, Moley J The pituitary and adrenal glands In: Townsend CM, Beauchamp RD, Evers BM, et al., eds Sabiston’s Textbook of Surgery: The Biological Basis of Modern Surgical Practice 17th ed Philadelphia, PA: Saunders Elsevier; 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1993 28 Winter T Possible Adrenal Mass In: Sanders RC, Winter T, eds Clinical Sonography: A Practical Guide 4th ed Baltimore, MD: Lippincott Williams & Wilkins; 2007: 154–161 29 Weinberg K General abdominal sonography In: Krebs C, Odwin CS, Fleischer AC, eds Appleton & Lange’s Review for the Ultrasonography Examination New York: McGraw-Hill; 2004:187–300 30 Al-Hawary MM, Francis IR, Korobkin M Andrenal imaging using computed tomography: differentiation of adenomas and metastasis In: Blake MA, Boland G, eds Adrenal Imaging Totowa, NJ: Humana Press; 2009:127–140 31 Brant WE Adrenal glands and kidneys In: Brant WE, Helms CA, eds Fundamentals of Diagnostic Radiology 3rd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2007:867–886 32 Kriegshauser JS, Carroll BA The adrenal glands In: Rumack CM, Wilson SR, Charboneau JW, eds Diagnostic Ultrasound 2nd ed St Louis, MO: Mosby; 1997:289–314 33 Mittelstaedt CA Retroperitoneum In: Mittelstaedt CA, ed General Ultrasound New York, NY: Churchill Livingstone; 1992:714–832 34 Goldstein RB Ultrasound evaluation of the fetal abdomen In: Callen PW, ed Ultrasonography in Obstetrics and Gynecology 3rd ed Philadelphia, PA: WB Saunders; 1994: 351–355 35 Frilling A, Tecklenborg K, Weber F, et al Importance of adrenal incidentaloma in patients with a history of malignancy Surgery 2004;136:1289–1296 36 Yeh HC Ultrasound and CT of the adrenals Semin Ultrasound 1982;3:97–113 37 Goldman SM, Coelho RD, Freire Filho E, et al Imaging procedures in adrenal pathology Arq Bras Endocrinol Metabol 2004;48(5):592–611 38 Mitty HA Adrenal disease In: Eisenberg RL, ed Diagnostic Imaging: An Algorithmic Approach Philadelphia, PA: Lippincott Williams & Wilkins; 1988:373–386 39 Robbins SL., Cotran RS Pathologic Basis of Diseases 2nd ed Philadelphia, PA: WB Saunders; 1979 40 Hall R The Ultrasound Handbook: Clinical, Etiologic and Pathologic Implications of Sonographic Findings 3rd ed Philadelphia, PA: Lippincott Williams & Wilkins; 1999 41 Lucey BC Adrenal trauma and intervention In: Blake MA, Boland G, eds Adrenal Imaging Totowa, NJ: Humana Press; 2009:193–204 42 Weissleder R, Wittenberg J, Harisinghani MG Primer of Diagnostic Imaging 5th ed Philadelphia, PA: Mosby Elsevier; 2011:231–234 417 43 Fleischer AC Renal and urological sonography In: Fleisher AC, Kepple DM eds Diagnostic Sonography: Principles and Clinical Applications Philadelphia: WB Saunders; 1995:470–557 44 Dimofte G, Dubei L, Lozneanu L, et al Right adrenal abscess—an unusual complication of acute appendicitis Rom J Gastroenterol 2004;13(3):241–244 45 Kao P, Liu C, Lee C, et al Non-typhi Salmonella adrenal abscess in an HIV-infected patient Scand J Infect Dis 2005;37(5):370–372 46 Uno K, Konishi M, Yoshimoto E, et al Fatal cytomegalovirus-associated adrenal insufficiency in an AIDS patient receiving corticosteroid therapy Intern Med 2007;46(9): 617–620 47 Grover SB, Midha N, Gupta M, et al Imaging spectrum in disseminated histoplasmosis: case report and brief review Australas Radiol 2005;49:175–178 48 Bullock BL Pathophysiology: Adaptations and Alterations in Function 4th ed Philadelphia, PA: JB LippincottRaven; 1996 49 Rockall AG, Babar SA, Sohaib SA CT and MR imaging of ACTH-independent Cushing syndrome Radiographics 2004;24(2):435–452 50 Mayo-Smith WW, Boland GW, Noto RB, et al State-of-theart adrenal imaging Radiographics 2001;21(4):995–1012 51 Sohaib SA, Rockall AG, Reznek RH Imaging functional adrenal disorders Best Prac Res Clin Endocrinol Metab 2005;19(2):293–310 52 Barzon L, Sonino N, Fallo F, et al Prevalence and natural history of adrenal incidentalomas Eur J Endocrinol 2003;149(4):273–285 53 Song JH, Chaudhry FS, Mayo-Smith WW The incidental adrenal mass on CT: prevalence of adrenal disease in 1049 consecutive adrenal masses in patients with no known malignancy AJR Am J Roentgenol 2008;190(5): 1163–1168 54 Johnson PT, Horton KM, Fishman EK Adrenal imaging with multidetector CT: evidence-based protocol optimization and interpretive practice Radiographics 2009;29(5):1319–1331 55 Zarco-González JA, Herrera MF Adrenal incidentaloma Scand J of Surg 2004;93(4):298–301 56 Gross MD, Avram A, Fig LM, et al Contemporary adrenal scintigraphy Eur J Nucl Med Mol Imaging 2007;34(4): 547–557 57 Kloos RT, Gross MD, Francis IR Incidentally discovered adrenal masses Cancer Treat Res 1997;89:286–292 58 Mansmann G, Lau J, Balk E, et al The clinically inapparent adrenal mass: update in diagnosis and management Endocr Rev 2004;25(2):309–340 59 Kenney PJ MRI of the adrenal glands In: Blake MA, Boland G, eds Adrenal Imaging Totowa, NJ: Humana Press; 2009:141–156 60 Yeh HC Ultrasonography of the Adrenal Gland In: Schwartz AE, Pertsemlidis D, Gagner M eds Endocrine Surgery Informa Healthcare:2003 61 Cintron E, Quntero EC, Perez MR, et al Computed tomography, sonographic, and radiographic findings in adrenal myelolipoma Urology 1984;23:608–610 62 Dieckmann KP, Hamm B, Pickartz H, et al Adrenal myelolipoma: clinical, radiologic, and histologic features Urology 1987;29(1):1–8 418 PART — ABDOMINAL SONOGRAPHY 63 Richman TS, Taylor JK, Kremkau FW Propagation speed artifact in fatty tumor (myeloleioma): significance for tissue differential diagnosis J Ultrasound Med 1983;2: 45–47 64 Friedman AC, Hartman MD, Sherman J, et al Computed tomography of abdominal fatty masses Radiology 1981;139(2):415–429 65 Fernández-Cruz L, Puig-Domingo M, Halperin I, et al Pheochromocytoma Scand J Surg 2004;93(4):302–309 66 Remer EM, Miller FH Imaging of pheochromocytomas In: Blake MA, Boland G, eds Adrenal Imaging Totowa, NJ: Humana Press; 2009:129–126 67 Schwerk WB, Görg C, Görg K, et al Adrenal pheochromocytomas: broad spectrum of sonographic presentation J Ultrasound Med 1994;13(7):517–521 68 Schwartz LH, Macari H, Huvos AG, et al Collision tumors of the adrenal gland: demonstration and characterization on MR imaging Radiology 1996;201(3):757–760 69 Eloubeidi MA, Morgan DE, Cerfolio RJ, et al Transduodenal EUS-guided FNA of the right adrenal gland Gastrointestinal Endoscopy 2008;67(3):522–527 70 Scott JA, Palmer EL Single photon imaging of the adrenal gland In: Blake MA, Boland G, eds Adrenal Imaging Totowa, NJ: Humana Press; 2009:127–162 71 Roedl JB, Boland GWL, Blake MA PET and PET-CT imaging of adrenal lesions In: Blake MA, Boland G, eds Adrenal Imaging Totowa, NJ: Humana Press; 2009:173–192 72 Stelow EB, Debol SM, Stanley MW, et al Sampling of the adrenal glands by endoscopic ultrasound-guided fineneedle aspiration Diagn Cytopathol 2005;33(1):26–30 73 Dietrich CF, Wehrmann T, Hoffmann C, et al Detection of the adrenal glands by endoscopic or transabdominal ultrasound Endoscopy 1997;29(9):859–864 74 DeWitt JM Endoscopic ultrasound-guided fine-needle aspiration of right adrenal masses J Ultrasound Med 2008;27(2):261–267 75 Piccolboni D, Ciccone F, Settembre A, et al The role of echolaparoscopy in abdominal surgery: five years’ experience in a dedicated center Surg Endosc 2008;22(1):112–117 76 Lucas SW, Spitz JD, Arregui ME The use of intraoperative ultrasound in laparascopic adrenal surgery: the Saint Vincent experience Surg Endosc 1999;13(11):1093–1098 14 The Retroperitoneum Joie Burns OBJECTIVES Identify the compartments of the retroperitoneum and the fascia that divide them List the muscles, organs, and vessels normally found in each retroperitoneal compartment Differentiate between the location and function of the deep abdominal (parietal) nodes and the superficial (visceral) nodes List the indications for the sonographic evaluation of the retroperitoneum Demonstrate the scanning techniques used to image the retroperitoneum Recognize the role retroperitoneal fascia play in identification and limiting the extent of pathology Describe the six scanning objectives the sonographer should employ when retroperitoneal pathology is identified Differentiate the sonographic appearance of inflammatory and malignant adenopathy Describe the pathology, etiology, clinical signs and symptoms, and sonographic appearance of solid lesions and retroperitoneal fluid collection found in the retroperitoneum Analyze sonographic images of the retroperitoneum for pathology Identify technically satisfactory and unsatisfactory sonographic examinations of the retroperitoneum KEY TERMS abscess | adenopathy | AIDS | fibroma | fibrosarcoma | hematoma | HIV | leiomyoma | leiomyosarcoma | lipoma | liposarcoma | lymphocele | retroperitoneal fibrosis | rhabdomyoma | rhabdomyosarcoma GLOSSARY abscess a pocket of infection typically containing pus, blood, and degenerating tissue adenopathy also called lymphadenopathy; enlargement of lymph nodes due to inflammation, primary neoplasia, or metastasis extravasate fluid, such as blood, bile, or urine, that is forced out or leaks out of its normal vessel into the surrounding tissues or potential spaces HIV human immunodeficiency virus; bloodborne virus that attacks T-lymphocytes resulting in their destruction or impairment eventually leading to AIDS mass effect distortion or displacement of normal anatomy due to a mass, neoplasm, or fluid collection metastasis the spread of cancer from the site at which it first arose to a distant site fascia a thin sheet-like tissue that separates muscles orthogonal planes that are perpendicular or 90 degrees to each other great vessels a term used to describe the aorta and inferior vena cava together primary neoplasm a new growth of benign or malignant origin hematoma an extravasated collection of blood localized within a potential space or tissues urinoma an extravasated urine collection due to a tear of the urinary collecting system 419 420 PART — ABDOMINAL SONOGRAPHY Sonography plays an important role in the examination of the retroperitoneum, as well as the organs and vessels located within the cavity Although computed tomography (CT) is the preferred imaging modality for retroperitoneal neoplasms and adenopathy, the radiation dose delivered to the patient over multiple examinations must be considered Sonography produces high-quality images without ionizing radiation, it can provide realtime biopsy guidance, and it provides safe imaging for follow up of disease progression or resolution The skill and creativity of the sonographer often dictates the quality of the examination produced A thorough knowledge of anatomy, pathophysiology, and sonography physics and instrumentation is required to produce the highest quality of sonographic examination This chapter focuses specifically on the normal anatomy and pathologies found in the retroperitoneum ANATOMY OF THE RETROPERITONEUM The parietal peritoneum is the outermost of two membranes that enclose most of the intra-abdominal contents, including the intestines, liver, pancreatic head, spleen, and pelvic organs The other membrane, the visceral peritoneum, lies in direct apposition to the parietal membrane, thus forming a potential space The area lying behind the peritoneal membrane is referred to as the retroperitoneum The retroperitoneum is a complex abdominal space located between the parietal peritoneum and anterior to the transversalis fascia.1,2 It extends from the diaphragm superiorly to the pelvic brim inferiorly.3–5 RETROPERITONEAL COMPARTMENTS The retroperitoneum is divided into three major compartments or spaces by the anterior and posterior perirenal fascia.6 These retroperitoneal compartments are the anterior pararenal space, the perirenal or perinephric space, and the posterior pararenal space.1,6,7 The fascial planes are fused superiorly but remain unfused caudally The literature frequently refers to both the anterior and posterior as Gerota fascia, although it is more correct to reference the anterior renal fascia as Gerota fascia and the posterior renal fascia as Zuckerkandl fascia.8 The anterior renal fascia courses anterior to the great vessels, kidneys, and adrenal glands and extends across the midline to fuse with the posterior renal fascia laterally The posterior renal fascia fuses with the anterior renal fascia laterally and tracks posterior to the kidney to blend with the anterior layer of the thoracolumbar fascia and the psoas fascial sheath medially An understanding of the retroperitoneal fascia is important to define the retroperitoneal compartments (Fig 14-1A,B) Anterior Pararenal Space The anterior pararenal space is bordered anteriorly by the posterior parietal peritoneum and posteriorly by the anterior perirenal fascia.6 The space communicates with the opposite side around the pancreas.1 Inferiorly, this space communicates with the extraperitoneal space of the pelvis and the posterior pararenal space.9 The communication is important because it allows cells and fluid to travel between the two spaces Along with a variable amount of fat, some portions of the digestive organs are embedded in this layer including the pancreas; distal common bile duct; the second, third, and fourth parts of the duodenum; and the ascending and descending colon.10 Perirenal or Perinephric Space The perirenal space is bordered anteriorly by the anterior renal fascia and posteriorly by the posterior renal fascia Superiorly, the fascias fuse and attach to the diaphragmatic crura bilaterally immediately superior to the adrenal glands Inferiorly, the perirenal space is open at the level of the pelvic brim as the fascial perirenal sheaths remain unfused The perirenal space encloses the kidneys, adrenal glands, perinephric fat, and the prevertebral aorta and inferior vena cava (IVC).1,10 Posterior Pararenal Space The posterior pararenal space lies between the posterior renal fascia and the transversalis fascia This space contains no organs, only fat.10 The retrofascial space is located immediately posterior to the posterior pararenal space and it contains the psoas muscle posteromedially and the quadratus lumborum muscle posteriorly The retrofascial space is not technically part of the retroperitoneum, but its muscles are frequently referred to in discussions of the retroperitoneal space Table 14-1 lists the organs and vessels contained in the retroperitoneum ANATOMY OF THE LYMPHATIC SYSTEM The lymphatic system extends throughout the body with lymph vessels found immediately adjacent to normal arteries and veins.7,11 Unlike the vascular system, the lymph vessels end in a blind-ending plexus of tubes at the vascular capillary level The lymphatic system acts as a fluid recovery system, collecting nearly L of plasma fluid that oozes from the normal vascular capillaries into the extracellular space The lymphatic system also collects cellular debris and bacteria within the extracellular fluid, as well as absorbing and transporting dietary fat Since the lymphatic system returns excess fluid to the bloodstream, homeostasis (internal fluid balance) is maintained The fluid that enters the lymphatic plexus is referred to as lymph This thin, colorless or slightly yellow 14 — The Retroperitoneum Renal sinus Renal hilum Peritoneum 421 Renal fascia (anterior layer) Perinephric fat (perirenal fat capsule) Body of lumbar vertebra Transversus abdominis Psoas fascia (sheath) Internal oblique Psoas major External oblique Kidney Paranephric fat (pararenal fat body) Transverse process of lumbar vertebra Aponeurotic origin of transversus abdominis Anterior layer of thoracolumbar fascia (quadratus lumborum fascia) Renal fascia (posterior layer) Latissimus dorsi Deep back muscles A Thoracolumbar fascia (posterior and middle layers) PR Quadratus lumborum P APR IVC A RF K K PPR B Figure 14-1 Retroperitoneum A: A transverse sectional retroperitoneum illustration at the renal hilum level demonstrates the fascial planes and musculature relationship B: The transverse drawing illustrates the three major compartments: anterior pararenal space (APR), perirenal space (PR), and posterior pararenal space (PPR) P, pancreas; K, kidney; RF, renal fascia fluid has a cellular composition similar to blood plasma Lymph flows from the lymph capillary plexus toward the great vessels in the abdomen, eventually to the right and left subclavian veins in the thorax The right lymphatic duct conducts lymph collected from the TABLE 14-1 Retroperitoneal Organs and Structures Diaphragmatic crura Pancreas Distal common bile duct Second, third, and fourth parts of duodenum Kidneys Adrenals Lymphatic vessels and nodes Aorta Inferior vena cava (IVC) Superior mesenteric artery (SMA) Superior mesenteric vein (SMV) Hepatic artery Splenic artery Splenic vein right head, neck, arm, and chest back into the venous system at the confluence of the right internal jugular and the right subclavian vein The thoracic duct conducts lymph collected from the rest of the body back into the venous system at the confluence of the left internal jugular and the left subclavian vein The chyle cistern is a dilated collecting area found in the midretroperitoneum collecting lymph from the lower extremities and pelvis before it ascends to the thoracic duct7,11 (Fig 14-2) Lymph moves through lymphatic vessels, passing through lymph nodes along the way Each lymph node is a small mass of lymphatic tissue that filters the lymph fluid, phagocytizing foreign proteins and infectious debris, and generating and sending lymphocytes to infected tissues Lymph nodes are described based on their location See Table 14-2 for a list of commonly affected abdominopelvic lymph node groups and measurements that indicate abnormal size 422 PART — ABDOMINAL SONOGRAPHY Celiac lymph nodes Phrenic lymph nodes Celiac trunk Celiac artery Cystic lymph nodes Hepatic lymph node Superior mesenteric lymph node Chyle cistern Superior mesenteric artery Inferior mesenteric lymph node Inferior mesenteric artery Lumbar (lateral aortic) lymph nodes Common iliac lymph nodes Internal iliac lymph nodes External iliac lymph node In the retroperitoneum, lymph nodes are generally divided into deep abdominal or parietal lymph nodes and superficial abdominal or visceral lymph nodes Parietal nodes are those lymph nodes found in the retroperitoneum surrounding the principal blood vessels They are grouped according to the arterial vessel with which they are associated In the upper retroperitoneum, aggregations can be found around three unpaired vascular branches: inferior mesenteric, superior mesenteric, and celiac Groups found in the lower retroperitoneum include the external, common, internal iliac, and epigastric TABLE Figure 14-2 Lymphatic system This illustration shows the thoracic duct receiving lymph collected from the rest of the body and returning it back into the venous system at the confluence of the left internal jugular and the left subclavian vein The chyle cistern is a dilated collecting area found in the midretroperitoneum collecting lymph from the lower extremities and pelvis before it ascends to the thoracic duct (Reprinted with permission from Moore K, Dalley A, Agur A Clinically Oriented Anatomy 6th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2010:316.) Nodes are positioned 360 degrees around the aorta and IVC Those that lie posterior to the main vessels provide the most reliable indicator of lymphadenopathy since they frequently displace the aorta or IVC anteriorly (Fig 14-3) Visceral nodes are located within the peritoneal cavity and are generally found at the hilum of organs The most common groups are gastric, hepatic, pancreatic, splenic, and various groups associated with branches of the colic artery A special type of lymph node found along the small bowel and mesentery are called lacteals Lacteals 14-2 Abdominopelvic Lymph Node Groups4,5,7,11 Retroperitoneum Location Retrocrural Retroperitoneal Posterior to the diaphragmatic crura Encircling the aorta (periaortic) or inferior vena cava (pericaval) or both (interaortocaval) Anterior to the abdominal aorta surrounding the origins of the celiac axis and mesenteric arteries Along the common, external and internal iliac (hypogastric) arteries and veins; also referred to as the iliac chain Mesenteric and celiac Pelvic Intraperitoneal Location Gastrohepatic Within the superior portion of the lesser omentum that suspends the stomach from the liver At the splenic hilum Between the duodenal sweep and the pancreatic head anterior to the inferior vena cava Surrounding the porta hepatis Perisplenic Parapancreatic Hepatic hilum Abnormal Size Ͼ6 mm Ͼ10 mm Ͼ10 mm Ͼ15 mm Abnormal Size Ͼ8 mm Ͼ10 mm Ͼ10 mm Ͼ6 mm 14 — The Retroperitoneum /HIWYHQRXV DQJOH 423 /HIWLQWHUQDOMXJXODUYHLQ 7KRUDFLFGXFW 6XSHULRU YHQDFDYD /HIW VXEFODYLDQ YHLQ 7KRUDFLF GXFW 'HVFHQGLQJ WKRUDFLF O\PSKDWLF WUXQNV 7UXQNIURP LQIHULRULQWHU FRVWDOO\PSK QRGHV &LVWHUQDFK\OL &K\OHFLVWHUQ ,QIHULRUYHQDFDYD ,QWHVWLQDO O\PSKDWLFWUXQN /XPEDU O\PSKDWLFWUXQN Figure 14-3 Retroperitoneal lymph nodes The illustration demonstrates the deep abdominal parietal lymph nodes following the course of the major blood vessels (Reprinted with permission from Moore K, Dalley A, Agur A Clinically Oriented Anatomy 6th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2010:316.) take on a milky white appearance as they also absorb dietary fat SCANNING TECHNIQUE AND NORMAL SONOGRAPHIC APPEARANCE Ideally, patients should be fasting for to hours prior to the examination This will reduce bowel gas and fluid that may be confused with pathology; however, if needed, an examination of the retroperitoneum may be performed without any patient preparation Due to the retroperitoneum’s deep position, a 3- to 6-MHz sector or curvilinear transducer should offer adequate penetration and a wide field of view for most adult retroperitoneal examinations Higher frequency transducers should be used on smaller children and a lower frequency transducer will provide better penetration on obese patients The retroperitoneum may be scanned using an anterior, coronal, or posterior approach The anterior approach frequently involves directing the sound beam through the left lobe of the liver in the epigastric region or through a fluid-filled stomach when overlying bowel gas obstructs visualization of deeper anatomy Coronal scan planes are frequently used, directing the beam through the liver on the right and the spleen on the left, to evaluate kidneys, adrenals, and midline retroperitoneal structures that are not seen well from an anterior approach The posterior or flank scanning Figure 14-4 Lymph node The longitudinal image displays a normal ovoid-shaped hypoechoic lymph node Note the echogenic central fatty hilum (Image courtesy of Philips Medical Systems, Bothell, WA.) approach may be employed, directing the ultrasound beam through the deep back muscles (see Fig 14-1), when the anterior and coronal approach offer less than desirable imaging The retroperitoneal examination should include assessment of the kidneys, pancreas, and vasculature for size, relationship, neoplasm, fluid collection, and mass effect Normal lymph nodes are not seen in the retroperitoneum Normal superficial lymph nodes may be identified as hypoechoic almond-shaped structures with a bright fat containing hilum (Fig 14-4) Normal adult adrenal glands are rarely identified, except in extremely thin patients A variable amount of fat is identified in the retroperitoneal compartments depending on the patient’s body fat composition Generally, more obese patients demonstrate more pronounced amounts of fat in each space Typically there is a more generous amount of fat in the perirenal space than in the other retroperitoneal compartments The anterior and posterior pararenal spaces may not be distinguishable from the perirenal space in average and thin patients The perirenal fascial planes may be identified only occasionally When seen, they appear as very fine echogenic lines surrounded by fat Fat typically appears moderately echogenic and homogeneous in these spaces In some typically obese patients, the perinephric fat may appear anechoic and should not be mistaken for fluid (Fig 14-5A,B) The diaphragmatic crura may be identified fairly routinely As a muscular structure, the diaphragmatic crura appear as a hypoechoic linear structure surrounded by hyperechoic tissue running obliquely between the aorta and IVC in the transverse epigastric plane and anterior to the longitudinal proximal aorta Muscles identified during the retroperitoneum examination include the quadratus lumborum and psoas Both muscles appear hypoechoic with bright linear fibers running along the length of the muscle Care must be taken not to mistake these muscles for inflammation or fluid collections when they are well developed in very muscular patients When there is a question, the patient may be asked to flex and extend his or her hip The muscle can be seen to extend and contract with leg movement 424 PART — ABDOMINAL SONOGRAPHY A B Figure 14-5 Retroperitoneal fat The perirenal space contains more fat than the other retroperitoneal compartments A: A longitudinal image of the right kidney (RK) and liver with echogenic fat (arrows) seen surrounding the kidney B: The transverse image of the right kidney also displays echogenic fat (arrows) PATHOLOGY OF THE RETROPERITONEUM When a mass is identified in the retroperitoneum, the sonographer should demonstrate the following: • The abnormality in orthogonal planes • Measurements of the mass in three dimensions • Mass characteristics (cystic/fluid, solid tissue, air, calcification, borders, wall thickness, septa, etc.) • The relationship of the mass to surrounding anatomy/mass effect • The organ or area of mass origin • Blood flow characteristics and feeding vessel(s) using color, power, and spectral Doppler SOLID LESIONS Solid masses found in the retroperitoneum are usually metastatic and most frequently involve the lymph nodes Although primary tumors occur in the retroperitoneum, they are rare The role of sonography in evaluating retroperitoneal adenopathy is limited Sonography can detect the presence of solid masses and, in cases where intestinal gas or overlying bony structures not obscure retroperitoneal imaging, may demonstrate the relationship of these masses to normal structures The exact histologic nature of solid masses cannot, however, be definitively ascertained by sonography alone When solid lesions are noted, the patient should be referred for additional diagnostic testing such as CT and possibly fine-needle biopsy of the solid mass.12 Lymphadenopathy Lymphadenopathy, also called adenopathy, describes the enlargement of lymph nodes caused by inflammation, primary neoplasia, or metastasis The pattern of lymph node enlargement can provide important clues to the origin and type of pathology Sonographically, enlarged lymph nodes typically appear as oval- to round-shaped masses with a low- to medium-level echo pattern compared to the more hyperechoic fat of the retroperitoneum Lymphadenitis, describes an enlargement of lymph nodes due to an inflammatory process Although lymph nodes are enlarged with lymphadenitis, they typically maintain an ovoid shape and fatty hilum On color or power Doppler, lymphadenitis demonstrates hyperemia within the node (Fig 14-6A,B) Primary malignant nodes, like those seen with lymphoma, tend to become more hypoechoic to anechoic and round shaped, with a length to width ratio of less than two5 (Fig 14-7A,B) Additional node characteristics that increase the likelihood of malignancy include asymmetric cortical widening and a loss of the normal fatty hilum, with color Doppler demonstrating avascular areas within the node or mass effect on normal vascular tree within the node.5 Metastatic adenopathy tends to appear more echogenic and heterogeneous.5 Care must be taken to adjust Doppler settings to levels that are sensitive to low flow levels when evaluating lymph nodes Enlarged nodes in the retroperitoneum may also fuse together forming a lobulated mantle-like soft tissue mass anterior to the aorta and IVC Adenopathy may completely encase the abdominal great vessels moving them away from the vertebral column It may also demonstrate a mass effect on arterial branches displacing them from their normal position while compressing surrounding veins (Fig 14-8A,B) Lymphadenopathy is a very common finding in patients with acquired immune deficiency syndrome (AIDS) Patients infected with the bloodborne virus 14 — The Retroperitoneum A 425 B Figure 14-6 Lymphadenitis Longitudinal (A) and transverse (B) images of an infected lymph node demonstrate hyperemia with power Doppler human immunodeficiency virus (HIV) experience depression of their immune system due to this virus’ destructive effect on T-lymphocytes Without retroviral medical therapy, the patient’s immune system fails and the disease evolves into AIDS AIDS patients experience multiple opportunistic infections and neoplasms The more common opportunistic fungal, viral, and bacterial infections include mycobacterium avium complex infection, tuberculosis, candidiasis, cytomegalovirus, and herpes These infections frequently affect the gastrointestinal tract and are demonstrated on sonography as hypoechoic appearing lymphadenopathy and gut wall thickening Tuberculosis may demonstrate very low attenuating, anechoic lymph nodes due to necrosis and punctuate echogenicities within the kidneys Common neoplasms associated with AIDS include Kaposi sarcoma and lymphoma Kaposi sarcoma is associated with chest and skin neoplasms and adenopathy The AIDS-related lymphomas are of B-cell origin and include primarily non-Hodgkin lymphoma AIDS lymphomas tend to affect the central nervous system, gastrointestinal tract, liver, and lungs A B Figure 14-7 Lymphadenopathy A: Retroperitoneal lymph nodes (N) are seen surrounding the aorta (AO) and inferior vena cava (IVC) The lymph nodes are more rounded in shape and a normal fatty hilum is not seen (Image courtesy of Philips Medical Systems, Bothell, WA.) B: Rounded lymph nodes (arrows) are seen at the splenic hilum (Image courtesy of Dr Taco Geertsma, Gelderse Vallei, Ede, The Netherlands.) 426 PART — ABDOMINAL SONOGRAPHY A B Figure 14-8 Midline adenopathy A: Longitudinal image of the abdomen demonstrates compression of the inferior vena cava (IVC; arrows) by lymphadenopathy seen anterior and posterior to the vessel B: Transverse midline image demonstrates an echogenic mass encompassing and compressing the aorta (A) and IVC (I) The mass is consistent with lymphadenopathy (Images courtesy of Dr Taco Geertsma, Gelderse Vallei, Ede, The Netherlands.) In the abdomen, hypoechoic retroperitoneal adenopathy is frequently seen.5 CT is the imaging modality of choice to evaluate retroperitoneal adenopathy because of its ability to generate standard and reproducible views of abnormal nodes without bowel gas interference.5 Sonography can be used to guide biopsy and assess the effects of lymphadenopathy on vascular and urinary structures of the retroperitoneum during therapy without additional radiation to the patient Therapies related to lymph node enlargement are dependent on the cause but may include medical therapy to treat infection, chemotherapy, radiation therapy, or surgical removal with malignancies.12 Retroperitoneal Fibrosis Retroperitoneal fibrosis, also called Ormond disease or chronic periaortitis, is a chronic inflammatory process that results in fibrous tissue proliferation affecting and encasing the great vessels, ureters, and lymphatics of the retroperitoneum.13–16 The disease affects middle-aged males twice as often as females.5 The majority of cases of retroperitoneal fibrosis are idiopathic, thought by some to be autoimmune in nature.16 Other causes include infiltrating neoplasia of the stomach, lung, breast, colon, prostate, and kidney; methysergide (medication prescribed to treat migraine headaches) use; and less frequently Crohn disease, sclerosing cholangitis, radiation therapy, aneurysm surgery or leakage, retroperitoneal infections, and urine leakage into the retroperitoneum.5,16 The ureters are frequently affected demonstrating a characteristic medial deviation or complete stenosis resulting in unilateral or bilateral hydronephrosis.9,15,16 Additional symptoms include unintended weight loss, nausea, malaise, hypertension, and renal insufficiency.9 Although CT is the imaging modality of choice for initial diagnosis, sonography is frequently used to follow this disease process Sonographically, retroperitoneal fibrosis appears as a hypoechoic smoothly marginated clump or layer in the para-aortic area of the perinephric space and may be mistaken for plaque surrounding the distal aorta (Fig 14-9A–H) Treatment typically includes corticosteroid therapy with ureteral stenting in cases of ureteral stenosis and medical therapy for concomitant renal insufficiency Primary Neoplasms Solid retroperitoneal tumors are rare Primary malignancies include liposarcoma, leiomyosarcoma, rhabdomyosarcoma, myxosarcoma, and fibrosarcoma Benign retroperitoneal tumors include lipoma, leiomyoma, rhabdomyoma, myxoma, and fibroma Malignant tumors tend to appear larger and more complex than their benign counterparts These neoplasms tend to demonstrate mass effect on the vasculature of the retroperitoneum, compressing the IVC, ureters, urinary bladder, and extrahepatic bile ducts The role of sonography beyond characterizing the neoplasm, evaluating the size, and demonstrating its blood flow characteristics is to demonstrate whether or not the tumor has infiltrated adjacent organs, as complete surgical resection determines prognosis.5 Liposarcoma is the most common primary malignancy of the retroperitoneum, representing 95% of all fatty retroperitoneal tumors.5 This slow growing neoplasm affects middle-aged males more frequently than females Patient complaints include abdominal pain, unintended weight loss, anemia, and a palpable mass.17 CT remains the imaging modality of choice; however, sonography may be employed initially due to its noninvasive nature Sonographically, liposarcoma demonstrates a poorly marginated, lobulated, complex mass that displaces adjacent anatomy rather than A B C D E F Figure 14-9 Retroperitoneal fibrosis A: Coronal, (B) sagittal, and (C) axial magnetic resonance images demonstrate retroperitoneal fibrosis (arrows) surrounding the aorta (A) Bilateral ureteral stents (arrowheads) are seen on the coronal and axial images D: Longitudinal and (E) transverse sonography images of the same patient demonstrate hypoechoic fibrosis seen surrounding the anechoic aorta (AO) F: Longitudinal image of the right kidney (RK) demonstrates moderate hydronephrosis Unilateral or bilateral hydronephrosis is a common finding with retroperitoneal fibrosis as the ureters are compressed by the tumor (continued) 427 428 G PART — ABDOMINAL SONOGRAPHY H Figure 14-9 (continued) G: Transverse image of the urinary bladder (BL) demonstrates bilateral echogenic ureteral stents (arrows) projecting into the bladder lumen H: The abdominal radiograph demonstrates bilateral ureteral stents (Image H courtesy of Dr Taco Geertsma, Gelderse Vallei, Ede, The Netherlands.) A B C D Figure 14-10 Liposarcoma A,B: A large heterogeneous mass seen posterior to the liver on both sonography and computed tomography It was diagnosed as a retroperitoneal liposarcoma (L, liver; S, spleen.) On this patient, the (C) transverse and (D) longitudinal images of the right upper quadrant demonstrate a large heterogeneous mass posterior to the right lobe of the liver The mass was diagnosed as a liposarcoma (Images courtesy of Dr Taco Geertsma, Gelderse Vallei, Ede, The Netherlands.) ... Diagnostic Medical Sonography ABDOMEN AND SUPERFICIAL STRUCTURES Diagnostic Medical Sonography ABDOMEN AND SUPERFICIAL STRUCTURES Third Edition Diane M Kawamura,... Cataloging-in-Publication Data Diagnostic medical sonography Abdomen and superficial structures / edited by Diane M Kawamura, Bridgette M Lunsford 3rd ed p ; cm Abdomen and superficial structures. .. Title: Abdomen and superficial structures [DNLM: Abdomen ultrasonography Digestive System ultrasonography Ultrasonography methods Urogenital System ultrasonography WI 900] 617 .5’5075 dc23 2 011 045980