Đang tải... (xem toàn văn)
(BQ) Part 1 book Differential diagnosis in ultrasound presents the following contents: Chest, neck lesions, hepatobiliary system and abdomen, spleen, pancreas, gastrointestinal tract, retroperitoneum, renal, urinary bladder, adrenal gland.
Differential Diagnosis in ULTRASOUND Differential Diagnosis in ULTRASOUND Second Edition Sumeet Bhargava MBBS DNB (Radiodiagnosis) FCGP FIAMS FICRI MNAMS Assistant Professor Department of Radiology and Imaging Subharti Medical College Meerut, Uttar Pradesh, India Satish K Bhargava MBBS MD (Radiodiagnosis) MD (Radiotherapy) DMRD FICRI FIAMS FCCP FUSI FIMSA FAMS Professor and Head Department of Radiology and Imaging School of Medical Sciences and Research Sharda Hospital Sharda University, Greater Noida, Uttar Pradesh, India Formerly, Professor and Head Department of Radiology and Imaging University College of Medical Sciences (University of Delhi) and GTB Hospital, Delhi, India ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Panama City • London • Dhaka • Kathmandu ® Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P Medical Ltd 83, Victoria Street, London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +02-03-0086180 Email: info@jpmedpub.com Jaypee-Highlights Medical Publishers Inc City of Knowledge, Bld 237, Clayton Panama City, Panama Phone: +507-301-0496 Fax: +507-301-0499 Email: cservice@jphmedical.com Jaypee Brothers Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh Mobile: +08801912003485 Email: jaypeedhaka@gmail.com Jaypee Brothers Medical Publishers (P) Ltd Shorakhute, Kathmandu Nepal Phone: +00977-9841528578 Email: jaypee.nepal@gmail.com Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2013, Jaypee Brothers Medical Publishers All rights reserved No part of this book may be reproduced in any form or by any means without the prior permission of the publisher Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com This book has been published in good faith that the contents provided by the contributors contained herein are original, and is intended for educational purposes only While every effort is made to ensure a accuracy of information, the publisher and the editors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work If not specifically stated, all figures and tables are courtesy of the editors Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device Differential Diagnosis in Ultrasound First Edition: 2005 Second Edition: 2013 ISBN 978-93-5025-999-3 Printed at Dedicated to My loving late wife Kalpana Whose inspiration and sacrifice have made possible to bring out this book Contributors Anoop Kumar Durga Das Resident Department of Radiology and Imaging University College of Medical Sciences (University of Delhi) and GTB Hospital, Delhi, India Avneesh Kumar Singh Senior Resident Department of Radiodiagnosis and Imaging All India Institute of Medical Sciences (AIIMS) Ansari Nagar, New Delhi, India Anubhav Sarikwal Senior Resident Department of Radiology and Imaging University College of Medical Sciences (University of Delhi) and GTB Hospital, Delhi, India Gopesh Mehrotra Professor Department of Radiology and Imaging University College of Medical Sciences (University of Delhi) and GTB Hospital, Delhi, India Anupama Tandon Senior Lecturer Department of Radiology and Imaging University College of Medical Sciences (University of Delhi) and GTB Hospital, Delhi, India Mamta Motla Ex Senior Resident Department of Radiology and Imaging University College of Medical Sciences (University of Delhi) and GTB Hospital Delhi, India Anurag Agarwal Additional Director National Board of Examination Ansari Nagar, New Delhi, India Meenakshi Prakash Resident Department of Radiology and Imaging University College of Medical Sciences (University of Delhi) and GTB Hospital Delhi, India Ashish Verma Assistant Professor Institute of Medical Sciences Banaras Hindu University (BHU) Varanasi, Uttar Pradesh, India viii Differential Diagnosis in Ultrasound Pardeep Kumar Senior Resident Maulana Azad Medical College and Associated GB Pant Hospital New Delhi, India Pushpender Gupta Department of Radiology Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem North Carolina, USA Rajul Rastogi Ex Senior Resident Department of Radiology and Imaging University College of Medical Sciences (University of Delhi) and GTB Hospital, Delhi, India Presently, Yash Diagnostic Center Civil Lines, Moradabad Uttar Pradesh, India Satish K Bhargava Professor and Head Department of Radiology and Imaging University College of Medical Sciences (University of Delhi) and GTB Hospital Delhi, India Shuchi Bhatt Reader Department of Radiology and Imaging University College of Medical Sciences (University of Delhi) and GTB Hospital Delhi, India Sumeet Bhargava Assistant Professor Department of Radiology and Imaging Subharti Medical College Meerut, Uttar Pradesh, India Swati Gupta Resident Department of Radiology and Imaging University College of Medical Sciences (University of Delhi) and GTB Hospital, Delhi, India Thingujam Usha Resident Department of Radiology and Imaging University College of Medical Sciences (University of Delhi) and GTB Hospital, Delhi, India Preface to the Second Edition With the feedback from the practicing selenologists and residents, more text and illustrations have been added so as to make this book more handy for better interpretation at bedside I am sure the book in the present format will be more acceptable and useful to the residents, sonologists and practitioners in their day-to-day practice Sumeet Bhargava Satish K Bhargava 286 Differential Diagnosis in Ultrasound Transitional Cell Carcinoma • • • • Men, 6th-7th decades, trigone/posterolateral walls 70 percent superficial, rest are invasive USG is 95 percent sensitive in its detection Presents as a focal nonmobile mass/wall thickening 9.2 DIFFERENTIAL DIAGNOSIS OF BLADDER CONTOUR AND CALIBER ABNORMALITY Symmetric Narrowing 10 Pelvic lipomatosis Pelvic hematoma Lymphoma Iliopsoas hypertrophy Narrow bony pelvis Nonlymphomatous lymphadenopathy Lymphocele/lymphangioma Iliac artery aneurysm Iliac vein varices Seminal vesicle cysts Asymmetric Narrowing/Contour Diverticulum Fistula Hernia – In all above conditions the dome is tapering while the base is rounded due to external compression – Mucosa is uniformly normal Bladder outlet obstruction (Figs 9.2.1 to 9.2.4) Urinary Bladder 287 Fig 9.2.1: US scans show bladder wall hypertrophy with vesical diverticula in a case of bladder outlet obstruction Fig 9.2.2: Narrow neck diverticulum as seen from the posterior wall of urinary bladder with evidence of debris inside 288 Differential Diagnosis in Ultrasound Fig 9.2.3: US scans show vesical calculus Pelvic Lipomatosis • Black, males • Proliferation of fat in pelvic organs seen as echogenic tissue compressing the bladder symmetrically • A pear-shaped/tear drop bladder ureter and elongated rectosigmoid Pelvic Hematoma • History of blunt abdominal trauma is important • Less echogenicity of extravesical tissue is the only factor that differentiates it Lymphoma • Involving pelvic nodes causes symmetric narrowing Iliopsoas Hypertrophy • Young athletic individual • The deviation of midureter clinches the diagnosis Urinary Bladder 289 A B Figs 9.2.4A and B: (A) TS and (B) LS of midline at infraumbilical level showing urachal cyst—urachus seen as hypoechoic band extending from superior aspect of UB to umbilicus in relation to anterior abdominal wall with a cyst in it 10 Adrenal Gland 10.1 BILATERAL LARGE ADRENAL GLAND • Lymphoma • Hyperplasia • Hemorrhage Infections • • • • • • • Tuberculosis Histoplasmosis Immunodeficiency states Pheochromocytoma (10%) Adenomas (10%) Metastasis Wolman’s disease Lymphoma Non-Hodgkin's is the most common cell type On sonography they appear as bilateral enlarged adrenal with discrete or conglomerate hypoechoic masses Masses may be so hypoechoic as to stimulate cysts The medulla cannot be differentiated from the cortex as in any other infiltration process Adrenal Gland 291 Hyperplasia Congenital adrenal hyperplasia is an autosomal recessive condition clinically presenting with features of visualization or salt loss depending upon the hormone which is deficit Both adrenals are enlarged but the differentiation of medulla and cortex is preserved Hemorrhage: Adrenal hemorrhage may be spontaneous or post-traumatic Sonographic appearance of acute hemorrhage is a bright echogenic mass in the adrenal bed, which becomes smaller and anechoic with time Patients with B/L hemorrhage are at increased risk for development of acute adrenal insufficiency Infections: Tuberculosis may cause bilateral diffuse, inhomogenous enlargement of adrenals Punctate calcification may also be seen Infection of adrenal glands are seen in association with AIDS and organ transplantation Common offending organisms are fungi, mycobacteria, CMV, herpes, toxoplasmosis, etc On ultrasound bilateral adrenal glands shows heterogeneously hypoechoic masses On formation of abscesses gas may be demonstrated in the lesion Pheochromocytoma They are usually solitary but in 10 percent cases they are bilateral Sonographically most are large and well-marginated Either homogenous or heterogeneous (b/o necrosis and hemorrhage) solid masses Metastasis (Fig 10.1.1) The most common primary tumors to give rise to adrenal metastasis are lung, breast, melanoma, kidney, thyroid and colon cancers 292 Differential Diagnosis in Ultrasound Fig 10.1.1: Metastases—a hypoechoic mass with irregular outline is seen in the region of left adrenal in a case of bronchogenic carcinoma May be unilateral or bilateral On ultrasound appears as solid masses round to oval hypoechoic lesions They may show inhomogeniety due to necrosis, hemorrhage and calcification (Fig 10.1.2) Wolman’s Disease This is a rare autosomal recessive lipid storage disease Infants less than months of age show marked hepatosplenomegaly and massive B/L adrenal gland enlargement Adrenal Gland 293 Fig 10.1.2: A large predominantly hypoechoic well-defined left adrenal mass lesion seen with evidence of calcification in it 10.2 UNILATERAL ADRENAL MASSES • • • • • • • • Pheochromocytoma Lymphoma Adenoma (Fig 10.2.1) Neuroblastoma Myelolipoma Hemorrhage Adenocarcinoma Metastasis Adenoma Adrenal adenoma may be hyperfunctioning or nonhyperfunctioning Hyperfunctioning adenomas give rise to Cushing’s syndrome or Conn’s disease On sonography they appear as solid, small, round and well-defined lesions Right upper quadrant 294 Differential Diagnosis in Ultrasound Fig 10.2.1: US scans shows adrenal adenoma retroperitoneal fat reflection is displaced posteriorly by hepatic or subhepatic masses while kidney and adrenal masses displace it anteriorly Neuroblastoma (Fig 10.2.2) The second most common abdominal tumor of childhood Thirty percent occurring in children < yr On ultrasound, they are seen as on poorly-defined and heterogenous lesion with areas of calcification, hemorrhage and necrosis The lesion often crosses the midline and causes displacement and compression of ipsilateral kidney without otherwise distorting the internal renal architecture They also tends to spread early and widelyspreads around aorta, celiac, SMA arteries Pheochromocytoma (Figs 10.2.3 and 10.2.4) are hyperfunctioning tumor-secreting norepinephrine and epinephrine and showing features of episodic hypertension, palpitation with tachycardia, headache Adrenal Gland 295 Fig 10.2.2: Longitudinal and transverse scan of abdomen of a 6-month-old child with marked heterogenicity and areas of high reflectivity within it—neuroblastoma Sonography demonstrate large, well-marginated heterogenous (due to necrosis and hemorrhage) solid lesions Ten percent lesions may demonstrate calcification Myelolipoma Adrenal myelolipomas are rare benign nonhyperfunctioning tumors composed of fat and bone marrow elements On sonography an echogenic mass with apparent diaphragmatic discursion is diagnostic of the condition 296 Differential Diagnosis in Ultrasound Fig 10.2.3: Pheochromocytoma—a hypoechoic rounded well-defined lesion with uniform echogenicity is seen in the right adrenal gland Fig 10.2.4: A solid heterogenous mass with a well-defined echogenic capsule and cystic areas of necrosis—pheochromocytoma Adrenal Gland 297 Tumor may appear isoechoic if composed predominantly of myeloid element Adrenocarcinoma rare malignant tumors It may arise from any of the layers of adrenal cortex Hyperfunctioning tumors are small and homogeneous in echo pattern, similar to renal cortex The nonhyperfunctioning tumors are larger and heterogeneous with central areas of necrosis and hemorrhage All lesions tend to be well-defined with a lobulated border Calcification may be seen in 20 percent cases A surrounding thin echogenic vascular capsule is a specific feature of adrenal cortical carcinoma 10.3 LARGE SOLID ADRENAL MASSES • Cortical carcinoma • Pheochromocytoma • Neuroblastoma (Figs 10.3.1 and 10.3.2) Fig 10.3.1: US scans show evidence of large pheochromocytoma of adrenal gland 298 Differential Diagnosis in Ultrasound A B Figs 10.3.2A and B: Heterogeneous mass with internal septa and vascularity in left adrenal gland Adrenal Gland • • • • 299 Ganglioneuroma Myelolipoma Metastasis Hemangiomas may become large in size They have nonspecific US features with cystic, solid or complex appearances Phleboliths may be seen within the lesions—inflammation/infection—tuberculosis, abscess Ganglioneuroma is a rare benign adrenal neoplasm It is slow growing and clinically silent until pressure symptoms are evident Sonographically they appear homogenously solid and change shape rather than displacing adjacent organs 10.4 CYSTIC ADRENAL MASSES Adrenal Cyst • Rare benign lesion, found incidently • Typically unilateral but bilateral in 15 percent of cases • Most common in 3rd to 4th decades and show a female preponderance Sonographically they are round or oval with a thin smooth wall Good through—transmission is present but often internal debris is noted According to their origin they are classified as: Endothelial: most common variety and include angiomatous, lymphangiectatic and hamartomatous lesions Pseudocysts: secondary to hemorrhage into a normal adrenal gland, i.e old hemorrhage or tumor-cystic adenoma—neuroblastoma Epithelial cysts Parasitic: Echinococcal cyst 300 Differential Diagnosis in Ultrasound 10.5 ADRENAL PSEUDOMASSES Structures that may simulate adrenal masses include: • Thickened diaphragmatic crura • Accessory spleen • Gastric fundus • Gastric diverticulum • Renal vein • Retrocrural and retroperitoneal lymphadenopathy • Upper pole renal cysts and renal tumors • Pancreatic tumors • Hypertrophied caudate lobe of liver • Fluid-filled colon interposed between stomach and kidney ... Delhi 11 0 002, India Phone: + 91- 11- 43574357 Fax: + 91- 11- 43574 314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P Medical Ltd 83, Victoria Street, London SW1H 0HW (UK) Phone: +44-20 317 08 910 ... xxii Differential Diagnosis in Ultrasound 13 TESTIS AND EPIDIDYMIS 3 41 13 .1 Differential Diagnosis of Cystic Testicular Lesions 3 41 Ashish Verma, Sumeet Bhargava, Satish K Bhargava 13 .2... Bhargava, Satish K Bhargava 11 PERITONEAL AND MESENTERIC MASSES 3 01 11. 1 Round Solid Masses in Mesentery 3 01 Satish K Bhargava, Sumeet Bhargava 11 .2 Ill-defined Mass 303 Satish K