other causes of focal liver lesions...

peak incidence before 5 years of age. It occurs invarious sites throughout the body.

Other causes of focal liver lesions

Liver metastases may occur from most paediatricmalignancies, particularly neuroblastoma, rhab-domyosarcoma and Wilms’ tumour (p. 229).Leukaemia and lymphoma may also cause focaldefects in the liver. Liver involvement may be man-ifested by hepatomegaly with normal liver texture,a non-specific sign, or by diffuse coarsened livertexture with or without hepatomegaly.

Haemangioendothelioma

Vascular tumours account for most benign livertumours in childhood, with haemangioendothe-liomas being seen more frequently than cavernoushaemangiomas. Although haemangioendothe-lioma may be asymptomatic, infants generally pres-ent before the age of 6 months with an abdominalmass, respiratory distress, anaemia and cardiac fail-ure, caused by the shunting of blood from theaorta through the tumour. Large tumours maybleed spontaneously, resulting in haemoperi-toneum. They may present with jaundice andincreased transaminase levels and 50% of childrenalso have cutaneous haemangioma.10

These tumours are generally multiple, of varyingechogenicity and may have a complex echotexturedue to thrombus, calcifications and internal septa-tions (Fig. 9.3B). The vascular nature of theselesions is demonstrated by a large coeliac axis andmarked decrease in the size of the aorta below theorigin of the coeliac axis. The main differentialdiagnosis of multiple haemangioendothelioma isfrom metastatic liver disease, particularly from dis-seminated neuroblastoma.

Although most asymptomatic paediatric hae-mangioendotheliomas regress spontaneously, thosecomplicated by cardiac failure require active treat-ment. Steroids may be administered and serialultrasound scans may be used to monitor the grad-ual resolution of the lesion. Angiographicembolization or surgical ligation of the majorfeeding vessels of the hepatic artery may be neces-sary in severe cases that fail to respond to steroidtherapy.

PANCREAS

Normal appearancesThe acoustic characteristics of the pancreas varywith age. Pancreatic echogenicity is quite variableand is occasionally hypoechoic in neonates com-pared with the adult gland. In older childrenechogenicity is equal to or slightly greater thanthat of the liver. The pancreas is relatively larger inyoung children than in adults, gradually increasingwith age, reaching adult size in late teens.11 Thepancreatic duct is often visualized but should notbe greater than 2 mm in width. The relativehypoechogenicity and relatively larger size of thenormal pancreas in childhood should not be mis-interpreted as a sign of probable pancreatitis whenscanning a child with abdominal pain (Fig. 9.4).

Pathology of the pancreasPancreatic abnormalities are relatively uncommonin childhood. Most ultrasound abnormalities arethe result of infiltrative processes associated withother syndromes or diseases (Table 9.1). Focalpancreatic lesions are rare.

Ultrasound is an ideal investigation for evaluat-ing the paediatric pancreas, as a high-frequency

ABDOMINAL ULTRASOUND220

Figure 9.4 Normal pancreas in a 13-year-old girl—relatively hypoechoic and bulky in comparison with theadult gland.

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probe demonstrates excellent detail. A water-baseddrink may be given to provide an acoustic window.In cases of blunt injury to the abdomen with sus-pected pancreatic damage, CT is the imagingmodality of choice in the acute situation, althoughsonography should be used during follow-up todetect the presence of a pseudocyst.

URINARY TRACT

Ultrasound is the first line of investigation in bothantenatally detected abnormalities and in sympto-matic children.

● The bladder should be scanned first, as voidingmay often occur during the examination.

● Measurements of both kidneys, either lengthor renal volume, should be taken to highlightany difference in size and to provide a baselinefor further growth comparison.

● A variety of planes can be used to view thekidneys in children. Often a posterior approachis best for obtaining an accurate bipolar length.

● Ensure that renal pelvic dilatation is notphysiological, by rescanning postmicturition.

● Measure the anteroposterior diameter of anyrenal pelvic dilatation in transverse sectionthrough the renal hilum.

● Always scan the bladder immediately aftermicturition, paying attention to the uretericorifice and looking for any ureteric or renaldilatation which may suggest reflux. Measureany residual volume.

● Colour Doppler may be helpful in identifyingthe ureteric orifice, by locating the jets of urineentering the bladder (Fig. 9.10D).

Normal appearancesAfter birth the renal cortex is relatively hyperechoiccompared to the adult kidney, in strong contrast tothe hypoechoic medullary pyramids. The outline ofthe kidney is often lobulated due to a persistentfetal lobulation. The renal pelvis is relativelyhypoechoic, as the fat deposition seen in the adultis not yet present (Fig. 9.5A).

Gradually the cortex becomes less hyperechoicwith age, the corticomedullary differentiationlessens and fat deposition in the renal sinus becomesmore evident. The outline becomes smooth,although fetal lobulations do persist in some adultkidneys.

Normal postnatal growth of the kidneys, in termsof length and volume, is closely related to the height,weight and age of the child. Charts giving normalage- and weight-related values should routinely bereferred to.12 Errors do occur in measurements ofrenal length with a potential error in the order of 1year’s growth.13 Thus follow-up measurements forrenal growth should not be undertaken at intervalsof less than 1 year.

Anatomical variants and pathologyThe duplex system

The duplex system is one of the more commoncongenital anomalies, occurring in up to 9% ofreferrals.14 It stems from aberrant budding ofthe Wolffian duct in utero, and can take a varietyof forms, from complete duplication with twokidneys, each with a separate ureter, to a partialduplication involving the kidney only. Complete

THE PAEDIATRIC ABDOMEN 221

Table 9.1 Paediatric pancreatic abnormalities

Increased echogenicityCystic fibrosis—fatty replacement of the pancreas, calcifications, ectatic

pancreatic duct, coarse texture, cystsPancreatitis—hereditary—trauma (physical abuse, road traffic accident)—congenital anomaly, e.g. choledochal cyst—drug toxicity—viral and parasitic infectionHaemochromatosis—pancreatic fibrosis, iron deposition in liver and pancreasFocal lesionsCysts—isolated congenital cyst—autosomal dominant polycystic disease—von Hippel–Lindau disease—Meckel–Gruber syndromeSolid lesions—primary pancreatic neoplasms are very rare in children

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duplication predisposes to reflux, particularly intothe lower moiety and subsequently to infection.

The upper pole moiety of a duplex kidney ismore prone to obstruction either secondary to aureterocoele or, less commonly, with an obstructedectopic ureter. In the former case the obstructedupper moiety may be associated with a dilatedureter which can be followed to the bladder wherea ureterocoele, that is, a cystic dilatation of the dis-tal ureter, may be seen within the bladder at theipsilateral vesicoureteric junction (Fig. 9.5 B, Cand D). The ureterocoele may extend into the

urethra, causing bladder outlet obstruction which,if severe, may result in bilateral hydronephrosis.

In the absence of any dilatation, it may be dif-ficult to demonstrate the duplex kidney on ultra-sound. Generally, the kidney is longer thannormal and two discrete, hyperechoic sinusechoes can be seen. Ectopic insertion of the upperpole ureter in a duplex system is a cause of urinaryincontinence in girls. It may not be possible tofollow an ectopic ureter to its distal end, evenwhen dilated, but one may be able to demonstratethat the ureter is passing distally to the bladder.


A B

C D

RT

LS LT LS

L

Figure 9.5 (A) Normal neonatal kidney, showing lobulated outline, hyperechoic cortex, increased corticomedullarydifferentiation and reduced renal sinus echoes. (B) Duplex kidney. The upper moiety is dilated with a thin cortex. Thelower moiety is normal. (C) Same patient as in (B). Dilated ureter (arrow) of the upper moiety of the duplex kidneyterminating in a uretercoele (arrowhead) seen in the base of the bladder at the vesicoureteric junction.(D) Ureterocoele (arrowhead) at the base of the bladder covering the urethral orifice.

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When there is a strong clinical suspicion of anectopic ureter an intravenous urogram or MRurogram will be required to identify a duplexkidney and site of ureteric insertion.

Renal fusion and ectopia

The horseshoe kidney is the most common form ofrenal fusion, in which the lower poles of the kidneysare fused with a central isthmus or ‘bridge’ acrossthe front of the spine (Fig. 9.6). The isthmus fre-quently lies behind gas-filled bowel and can be diffi-cult to detect. The sonographer should be suspiciousof a horseshoe kidney when the lower poles of thekidneys cannot be clearly outlined, particularly whenboth kidneys look a little smaller than expected forage. Always ensure you see the outline of the lowerpoles clearly by turning the child prone or by scan-ning coronally through the side if necessary.

A dimercaptosuccinic acid (DMSA) scan maydemonstrate the isthmus or bridge of renal tissue(when the ultrasound scan is equivocal) but only ifit is functioning. In some cases the bridge is com-posed of non-functioning, fibrous tissue.

Fusion can take other forms, including an Lshape, where one kidney lies horizontally acrossthe midline; crossed ectopia, where both kidneyslie on the same side; H-shaped fusion of the hilarregions; and complete fusion to form a ‘cake’-shaped solitary kidney.

Ectopic kidneys occur most frequently in thepelvis (Fig. 9.7). In rare cases the kidney may besituated in the thorax.

Ectopic and horseshoe kidneys are often associ-ated with a degree of malrotation of the kidney.This can be associated with a degree of obstructionat the pelviureteric junction, and predispose to thedevelopment of renal calculi.


A B

RK

C

Figure 9.6 (A) The lower pole of this right kidney (RK)could not be successfully demonstrated. Horseshoe kidneywas suspected, and confirmed on coronal scanning planes. (B) Longitudinal section (LS) in the midline shows therenal isthmus of a horseshoe kidney anterior to the aorta.(C) Transverse section (TS) through the lower abdomendemonstrates the isthmus anterior to the spine.

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Renal agenesis

The kidneys form from the ureteric bud, whicharises from the pelvic area during the fifth to sixthweek of gestation. The bud undergoes numerousdivisions, forming the ureters, renal pelvis, calycesand renal tubules. Any interruption of this processmay cause renal agenesis or ectopia.

Bilateral renal agenesis is lethal and is usuallydiagnosed prenatally. The incidence of unilateralrenal agenesis is about 1:450 live births and is usu-ally prenatally detected. Ultrasound is useful inconfirming the prenatal diagnosis and excludingthe presence of an ectopic kidney. A DMSA scanconfirms the diagnosis. Renal agenesis is associatedwith VATER syndrome and with ipsilateral gynae-cological anomalies in girls.

Multicystic dysplastic kidney (MCDK)

The MCDK is generally the result of complete,early ureteric obstruction in utero before 10 weeks,and is frequently diagnosed antenatally. The result-ing kidney is non-functioning and contains cysts ofvarying sizes, separated by echogenic ‘dysplastic’renal parenchyma. In general the cysts do not com-municate but occasionally some communicationcan be seen, making differentiation from a severehydronephrosis difficult.

MCDK is usually unilateral and is considered abenign condition, although there is a slight risk of

malignancy and hypertension in later life. The kid-ney gradually involutes and often completely dis-appears (Fig. 9.8A, B). Surgical removal isunnecessary unless symptomatic due to its largesize or is associated with repeated episodes of infec-tion. Provided the contralateral kidney is normal,with good function, the prognosis is good. Thereis, however, an increased risk of associated urinarytract anomalies, such as ureterocoele, vesi-coureteric reflux or contralateral pelviureteric junc-tion obstruction, which may predispose toinfection. These can be demonstrated with ultra-sound and micturating cysto-urethrogram.

A DMSA scan differentiates MCDK, which iscompletely non-functioning, from a grosslyhydronephrotic kidney, a distinction which maysometimes be difficult to make on ultrasound.Follow-up ultrasound scanning is generally advisedin view of the slight increased risk of Wilms’tumour and to monitor the growth of the con-tralateral kidney.

Polycystic disease of the kidneys

Autosomal recessive polycystic disease of the kid-ney (ARPCDK: infantile) may be diagnosed prena-tally. Both kidneys are abnormal, being large andhyperechoic, with loss of corticomedullary differ-entiation (Fig. 9.8C). There is a spectrum of sever-ity of disease and in some cases it may present later


A B

b

Figure 9.7 (A) Pelvic kidney (b = bladder). (B) Dimercaptosuccinic acid (DMSA) scintigraphy shows 33% function inthe smaller, pelvic RK and 66% in the left kidney (LK).

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in childhood with the milder, juvenile form of thedisease. Prenatally the less severe forms appear nor-mal on ultrasound. ARPCDK is associated withhepatic fibrosis and portal hypertension.

Autosomal dominant polycystic disease of the kid-ney (ADPCDK: adult) also has a wide spectrum ofseverity. Although it tends to present later in life, themore severe forms can present in childhood and canoccasionally be diagnosed prenatally. Frank cysts canusually be demonstrated on ultrasound, but may notbe detected until the second or third decade of life.The disease is also associated with cysts in the liverand pancreas, and with intracranial berry aneurysms.

Renal dilatation

Hydronephrosis is frequently detected antenatally,although the cause may be difficult to demonstrate.Dilatation is due either to obstructive uropathy, forexample vesico- or pelviureteric junction obstruction,posterior urethral valves or obstructed upper moietyof a duplex kidney (Fig. 9.9), or it may be non-obstructive, for example due to reflux (Fig. 9.10).

Postnatal ultrasound scans should be performedwhen the infant is more than 4 days old, becausethere is commonly a period of dehydration immedi-ately after birth. This may cause an obstructed orotherwise dilated kidney to appear normal for thefirst few days of life. If normal a follow-up scan is gen-erally recommended at about the age of 6 weeks.

The presence of any calyceal dilatation or uretericdilatation, as opposed to dilatation confined to therenal pelvis, is an important factor to note, indicatinga greater degree of severity. A measurement of theanteroposterior diameter of the dilated intrarenalpelvis is a useful baseline from which to compare sub-sequent follow-up scans (Fig. 9.9D). It should benoted that slight separation of the renal pelvis is anormal finding in the newborn: an anteroposteriorrenal pelvis of 5 mm is the upper limit of normal.

The presence of a baggy, extrarenal pelvis, lessthan 10 mm, without pelvicalyceal system (PCS)dilatation is usually managed conservatively usingultrasound monitoring to demonstrate any increas-ing dilatation. PCS dilatation with a renal pelvicdiameter of between 10 and 20 mm is more serious

A

+ 78

C

B

20.3 mm

Figure 9.8 (A) Multicystic dysplastic kidney. (B) This multicystic dysplastic kidney, diagnosed antenatally, has shrunkto little over 2 cm in length by the age of 1 year. (C) Large, hyperechoic kidneys in a neonate in autosomal recessivepolycystic disease.

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and likely to require an assessment of renal functionwith a MAG3 renogram. Conservative treatment ispossible, but surgery may be required for very poorfunction.

The dilated renal tract is predisposed to infectiondue to ascending infection in reflux or haematoge-nous infection in an obstructed system, where apyonephrosis requiring percutaneous nephrostomymay develop. As a consequence antibiotic prophy-laxis is frequently advised in the neonate with signif-icant renal tract dilatation.

Bilateral renal tract dilatation in boys may be dueto posterior urethral valves with secondary dilatationof the upper tracts due to the urethral obstruction.

The diagnosis is confirmed by fluoroscopic mic-turating cystography. This diagnosis may be sus-pected sonographically by the association of bilateralhydronephrosis with a distended and thick-walledbladder.

Vesicoureteric reflux

Vesicoureteric reflux, the retrograde passage ofurine from the bladder up the ureter and into thekidney, predisposes the child to urinary tract infec-tion and the development of reflux nephropathy.In the first year of life only, reflux is more com-mon in boys than in girls and is usually more


A B

DC

Figure 9.9 Renal dilatation. (A) Dilatation of the pelvicalyceal system (PCS) due to pelviureteric junction obstruction.(B) TS of the same kidney. The ureter was not dilated. (C) Duplex RK with gross dilatation of the lower pole moietycontaining echoes due to infection. The cortex is thin. The smaller upper pole moiety is also dilated. A ureterocoele waspresent at the right vesioureteric junction (VUJ). (D) Mild dilatation of the LK. An anteroposterior (AP) measurement ofthe PCS provides a good baseline for follow-up.

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A B

C D

Figure 9.10 (A) Mild PCS dilatation due to reflux. (B) The right lower ureter is dilated (arrowheads) and urine wasseen to reflux back up the ureter, dilating the kidney. (C) Bilateral reflux (right worse than left) is observed in a TSthrough the base of the bladder. Both ureters (arrows) are seen to dilate intermittently. (D) Compare (C) with a normalpatient, in whom the vesicoureteric junctions can be identified by the presence of jets on colour Doppler. No uretericdilatation can be demonstrated either before or after micturition.

severe.15 Conversely, after the first year of lifereflux is more likely to present in girls and is oftenless severe. Vesicoureteric reflux is a commoncause of hydronephrosis antenatally, accountingfor up to 38% of all prenatal urinary tract dilata-tions, requiring ultrasound follow-up and anti-biotic prophylaxis.16,17

Reflux may either be due to a developmentalanomaly at the vesicoureteric junction, or theresult of a neurogenic bladder, partial outletobstruction or foreign bodies such as calculi andthe presence of a catheter.

Children who have had one or more episodes ofurinary tract infection should be investigated tosearch for an underlying cause and to identify evi-dence of reflux nephropathy (Tables 9.2 and 9.3).Approximately 2% of boys and 8% of girls willdevelop at least one urinary tract infection by 10years of age, requiring investigation, and in mostcentres will account for a substantial proportion ofthe paediatric sonography performed.

Reflux itself is not reliably diagnosed by ultra-sound as it is possible to have intermittent reflux inthe presence of a normal ultrasound scan, with a

(Continued)

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non-dilated urinary tract.17,18 There may be evidenceof thickening of the uroepithelium of the renal pelvisdue to intermittent renal pelvis distension. Uni- orbilateral dilatation may be present to a mild or severedegree and may involve the kidney and/or ureter(Fig. 9.10). It is important to scan the renal pelvesand ureteric orifice immediately after micturition,when intermittent dilatation due to reflux may bedemonstrated on an otherwise normal scan.

When dilatation is seen, the exact cause may beuncertain unless reflux is actually visualized, whichis rare, and micturating cystography is required.

Although most commonly performed convention-ally by fluoroscopy using iodinated contrastmedium, radionuclide cystography and morerecently contrast sonocystography have been usedas an alternative, particularly in the older child.18

The most common complication of reflux is infec-tion and most children present with at least oneepisode of urinary tract infection. This can causerenal scarring. It is important to make the diagnosisof vesicoureteric reflux and renal scarring early inorder to prescribe prophylactic antibiotics in anattempt to avoid the damaging complications causedby reflux of infected urine. The ultrasound appear-ances of scarring include a focal reduction in corticalthickness, irregular outline, interruption of or loss ofthe renal capsule echo or a disruption in the renalarchitecture. Colour flow and power Doppler mayshow triangular areas of decreased or absent bloodflow (and occasionally increased flow) and canimprove the detection rate of focal scarring onsonography.19 These signs can be difficult to demon-strate in young children’s kidneys, particularly whenhighly lobulated, and the most reliable method ofscar detection is a DMSA scan (Fig. 9.10F).

Chronic reflux nephropathy leads to failure ofrenal growth, resulting in a shrivelled, poorlyfunctioning kidney. Measurements of the maximumlength of the kidneys should be routinely performed,and can be related to age, height and weight.12 A dif-ference in renal length of more than 10% between


E F

POSTERIOR

Figure 9.10 cont’d (E) Small, scarred RK, due to reflux. (F) DMSA scan showing bilateral renal scarring due to reflux.Note in particular two wedge-shaped scars in the RK.

Table 9.2 Conditions associated with urinary tractinfection (UTI)

● Vesicoureteric reflux● Obstruction

—pelviureteric junction—vesicoureteric junction—posterior urethral valves—duplex kidney with obstructed moiety/ectopic ureter—ureterocoele

● Other structural anomalies—duplex and/or ectopic renal anatomy—multicystic dysplastic kidney—prune belly syndrome

● Calculi● Neurogenic bladder

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the two kidneys should prompt further investigationinto renal function with a DMSA scan.

Fungal infection

Candidiasis is a fungal infection which is mostcommonly seen in infants who are acutely ill orimmunocompromised or in sick ventilatedneonates. Fungal balls dilate and may obstruct thecollecting system of the kidney (Fig. 9.11).Ultrasound is particularly useful in making thediagnosis by demonstrating the hyperechoic fungalballs within the dilated collecting system. Fungal

infection may also undergo haematogenous spreadto the spleen and liver, where it can result in multi-focal abscess formation.

Wilms’ tumour

The most common paediatric renal malignancy,Wilms’ tumour usually presents before the age of 3years. Although the lesion generally occurs in previ-ously fit individuals, there are several known predis-posing conditions, including hemihypertrophy,Beckwith–Wiedemann syndrome and sporadicaniridia, with a 30–40% incidence in sporadic aniridia.


Table 9.3 Imaging the paediatric renal tract

Ultrasound First-line investigation in all cases. Excellent structural detailLimited sensitivity for duplex kidneys, reflux, ureteral pathology and small scarsMonitoring of disease progressionMonitoring of treatment

Contrast sonocystography Alternative to X-ray or radionuclide cystography. Poor structural detail, unsuitable for the demonstration of urethral anomalies

Diuretic renogram (dynamic) Tc99m MAG3 Outlines the pelvicalyceal system. Diagnosis of obstruction and relative renal function by analysis of excretion curves

Radionuclide cystography (dynamic) Diagnosis of refluxDirect (via catheter or suprapubic injection of isotope into the bladder) or indirect (following diuretic renogram)Cortical scintigraphy (static)—Tc99m DMSA Demonstrates uptake in the renal cortex

Superior detection of renal scarring in vesicoureteric reflux and acute pyelonephritisDemonstration of congenital anomalies, e.g. ectopic or solitary kidneyAnalysis of differential renal function

Intravenous urography (IVU) Limited use in childrenAssessment of level of ureteric obstructionAssessment of congenital anomalies, e.g. ectopic ureters and duplex kidneyPostoperative evaluation

Micturating cystourethrogram Accurate diagnosis of reflux, polyps, diverticula, strictures and urethral anomalies, but involving a significant radiation dose

Plain X-ray Some calculi, mainly those in the ureterOf limited value in paediatric renal work-upMay show gross spinal anomalies

CT Reserved mainly for confirmation and staging of malignant tumours, due to significant radiation doseRenal traumaIncreasingly used for ureteric calculus detection

MRI Assessment of difficult congenital anomalies and focal masses. Staging of malignancy

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The tumours are large at presentation, presentingwith a palpable abdominal mass, and, less frequently,pain, haematuria and fever. About 5% of thesetumours are bilateral.20 The prognosis when unilat-eral is generally good.

The ultrasound appearances are of a relativelywell-defined heterogeneous mass, predominantlysolid but frequently with some necrotic or haem-orrhagic areas, often almost completely replacingthe kidney (Fig. 9.12). Small focal areas of calcifi-cation are seen very occasionally. A search shouldbe made for tumour invasion of the renal vein andIVC which occurs in up to 10% of cases. Tumourinvasion may extend into the right atrium.Occasionally a large, right-sided Wilms’ tumourmay compress the IVC but not invade it; colour orpower Doppler may be useful in the difficult dis-tinction between compression and invasion onultrasound. Ultrasound also identifies associatedlymphadenopathy, particularly in the para-aorticand paracaval regions, and metastatic liver disease.

In a small percentage of cases, tumour may alsobe found in the contralateral kidney. This is usuallymuch smaller than the mass on the presenting sideand may be acoustically subtle. Up to 7% of con-tralateral tumours are missed on preoperativeimaging due to their small size and the operatormust be alert to the possibility of bilateral disease.20

Occasionally a Wilms’ tumour may be found tobe predominantly cystic, having the appearances of

a large, multiloculated cystic mass. The main dif-ferential diagnosis would be of a mesonephric blas-toma occurring during the first year of life andhistology is required to establish the diagnosis.

In most cases, an ultrasound and chest radio-graph are sufficient to diagnose correctly Wilms’tumour but CT of the chest and abdomen is gen-erally used for staging, and to exclude metastaticdisease in the chest and liver.21 Percutaneousbiopsy for confirmation of histological type is gen-erally performed. CT or MRI is more sensitivethan ultrasound scanning in demonstrating smalltumours in the contralateral kidney.

Xanthogranulomatous pyelonephritis

Xanthogranulomatous pyelonephritis results fromchronic infection in an obstructed kidney and chil-dren present with a history of general malaise, low-grade fever and flank pain and may be found to beanaemic. The finding of a palpable abdominal masson examination often leads to an early diagnosis ofa possible Wilms’ tumour. On sonography the kid-ney is diffusely enlarged, with loss of the normalcorticomedullary differentiation. The presence ofcalyceal dilatation with debris and calculi in the col-lecting system and confirmation of urinary infec-tion in addition to the generalized involvement ofthe kidney helps to differentiate this conditionfrom Wilms’ tumour (Fig. 9.12B). Occasionally


A B

LT LT

Figure 9.11 (A) The dilated collecting system of this kidney is filled with a large, rounded fungal ball of candidiasisinfection. (B) The fungus ball is seen to disintegrate, emptying into the renal pelvis.

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CT scanning may also be helpful. The kidney willusually be found to be non-functioning on aDMSA scan and nephrectomy is required.

Renal vein thrombosis (RVT)

RVT primarily occurs in the neonatal period butmay occur in the older child, particularly in associa-tion with renal malignancy and amyloidosis.

Classically the sick neonate is noted to develop grosshaematuria in association with a palpable abdominalmass. RVT is usually unilateral but may be bilateraland is associated with acute adrenal haemorrhagewhen left-sided. Sonographically the affected kidneyis enlarged and globular and develops an inhomo-geneous echogenicity of the renal parenchyma withareas of increased echogenicity due to haemorrhage(Fig. 9.12C). Thrombus may be detected in the


B

LT

A

C

Figure 9.12 (A) Large Wilms’ tumour arising in the left kidney and filling the left flank with a solid, heterogeneousmass. (B) Xanthogranulomatous pyelonephritis was the cause of the renal mass in this 8-year-old boy presenting withanaemia and a flank mass. (C) Renal vein thrombosis in a dehydrated neonate, showing an enlarged ‘globular’ kidneywith loss of the normal corticomedullary differentiation.

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ipsilateral renal vein and IVC and Doppler sonogra-phy shows reduced or absent blood flow in the renalvein and loss of the normal variation in the renalvein waveform. Arterial flow is also decreased. Onfollow-up the kidney may completely recover due tothe development of collateral blood flow or earlyrecanalization of the renal vein, but in severe casesthe kidney may atrophy and calcify.

ADRENAL GLANDS

Normal appearancesIn utero and postnatally, the adrenal glands arelarge, about one-third the size of the kidney, andcomposed mainly of the bulky, hypoechoic fetalcortex which makes up about 80% of the gland.The neonatal adrenal glands are easily demon-strated on ultrasound. The bulky fetal cortex issonographically apparent as a thick hypoechoiclayer surrounding the thinner, hyperechoic adre-nal medulla (Fig. 9.13A). The fetal cortex sur-rounds the smaller, permanent cortex andgradually starts to involute after birth. By the ageof 2–4 months, the adrenal glands have attainedtheir normal adult configuration of the thin,hypoechoic cortex with a tiny layer of hyperechoicadrenal medulla within.

Neuroblastoma

The neuroblastoma is a malignant tumour arisingin the sympathetic chain, most commonly theadrenal medulla. The majority of neuroblastomaspresent before the age of 4 years with a palpableabdominal mass, and many already have metas-tases at the time of presentation to the liver, bonemarrow, skin or lymph nodes. Table 9.4 lists themost frequent abdominal tumours occurring inchildhood.

The tumour is usually large on presentation,displacing the kidney downwards and laterally. Insome cases it may invade the adjacent kidney,becoming difficult to distinguish from a Wilms’tumour. Neuroblastoma is predominantly solid onultrasound, having a heterogeneous texture andfrequently containing calcification. The tumourmargins are ill-defined and infiltrate the surround-ing organs and tissues, crossing the midline and

encasing vascular structures: it may be difficult todifferentiate from lymphadenopathy (Fig. 9.13B,C and D). Nodes tend to surround and elevate theaorta and IVC.

MRI and CT are used for staging, particularly inassessing retroperitoneal spread.22 Bone scintigra-phy and MIBG scans are also useful in demon-strating metastases.

Adrenal haemorrhage

After birth, the bulky fetal cortex normally invo-lutes. Adrenal haemorrhage occurs in the neonateas a result of trauma to the vulnerable fetal cortexduring delivery or in association with perinatalasphyxia. Haemorrhage may occur in up to 2% ofbirths.23 This may be uni- or bilateral and maycause a palpable mass and abdominal pain.Ultrasound can be used to follow the resolution ofthe haemorrhage over a period of weeks; in the ini-tial stages of haemorrhage the adrenal mass ishyperechoic, gradually liquefying into a well-defined mass of mixed echo pattern and becomingcystic (Fig. 9.13 E, F). This may completely resolveover a period of some weeks leaving a normal adre-nal gland or the gland may become atrophic andcalcify. In rare cases an adrenal haemorrhage mayprogress to an abscess.24

Adrenal calcification

Calcification of the gland in babies and infants isusually the result of previous infection or haemor-rhage. Adrenal abscess cavities may calcify aftersuccessful treatment. Gross calcification in bilateral adrenal glands in association withhepatosplenomegaly in the infant indicates thelikely diagnosis of Wolman’s disease, an inbornerror of lipid metabolism that is invariably fatal.

GASTROINTESTINAL TRACT

Bowel ultrasound in paediatrics is an establishedand readily accepted investigation, replacing con-trast radiology in many cases. The range of poten-tial applications continues to increase.25 Mostgastrointestinal tract scanning in paediatrics is bestperformed with a high-frequency (15–7.5 MHz)linear or small footprint curvilinear probe.


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A B

DC

Figure 9.13 (A) Normal adrenal gland in a neonate, demonstrating the bulky, hypoechoic fetal cortex surrounding thethinner, hyperechoic medulla. (B) Left adrenal neuroblastoma. (C) Metastases were also present throughout the liver. (D) Confirmation of the left adrenal neuroblastoma and liver metastases on CT. (E) Adrenal haemorrhage in a neonate.(F) Same patient as in (E); 3 months later the haemorrhage has resolved and calcification has developed in theinvoluted adrenal gland.

E F

RT

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Hypertrophic pyloric stenosis (HPS)

HPS is a condition occurring in newborn infantscommonly about 6 weeks of age when the pyloricmuscle becomes hypertrophied and elongated,restricting the passage of gastric contents, causingprojectile vomiting. Most infants with HPS arefound to have a hypochloraemic alkalosis and,when seen in association with a palpable epigastricmass the size of an olive on test feeding, the diag-nosis is clear without the need for ultrasonic imag-ing. However, ultrasound is very successful indemonstrating HPS in approximately 20% ofinfants in whom the pyloric olive cannot be pal-pated.26,27

The baby should be positioned comfortably rightside down and the stomach and pylorus identifiedusually just to the right of the midline in the low epi-gastric region. A small feed, of approximately 20–30 ml of sugared water (preferable to milk as it doesnot contain echoes which may obscure vital detail),may be used to aid visualization of the gastric antrumif the stomach is empty. A nasogastric tube may alsobe used to administer clear fluid in a controlled wayproviding that the gastric position of the tube is con-firmed prior to injection of the fluid. A small, high-frequency linear or curved linear transducer is best.

The pylorus projects into gastric lumen and isoutlined by the fluid. HPS can be confirmed by thedemonstration of:

● thickened and elongated pyloric muscle● increased but ineffective peristalsis● failure of the pylorus to relax and open

Various figures have been quoted for musclethickness in hypertrophic pyloric stenosis rangingfrom 2.5 to 5 mm but 3 mm is most commonlyaccepted28,29 (Table 9.5).

It must be stressed that the examination isdynamic and measurements of muscle thicknessmust be interpreted in conjunction with the obser-vations of gastric peristalsis and failure of thepylorus to relax normally. Sensitivity and specificityof 97% and 99% for the diagnosis of HPS have beenreported in expert hands (Fig. 9.14). If clinical sus-picion persists after a negative ultrasound, a repeatexamination after 1 or 2 days may be performed toexclude an evolving pyloric stenosis.

Intussusception

Intussusception is the invagination of a segment ofbowel into the lumen of the adjacent bowel. It is acommon paediatric emergency, especially inyounger children aged 3 months to 3 years, andtends to affect the ileocaecal region.

The child presents with abdominal pain, some-times with a palpable mass, vomiting or rectal bleed-ing. Intussusception can result in bowel necrosis andsubsequently perforation requiring surgery.

The ultrasound appearances of bowel withinbowel are characteristic. In cross-section, thebowel assumes a ‘doughnut’ configuration, withconcentric rings of bowel wall (Fig. 9.15). Dilatedloops of fluid-filled obstructed bowel may bedemonstrated proximal to the intussusception.

The use of ultrasound to diagnose this condi-tion is highly reliable,30 reducing or eliminating theneed for contrast radiology.

An air enema is most commonly used to reducethe intussusception using inflation pressures of upto 120 mmHg. Hydrostatic reduction (that is,with water/saline) under fluoroscopic or ultra-sound control is also an accepted treatment.31


Table 9.5 Pyloric muscle dimensions

Normal Hypertrophic pylorus pyloric stenosis

Pyloric length < 15 ≥ 16(mm)Pyloric width < 11 ≥ 11(mm)Muscle thickness < 2.5 ≥ 3(mm)

Table 9.4 Paediatric abdominal malignancies

Wilms’ tumourNeuroblastomaHepatoblastomaHepatocellular carcinomaRhabdomyosarcomaLeukaemiaLymphoma

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A B

DC

E

Figure 9.14 Hypertrophic pyloric stenosis. (A) Normal pylorus demonstrating measurement of lengthof pyloric canal and thickness of the muscle. (B) A fewminutes later the pylorus relaxed and opened widely,excluding the diagnosis of hypertrophic pyloric stenosis.(C) Thickened and elongated pylorus of hypertrophicpyloric stenosis seen in longitudinal section. S representsa fluid-filled stomach. (D) TS view of the thickenedpylorus. (E) Demonstrates the measurements of pyloriclength, muscle thickness and pyloric width.

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The main contraindications to attempting a non-surgical reduction are peritonitis and free intraperi-toneal air. A number of sonographic features havebeen reported to be associated with a decreased suc-cess rate of non-surgical reduction, including a hypo-echoic rim greater than 10 mm, absent blood flow oncolour flow Doppler sonography, or a large amountof fluid trapped within the intussusception, but thesefindings are not contraindications to a careful attempt

at non-surgical reduction.32 Approximately 10% ofcases recur whether the initial intussuception wastreated surgically or non-surgically.

Midgut volvulus

Malrotation of the midgut occurs as a result of failureof normal rotation of the small bowel duringintrauterine development, resulting in a shortened


A

B

C

Figure 9.15 Intussusception. (A) The characteristicappearance of bowel within bowel due to anintussusception. (B) Dilated, fluid-filled loops of obstructedbowel are seen proximal to the intussusception. (C) Airenema; the intussusceptum is seen indenting into thelumen of the air-filled sigmoid colon during a successfulair enema reduction (arrow).

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mesenteric fixation of the small bowel to theposterior abdominal wall. This predisposes the smallbowel to twisting (volving) around the mesentericvascular axis, resulting in bowel obstruction and vas-cular compromise with a risk of infarction of most ofthe small bowel if the volvulus is not treated quickly.

Following volvulus the child presents with acutepain and bile-stained vomiting. The bowel mayintermittently twist and untwist, resulting intemporary alleviation of symptoms, which maymake diagnosis more difficult.

The definitive diagnosis is usually made fluoro-scopically during an upper gastrointestinal contraststudy. In malrotation the duodenal jejunal flexure isgenerally found to be lower and in a more medialposition than is normal and if a volvulus has occurreda corkscrew appearance of the volved small bowelmay be seen (Fig. 9.16). The proximal duodenumwill be dilated secondary to the duodenal obstruc-tion.

Malrotation without volvulus may be suspectedduring a sonographic examination performed for

intermittent abdominal pain due to the associatedmalposition of the mesenteric vessels and is best seenon colour Doppler sonography. The normal rela-tionship of the superior mesenteric vein to the supe-rior mesenteric artery is reversed, with the superiormesenteric vein lying anteriorly and/or to the left ofthe superior mesenteric artery.33 However this find-ing is not always present and may occasionally beseen in normal individuals and therefore a contraststudy is required for confirmation.

When volvulus has occurred the vessels may benoted to be spiralling around a bowel mass, that is,the ‘whirlpool sign’34 (Fig. 9.16). Other ultrasoundappearances include a dilated, fluid-filled obstructedduodenum, although the obstructed duodenummay be gas-filled, obscuring visualization. This signis not invariable, however, and a contrast study maystill be needed to confirm or exclude the diagnosis ofa midgut volvulus. Surgery is performed to untwistthe bowel, which is then laid carefully in the cor-rect position; attachment is usually unnecessary, asabdominal adhesions tend to stabilize the bowel.


A

TS

B

Figure 9.16 Volvulus. (A) Mesentery and superior mesenteric vein are twisted around the superior mesenteric artery,which is seen in cross-section at the centre of the film. (B) Barium meal shows corkscrewing of the duodenum awayfrom the midline, consistent with a malrotation and volvulus. (By kind permission of Dr Delia Martinez, Leeds.)

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Gastro-oesophageal reflux

Reflux through the gastro-oesophageal hiatus is acommon problem associated with neonatal vomit-ing, leading to oesophagitis. The diagnosis is usuallymade with a contrast meal, PH probe and isotopemilk scan. Reflux can be observed on ultrasound asthe retrograde flow of stomach contents throughthe hiatus and up the oesophagus.

The normal intra-abdominal segment of theoesophagus can be demonstrated through the leftlobe of the liver, is usually between 2 and 3 cmlong, and makes an acute angle with the gastricwall. When episodes of reflux are seen over threetimes in 10 minutes, this is said to be pathological.

Appendicitis

Ultrasound is the first line of investigation for thechild presenting with acute abdominal pain, wherethe diagnosis is uncertain following clinical assess-ment. The position of the appendix in small childrenmay vary—pointing upwards, downwards or to thepatient’s left—making the clinical diagnosis difficult,as the pain is not always confined to the right lowerquadrant. Ultrasound is particularly useful in estab-lishing the diagnosis of acute appendicitis and indiagnosing other possible causes of acute abdominalpain, such as gynaecological disorders.35,36 It is alwaysgood practice to perform a full abdominal surveywhen the clinical presentation is indeterminate.


A B

TS

DC

LS

Figure 9.17 Appendicitis. (A) The normal appendix (arrows) lying transversely across the psoas muscle. (B)Longitudinal scan through dilated inflamed appendix containing appendicolith. (C) Dilated thick-walled appendix seenin LS. (D) Same patient as (C) where appendix is seen in cross-section surrounded by echogenic oedematous mesentery,with dilated fluid-filled caecum seen just laterally.

(Continued)

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Ultrasound demonstrates a hypoechoic, thick-ened appendix, > 6 mm thick, with a blind end (Fig.9.17). Occasionally an appendicolith, with strongacoustic shadowing, is present. The inflamed appen-dix is not compressible on gentle, graded compres-sion with the transducer. This should be done verycarefully, and released very slowly to avoid reboundtenderness. Ultrasound cannot reliably excludeappendicitis, especially if the appendix is retrocaecal.

Perforation may not be easy to see with ultra-sound, as fluid may disperse through the abdomenwith decompression of the appendix itself.However, a frank periappendiceal fluid collectionor abscess is easily demonstrable in a proportion ofchildren and may, in some cases, be treated conser-vatively with antibiotics or drained percutaneouslyprior to surgery. The presence of free fluid, partic-ularly if clear, in the abdomen is a non-specific

finding and is not a reliable indicator of an acuteabdomen. If echogenic fluid is seen, this is sugges-tive of intraperitoneal infection in the child withacute abdominal pain, but may be seen in otherconditions, for example rupture of a haemorrhagicovarian cyst. If ultrasound is equivocal, the clini-cians may decide to observe the child but furtherimaging with CT scanning can be helpful in a fewselective cases. Alternatively a laparoscopic exami-nation may be performed where there is significantclinical concern37.

Enteric duplication cysts

These comparatively rare lesions present in infancy orearly childhood with nausea, gastrointestinal bleed-ing, intestinal obstruction and, occasionally, a palpa-ble mass. Most are intra-abdominal but oesophageal


E

F G

Figure 9.17 cont’d (E) Increased vascularity of inflamed appendix seen on colour flow Doppler imaging. (F) Walledoff appendix abscess containing fluid and gas. (G) Complex inflammatory mass containing appendicolith.

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duplication cysts cause a thoracic lesion with respira-tory symptoms. Multiple cysts may be present.

The fluid-filled lesion may demonstrate a spec-trum of ultrasonic appearances, from anechoic to

hyperechoic, sometimes with gravity-dependentdebris or blood.38

The wall is well defined and a hyperechoic innerrim of mucosa may be identified in some cases ofintestinal duplication (Fig. 9.18). The cyst isclosely related to the adjacent bowel and this canbe appreciated on real-time scanning as the bowelperistalses. CT and MRI rarely add anything to theultrasound information. Contrast radiography mayshow an extrinsic defect but communication withthe cyst is rare.

There are many causes of intra-abdominal cysticmasses in children. (Table 10.6). The main differ-ential diagnosis in the infant girl is from an ovariancyst as the ovary is generally an intra-abdominalorgan at this age. Useful indicators of an ovarianorigin can be detected on careful sonography, bydetecting some residual ovarian tissue in the cystwall, and the finding of a clearly seen multifollicu-lar ovary on one side with absent visualization of adefinite ovary on the other side.


A B

Figure 9.18 (A) Duplication cyst with thickened wall adjacent to bowel. (B) Typical ‘double’ wall seen in entericduplication cysts.

Table 9.6 Abdominal fluid-filled masses in paediatrics—differential diagnoses

Choledochal cystMesenteric cystDuplication cystHepatic cystPancreatic pseudocystEpidermoid cyst of the spleenLymphangiomaOvarian cystEncysted fluid associated with ventriculoperitoneal

shunt tubingRenal cyst or renal dilatationCystic renal tumour

References1. McHugo JM, McKeown C, Brown MT et al. 1987

Ultrasound findings in children with cystic fibrosis.British Journal of Radiology 60: 137–141.

2. Williams SM, Goodman R, Thompson A, Mchugh K,Lindsell DRM. 2002 Ultrasound evaluation of liver

disease in cystic fibrosis as part of an annualassessment clinic: a 9-year review. Clinical Radiology57: 365–370.

3. Wilson-Sharpe RC, Irving HC, Brown RC et al. 1984Ultrasonography of the pancreas, liver and biliary

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system in cystic fibrosis. Archives of Diseases ofChildhood 59: 923–926.

4. McEvoy CF, Suchy FJ. 1996 Biliary tract disease inchildren. Pediatric Gastroenterology 43: 75–98.

5. Farrant P, Meire HB, Mieli-Vergani G. 2000Ultrasound features of the gallbladder in infantspresenting with conjugated hyperbilirubinaemia.British Journal of Radiology 73: 1154–1158.

6. Kim SH, Lim JH, Yoon HK et al. 2000 Choledochalcyst: comparison of MR and conventionalcholangiography. Clinical Radiology 55 (5): 378–383.

7. Siegel MJ. 2002 Gallbladder and biliary tract. In:Siegel M (ed.) Pediatric Sonography. LippincottWilliams & Wilkins, Philadelphia, pp. 275–304.

8. Takano H, Smith WL. 1997 Gastrointestinal tumorsof childhood. Radiologic Clinics of North America35: 1367–1389.

9. Buetow PC, Rao P, Marshall WH. 1997 Imaging ofpaediatric liver tumours. Magnetic ResonanceImaging Clinics of North America 5: 397–413.

10. Boon LM, Burrows PE, Patiel HJ et al. 1996Hepatic vascular anomalies in infancy: a twenty-sevenyear experience. Journal of Paediatrics 129:3346–3354.

11. Siegel MJ, Martin KW, Worthington JL. 1987Normal and abnormal pancreas in children: USstudies. Radiology 165: 15–18.

12. Han BK, Babcock DS. 1985 Sonographicmeasurements and appearances of normal kidneys inchildren. American Journal of Roentgenology 145:611–616.

13. Ferrer FA, McKenna PH, Bauer B, Miller SF. 1997Accuracy of renal ultrasound measurements forpredicting actual kidney size. Journal of Urology 157:2278–2281.

14. Bisset GS, Strife JL. 1987 The duplex collectingsystem in girls with urinary tract infection prevalenceand significance. American Journal of Roentgenology148: 497–500.

15. Assael BM, Guez S, Marra G et al. 1998 Congenitalreflux nephropathy: a follow-up of 108 casesdiagnosed perinatally. British Journal of Urology 82:252–257.

16. Tibballs JM, De Bruyn R. 1996 Primaryvesicoureteric reflux: how useful is postnatalultrasound? Archives of Diseases of Childhood 75:444–478.

17. Zerin JM, Ritchey ML, Chang CCH. 1993 Incidentalvesicoureteral reflux in neonates with antenatallydetected hydronephrosis and other renalabnormalities. Radiology 187: 157–160.

18. Mackenzie S. 2001 Radiological investigation ofpaediatric UTI. Imaging 13(4): 285–294.

19. Dacher JN, Pfister C, Monroc M, Eurin D, LedosseurP. 1996 Power Doppler sonographic pattern of acutepyelonephritis in children: comparison with CT.American Journal of Roentgenology 166: 1451–1455.

20. Ritchey ML, Green DM, Breslow NB et al. 1995Accuracy of current imaging modalities in thediagnosis of synchronous bilateral Wilms’ tumour: areport from the National Wilms’ Tumour StudyGroup. Cancer 75: 600–604.

21. Scott D J, Wallace WHB, Hendry GMA. 1999 Withadvances in medical imaging can the radiologistreliably diagnose Wilms’ tumours? Clinical Radiology54: 321–327.

22. Abramson SJ. 1997 Adrenal neoplasms in children.Radiologic Clinics of North America 35 (6):1415–1453.

23. Felc Z. 1995 Ultrasound in screening for neonataladrenal haemorrhage. American Journal of Perinatology12: 363–366.

24. Steffens J, Zaubitzer T, Kirsch W, Humke U. 1997Neonatal adrenal abscesses. European Journal ofUrology 31: 347–349.

25. John SD. 1999 Trends in pediatric emergencyimaging. Radiologic Clinics of North America 37:995–1007.

26. Godbole P, Sprigg A, Dickson JAS, Lin PC. 1996Ultrasound compared with clinical examination ininfantile hypertrophic pyloric stenosis. Archives ofDiseases of Childhood 75: 335–337.

27. Morrison SC. 1997 Controversies in abdominalimaging. Pediatric Clinics of North America 44:555–574.

28. Stunden RJ, LeQuesne GW, Little KE. 1986 Theimproved ultrasound diagnosis of hypertrophic pyloricstenosis. Pediatric Radiology 16: 200–205.

29. O’Keefe FN, Stansberry SD, Swischuk LE et al. 1991Antropyloric muscle thickness at ultrasound in infants:what is normal? Radiology 187: 827–830.

30. Verschelden P, Filiatrault D, Garel L et al. 1992Intussusception in children: reliability of US indiagnosis – a prospective study. Pediatric Radiology184: 741–744.

31. Chan KL, Saing H, Peh WCG et al. 1997 Childhoodintussusception: ultrasound-guided Hartmann’ssolution, hydrostatic reduction or barium enemareduction? Journal of Pediatric Surgery 32: 3–6.

32. Britton I, Wilkinson AG. 1999 Ultrasound features ofintussusception predicting outcome of air enema.Pediatric Radiology 29: 705–710.

33. Zerin JM, DiPietro MA. 1992 Superior mesentericvascular anatomy at US in patients with surgicallyproved malrotation of the midgut. Radiology 183:693–694.


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34. Pracros P, Sann L, Genin G et al. 1992 Ultrasounddiagnosis of midgut volvulus: the ‘whirlpool’ sign.Pediatric Radiology 22: 18–20.

35. Siegal MJ. 1995 Appendicitis in childhood:usefullness of ultrasound in diagnosis. PaediatricSurgery International 10: 62–67.

36. Pena BM, Taylor GA, Fishman SJ et al. 2002 Effectof an imaging protocol on clinical outcomes amongpediatric patients with appendicitis. Pediatrics 110:1088–1093.

37. Quillan SP, Siegel MJ, Coffin CM. 1992 Acuteappendicitis in children: value of sonography indetecting perforation. American Journal ofRoentgenology 159: 1265–1268.

38. Segal SR, Sherman NH, Rosenberg HK et al. 1994 Ultrasonic features of gastrointestinalduplications. Journal of Ultrasound in Medicine 13:863–870.


General reading1. Carty H, Brunelle F, Shaw D, Kendall B. 1994

Imaging Children. Churchill Livingstone, Edinburgh.2. Siegel MJ. 2002 Pediatric Sonography, 3rd edn.

Lippincott/Williams & Wilkins, Philadelphia.

3. Stringer DA, Babyn PS. 2000 Pediatric GastrointestinalImaging and Intervention. BC Decker, Ontario.

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Ultrasound has an increasingly important role inthe initial evaluation of the acute abdomen. Manytrauma centres recognize the value of ultrasound asa first-line investigation in properly trained hands.Small portable scanners now offer bedside—evenroadside—assessment that can speed the triageprocess, whereas higher-specification scannersenable the experienced operator to diagnosedetailed pathology in the acute abdomen. CT alsohas an increasing role in this situation. It is readilyavailable in most centres and is proven to be highlyaccurate. But CT is static, takes longer to arrangeand perform and is not always possible, particularlyin acutely ill and unstable patients.

There is little doubt that the accuracy of theultrasound scan is directly attributable to the skilland experience of the operator.1 For instance, adetailed knowledge of the anatomy, and thereforepotential communications, of the peritoneal andretroperitoneal fascial spaces is essential in order tounderstand the significance and likely origin of anabdominal fluid collection. A left iliac fluid collec-tion may simply be due to local causes such as adiverticular abscess, but could be the result of fluidtracking from a leaking aortic aneurysm or anacutely inflamed or ruptured pancreas.

One other significant advantage of ultrasound isthat it is usually an ‘interactive’ process. In theacute setting, the simple question ‘Where does ithurt?’ will frequently direct the operator to theunderlying pathology, for example in acute bowelinflammation or acute cholecystitis. Clinical signs,such as erythema ab igne, which results from painrelief by the patient applying a hot water bottle to

Chapter 10

The acute abdomen

243

CHAPTER CONTENTS

Trauma 244Gastrointestinal tract 245Hepatobiliary emergencies 246The acute pancreas 248Renal tract emergencies 248Other retroperitoneal emergencies 248

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the symptomatic area, may also help to focus theexamination. The operator should be alert topotential clues and be prepared to step outsidestandard scanning protocols, adapting to the manypossible presentations of trauma or other acuteabdominal conditions.

Although many of the following conditions aredealt with in other relevant chapters, together withdetails of the respective ultrasound appearances,there are issues that are specific to the patient whopresents acutely.

TRAUMA

Blunt or penetrating trauma to the torso, fre-quently due to a road traffic accident (RTA) orother forms of accident or violence, is a frequentcause of referral to most accident and emergencydepartments, and forms the main indication fortrauma ultrasound. Internal organ injury as a resultof trauma is extremely difficult to assess clinically,especially as many patients are admitted uncon-scious or in a highly unstable condition. Suchtrauma patients may require emergency laparo-tomy and ultrasound has been shown to be aninvaluable tool in the triage process.2,3 This may beaccompanied by CT, which has the advantage ofbeing able to recognize other injuries which maybe present, such as bony, spinal or retroperitonealtrauma which may or may not be accessible toultrasound investigation.

A system of scanning known as FAST (focusedassessment with sonography for trauma) hasrecently become widely adopted in trauma centres.This system depends upon the proper training ofappropriate personnel, and a number of standard-ized training and accreditation programmes havebeen devised, notably by the American College ofEmergency Physicians.4 FAST scanning involves aminimum four-view examination, principally todetect the presence of fluid which may result fromthe rupture of internal organs. The four-view scanshould include the right and left flanks (for hepa-torenal space, perisplenic regions and spaces aboveand below the diaphragm), the subcostal region(to include the pericardial space) and the pelvis(retrovesical and retrouterine spaces).5

Free fluid is associated with numerous types ofinjury, which may be detected on ultrasound with

varying success. These include rupture of theliver, spleen, kidney, pancreas or bowel (Fig. 10.1).A notable limitation of sonography in the traumasituation is in detecting free fluid in the pelvis, asthe bladder is frequently empty or underfilled, andthe use of the Trendelenburg position, if possible,helps to reduce the number of false-negative resultsin this respect by allowing any free fluid to collectin the pelvis under the influence of gravity.Ultrasound is more successful in detecting freefluid than in detecting organ injury directly.6,7 Onestudy reported a 98% sensitivity for detection offluid, but only 41% of organ injuries could bedemonstrated.8 However, most of the publishedstudies have concentrated only on the presence orabsence of free fluid, rather than the comprehen-sive assessment of the abdomen by suitably quali-fied sonographers. The presence of free fluid onultrasound in a trauma situation therefore infersorgan injury requiring careful ultrasonic assess-ment, further investigation with CT or direct refer-ral for surgery depending on the state of thepatient.

Direct visualization of organ rupture is difficultunless a haematoma or other collection is seen.Laceration or contusion may be demonstrated inthe liver, kidneys or spleen, but less easily inthe pancreas and very infrequently in the bowel.A subtle change in texture may be observed by theexperienced operator, or a fine, high-reflectivitylinear band representing an organ tear. A delayedscan may demonstrate more obvious organ injurythan that apparent on an immediate post-traumaexamination. Small visceral lacerations not visibleon ultrasound may become apparent when imagedwith CT. In particular, pancreatic damage (oftendue to the sudden pressure of a seat belt across theabdomen during road accidents) may not be obvi-ous immediately post-trauma on either ultrasoundor CT.9 Damage to the pancreatic duct (Fig. 10.1E)causes leakage of pancreatic fluid into the abdomi-nal cavity, resulting in pancreatitis and possiblepseudocyst formation or peritonitis.

Free fluid may be present as the result of vessel,rather than organ, rupture. A reduction or loss ofblood flow to all or part of the relevant organ, forexample the kidney, may be demonstrated usingcolour and power Doppler ultrasound. The findingof free fluid in women should prompt a detailed


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scan of the pelvis where possible. Gynaecologicalmasses may rupture or haemorrhage, presentingacutely, and in women of childbearing age, ectopicpregnancy should be included in the list of differ-ential diagnoses.

When visceral trauma is treated conservatively,follow-up ultrasound may be used to monitor theresolution of any fluid collections or haematoma.

GASTROINTESTINAL TRACT

Most acute presentations of gastrointestinal tractpathology are due to obstruction or inflammation,and the ultrasound appearances of these conditionsare discussed more fully in Chapter 8. Appendicitis,and its possible complications, is one of the mostcommon reasons for referral (Fig. 10.2). Ultrasound

THE ACUTE ABDOMEN 245

A

C

B

D

Figure 10.1 (A) The presence of free fluid in a trauma patient implies organ injury, even if this cannot be successfullydemonstrated on ultrasound. CT on this patient demonstrated perforation of the bowel. (B) A patient who has beenstabbed on the right side has injury to the liver causing a subcapsular haematoma. Blood is also present in the rightchest. (C) Laceration of the spleen following a road traffic accident. Free fluid was also present in the abdomen. (D) Splenic lacerations are more obvious several hours after injury. This large splenic haematoma resolved followingconservative treatment.

(Continued)

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has a high sensitivity for acute appendicitis, partic-ularly in children.

Although the detailed assessment of the primarygastrointestinal pathology usually requires evaluationby an experienced operator with a high-frequency

linear probe, many useful indicators can be foundwith the basic curvilinear or sector abdominal scan.The presence of fluid-filled bowel segments, whichmay also show ‘overactive’ peristalsis, should alertthe operator to the possibility of acute intestinalobstruction. Such segments frequently lie proximalto the obstructing lesion, and so the point at whichthey appear to end should be the subject ofdetailed examination. Ultrasound is highly accu-rate in demonstrating obstruction. However, it isless successful in finding its cause and contrast CTor other bowel studies are usually undertakenwhen obstruction is diagnosed. With both intes-tinal obstruction and focal pain it may be necessaryto examine the hernial orifices. A small but symp-tomatic epigastric hernia often goes unnoticedunless a detailed scan of the abdominal wall isperformed.

Fluid collections such as abscesses may alsopoint to the diseased segment, for example inCrohn’s disease or acute diverticulitis. Such inflam-matory bowel conditions may well present with anestablished history which helps the operator tofocus the ultrasound examination accordingly.

Perforation of an abdominal viscus can producesmall amounts of ascites. This is usually ‘mucky’,i.e. containing particulate or gas bubble echoes,and may be localized close to the perforation site,around the duodenum or within the lesser sac.Although gas is usually regarded as an obstacle toultrasound diagnosis, recent studies have shownthat specific patterns of gas echoes can make ultra-sound more sensitive than plain radiography in thediagnosis of pneumoperitoneum.10

HEPATOBILIARY EMERGENCIES

Ultrasound scanning is invariably the first-lineinvestigation for suspected biliary tract emergen-cies. These include inflammatory conditions caus-ing right upper quadrant and epigastric pain,mostly acute cholecystitis or gallstone pancreatitis,and the various causes of obstructive jaundice(Fig. 10.3). If possible, interventional treatmentshould be delayed until a detailed imaging assess-ment of the cause of biliary obstruction has beenmade, since the presence of a biliary stent cancompromise subsequent imaging by CT, MRI orendoscopic ultrasound. Similarly, biliary stents


E

Figure 10.1 cont’d (E) CT demonstrating pancreaticfracture (arrow) in the tail of the pancreas following aroad traffic accident. Ultrasound was not able todemonstrate the fracture but did demonstrate free fluidfollowing the accident and also diagnoseddevascularization of the left kidney (no Doppler flowwithin the kidney) following a severed left renal artery.This is also confirmed on CT.

Figure 10.2 Appendicitis abscess.

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frequently cause bile duct wall thickening and mayintroduce gas into the biliary tree. These will pre-vent the diagnosis of cholangitis or ductal calculiwith ultrasound, and may impede detailed Dopplerinvestigation of, for example, the portal vein. Ifurgent biliary drainage is required, particularlywhen the bile is infected, this can quickly beeffected by endoscopic stent placement or sphinc-terotomy.11 These less invasive methods are replac-ing surgery as the treatment of choice in thissituation, having a lower mortality rate. Endo-scopic sphincterotomy and stone extraction havebeen found to be preferable to surgery, particularlyin cases of severe gallstone pancreatitis where

patients may be poor operative risks12 and in casesof stone-related cholangitis.

Ultrasound-guided bed-side cholecystostomymay also be useful in high-risk patients withinfected gallbladders and is an effective treatmentfor acalculous cholecystitis brought on by pro-longed postoperative fasting.

The liver itself may be acutely tender in systemicvenous congestion due to cardiac failure, acutehepatitis, or the presence of an intrahepaticabscess. The management of liver abscesses isdetermined by their size, number and cause.Ultrasound is used to guide diagnostic aspirationand drainage procedures, and most types of hepatic


A

LIVER LS GBSTENT RUQ

B

DC

Figure 10.3 (A) An acutely tender, inflamed gallbladder containing stones and debris. (B) A patient with knowncarcinoma of the head of the pancreas has presented acutely with obstructive jaundice. Her stent (arrow) is blocked,causing intrahepatic biliary duct dilatation with cholangitis (C). (D) Large liver abscess in an acutely ill patient.

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abscess can be treated successfully using these tech-niques combined with appropriate antibiotictherapy.

THE ACUTE PANCREAS

(See also Chapter 5.) Most cases of acute pancreati-tis are suspected clinically, with raised amylase lev-els and often a history of recurrent epigastric painpointing to the diagnosis of acute pancreatitis (Fig.10.4). Although pancreatitis may be due toabdominal trauma, it is more frequently due togallstone obstruction or alcohol abuse. The pan-creas often appears normal even when acutelyinflamed, so ultrasound examination should focuson the possible causes (such as gallstones, biliarydilatation or evidence of alcoholic liver disease) andcomplications (pseudocysts, portal or splenic veinthrombosis). Many pancreatic pseudocysts are nowmanaged successfully by endoscopic ultrasound-guided transgastric drainage.13

RENAL TRACT EMERGENCIES

(See also Chapter 7.) Ultrasound is usually the first-line investigation in the assessment of acute loinpain, which in the absence of trauma is commonlydue to acute urinary tract obstruction and/or renalinfection (Fig. 10.5). Less common acute presen-

tations include renal vein thrombosis or sponta-neous haemorrhage, usually from a renal tumouror cyst.

Until recently, ultrasound and/or intravenousurography (IVU) have been the investigations ofchoice in acute renal colic due to suspected uretericcalculus, and in most UK centres the IVU is cur-rently the method of choice for demonstratingureteric obstruction (Fig. 10.5E). Low-doseunenhanced multislice CT is increasingly beingrecommended as a replacement for these twomodalities,14 but even with this technique diagnos-tic pitfalls exist.15 Abdominal ultrasound with orwithout plain radiography may still provide com-parable accuracy where CT resources are lim-ited.16,17

The main limitation of ultrasound in acuteureteric obstruction is that obstruction may bepresent in the early stages without collecting sys-tem dilatation. But the minimally dilated renalpelvis, which would normally be dismissed as unre-markable in a patient with a full bladder, shouldraise the operator’s suspicion in the patient withacute loin pain. Doppler ultrasound of the kidneysshows a higher resistance index in the obstructedkidney than in the normal side.18 Upper tractobstruction can be relieved via cystoscopy-guidedureteric stent placement. Ultrasound-guided per-cutaneous nephrostomy may be required if this isnot practicable, or if there is evidence of infection.

Renal infection with parenchymal involvement(acute pyelonephritis) may be the cause of severeacute loin pain with fever, but ultrasound examina-tion mostly shows no abnormality. Occasionallythe skilled operator using high-specification equip-ment may be able to identify segmental areas ofhigh reflectivity, showing decreased blood flowwith power Doppler. The diagnosis of this con-dition is usually based on clinical criteria, butthese segments can be demonstrated with CT ifnecessary.

OTHER RETROPERITONEAL EMERGENCIES

(See also Chapter 8.) Ultrasound has an establishedrole in identifying the presence of an abdominalaortic aneurysm, but should not be used to assesssubacute leakage or rupture. However, where rup-ture is suspected, and no previous imaging results


Figure 10.4 Pancreatitis with a large pseudocyst. Thepatient was acutely tender, and the cyst was drainedunder ultrasound guidance.

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A

B

RT

C E

D

Figure 10.5 (A) Obstructed kidney with pelvicalyceal system (PCS) dilatation and a dilated upper ureter. (B) Mobilestones were demonstrated in the bladder, but the level of obstruction in the ureter could not be positively identified.Intravenous urogram (IVU) confirmed a stone in the ureter. (C) Severe laceration to the liver following a road trafficaccident. (D) The same patient’s CT scan confirms the liver injury and demonstrates an avascular right kidney(compared with the normal left kidney (LK)) due to laceration of the renal vessels. (E) Acute renal colic. IVU demonstratesa left hydronephrosis with a stone in the lower ureter. (This area is not usually demonstrable with ultrasound.)

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are available, ultrasound can be a time-saving triagetool to exclude an aneurysm from the differentialdiagnosis of abdominal pain. Suitably trainedemergency department clinical staff can performthis quickly and successfully.19 Rupture of an aorticaneurysm is a catastrophic event, and although anurgent contrast-enhanced CT can be helpful,emergency surgery based on clinical findingsshould not be delayed by imaging investigations.

Ultrasound is also the first investigation ofchoice for demonstrating suspected psoas abscessor haematoma20 (Fig. 10.6).


SAG RT

Figure 10.6 A large, right-sided psoas haematoma.

References1. Forster R, Pillasch J, Zielke A. 1993 Ultrasonography

in blunt abdominal trauma: influence of the inves-tigator’s experience. Journal of Trauma 34: 264–269.

2. Porter RS, Nester BA, Dalsey WC et al. 1997 Use ofultrasound to determine the need for laparotomy intrauma patients. Annals of Emergency Medicine 29:323–330.

3. McGahan JP, Rose J, Coates TL et al. 1997 Use ofultrasonography in the patient with acute abdominaltrauma. Journal of Ultrasound in Medicine 16:653–662.

4. American College of Emergency Physicians. 1997 Useof ultrasound imaging by emergency physicians[policy statement]. Annals of Emergency Medicine30: 364–365.

5. Scalea TM, Rodriguez A, Chiu WC et al. 1999Focused assessment with sonography for trauma(FAST): results from an international consensusconference. Journal of Trauma-Injury, Infection andCritical Care 46: 466–472.

6. Bode PJ, Neizen RA, Van Vugt AB. 1993 Abdominalultrasound as a reliable indicator for conclusivelaparotomy in blunt abdominal trauma. Journal ofTrauma 34: 27–31.

7. Lentz KA, McKenney MG, Nunez DB et al. 1996Evaluating blunt abdominal trauma. Journal ofUltrasound in Medicine 15: 447–451.

8. Rothlin MA, Naf R, Amgwerd M. 1993 Ultrasoundin blunt abdominal and thoracic trauma. Journal ofTrauma 34: 488–495.

9. Craig MH, Talton DS, Hauser CJ, Poole GV. 1995Pancreatic injuries from blunt trauma. AmericanSurgeon 61: 125–128.

10. Chen SC, Wang HP, Chen WJ et al. 2002 Selectiveuse of ultrasonography for the detection ofpneumoperitoneum. Academic Emergency Medicine9: 643–645.

11. Lameris JS, Van-Overhagen H. 1995 Imaging andintervention in patients with acute right upperquadrant disease. Baillière’s Clinical Gastroenterology9: 21–36.

12. Cohen SA, Siegel JH. 1995 Biliary tract emergencies:endoscopic and medical management. Critical CareClinics 11: 273–294.

13. Norton ID, Clain JE, Wiersema MJ et al. 2001Utility of endoscopic ultrasonography in endoscopicdrainage of pancreatic pseudocysts in selectedpatients. Mayo Clinic Proceedings 76: 794–798.

14. Tack D, Sourtzis S, Delpierre I, de Maertelaer V,Gevenois PA. 2003 Low-dose unenhancedmultidetector CT of patients with suspected renal colic.American Journal of Roentgenology 180: 305–311.

15. Colistro R, Torreggiani WC, Lyburn ID et al. 2002Unenhanced helical CT in the investigation of acuteflank pain. Clinical Radiology 57: 435–441.

16. Catalano O, Nunziata A, Altei F, Siani A. 2002Suspected ureteral colic: primary helical CT versusselective helical CT after unenhanced radiography andsonography. American Journal of Roentgenology 178:379–387.

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17. Patlas M, Farkas A, Fisher D et al. 2001 Ultrasoundvs CT for the detection of ureteric stones in patientswith renal colic. British Journal of Radiology 74:901–904.

18. Rodgers PM, Bates JA, Irving HC. 1992 IntrarenalDoppler ultrasound studies in normal and acutelyobstructed kidneys. British Journal of Radiology 65:207–212.

19. Kuhn M, Bonnin RL, Davey MJ et al. 2000Emergency department ultrasound scanning forabdominal aortic aneurysm: accessible, accurate, andadvantageous. Annals of Emergency Medicine 36:219–223.

20. Monnier-Cholley L, Arrive L, Taboury J et al. 1996Non-vascular retroperitoneal emergencies. Annales deRadiologie 39: 72–77.


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The development of ultrasound-guided minimallyinvasive procedures, incorporating diagnosticbiopsy, therapeutic drainage and treatment tech-niques, has developed significantly over the lastdecade and is now accepted practice, in many cir-cumstances being used in isolation as a definitivetreatment, and in others in conjunction with otherradiological or surgical options. These minimallyinvasive methods are advantageous, with lowerpatient mortality and morbidity, increased patientacceptability, and are economically beneficial.

The relative speed and ease with which theseprocedures can be carried out have resulted in areduction of the diagnostic laparotomy and moreprompt and appropriate patient treatment. Whilstboth ultrasound and CT may be used for many ofthese procedures, in general, ultrasound is oftenthe first-line method as it is effective in the vastmajority, generally more accessible, and does notcarry a radiation risk. Clearly, the choice of tech-nique will depend upon the experience of the indi-vidual, machine availability and the site and depthof the lesion.

ULTRASOUND-GUIDED BIOPSY: GENERALCONSIDERATIONS

Percutaneous biopsy of organs, masses or focal vis-ceral lesions is an integral part of the diagnosticprocess for a large number of patients. Althoughchanges on ultrasound may confirm the suspectedclinical suspicion, that is, a bright liver may indicatefatty change, a nodular liver may suggest cirrhosisor enlarged kidneys of increased echogenicity may

Chapter 11

Interventional and othertechniques

253

CHAPTER CONTENTS

Ultrasound-guided biopsy: generalconsiderations 253Analgesia 254Methods of ultrasound guidance 255

Ultrasound-guided biopsy procedures 257Complications of ultrasound-guided biopsy 261

Ultrasound-guided drainage 261Intraoperative ultrasound 264Laparoscopic ultrasound 265Ultrasound contrast agents in the

abdomen 266The treatment of primary and secondary hepatic

tumours by percutaneous methods 268Endoscopic ultrasound 269

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suggest glomerulonephritis, imaging alone is notenough and a definitive histological diagnosis isrequired. The advantages of using ultrasound toguide such procedures are numerous:

● The needle tip is directed, in real time, alongthe biopsy path and visualized within the lesion.

● Greater precision is obtained; needle guidanceis essential for all small lesions and lesions atdepth.

● Fewer needle passes are required to obtain thedesired result.

● The best route can be utilized and vitalstructures, such as blood vessels, avoided.

● Postprocedure complications, such as haema-toma, are minimized.

● Confidence in the biopsy result, particularly anegative one, is increased due to directvisualization of the needle tip in the lesion.

● All the advantages of ultrasound over otherimaging methods apply (quick, direct vision,no radiation hazard, low cost). The limitationsdue to bone and air-filled structures also apply.

● The capability to perform bedside proceduresfor critically ill patients and to use inconjunction with other imaging techniques, forexample fluoroscopy, is advantageous.

With ultrasound the biopsy procedure is quick,safe and accurate and is therefore acceptable to thepatient. There are several accepted methods of per-forming a guided biopsy, but certain generic rulesare common to the procedure, regardless of theorgan under investigation:

● A written request form from a medicalpractitioner with the results of any previousinvestigations should be available. The reasonfor biopsy should be appropriate.

● Assessment of blood clotting status. Normallythe prothrombin time should be within 3 s ofthe control, platelet count > 75 000/ml andinternational normalized ratio (INR) < 1.3.

● Identification of possible contraindications tobiopsy, for example an uncooperative patient,coagulopathy.

● Careful explanation of the procedure to thepatient, including risks and benefits.

● Informed, written consent for the procedure.

● Procedure should be performed in a quiet andclean environment. Appropriate measuresshould be taken to preserve pre-, peri- andpostprocedure sterility.

● A prebiopsy scan to identify a suitable biopsyroute avoiding vital structures.

● Satisfactory care of the patient both during andafter the biopsy procedure with relevantobservations of vital signs. A pulse oximeterand appropriate nurse cover are nowrecommended.

● Appropriate preparation of the specimen.

● Contraindications are relative and include thebiopsy pathway, an uncooperative patient anduncorrectable coagulation and should beassessed on an individual basis.

AnalgesiaFor the vast majority of biopsy procedures localanaesthetic is administered following localizationof the biopsy site on ultrasound. Either 1% or 2%lidocaine (lignocaine) is commonly used; the vol-ume will depend upon patient build, depth oflesion and patient anxiety. Normally a short periodof time, commonly 4–5 min, is allowed to pass sothat the anaesthetic can work, after which a smallscalpel incision is made in the skin to facilitate thebiopsy needle’s introduction, with little or no dis-comfort to the patient.

In cases of, for example, simple aspiration with a22-gauge needle or smaller, local anaesthetic isnormally unnecessary.

Patients who are particularly apprehensive mayrequire preprocedure medication with a sedativesuch as diazepam or similar anxiolytic agent;however this is not common. Very occasionally intra-venous analgesia and/or sedation may be requiredduring the procedure; it is often a good idea to havean intravenous cannula in situ prior to biopsy.

The use of a general anaesthetic for children iscommon practice, to enable the procedure to becarried out quickly and accurately while the childremains still.


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Methods of ultrasound guidanceThere are various ways of performing ultrasound-guided procedures: organ/lesion localization(‘blind biopsy’), biopsy guide or freehand tech-nique. The choice of method depends upon theprocedure in question, equipment and the experi-ence and skill of the operator.

Blind biopsy

With this method a position on the skin surface ismarked overlying the organ or lesion to be biopsied,using ultrasound to localize. This remains accept-able for diffuse disease, when only a representativesample of liver tissue is required. Nevertheless, it isgood practice even in these situations to visualizethe needle during the procedure, and this methodof biopsy is now used less frequently.

Biopsy guidance

Most manufacturers provide a biopsy guide whichfits snugly on to the transducer head and providesa rigid pathway for the needle (Fig. 11.1). Theseare now the commonest and preferred method ofbiopsy. Previously adjustable angle biopsy guideswere available; however these offered no specificadvantages and were prone to user error. The fixedbiopsy guides contain a groove for a series of plas-tic inserts ranging from 14G to 22G size, depending

on the size of the biopsy needle. It is often pre-ferred to use one size greater than the needle, thatis a 16G insert for an 18G needle, as the needletends to move more freely. These guides are steril-ized and fitted on to the transducer, which caneither be covered by a sterile sheath or thoroughlycleaned with chlorhexidine solution. The use of asheath is highly recommended, as it maintains thesterility of the procedure, reducing the risk ofinfection, with no adverse effect on the image.

The needle pathway is displayed on the ultra-sound monitor electronically as a line or narrowsector, through which the needle passes. The oper-ator then scans in order to align the electronicpathway along the chosen route, the needle isinserted and the biopsy taken. These attachmentsshould be tested regularly to ensure the needle fol-lows the correct path (Fig. 11.2).

Freehand

A freehand approach, in which the operator scanswith one hand and introduces the needle near tothe transducer with the other, may be used forlarger or more superficial lesions. This technique iscommonly used for breast biopsy and biopsy in thehead and neck. The needle is inserted from oneend of the probe at right angles to the ultrasoundbeam; generally speaking the angle utilized is shal-low in comparison with the fixed guide systems fordeeper structures.

INTERVENTIONAL AND OTHER TECHNIQUES 255

A B

a

d

C

b

Figure 11.1 (A) Necessary component parts to perform an ultrasound-guided biopsy procedure. A series of plasticinserts (A) range in size from 14 to 22G. The appropriate insert is inserted into a fixed biopsy guide (B). The procedureis performed with sterile jelly (C) and a sterile probe cover (D) if required. (B) The assembled biopsy guide.

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Equipment and needles

The core of tissue for histological analysis isobtained with a specially designed needle consist-ing of an inner needle with a chamber or recess forthe tissue sample and an outer, cutting needlewhich moves over it—the Tru-Cut needle. Thebiopsy is obtained in two stages: first the innerneedle is advanced into the tissue, then the outercutting sheath is advanced over it and the needlewithdrawn containing the required tissue core(Fig. 11.3).

The use of a spring-loaded gun to operate theseneedles is now commonplace (Fig. 11.4). Suchdevices are designed to operate the needle withone hand; the whole needle is advanced into thetissue, just in front of the area to be biopsied. Bypressing the spring-loaded control, the inner partis rapidly advanced into the lesion, followed rapidlyby the cutting sheath over it. These needles can beobtained in a variety of sizes—generally 14, 16, 18or, less commonly, 20 gauge. Most focal lesions arebiopsied with a standard 18G needle. As a generalprinciple, as the needle advances approximately1.5–2.0 cm during biopsy, it is advisable to posi-

tion the needle tip on the edge of a lesion to obtaina good histological sample as most lesion necrosistends to be centrally located.

Such biopsy guns enable the operator to scanwith one hand and biopsy with the other, observ-ing the needle within the lesion, yielding a highrate of diagnosis with a single-pass technique1 andminimizing post-biopsy complications.


Figure 11.2 Testing the alignment of the biopsy guide. The electronic pathway is activated on the image, and theneedle is scanned as it is passed into a jug of water.

Figure 11.3 Biopsy needle closed (top) and open(bottom).

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As an alternative to the gun/needle combina-tion a number of ‘self-fire’ needles are available.This is essentially a single-use spring-loaded biopsyneedle. Again these come in a variety of sizes buttheir advantage is that they are easier and lighter touse than the gun/needle combination, and there-fore are easier employed in the CT situation. Mostdepartments will tend to utilize a combination ofboth.

In cases where the clinician is not familiar withultrasound techniques, appropriate guidance bya sonographer, while the clinician biopsies, ishighly successful, quick and avoids potentialcomplications.

Fine-needle histology, involving the use of nee-dles of 21 gauge or less, reduces even further thepossibility of postprocedure complications. Theseare generally not used as only small amounts of tis-sue are obtained for analysis and, as thin needles,they are apt to bend more easily, and are thereforemore difficult to see and retain within the plane ofthe scan. Biopsy of deep lesions is therefore moredifficult, if not impossible.

Fine-needle aspiration cytology

Cytology is the analysis of cells rather than the coreof tissue obtained for histology. This is generallymore difficult to interpret pathologically, as thecharacteristic architecture and intercellular rela-tionships seen in a histological sample are absent.It has the advantage, however, of allowing a finerneedle to be used. This can be passed through

structures, for example the stomach, blood vessels,en route to the site of interest, with no adverseeffects.

Fine needles for cytology are of 21 gauge orsmaller. They are of a simple design with a bev-elled, hollow core and no cutting mechanism.

The needle is introduced under ultrasoundguidance to the required position. Fragments oftissue are removed into the needle by applyingnegative (sucking) pressure with a syringe to theneedle, while moving the needle to and fro toloosen the tissue.

These can then be expelled on to a microscopeslide and smeared. The main disadvantage of thistechnique is that it requires a highly trained andspecialized pathologist to interpret the samples,whereas all trained pathologists can view histo-logical specimens. In addition, for many condi-tions, histological diagnosis is required, althoughcytology remains a useful tool in the breast andthyroid.

ULTRASOUND-GUIDED BIOPSYPROCEDURES

Liver biopsy

The most common reason for ultrasound-guidedbiopsy is for suspected metastatic disease. The liveris one of the most common sites for metastases andhistology is often required to confirm the diagno-sis, or to identify the origin of an unknown primarylesion (Figs 11.5 and 11.6).

Biopsy of other focal lesions in patients withchronic liver disease (for example, cirrhosis, hepa-titis B or C) in whom there may be suspected hepa-tocellular carcinoma and occasionally in patientswith benign disease (for example, capillary hae-mangiomas or focal nodular hyperplasia) can alsobe performed, although MRI and contrast ultra-sound are increasingly used to characterize lesions,without recourse to biopsy.

Focal lesion biopsy is generally safely and accu-rately performed with an 18G Tru-Cut needlewhich yields reliable tissue for histological analysis.In general an accuracy of 96% should be achiev-able2 (Fig. 11.7).

In addition to focal lesion biopsy anothercommon reason for liver biopsy is to assess the


Figure 11.4 Spring-loaded gun designed to operate thecutting needle.

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presence/absence of parenchymal liver disease,severity of disease and, where appropriate, theaetiology of the disease process. This is often per-formed in patients with abnormal liver functiontests with no evidence of biliary obstruction. The

clinical history and serological analysis can behelpful in determining aetiology; however biopsyis often required. This is normally performedwith a 14G or 16G Tru-Cut needle. Very oftenthe liver is simply identified with ultrasound anda suitable mark made on the skin, often in themid-axillary line, and the biopsy performedthrough the right lobe. Although this is accept-able for this type of biopsy, as no guidance isrequired towards a specific focal lesion, ultra-sound guidance during the procedure is stillpreferable to the ‘blind’ technique in order toavoid large vessels and reduce the subsequent riskof haematoma. Biopsy may also be performed forpatients with suspected rejection followinghepatic transplantation.

Where coagulation profiles are not correctable(and most generally are), liver biopsy can be per-formed using a ‘plugged’ technique or, more com-monly, by the transjugular route (Fig. 11.8).

Pancreatic biopsy

The commonest reason for biopsy of the pancreasis in patients presenting with obstructive jaundicedue to a mass in the head of the gland. A fine-needle technique enables the mass to be accessedthrough the stomach and left lobe of liver without


Figure 11.5 In a liver full of metastases, the electronicpathway is lined up on a hyperechoic lesion near thesurface (arrows).

Figure 11.6 The needle is introduced into the liver, justin front of the lesion, and the gun is fired, propelling theneedle tip into the chosen lesion (arrows).

RT

Figure 11.7 A focal liver lesion immediately post-biopsy,two passes. Residual air is noted within the lesionoutlining the recent biopsy tracks. This is a very usefulappearance and visually confirms that the biopsy hasbeen taken from the correct area.

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complications. However an 18G needle biopsy isadvisable to reduce false-negative results due to thewell-known situation of a carcinoma being associ-ated with an element of peripheral inflammation.Pancreatic biopsies are often better performedunder CT control (Fig. 11.9), particularly whenlesions are small, patients big and/or the lesion isdifficult to identify with ultrasound. In thosepatients with negative biopsies very often intervalCT scans are performed to see if the lesion is staticor progressive.

Native kidney biopsy

Histology is frequently required in order to directfurther management of diffuse renal disease.Biopsy of solid renal masses is rarely performed asthe diagnosis of renal cell or transitional cell carci-noma is usually clear from imaging. Biopsies arestill performed however in those patients who arenot having surgery to confirm the diagnosis; this isoften required prior to chemotherapy or new ther-apeutic regimes. Biopsy of the native kidney is


A

B

C

Figure 11.8 (A) Transjugular biopsy of the liver. Access is via the right internal jugular vein, through the right atriumand into the inferior vena cava and hepatic veins. Once the catheter is wedged in the hepatic vein the cutting needle isreleased and a biopsy is taken. (B) Plugged liver biopsy technique. This is no longer, or only rarely, used. A 4F sheathcan accept an 18G biopsy needle and is inserted into the liver. Multiple biopsies can be taken: at the end of theprocedure the needle is removed and the biopsy track embolized via the sheath with embolic material, e.g. sterisponand coils. (C) X-ray of the post-embolization track.

AU: brandname?

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performed in the majority of centres under ultra-sound guidance. Contraindications to biopsyinclude hydronephrosis, which may be moreappropriately treated with catheterization ornephrostomy, or small kidneys, that is < 8 cm lon-gitudinal axis (these appearances being indicativeof chronic renal impairment). Kidneys > 9 cm canpotentially be biopsied; however other factors,including cortical thickness, age, clinical historyand the requirement for definitive diagnosis willall have a bearing on whether biopsy is performedor not. Hydronephrosis and kidney size are easilyassessable with a prebiopsy scan.

In most cases the biopsy is performed with thepatient prone over a small bolster to maximizeaccess to the kidney. The shortest route, avoidingadjacent structures, is selected; subcostally, travers-ing the cortex of the lower pole and avoiding thecollecting system and major vessels is recom-mended. With ultrasound guidance, either kidneymay be chosen and accessibility will vary betweenpatients. The depth of penetration and angle ofapproach are carefully assessed. Biopsy is normallywith a 16G needle.

The patient’s cooperation is required with sus-pending respiration at the crucial moment. This

avoids undue damage to the kidney as the needle isintroduced through the capsule. The needleshould be positioned just within the capsule priorto biopsy so that the maximum amount of corticaltissue is obtained for analysis, as the throw of theneedle may be up to 2 cm.

Renal transplant biopsy

Biopsy is a valuable tool in the postoperative man-agement of the transplant patient (Chapter 7),enabling the cause of graft dysfunction to be iden-tified, in particular differentiating acute tubularnecrosis from acute rejection. Ultrasound guidanceis essential in order to reduce complications such ashaematoma, vascular damage (which may result inarteriovenous fistula or pseudoaneurysm forma-tion) and laceration of the renal collecting system.A single-pass technique, using the spring-loadedbiopsy gun with a 16-gauge needle, is usuallysufficient for histological purposes; howevertwo passes are often required so that electronmicroscopy and immunofluorescence can also beperfomed. The procedure is well tolerated by thepatient and the complication rate low, at lessthan 5%.3


A B

R L R

Figure 11.9 (A) CT-guided biopsy of a pancreatic head mass. The tip of the biopsy needle (arrow) is positioned in theperiphery of the lesion so that when the biopsy is taken a good core of tissue is obtained. Note the artifact from theneedle tip. (B) CT-guided bioposy of a retroperitoneal lymph node mass (arrowheads). The mass lies adjacent to theaorta (arrow); however this is protected from the needle by the angle of approach and its relationship to the vertebralbody. CT is the preferred biopsy method of choice for deep structures within the retroperitoneum.

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A full scan of the kidney is first performed tohighlight potential problems, for example peri-renal fluid collections, and to establish the safestand most effective route. The transplanted kid-ney lies in an extraperitoneal position and thechosen route should avoid puncturing the peri-toneum, to minimize the risk of infection. Unlikethe native kidney, the upper pole of the trans-planted kidney is usually chosen to avoid majorblood vessels and the ureter, which pass close tothe lower pole.

The biopsy aims to harvest glomeruli, and thechosen route should therefore target the renal cor-tex. An angle is chosen to include the maximumthickness of cortex and, where possible, avoid therenal hilum (Fig. 11.10).

Complications of ultrasound-guided biopsyPostprocedure complications such as haematomarequiring blood transfusion and trauma to adjacentviscera occur very infrequently when ultrasoundguidance is used. As expected, the risk of complica-tions is less in fine-needle biopsy than with largerneedles;4 however, there is no significant differencein complication rate between a standard 18G Tru-Cut needle and a 22G Chiba needle.5 The mortal-ity and major complication rates vary but using astandard 18G needle these are approximately0.018–0.038% and 0.18–0.187% respectively, mor-tality being due to haemorrhage in 70%. As a work-ing figure this means the mortality is approximately1 in 3300–5400 and morbidity 1 in 530 biopsies(Table 11.1).4,6,7 The risk of haemorrhage isincreased in patients with coexistent cirrhosis and ismore likely to occur with malignant than benignlesions,8,9 although large haemangiomas also cancarry a significant risk of bleeding.

As with any procedure of this nature, there is avery small risk of infection, which can be mini-mized by using an aseptic technique.

Tumour seeding of the biopsy tract is an uncom-mon complication of biopsy and reports of tumourseeding are associated with repeated passes into themass using large needles. Although much talkedabout, tumour track seeding is in fact rare, occurringin approximately 1 in 20 000 biopsies.7,10 The best-known tumours for this are mesothelioma andhepatoma.

Complications following abdominal biopsy areincreased with multiple passes and are at least inpart related to the skill and experience of theoperator.

If the biopsy result is negative or unexpectedthen a number of scenarios should be consideredand include sampling error, poor histological spec-imen, sonographic or pathological misinterpreta-tion or indeed a true negative finding. A repeatbiopsy is sometimes justified.

ULTRASOUND-GUIDED DRAINAGE

Many fluid collections are the result of surgicalintervention and often cannot be differentiatedon ultrasound alone. Diagnostic aspiration of


Figure 11.10 (A) The transplanted kidney lies in theiliac fossa and is biopsied with the patient supine. (B)The needle is seen entering a transplanted kidney(arrowheads).

Proposed route

Lowerpole

Upperpole

A

B

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fluid collections is used to establish theirexact nature: this may include haematoma,lymphocoele, urinoma, biloma, pseudocysts andothers.

Postoperative haematomas are normally treatedconservatively and tend to resolve spontaneously.Insertion of a drain into such a collection is at highrisk of converting the collection into an abscess.

Abscess drainage

Ultrasound-guided drainage of abscesses is nowthe preferred treatment when the collection canbe visualized on ultrasound and a safe route cho-sen. These may result from postoperative infec-tion, inflammatory bowel conditions, such asCrohn’s disease or appendicitis, or other sourcesof infection, particularly in immunosuppressedpatients. Drains come in different sizes and gen-erally the thicker the pus, the larger the bore ofdrain that is required. Whilst aspiration is initiallyperformed to confirm the nature of the collec-tion, very often a drain is left in situ; togetherwith appropriate antibiotic therapy this is usuallyeffective. At the very least it normally leads to animprovement in the overall clinical condition toallow definitive treatment and can in itself be adefinitive cure.

Ultrasound is particularly useful in cases of hepaticabscesses and in draining the subphrenic, pericolicand subhepatic areas. Superficial collections, usuallyassociated with wound sites, are also readily accessi-ble to ultrasound. Collections obscured by bowel gasare best drained under CT guidance.

Gallbladder drainage

Gallbladder drainage under ultrasound control is atemporary, palliative procedure which tends to bereserved for particularly ill patients with septi-caemia, as a method of stabilizing their conditionprior to surgery. Drainage of, for example, a gall-bladder empyema buys useful time, reducing therisk of perforation and subsequent peritonitis andimproving clinical status prior to surgical removal.Although the portable nature of ultrasound allowsa bedside procedure to be performed (which is par-ticularly useful in patients under intensive therapywho cannot be moved), these procedures carry ahigh risk to the patient and full anaesthetic, nurs-ing and medical support is required.

Nephrostomy

Renal obstruction in which the pelvicalyceal systemis dilated may be alleviated by the percutaneousintroduction of a nephrostomy tube under ultra-sound guidance. This procedure relieves pressure inthe renal collecting system and avoids potential irre-versible damage to the renal parenchyma (Fig.11.11). Although the procedure may be carried outcompletely under ultrasound control, it is normallyperformed in a screening room where a combina-tion of ultrasound and X-ray screening can be usedto maximal effect.

Cyst drainage

The percutaneous treatment of renal and hepaticcysts by simple aspiration may afford only temporaryrelief as they frequently recur, but a more permanentresult may be achieved by injecting a sclerosant, forexample absolute alcohol or tetracycline into thecyst. In addition, percutaneous treatment of hydatidliver disease (traditionally avoided because of the riskof spreading parasites along the needle track andcausing further infection) has been successfully per-formed by injecting of a scolicidal agent,11 avoidingthe need for surgical removal.

Other applications include draining of pancre-atic pseudocysts and inserting a cystogastrostomytube with combined fluoroscopy and ultrasoundguidance; the cyst is allowed to drain through this


Table 11.1 Complications of ultrasound-guidedbiopsy

Major Number compli-of Mortality cation

Author Year biopsies rate rate

Fornari et al4 1989 10 800 1:5400 1:530Nolsoe et al6 1990 8000 1:2700 1:540Smith7 1991 16 400 1:3300 —

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tube into the stomach. This is now better doneendoscopically.12

Indirect ultrasound guidance

Not infrequently drainage of fluid, for examplefrom the pleural cavity, may be performed awayfrom the ultrasound department in the ward orclinic. Although ideally this is done under guidance

with a portable scanner, in practice excellent resultsare obtained for larger, non-loculated collections,particularly pleural effusions, by marking the skinsurface with a felt-tip marker in the main scanningdepartment to enable drainage to be safely carriedout on the ward.

The mark should be made with the patient inthe position in which drainage is to be attempted,for example sitting or decubitus right side raised,


A B

C

LT

Figure 11.11 (A) Longitudinal ultrasound image of the left kidney. There is clear evidence of hydronephrosis. (B) Similar image during a nephrostomy procedure. The electronic ultrasound guide path can be easily visualized. Theguide wire (arrow) can also be seen within the renal pelvis and collecting system. (C) Longitudinal ultrasound scan ofthe left kidney immediately following nephrostomy. The collecting system remains dilated due to injected contrast. Theechogenic tips of the drainage cathether (arrow) can be visualized within the renal pelvis.

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and this information communicated to the clini-cian performing the drainage, together with thedepth from the skin surface to the fluid. The punc-ture site should be marked so that the route is per-pendicular to the skin surface. Drainage of pleuraleffusions and of ascites are the two most com-monly performed procedures using this method.

INTRAOPERATIVE ULTRASOUND (IOUS)

IOUS is increasingly used in the abdomen, inboth the diagnosis and treatment of lesions. Itsapplications are varied and its dynamic nature,mobility and high resolution make it ideal for sur-gical work.

Hepatic IOUS

The most frequent application in the abdomen isin diagnosing and locating liver metastases prior tosurgical resection. Resection of metastases, partic-ularly from colorectal tumours, is a potentialcure, but results are unsuccessful if small lesions,undetected preoperatively, are not removed atoperation.

The direct contact of the IOUS probe with theliver surface, avoiding attenuative subcutaneoustissue, enables a high-frequency (7.5 MHz) probeto be used. IOUS can demonstrate lesions toosmall to be detected on preoperative imaging, andas a result can change operative management13,14

in terms of altering the resection line to includemore tissue, removing additional hepatic seg-ments or even abandoning the operative proce-dure altogether.

A combination of surgical palpation, whichdetects small surface lesions, and IOUS, whichdetects small, deep lesions, has the highest diagnos-tic accuracy. IOUS is quick to perform in the handsof an experienced operator and its contribution tothe success of surgery is invaluable15 (Fig. 11.12).

IOUS is particularly useful when there has been adelay between preoperative imaging and surgery, asprogression of disease may have occurred duringthis interval, or when preoperative imaging is equiv-ocal (for example, differentiating tiny cystic fromsolid lesions). IOUS is often able to offer a defini-tive diagnosis and when doubt still exists guidedbiopsy under ultrasound control may be performed.

In addition to lesion detection it is able to demon-strate vascular invasion by tumour and to demon-strate clearly, in real time, the relationship of thetumour to adjacent vascular structures; this is essen-tial for planning a resection line. The greater themargin of normal tissue around the resectedtumour, the better the long-term prognosis, and amargin of greater than 1 cm normal tissue is pre-ferred. IOUS can also be used to locate deep lesionsfor ultrasound-guided biopsy or ablation.

Other applications of IOUS

There are numerous extrahepatic applications forIOUS in the abdomen, including urological, vas-cular and gastrointestinal tract scanning.

Ultrasound evaluation of the common duct forcalculi following cholecystectomy can identifysmall fragments which may not be easily palpablethrough the duct wall. Using this technique theduct is less susceptible to injury which may be asso-ciated with direct examination or the introductionof X-ray contrast agents.

Pancreatic scanning is particularly useful inidentifying small tumours of the body and tail ofpancreas for curative resection16 and in differenti-ating small pancreatic retention cysts from solidnodules.17

The treatment of tumours by percutaneous ultra-sound-guided techniques, rather than surgical resec-tion, is becoming more common. However, it maynot always be possible to achieve success percuta-neously and techniques have been developed toablate tumours during open surgery. Cryotherapy,18

in which the lesion is frozen by introducing a cryo-probe into the centre of the lesion under intraoper-ative ultrasound guidance, has been successfullyused, but is now largely superseded by radio-frequency and microwave ablation (Fig. 11.13).These techniques have resulted in long-term sur-vival in patients with hepatocellular carcinoma19 andmultiple liver metastases.20 The success of such tech-niques depends to a large extent upon patient selec-tion. Those with very large and/or multiple lesionstend to have a poor prognosis compared withpatients with smaller, well-confined disease.However these techniques continue to develop andare likely to offer hope to many patients currentlyuntreatable with conventional methods.


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LAPAROSCOPIC ULTRASOUND

Dedicated laparoscopic ultrasound probes may bepassed through the laparoscopic port during surgicalprocedures to investigate the liver, biliary tree,pancreas and other viscera without the need for opensurgery (Fig. 11.14).

The trend towards laparoscopic rather thanopen cholecystectomy has increased the need foraccurate laparoscopic exploration of the biliaryductal system to confirm the presence or absenceof stones. Laparoscopic ultrasound is better atdemonstrating stones in the duct and anatomicalductal variations than conventional intraoperativecholangiography.21

Laparoscopic ultrasound has also provenadvantageous in staging patients with hepatictumours for liver resection,22 demonstrating deeptumours not visible on surgical laparoscopy, or bypreoperative imaging methods and so avoiding theneed to proceed to open hepatic resection in somepatients.

Patients with pancreatic head and ampullary car-cinomas are potentially resectable in only a minorityof cases. Preoperative imaging is known to under-estimate the extent of the disease, and so manypatients traditionally undergo a staging laparotomybefore resection is attempted. However, over one-third of patients previously considered resectable


A B

C D

Figure 11.12 Intraoperative ultrasound (A) Demonstrating a margin of tissue of only 2 or 3 mm between themetastasis and the hepatic vein. (B) Metastasis in segment 8, at the confluence of the hepatic veins. (C) This metastasishas started to invade the hepatic vein. (D) Tiny metastasis, not diagnosed on preoperative imaging and not surgicallypalpable. (Differential diagnosis would be of haemangioma.)

ch11.qxd 6/30/04 10:43 PM Page 265

will demonstrate occult metastases, often in theperitoneum.

Staging laparoscopy still cannot demonstrateintrahepatic metastases, and the use of laparoscopicultrasound at this stage greatly increases the accu-racy of staging and influences the surgical deci-sion.23

Laparoscopic ultrasound is also useful in stag-ing patients with gastric cancer24 and colorectalcancer.25 Curative resection of bowel cancer canbe performed with either open surgery or laparo-scopic resection. Laparoscopic ultrasound can beused to examine the liver to confirm the absenceof metastases: this is particularly useful in alaparoscopic resection as the surgeon is unableto palpate the liver under these circumstances.This laparoscopic approach reduces patient mor-bidity when compared with open surgical explo-ration.

ULTRASOUND CONTRAST AGENTS IN THE ABDOMEN

Ultrasound contrast media have been well estab-lished for cardiac imaging since the 1980s and thefirst clinical use of such an agent was in 1968 andinvolved the injection of saline to identify echoesfrom the mitral valve.26

These early contrast agents were composed ofrelatively large (by today’s standards) microbub-bles of air in solution. They were unstable, short-lived and the bubbles were too large to passthrough the capillary beds, hence their use exclu-sively for cardiac ultrasound.


A B

Figure 11.13 Radiofrequency ablation (RFA). (A) The RF probe is introduced into the metastasis under intraoperativeultrasound guidance. (B) The lesion is gradually ablated; the area of ablated tissue reflects the sound and can be seento increase in size progressively during the course of the therapy.

Figure 11.14 Laparoscopic ultrasound demonstratingmultiple liver metastases in a patient with carcinoma inthe tail of the pancreas.

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Since those early years there have been a num-ber of developments in the field of contrast ultra-sound. Agents such as Albunex (MolecularBiosystems, San Diego, USA), consisting of albu-min-coated microbubbles, were small enough topass through the pulmonary capillaries and enterthe left side of the heart; however they were tooweak to withstand systolic pressure and could nottherefore enter the blood pool in any appreciablequantity.

A more stable suspension was then produced,consisting of small microbubbles in the order of2–5 µm which passed through the pulmonary cap-illary bed after intravenous injection, and actedas a true blood-pool agent. Called Levovist(Schering, Berlin, Germany), this is a galactose-based agent (99.9%) containing palmitic acid(0.1%) for stability, which traps air which is subse-quently released when the bubbles burst. As thefirst stable blood-pool agent it could be used forexamining the abdominal viscera and vasculature.

By coincidence, microbubbles of this size canpass through the pulmonary capillaries and res-onate at frequencies used in clinical diagnosticultrasound (1–20 MHz). This resonance causes amuch greater capacity for scattering the beam thanthat from a non-resonating particle and thus astronger signal is produced of up to 25 dB on bothgrey-scale and Doppler. The Doppler signal from acontrast-enhanced blood vessel is therefore mucheasier to identify. In addition, vessels too small tobe identified on normal grey-scale or non-enhanced Doppler scans can be identified whenusing a microbubble agent (Fig. 11.15).

Despite the use of microbubble agents, bloodflow in tiny vessels can still be difficult to detect;harmonic imaging techniques however aid detec-tion further. When insonated with ultrasound of acertain frequency, microbubbles emit a secondaryharmonic frequency twice that of the incidentwave, in addition to the primary harmonic. As thesecond peak is a purer signal, this increases the sen-sitivity, enabling smaller vessels with slow flow tobe successfully detected and distinguished fromsurrounding tissues. Many harmonic-based pulsemethods are used with contrast agents and some ofthe more popular ones include pulse and phaseinversion, for example pulse inversion is a dualpulse technique, 180º out of phase, resulting in

summation of signal from non-linear scatterers(microbubbles) and cancellation of signal fromlinear scatterers (tissue).

Potential applications of these agents includesituations in which ultrasound findings are equivo-cal or in which Doppler information is suboptimal.A contrast agent will enhance the Doppler ultra-sound signal from the blood pool and increasediagnostic confidence. This may therefore obviatethe need for other more invasive angiographicinvestigations.27 These agents therefore have thepotential to extend the applications of Dopplerultrasound in the abdomen.

With regard to the abdomen it can be useful inpatients with chronic liver disease for the investiga-tion of portal vein thrombosis. Increased sensitivityand specificity have been reported for examinationof the portal vein,28 avoiding the need for contrastangiography. In patients with hepatic transplanta-tion it is helpful in confirming hepatic artery patencyin the early postoperative period: this can be difficultto confirm with conventional imaging alone.Although it is felt intuitively that it may be of helpin the diagnosis of renal artery stenosis, the evidenceis as yet not convincing to support its routine use.

The diagnosis and characterization of hepatictumours are also improved with contrast agents asthese agents, for example, Levovist and Sonovue,are preferentially taken up by the hepatosplenicparenchyma and so focal lesions appear as fillingdefects in much the same way as CT or MRI (Fig.11.16). The exact site of accumulation within theliver is unknown but may be within the reticulo-endothelial system or liver sinusoids. There isgrowing evidence to support the differentiation oflesions within the liver, not previously possiblewith conventional ultrasound,29,30 and certainlymicrobubble agents are helpful in the diagnosis ofcapillary haemangiomas, hepatomas and focalnodular hyperplasia. How are microbubble agentsused currently? Generally an agent such as Sonovue,currently the most commonly used, which consistsof a phospholipid membrane containing perfluoro-carbon gas, is injected intravenously. Imaging, forexample in the liver, can now be performed in botha hepatic arterial and portal venous phase similar toCT. Most imaging is performed with a harmonic-based technique—pulse or phase inversion—andutilizing a low mechanical index (< 0.15) to


ch11.qxd 6/30/04 10:43 PM Page 267

prolong longevity of the bubbles. Although thereis no definitive evidence as yet to support its rou-tine use, it is currently undergoing a number of tri-als comparing it with CT and MRI in the detectionof focal liver disease, and early results arefavourable.31

Other simple substances, technically consideredcontrast agents, including water or saline, are used tooutline the stomach (for example, to visualize thepancreas or to assess the nature of an epigastric mass)or the rectum. In the future, oral ultrasound contrast

agents may be developed specifically to examine thestomach or colon and to reduce bowel gas.

THE TREATMENT OF PRIMARY ANDSECONDARY HEPATIC TUMOURS BYPERCUTANEOUS METHODS

In patients with colorectal carcinoma the presenceof liver metastasis is the most accurate predictor ofsurvival. Resection of liver metastases is known toincrease the lifespan of patients, with good quality


A (i)

B (i) B (ii)

A (ii)

TIPS

HA

TIPPS

LAEVOVIST 300 MG/ML

Figure 11.15 (A) i, Pre-injection of contrast—no flow is demonstrated in this transjugular intrahepatic portosystemicshunt; ii, post-injection, flow is still not demonstrated, confirming the shunt to be thrombosed. (B) i, the same patient—pre-injection the hepatic artery is identified adjacent to the shunt; ii, post-injection: without altering the settings,greatly enhanced arterial Doppler signals are demonstrated from even the most peripheral hepatic arteries.

(continued)

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of life and an overall 5-year survival of 20–45%,and up to 60% in unifocal disease. Without surgerythe 5-year survival in this patient group is effec-tively zero. However, not all patients with livermetastases are deemed suitable for resection, beingpoor surgical risks or having lesions which areeither too large or affect too many hepatic seg-ments. Percutaneous ablation of liver tumours isnow a viable and rapidly developing option forcontrol of liver metastases, prolonging survivaltime after initial diagnosis and, in some cases,shrinking tumours to enable future curative resec-tion. Various methods have been investigated,using ultrasound guidance.

● Alcohol injection has proved highly effectivefor hepatocellular carcinoma (HCC),32,33

shrinking tumours over a period of time andcausing necrosis within them, but has notproved as effective for metastatic liver disease.This is thought to reflect the fact that HCC isa ‘soft’ tumour and so the alcohol can beinstilled effectively into the tumour whereasmetastases are ‘hard’ lesions and often thealcohol seeps out of the lesion.

● Radiofrequency (RF) thermal ablation and laserablation are also developing as minimallyinvasive percutaneous therapeutic techniquesand are becoming increasingly popular.

Ablation of liver metastases using RF is arecent method of ultrasound-guided therapyfor liver metastases and HCC in which RF,applied to monopolar electrodes eitherindividually or with multiprobe arrays, isguided into the lesion to be treated. RF tissueablation through an 18G needle uses fewerprobes than laser. It is an outpatient procedure:1–4 sessions has been reported to achievecomplete necrosis of liver metastases in 67% oflesions.34 It is a simple, safe and potentiallyeffective treatment for liver metastases,associated with a low rate of complications (inone study only one small area of haemorrhagewas observed in 75 sessions)35 together with asignificant rate of shrinking or stabilization ofthe metastases.

ENDOSCOPIC ULTRASOUND

Some of the limitations of conventional ultra-sonography in biliary and pancreatic imaging canbe overcome by the use of endoscopic probes andminiprobes. Endoscopic probes are either radialor linear arrays which are incorporated into theend of an endoscope. They have a frequency of7.5–12 MHz and are used to image the pancreas,biliary tract, portal vein and adjacent structures


c(i) c(ii)

RPV

PV

MPV

Figure 11.15 cont’d (C) i, Before contrast injection, portal vein thrombosis is suspected in a patient with alcoholicliver disease; ii, after injection, the main portal vein is confirmed as thrombosed. Forward flow is seen in the rightportal vein (presumably due to collateral circulation), and increased hepatic arterial flow is clearly demonstrated.

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within 5–6 cm of the probe. Radial probes may beused in the preoperative staging of a number ofdiseases, including oesophageal, gastric, pancre-atic and lung cancer, whilst linear array probes areused for interventional procedures such as fine-needle aspiration analysis of mediastinal lymphnodes, solid organ assessment, for example pan-creas, occasionally liver, adrenals, pseudocystdrainage and coeliac plexus neurolysis.

Endoscopic ultrasound is more sensitive and spe-cific than spiral CT, MRI or transabdominal ultra-sound in the detection of small pancreatic massesand its diagnostic ability can be further enhancedby the use of endoscopic ultrasonically guided fine-needle aspiration cytology36 and biopsy.

It may also detect early changes of pancreatitiswhich are not visible on endoscopic netrogradecholangiopancreatography (ERCP), and one of its


A

C D

B

Figure 11.16 (A) Conventional ultrasound of the liver showing no abnormality. (B) Pulse inversion mode followingintravenous Levovist injection showing a focal lesion (arrow) i.e. metastasis in the same patient as Fig. 16a. (C)Conventional grey-scale scan of the liver. A number of metastases were seen throughout the liver. One in the left lobehas been arrowed. (D) Pulse inversion mode with intravenous Levovist in the same patient as (C). The metastasis seenon the unenhanced grey-scale image can still be seen (arrow); however, easily discernible additional lesions are nowalso appreciated.

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main uses is in staging pancreatic tumours, pre-dicting their resectability, identifying small lymphnode metastases and assessing vascular invasion.37

It is particularly accurate in identifying small pan-creatic insulinomas,38 often difficult or impossibleto identify on conventional cross-sectional imagingdespite a documented biochemical abnormality,and thus guiding subsequent surgical procedures.Endoscopic ultrasound is also used in the detectionof biliary calculi, particularly in the normal-calibrecommon bile duct, with a much higher accuracythan other imaging techniques and without thepotential additional risks of ERCP.39

Further, less-established uses of endoscopicultrasound include gastrointestinal examinations,in which invasion of gastric lesions into andthrough the wall of the stomach can be assessed,40

anal ultrasound, which is used to visualize thesphincter muscles in cases of sphincter dysfunction,the staging of colorectal carcinomas and thedemonstration of bowel wall changes in inflamma-tory bowel conditions.41

The miniprobe has a higher frequency (20–30MHz) and may be passed down a conventionalendoscope. It therefore has the advantage of a one-stage gastrointestinal tract endoscopy/ERCP,rather than requiring a separate procedure. It maybe inserted into the common duct of the biliarytree to assess local tumour invasion and to clarify

the extent and/or nature of small lesions alreadyidentified by other imaging methods. It showsremarkable accuracy in the detection of commonbile duct tumours and other biliary tract diseasewhen compared with other imaging modalities.42

It may be used in the staging of oesophageal andgastric cancer, and is especially useful when a tightoesophageal stricture prevents the passage of theendoscope.41 The layers of the oesophageal or gas-tric wall and the extent of tumour invasion can beaccurately assessed.

The miniprobe is also used in patients with sus-pected pancreatic carcinoma, for example in patientswith a negative CT but who have irregularity of thepancreatic duct on contrast examination. The probecan be passed into the pancreatic duct during ERCPto detect small lesions, assess the extent of thetumour and predict resectability.43 It is superior toconventional endoscopic ultrasound in the detec-tion of the smaller, branch tumour nodules, and canalso detect local retroperitoneal or vascular invasionin areas adjacent to the probe.

The use of endoscopic ultrasound is currentlylimited to a few specialist centres. A steep learningcurve together with the expense of the equipmentis likely to restrict its widespread use; however, asits applications expand and its value becomesproven, it is likely to become a more routine inves-tigation at many centres.41


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Bibliography and further reading

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A

Abdomen, acutegastrointestinal tract, 245–6hepatobiliary emergencies, 246–8other retroperitoneal emergencies,

248–50pancreas, acute, 248renal tract emergencies, 248trauma, 244–5use of ultrasound, 243–4

Abdominal aorta, 195–9, 196Abdominal aortic aneurysms, 248Abscesses

appendicitis, 246, 246drainage of, 262hepatic, 82–4, 84, 95, 96, 116,

247psoas, 250renal, 175, 176, 187splenic, 145

Acalculous cholecystitis, 59Acquired cystic disease, 162, 162Acquired immunodeficiency

syndrome (AIDS), 111, 139Acute abdomen see Abdomen, acuteAcute appendicitis, 209Acute cholecystitis, 59, 246Acute diverticulitis, 246Acute fatty liver, 109Acute hepatitis, 106, 107Acute pancreas, 248Acute tubular necrosis (ATN),

177–8, 189, 260Acute ureteric obstruction, 248Adenocarcinomas, 130, 132Adenomas, 86, 86–7, 95, 162–3,

203, 205

Adenomyomatosis, 51–3, 52Adrenal glands, 201–6, 204, 232,

233Adrenal haemorrhage, 232, 233Agenesis, renal, 224Air in the biliary tree, 72–3, 73Alagille’s syndrome, 218Alcoholic cirrhosis, 98, 129Alcoholic-induced liver disease, 96,

97, 125, 126, 248Alcoholism, 125American Institute for Ultrasound in

Medicine (AIUM), 10Amoebic abscess, 83Amyloid, 179Anaemia, 82–3, 109–10, 139, 146Analgesia, 254Aneurysms

aortic, 196–9, 198, 199, 248renal artery, 191splenic artery, 147–8

Angiomyolipoma, 162, 163Aorta, 38, 213Aortic aneurysms, 196–9, 199, 248Appearances, ultrasound

adrenal glands, 201Budd–Chiari syndrome, 107–9cirrhosis, 97–9hepatic metastases, 90–2hepatitis, 106–7hepatocellular carcinoma, 94kidneys, 155normal spleen, 137–9, 138normal transplanted kidney,

182–5pancreas, 123pancreatic carcinoma, 132pancreatic transplant, 135pancreatitis, 125

renal artery stenosis (RAS),179–80

renal calculi, 172–3renal cell carcinoma (RCC),

163–4renal cysts, 160–1splenic lymphoma, 141

Appendicitis, 209, 238, 238–9, 239,245–6, 246

Appendix, 206–7, 209Arrays, 7Artefacts, 30Arteriovenous fistulae, 181, 189, 191Artery aneurysm, splenic, 147–8Artery stenosis, renal (RAS), 179–80,

180, 187–9, 188Ascaris worm, 70, 71Ascites, 103, 212, 213Atresia, biliary, 112, 216–18Atrial systole, 29Autosomal dominant polycystic

kidney disease (APKD), 161–2Autosomal recessive disease (PCKD),

162Autosomal recessive polycystic disease

of the kidneys (ARPCDK),224–5

B

Beckwith–Wiedemann syndrome,218, 229

Benign focal liver lesions, 79–89Benign focal pancreatic lesions,

133–4Benign focal renal tumours, 162–3Benign splenic conditions, 143–8Bile, 49, 71

Index

277

Index.qxd 6/30/04 6:21 PM Page 277

Bile ducts, 31–3see also Common bile duct (CBD)

Biliaryatresia, 112, 216–18, 219biliary tree, 17calculi, 125colic, 52, 70crystals, 72, 72dilatation, 248dilation without jaundice, 66–7obstruction, 246reflux, 47sludge, 56stasis, 71–2see also Bile ducts; Gallbladder

Bilirubin, 34–5Biochemical analysis, pancreas, 123Biological effects of ultrasound, 10–11Biopsy attachments, 7Biopsy, renal, 179, 259–61Biopsy, ultrasound-guided see

Ultrasound-guided biopsyBladder

diverticulum, 175, 176paediatric, 221tumour, 4

Blind biopsy, 255Blood clot, renal, 167, 168–9Blood in the gallbladder, 72Blood tests for renal function, 157Bone-at-focus index (TIB), 11Bone-at-surface index (TIC), 11Bowels

carcinoma, 91gas in, 29, 63, 223malignant tumours in the, 210–11perforation of the, 245problems in the, 36rupture of the, 244

Breast carcinoma, 143, 213Budd–Chiari syndrome (BCS)

free intraperitoneal fluid, 111indications for liver

transplantation, 112liver metastasis, 203management of, 108–9risk of thrombosis, 115ultrasound appearances of, 107–8,

108with suspected liver lesion, 94

C

Caecal carcinoma, 212, 212Calcification

adrenal, 232, 233hepatic, 88–9, 90

pancreatic, 128, 129, 132renal tract, 170–4splenic, 145, 145–6

Calcium stones, 171Candidiasis, 229, 230Candidiasis abscess, 83–4CAPD fluid, 111Capillary haemangiomas, 257Carcinomas

adenocarcinoma, 130, 132adrenal, 206bowel, 36, 91, 212, 212breast, 143, 213cervical, 167cholangiocarcinoma, 64, 67, 68,

74, 75, 95colorectal, 268–9, 271cystadenocarcinoma, 130, 132gallbladder, 50, 73, 73gastric, 208hepatocellular carcinoma (HCC)

(see Main entry)lung, 205oesophagus, 207ovarian, 75, 80, 81, 90, 111pancreatic, 128–33, 131, 247, 266,

271renal, 134, 163–5, 164, 202transitional cell carcinoma, 164–5,

165, 166Cardiac failure, 111Caroli’s diesease, 68–70, 70Cervical carcinoma, 167Chemotherapy, 91Children see Paediatric abdomenCholangiocarcinomas, 64, 67, 68,

74, 75, 95Cholangitis, 66, 66, 70, 247, 247Cholecystectomy

acalculous cholecystitis, treatmentfor, 247

bile duct measurements, 33, 33choledocholithiasis, 45gallstones, management of, 47, 52laparoscopic, 56, 67scar, 29

Cholecystitisacalculous, 56–7, 59, 247acute, 54–6, 55, 59, 111, 246chronic, 56, 59complications of, 47, 57–8emphysematous, 60

Cholecystokinin-stimulated hepaticiminodiacetic acid (HIDA)scan, 57

Choledochal cysts, 64–6, 66, 68–70,218, 219

Choledocholithiasis, 45–7

Cholelithiasis see GallstonesCholestasis, 110, 112, 216–18, 218Cholesterolosis, 53–4, 54Choosing a machine, 6–9Chronic cholecystitis, 59Chronic liver disease, 257

see also specific diseaseCiclosporin nephrotoxicity, 191Cirrhosis

alcoholic, 98, 129and chronic hepatitis, 107and hepatocellular carcinoma

(HCC), 94causes of non-obstructive

jaundice, 96increased echogenicity, 111liver biopsy in patients with, 257,

261liver transplants, 110, 112micronodular, 97ultrasound appearances, 97–9

Coarse texture of the liver, 111Colic, acute renal, 249Colitis, ulcerative, 209Colonic carcinoma, 36Colonic mass, 210Colorectal carcinoma, 268–9, 271Colour Doppler

diagnosing cholecystitis, 54dilated bile duct, 61hepatic vein, 5pancreatic duct, 131pancreatic transplant, 135portal venous system, 26, 101renal tract, 155–6, 157thermal effects of, 11use of, 2–4

Common bile duct (CBD)cysts, 64–6, 66, 68–70, 218, 219dilated, 58–67, 59, 62, 65, 66–7normal, 25, 27, 31–3, 32obstructed, 130postoperative ultrasound

appearances, 116stones in, 45–7, 46, 218see also Gallbladder

Complex cysts, 80–1, 81Complications, post operative renal

transplant, 185Computed tomography (CT) scan,

167, 212, 229, 232, 244, 246,259

Congenital anomalies of thepancreas, 123–4

Congenital intrahepatic biliarydilation, 68–70

Congenital megacalyces, 170Congestive cardiac disease, 109

278 INDEX


Continuous ambulatory peritonealdialysis (CAPD), 181–2

Contracted gallbladder, 49–50, 50Contrast agents, 266–8, 268, 269Contrast sonocystography, 229Cortical scintigraphy, 229Cranial index (TIC), 11Crohn’s disease, 111, 209, 211, 246Cryotherapy, 264, 266Cyst drainage, 262–3Cystadenocarcinomas, 130, 132Cystadenomas, 81, 81Cystic disease, 160–2Cystic duct, 49Cystic duct obstruction, 48, 50Cystic fibrosis (CF)

changes in liver reflectivity, 111cholestasis, 218cysts, 134gallstones, 50general information, 216increased echogenicity, 221microgallbladder, 51ultrasound appearances, 109, 109,

217Cystine stones, 171Cystinuria, 173, 173Cysts

adrenal, 203choledochal, 218, 219enteric duplication, 239–40, 240hepatic, 79–81, 80, 81, 82hydatid, 82in children, 221in obese patients, 4ovarian, 111pancreatic, 132, 134, 134renal, 160–1, 161splenic, 144, 144

Cytology, 257

D

Deep inspiration, 18Defensive scanning, guidelines for, 13Departmental guidelines, 13Design of machines, 7Dialysis, ultrasound in, 181–2Diethylene triaminepenta-acetic acid

(DTPA) scan, 158, 167Diffuse liver conditions, 95–110Dilation

PCS, 166renal, 225–6, 226renal transplant, 185

Dimer capto succinic acid (DMSA)scan, 223

Dissolution therapy, 48Diuretic renogram, 229Diverticulitis, 210, 211, 246Doppler

cirrhosis, 98correlation, 189detecting flow, 7hepatic metastases, 92kidneys, 248pancreatitis, 125sensitivity, 114spectra, 26use of, 2–6, 18using microbubble agents, 267see also Colour Doppler; Power

DopplerDouble gallbladder, 31Drainage, ultrasound-guided, 261–4Drug-induced liver disease, 96Drug-induced pancreatitis, 125Duodenal gas, 63Duodenum, 30, 32Duplex kidneys, 158, 159, 221–3,

222, 225

E

Echogenic bile, 71–3Echogenicity, 111, 124, 221Ectopic gallbladder, 30Ectopic kidneys, 158, 223Ectopic pregnancy, 111Electrical safety, 11Emphysematous cholecystitis, 58, 60Empyema, 58, 61Endocrine tumour, 132Endometriosis, 167Endoscopic retrograde

cholangiopancreatography(ERCP), 47, 62

Endoscopic ultrasound, 64, 246,269–71

Endosonography, 210Enlargement of the gallbladder, 48–9Enlargement of the spleen, 109, 139,

139, 140, 146Enteric duplication cysts, 239–40,

240Epigastrium, 28, 29, 208Equipment for biopsy, 255, 256–7Equipment tests, 14–15Ergonomics of machines, 8European Committee for Ultrasound

Radiation Safety (ECURS), 10European Federation of Societies for

Ultrasound in Medicine andBiology (EFSUMB), 10

Extracorporeal shock wave lithotripsy(ESWL), 48

Extrarenal pelvis, 158, 160

F

Faeces, impacted, 36Failure, renal, 111, 177–9Fasting, 27, 29Fatty infiltration, 87, 88, 95–7, 96,

111Fatty sparing, 87, 87–8Fever, 82–3Fibrosis, 67, 111Field, size of, 2Fine needle aspiration cytology, 257Fistulae, 209Flow

detection with Doppler, 7in major vessels, 5–6velocity waveforms, 6

Fluid collections, transplantation,186–7

Focal fatty change, 87–8, 87–8, 95Focal fatty sparing of the pancreas,

133Focal lesions, 116Focal liver lesions, 24, 112Focal nodular hyperplasia, 88, 89, 95,

257Focal obstruction, 67Focal pancreatitis, 133–4Focal zone, 2, 3, 5, 44Focused Assessment with

Sonography for Trauma(FAST), 244

Folded gallbladder, 29, 30, 31Fracture, pancreatic, 246Frame rate, 2, 3, 5Free fluid detection, 244, 245Free intraperitoneal fluid, 111Freehand biopsy, 255Frequency

changing, 2increasing the, 1, 5range of, 7settings for gallbladder, 2, 27, 30

Fundamental imaging mode, 4Fungal balls, 167, 191, 229, 230Fungal infections, 229

G

Gallbladderbiliary dilation without jaundice,

66–7

279INDEX


Gallbladder (Continued)blood in the, 72carcinoma, 50, 73, 73cholecystitis (see Main entry)cholelithiasis, 41–8contracted or small, 49–50, 50double, 31drainage of, 262echogenic bile, 71–3ectopic, 30enlargement of the, 48–9folded, 29, 30, 31frequency settings for, 2, 5, 27, 30full abdominal survey, 17hyperplastic conditions of the

wall, 51–4in children, 216in the obese patient, 4inflammatory gallbladder disease,

54–8introduction, 27–9malignant biliary disease, 73–6metastases, 76microgallbladder, 50, 51, 216, 217mucocoele, 48normal variants of the, 29obstruction without biliary

dilation, 67obstructive jaundice and biliary

duct dilation, 58–66other biliary diseases, 67–71pitfalls in scanning the, 29–31polyps, 28porcelain, 50, 51removal (see Cholecystectomy)septum, 29stones (see Gallstones)strawberry, 53–4, 54ultrasound appearances, 31, 32

Gallstonesabdominal pain, 36, 248chronic cholecystitis, 56clinical features, 41–2gallstone pancreatitis, 47, 246general information, 42–5in the common bile duct, 45–7small gallbladder, 50ultrasound appearances, 42, 51

Gangrenous cholecystitis, 57–8, 59Gas, bowel, 29, 63, 212, 223Gastric carcinoma, 208Gastrinomas, 128Gastro-oesophageal reflux, 238Gastrointestinal tract

acute presentations of, 245–6appendix, 206–7inflammatory bowel conditions,

209–10

malignant tumours, 210mesenteric ischaemia, 207–9obstruction, 211oesophagus and stomach, 206paediatric, 232–40

Gilbert’s disease, 96Glomerulonephritis, 178–9Glycogen storage disease, 99Granulomatas, 88, 90, 95, 146Guidance, biopsy, 255Guidelines, departmental, 13

H

Haemangioblastomas, 134Haemangioendotheliomas, 220Haemangiomas, 3, 85–6, 85–6, 95,

145Haemangiomatas, 219Haematomas

complications of biopsy, 258, 261hepatic, 84, 84–5, 96, 116psoas, 250, 250renal, 187subcapsular, 245subphrenic, 117

Haematuria, 182Haemo-hydronephrosis, 168–9Haemobilia, 72Haemochromatosis, 99, 221Haemodynamics, 25–7, 155–6Haemolysis, 96Haemolytic anaemia, 139, 146Haemorrhage, 232, 233, 248, 261Haemorrhagic tumour, 132Harmful effects of ultrasound, 10–12HELLP syndrome, 109–10, 110Hepatic see LiverHepatitis, 106–7, 107, 111, 139,

216, 257Hepatobiliary system

bile ducts, 31–3common referral patterns, 33–6gallbladder, 27–31hepatobiliary emergencies, 246–8hepatobiliary pathology: paediatric

abdomen, 216–20introduction, 17–18liver, 18–27upper-abdominal anatomy, 36–9upper-abdominal technique, 18see also Bile ducts; Liver

Hepatoblastomas, 218–20, 219, 234Hepatocellular carcinoma (HCC)

biopsy procedures, 257general information, 93–5hepatobiliary pathology, 218–20

in a patient with cirrhosis, 94, 95,98

treatment of, 269viral hepatitis, 106

Hepatomas, 261Hepatomegaly, 220Hippel–Lindau disease, 134Hodgkin’s lymphoma, 139, 165Horseshoe kidneys, 158, 159, 223,

223Hydatid cysts, 82, 82, 177Hydronephrosis, 168, 168–9, 170,

225–6, 263Hyperaemia, 54, 56Hyperparathyroidism, 173–4Hyperplastic conditions of the gall

bladder wall, 51–4Hypertension, portal see Portal

hypertensionHypertrophic pyloric stenosis (HPS),

234, 235Hypervascularized bowel, 210Hypotrophied column of Bertin,

158–9

I

Image optimization, 1–2Image quality, 1–2, 7–8Images, recording of, 9–10Imaging the paediatric renal tract,

229Impacted faeces, 36Impacted gallstones, 45, 45Incorrect use of equipment, 5Increasing the frequency, 1Indirect ultrasound guidance,

263–4Infarction of the spleen, 146, 147Infection, renal tract, 174–7, 189Inferior vena cava (IVC), 199–201,

200, 201Inflammation

gastrointestinal tract, 245–6renal tract, 174–7

Inflammatory bowel conditions,209–10

Inflammatory gallbladder disease,54–8

Inspiration, deep, 18Inspissated bile, 71, 71Insulin-dependent diabetes, 135Insulinomas, 128Intercostal scanning, 18Intrahepatic tumours, 64, 67Intraoperative ultrasound (IOUS),

113, 264, 265

280 INDEX


Intravenous urography (IVU), 229,248

Intussusception, 234–6, 236

J

Jaundicecommon causes of, 34general information, 34–5neonatal, 216non-obstructive, 93, 96obstructive, 58–67, 213, 246,

247, 258

K

Kidneysabscesses, 175, 176, 187acute renal colic, 249agenesis, 224aneurysms, renal artery, 191autosomal dominant polycystic

kidney disease (APKD), 161–2autosomal recessive polycystic

disease of the kidneys(ARPCDK), 224–5

benign focal renal tumours,162–3

biopsy, 179, 259–61calcification of, 170–4carcinoma, 134, 163–5, 164, 202cysts and cystic disease, 160–2,

161devascularization of the, 246diffuse renal disease and renal

failure, 177–9dilation, 185, 225–6, 226disease, 135duplex kidneys, 158, 159, 222,

225ectopic kidneys, 158, 223failure, 111, 177–9full abdominal survey, 17function tests, 157horseshoe kidneys, 158, 159, 223,

223inflammation and infection,

174–7, 189malignant renal tract masses,

163–6measurements of, 155medullary sponge kidney, 179metastases, 165–6multicystic dysplastic kidney

(MCDK), 162, 224, 225normal, 154, 154–60

obstruction of the, 166–7,169–70, 249

PCS dilation and obstructiveuropathy, 166–70

pelvic kidney, 224renal artery stenosis (RAS),

179–80, 180, 187–9, 188renal cell carcinoma (RCC),

163–4renal fusion, 223renal humps, 160renal tract emergencies, 224, 248renal transplants, 182–91renal vein thrombosis (RVT) (see

Main entry)rupture of the, 244stones, 167, 171–3, 172transplant biopsy, 260–1, 261transplants, 182–91, 183, 184trauma, 182vascular pathology, 179–82

Klatskin tumour, 74, 74

L

Laparoscopic cholecystectomy, 56Laparoscopic ultrasound, 48, 64,

265–6, 266Laser ablation, 269Legal issues, 12–13Leukaemia, 111, 139, 142–3, 220,

234Line density, 1, 2Links to image-recording devices,

8–9Lipomas, 88Litigation, 12–13Liver

abscesses, 82–4, 84, 95, 96, 116,247

acute fatty liver, 109alcohol-induced liver disease, 96,

97, 125, 126, 248anatomy, 36, 37benign focal liver lesions, 78–9,

79–89calcification, 88–9, 90chronic liver disease, 257cirrhosis (see Main entry)conditions in pregnancy, 109–10diffuse liver conditions, 95–110drug-induced liver disease, 96failure of the, 111full abdominal survey, 17haematoma, 84–5haemodynamics of, 25–7hepatic abscess, 247

hepatic artery (HA), 6, 27, 30,104, 113

hepatic biopsy, 257–8, 258, 259hepatic venous system, 5, 28, 38jaundice, 34, 34–5liver fluke, 70liver function tests (LFTs), 35, 58,

82–3liver transplants, 110–17malignant focal liver lesions,

89–95mass, 89, 90metastases (see Hepatic under

Metastases)normal appearances, 18–24,

18–24polycystic, 81–2rupture of the, 244segments of, 24, 24texture of the, 111transplants

indications for, 110–11operative procedure, 112–13postoperative assessment, 113postoperative ultrasound

appearances, 113–17preoperative assessment,

111–12tumours, treatment of, 268–9use of equipment, 2, 3vasculature, 25see also Cirrhosis

Lung cancer, 270Lymph nodes, enlarged, 213Lymphadenopathy, 92, 132, 149,

149, 213Lymphangiomas, 150, 150Lymphatics, 148, 148–50, 149Lymphocoele, 187, 187Lymphomas

hepatic, 220Hodgkin’s, 139, 165in children, 234metastases, 91non-Hodgkin’s, 139, 165, 203renal, 165splenic, 141, 142

Lymphoproliferative disorder, 116

M

Magnetic resonancecholangiopancreatography(MRCP), 62

Magnetic resonance imaging (MRI),212, 229, 232, 246

Maintenance of machines, 8

281INDEX


Malignant biliary disease, 73–6Malignant focal liver lesions, 89–95Malignant obstruction, 64Malignant renal tract masses, 163–6Malignant splenic disease, 141–3Malignant tumours, bowel, 210–11Management of gallstones, 47Mass

colonic, 210hepatic, 89, 90malignant renal tract, 163–6retroperitoneal, 212see also specific condition

Measurements of the bile duct, 33Measurements of the kidneys, 155Mechanical effects of ultrasound, 11Mechanical Index (MI), 11Meckel–Gruber syndrome, 221Medicolegal issues, 12–13Medullary sponge kidney, 179Meig’s syndrome, 111Melanomas, 143Mesenteric ischaemia, 207–9Mesotheliomas, 261Metastases

adrenal gland, 203, 233gallbladder, 76hepatic

biopsy, 257, 258causes of, 203, 220changes in liver reflectivity, 111clinical features and

management, 90–2examples of, 91, 93intraoperative ultrasound,

264laparascopic ultrasound, 266multiple, 208necrotic, 92ultrasound appearances, 90–2

pancreatic, 132, 133, 133renal, 165–6retroperitoneal, 213splenic, 141–2, 143

Microbiological safety, 12Microbubble agents, 267Microgallbladder, 50, 51, 216, 217Microlithiasis, 72, 72Micturating cystourethrogram, 229Midgut volvulus, 236–7, 237Minimizing the ultrasound dose,

12–13Mirizzi syndrome, 48–9, 50Misinterpretation, 1Mobility, gallstones, 44, 45Mononucleosis, 139Mucinous tumour, 132Mucocoele of the gallbladder, 48

Multicystic dysplastic kidney(MCDK), 162, 224, 225

Murphy’s sign, 54, 57Myelolipomas, 204, 205

N

Necrotic tumour, 132Needles, biopsy, 256, 256–7Neonatal cholestasis, 216–18Neonatal hepatitis, 216Neonatal jaundice, 216Nephrocalcinosis, 173, 174Nephrostomy, 262, 263Nephrotic syndrome, 90Neuroblastomas, 232, 234Nodular texture of the liver, 111Non-Hodgkin’s lymphoma, 139,

165, 203Non-obstructive hydronephrosis, 170

O

Obese patients, 4Obstruction

biliary, 246gastrointestinal tract, 245–6intestinal, 211non dilated renal, 169–70of the pancreatic duct, 128pelvi-ureteric junction, 226renal, 166–7, 249urinary tract, 248without biliary dilation, 67

Obstructive jaundice, 58–67, 213,246, 247, 258

Oedema, 187Oesophagus, 206, 207Operator safety, 12Operator skill, 17Oral contraceptives, 86Organ damage, 111Organ failure, 111Output Display Standard (ODS), 11Ovarian carcinoma, 75, 80, 81, 90,

111Ovarian cyst, 111Ovarian fibroma, 111

P

Paediatric abdomensadrenal glands, 232gastrointestinal tract, 232–40hepatobiliary pathology, 216–20

pancreas, 220, 220–1techniques, 215–16urinary tract, 221–32

Pain, upper abdominal, 36see also Abdomen, acute

Palpable right upper quadrant mass,36

Pancreasacute, 248anatomy, 37, 39benign focal pancreatic lesions,

133–4biochemical analysis, 123biopsy, 258–9, 260calcification, 128, 129, 132congenital anomalies, 123–4cysts, 132, 134, 134focal fatty sparing, 133fracture of, 246frequency settings, 2full abdominal survey, 17malignant pancreatic disease,

128–33metastases, 132, 133, 133normal, 121–4, 122paediatric, 220, 220–1pancreatic carcinoma, 128–33,

131, 247, 266, 271pancreatic ducts, 59, 128, 131pancreatic transplant, 135pancreatitis

acute, 81, 111, 126, 248endoscopic ultrasound, 270focal, 132, 133–4gallstone, 47, 246general information, 124–8paediatric, 221

rupture of the, 244techniques, ultrasound, 121–3transplants, 135trauma of the, 125, 134–5

Papillary necrosis, 167, 170, 171Parasites, 70–1, 82Pelvic kidney, 224Pelvicalyceal system (PCS) dilation

and obstructive uropathy,166–70

Percutaneous drain, 84Perforated appendix, 209Pericholecystic abscess, 56–7Peritoneum, 195

see also RetroperitoneumPeritonitis, 111Pernicious anaemia, 139Phaeochromocytomas, 134, 204–6,

205Photographic archiving

communications (PAC), 8, 10

282 INDEX


Phrygian cap, 29Pneumobilia, 72–3, 73Polycystic disease, 134, 144, 161,

224–5Polycystic liver, 81–2Polyps, 53, 53, 54Polyps, gallbladder, 28Porcelain gallbladder, 50, 51Portal hypertension

free intraperitoneal fluid, 111general information, 99–105management of, 105–6splenomegaly in, 139, 139, 217ultrasound appearances, 100, 102

Portal veinanastomosis, 114flow, 99–103liver transplants, 115portal venous system, 24, 24, 25,

25, 26, 27thrombosis, 111–12, 127, 248

Positioning the patient, 18Post-processing options, 3Postoperative bile collection, 49Postsurgical CBD dilation, 66–7Power Doppler

diagnosing cholecystitis, 54general information, 4liver transplant, 114of the hepatic vein confluence, 5thermal effects of, 11

Pre-eclampsia, 109–10Pregnancy, liver conditions in,

109–10Primary biliary cirrhosis (PBC), 97,

98, 111, 112Primary gallbladder carcinoma, 73,

73Primary sclerosing cholangitis

(PSC), 67–8, 68, 69, 107,111, 112

Probe number, 7Processing options, 2Prostate enlargement, 167Pseudoaneurysm, 148, 189Pseudocysts, 125, 126, 132, 248,

248Psoas abscesses, 250Pulsed Doppler, 5, 11Pyelonephritis, 174–5, 176, 248Pyogenic abscess, 83, 83Pyonephrosis, 167, 169, 169

Q

Quality assurance, 13–15Quality of the image, 1–2

R

Radio frequency (RF) thermalablation, 269

Radioisotope scans, 158Radionuclide cystography, 229Recording of images, 9–10Rectal cancers, 210Referral patterns for hepatobiliary

ultrasound, 33–9Reflectivity, 44, 111Reflux, 170, 225, 227, 238Reidel’s lobe, 36Rejection, transplant, 117, 185–6,

186Renal cell carcinoma (RCC), 163–4Renal tract see KidneysRenal vein thrombosis (RVT)

causes of renal tract obstruction,167

general information, 180–1, 191hydronephrosis, 168–9in neonates, 231, 231–2ultrasound appearances, 181, 190

Retroperitoneumabdominal aorta, 195–9adrenal glands, 201–6gastrointestinal tract, 206–11inferior vena cava, 199–201normal anatomy of, 195other abnormalities in, 212–13

Rhabdomyosarcomas, 219–20, 234Rokitansky–Aschoff sinuses,

51, 52Rupture, organ, 244

S

Safety indices, 11Safety of diagnostic ultrasound,

10–12Schemes of work, 13Sclerosing cholangitis, 60, 218Secondary biliary cirrhosis, 98–9Sepsis, 139Septum, gallbladder, 29Shadowing, gallstones, 42–4, 42–4Sickle cell disease, 139, 146Simple cysts, 79–80, 80Skills of the operator, 17Small gallbladder, 49–50Small spleen, 139–40Soft tissue thermal index (TIS), 11Spectral Doppler, 115, 169Spectral waveform, 5–6Spherocytosis, 139, 146Sphincter dysfunction, 271

Spleenabscess, 145benign splenic conditions, 143–8calcification, 145, 145–6cysts, 144, 144enlarged paediatric, 217full abdominal survey, 17haemangioma, 145laceration of, 245lymphoma, 141, 142malignant splenic disease,

141–3metastases, 141–2, 143normal, 137–9, 138rupture of the, 244small accessory spleen, 139–40splenic artery aneurysm, 147–8splenic infarction, 146, 147splenic vein thrombosis, 127,

146–7, 248splenomegaly, 103, 139, 139, 140,

146splenunculi, 139–41trauma, 148

Staghorn calculi, 173Steatosis, 95–7Stenosis, 114Stomach, 206Stones

bladder, 249gallbladder, 28, 30, 247 (see also

Gallstones)renal, 167, 171–3, 172struvite, 171

Strawberry gallbladder, 53–4, 54Stricture, renal tract, 167Struvite stones, 171Sub-scanning, 18

T

Techniques, ultrasoundadrenal glands, 201bile ducts, 33paediatric abdomen, 215–16pancreas, 121–3renal tract, 154–7upper-abdominal, 18

Teratomas, 213Thalassaemia, 139, 146Thermal effects of ultrasound, 11Thermal Index (TI), 11Thin patients, 30Thrombosis

misinterpretation of results, 6portal vein, 100, 101, 111–12,

127

283INDEX


Thrombosis (Continued)renal vein thrombosis (RVT)

causes of renal tractobstruction, 167

general information, 180–1,189

hydronephrosis, 168–9in neonates, 231, 231–2ultrasound appearances, 181,

190splenic, 127, 248thrombosed vessels, 5–6

Time gain compensation (TGC), 28,96

Tissue Harmonic Imaging, 2, 4, 18,28

Tissue-mimicking phantom, 14TORCH screen, 88Toxic shock syndrome, 111Transitional cell carcinomas, 164–5,

165, 166Transjugular intrahepatic

portosystemic shunt (TIPS),105, 105–6, 106

Transplantshepatic, 110–17pancreatic, 135renal, 182–91, 183, 184

Traumaabdomen, 244–5pancreatic, 125, 134–5renal, 182splenic, 148

Tuberculosis, 111, 167, 175Tuberose sclerosis, 163Tubular necrosis, acute (ATN),

177–8, 189

Tumoursbladder, 4hepatic, 268–9malignant bowel, 210–11renal, 167tumour seeding, 261vascular, 220see also specific tumour

U

Ulcerative colitis, 209Ultrasound contrast agents, 266–8,

268, 269Ultrasound-guided biopsy

complications, 261general considerations, 253–7procedures, 257–61

Ultrasound-guided drainage, 261–4Upgradability of machines, 8Upper-abdominal anatomy, 36–9,

36–9Upper-abdominal technique, 18Ureteric obstruction, 248Urethral stricture, 167Uric acid stones, 171Urinary tract, 221–32, 248

see also KidneysUrine tests for renal function, 157Urinomas, 187

V

Varices, 103

Vascular abnormalities of the spleen,146–8

Vascular occlusion, 187Vascular pathology, renal, 179–82Vascular tumours, 220VATER syndrome, 224Veins see specific veinVesico-ureteric junction, 170Vesicoureteric reflux, 226–9Vessel occlusion, 6, 6Viral hepatitis, 96, 106Volvulus, 236–7, 237Von Hippel–Lindau disease, 221

W

Wilms’ tumour, 220, 229–30,230–1, 231, 234

Wilson’s disease, 99Work-related musculoskeletal

disorders (WRMSD), 8, 12World Federation for Ultrasound in

Medicine and Biology(WFUMB), 10

X

X-ray, 229Xanthogranulomatous pyelonephritis

(XGP), 177, 177, 230–1, 231

284 INDEX


other causes of focal liver lesions...

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