(临床诊断学) 仁济临床医学院诊断学教研室 An Introduction to Clinical Diagnostics

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LHV

HH


RHV



HH

Figure 6 Hepatic venous anatomy

The three hepatic veins-right (RHV), middle (MHV), and left (LHV), are interlobar and intersegmental, separating the lobes and segments. Three hepatic venous confluence with the inferior vena cava




  1. USG of common diseases of liver

  1. Liver cirrhosis

① Clinical manifestation:

There are three major pathologic mechanisms which, in combination, create cirrhosis: cell death, fibrosis, and regeneration. Hepatitis B is the main cause in China. The main clinical manifestations are liver dysfunction, portal hypertension and ascites.

② USG:


    • In the early stages, the liver may be enlarged, whereas in the advanced states, the liver is often small, with relative enlargement of the caudate, left lobe, or both, in comparison with the right lobe.

    • Nodular surface

    • Coarse echotexture, regeneration nodules

    • Decreased amplitude of phasic oscillations with loss of reversed flow, and a flattened waveform.

    • Luminal narrowing of the hepatic veins

    • Wide PV

    • Splenomegaly

    • Ascites

③Differential diagnoses:

The liver cirrhosis tubercle need to identify with the small liver cancer, CT can clear diagnosis.





Figure7 Liver cirrhosis

Small end-stage right liver(RL) with surface nodularity, best appreciated with ascites(As), hydropic wall of gallbladder(GB), Wide portal vein(PV)




  1. Liver cyst

① Clinical manifestation:

Liver cysts have a ductal origin, although their precise cause is unclear. Occasionally, the patient may develop pain and fever secondary to cyst hemorrhage or infection.

② USG:


    • Anechoic lumen

    • Well-demarcated thin wall

    • Posterior acoustic enhancement

    • Sidewall echo loses

    • When the cyst complicated with hemorrhage or infection, it may contain internal echoes and septations, a thickened wall, or may appear solid.

③ Differential diagnoses:

Identify with cystic metastases and the liver abscess at the liquefaction period, according to the wall thickness, thickness uneven and the margin.





Figure 8 Liver cyst

Anechoic cyst with a clear and thin wall, posterior acoustic enhancement, sidewall echo loses



  1. Liver abscess

① Clinical manifestation:

The most common presenting features of liver abscess are fever, malaise, anorexia, and right upper quadrant pain. It is usually cased by pyogenic bacteria infection or amoebic parasite, and can often be find in right lobe.

② USG:


    • The abscess appears cystic, with the fluid ranging from echofree to highly echogenic.

    • Rough wall

    • A round or oval-shaped lesion

    • Clear sidewall

    • Posterior acoustic enhancement

    • Occasionally gas-producing organisms give rise to echogenic foci with a posterior reverberation artifact.

③ Differentiaion:

the differential diagnaosis of liver abscess includes amebaic or echinococcal infection, simple cyst with hemorrhage, hematoma, and necrotic or cystic neoplasm.




  1. Liver hemangioma

① Clinical manifestation:

Four types: angiocavemoma, sclerosing hemangioma, hemangioendothelioma and capillary hemangioma.

② USG:


    • Hyperechoic or homogeneous

    • Clear margin

    • Uniformly granular or lacelike in character

    • Echogenic border, either a thin rim or a thick rind

    • A tendency to scalloping of the margin

    • Extremely slow blood flow

③ Differential diagnoses:

Identify with liver cancer, according to the wall thickness, acoustic halo surround.




RL


liver


Figure 9 Liver hemangioma

An echoic mass with clear margin in the liver



  1. Primary liver carcinoma

① Clinical manifestation:

More than 90% is HCC. Generally it has no symptom at early, but later shows liver pain, fatigue and abdominal mass. Most patients has AFP positive.

② USG:


    • The mass may be hypoechoic, complex, or echogenic

    • Solid mass

    • Multiple nodules

    • Diffuse infiltration

    • A thin, peripheral hypoechoic halo

    • “Hump sign”

    • Small tumors may appear diffusely hyperechoic, secondary to fatty metamorphosis or sinusoidal dilation

    • Doppler: high-velocity signals

③ Differential diagnoses:

Identify with liver hemangioma, liver cirrhosis tubercle and focal hyperplasia nodular.




Figure 10 Primary liver carcinoma

A, A large hyperechoic mass in the right liver lobe

B, Color Doppler shows a disorganized flow pattern


  1. Metastatic liver disease

① Clinical manifestation:

It is usually origin the cancer of esophagus, stomach, gallbladder, pancreas and other digestive organs.

② USG:


    • Multiple masses: echogenic, hypoechoic, target, calcified, cystic and diffuse

    • Bull's-eye configuration or target pattern is characterized by a peripheral hypoechoic halo

    • Calcified metastases are distincitive by virtue of their marked echogenicity and distal acoustic shadowing. Adenocarcinoma of the colon is most frequently associated with calcified mestases.

    • Carcinoma of pancreas is associated with multiple hypoechoic metastases with no posterior acoustic enhancement.

③ Differential diagnoses:

Identify with hepatic abscess, echinococcosis of liver, hepatic phthisis and other liver disease with multiple nodules.




  1. Gallbladder

  1. USG of normal gallbladder

    • Location: inferior to interlobar fissure between left and right lobe;

    • Size: <3cm transverse, <9cm longitudinal;

    • Wall: clear wall, <3mm in thickness;

    • Lumen: anechoic

  1. USG of common diseases of gallbladder

  1. Cholelithiasis

① Clinical manifestation:

More common in adult females, pain in the right upper quadrant, fever, nausea or vomiting

② USG:


    • Typical gallstone:

Hyperechoic, clear acoustic shadow, mobility (when the patient position changed)

    • Stone-filled gallbladder:


Echo shadowing structure in the right upper quadrant, WES (wall-echo-shadow) complex: three arc-shaped lines followed by a shadow

    • Multiple dependent gallstones:

Multiple dependent stones arrange along the dependent gallbladder wall, acoustic shadow, and mobile.

    • Intramural cholesterol crystals:

Multiple bright reflectors in the gallbladder lumen, short comet tail artifact, lack of acoustic shadow non-mobile

③ Differential diagnoses:

According to the echo, shadow and mobility. Mobility is a key feature of stones, allowing differentiation from polyps or other entities.

RL

GB


S

Figure 11 Typical gallstone

Image show a stone (arrow) in the gallbladder (GB) appearing as hyperechoic stone with acoustic shadow(S)



  1. Acute cholecystitis

① Clinical manifestation:

Usually have pain in the right upper quadrant, fever, disgusting or vomiting. It is caused by Stone obstruction, bacterial infections and pancreatic reflux.

② USG:


    • Gallbladder enlargement

    • Gallbladder wall thickening>3 mm

    • Hyperemia of the gallbladder wall

    • Biliary sludge in the gallbladder lumen

    • Gallbladder distention

    • Choledocholithiasis

    • Hepatic abscesses

③ Differential diagnoses:

Generally according to the clinical symptom, physical sign and laboratory examination can make diagnoses.

GB


Figure 12 Acute cholecystitis

Classic appearance with hyperemia and thickening wall and biliary sludge




  1. GB polyp

① Clinical manifestation:

It contains cholesterol polyp, inflammatory polyps, adenomatoid polyps and adenomyomatosis of gallbladder.

② USG:


    • Multiple, oval lesions attached to the gallbladder wall

    • High-level echo

    • Non-shadowing

    • Non-mobile

    • Larger lesions may contain a fine pattern of echogenic foci within them

③ Differential diagnoses:

According to the echo, shadow and mobility.




  1. Pancreas

  1. USG of normal pancreas

    • Size: head<3cm, body<2cm, tail 1~3cm

    • Pancreatic duct:<2mm

    • Echogenicity: isoechoic or hyperechoic compared with liver

    • Texture echo: homogeneous



F

SP
igure 13 Normal pancreas

Splenic vein(SPV), superior mesenteric artery (SMA), aorta(AA), inferior vena cava(IVC), common bile duct(CBD), duodenum(DUO), spine(SP), left renal vein(LKV); Liver and stomach is anterior to the pancreas.




  1. USG of common diseases of pancreas

  1. Acute pancreatitis

① Clinical manifestation:

Mainly have intense abdominal pain suddenly, nausea and vomiting, hypotension and shock, muscular tension, tenderness. Amylase in blood and urinary is high. It has two styles: dropsy and hemorrhage necrosis.

② USG:


    • Pancreas enlargement

    • Pancreatic echogenicity: decreased

    • Echotexture: inhomogeneous

    • Inflammatory mass

    • Hemorrhage

    • Intrapancreatic and extrapancreatic fluid collections

    • Pseudocyst formation

    • Ascites

③ Differential diagnoses:

The diagnosis of acute pancreatitis is usually based on clinical and laboratory findings.




  1. Pancreatic carcinoma

① Clinical manifestation:

It is easy to see in middle-aged person and old person, and generally has no symptom at early, but later shows stomachache, jaundice, body weight decreased significantly, besides has anorexia, nausea, vomiting and diarrhea.

② USG:


    • Poorly defined, homogeneous or inhomogeneous, hypoechoic mass

    • Obstruction of the pancreatic and biliary duct: double-duct sign (combined dilation of the pancreatic and common bile duct) and enlarged gallbladder

    • Lesional vascularity is uncommonly shown with conventional Doppler imaging

③ Differential diagnoses:

It needs identify with chronic pancreatitis, which has pancreatic atrophy and calcify, thickening perirenal fascia, and string-of-beads pancreatic duct.




  1. Spleen

  1. USG of normal spleen

    • Size: length 10-12cm, Spleen port thick 3-4cm

    • Echo:

    • Texture echo: homogeneous

  1. USG of common diseases of spleen

  1. Spleen trauma

① Clinical manifestation:

Spleen is the most vulnerable organ in abdomen. It has three styles: central rupture (breakage in deep parenchyma), capsule rupture (breakage in the surrounding parenchyma) and true rupture (breakage involved capsule)

② USG:


Spleen sub-capsular hematoma


    • Size: normal

    • Anechoic area between spleen surface contour and spleen capsule

    • Move with breath

    • Internal distribution of scattered small weak echo

Spleen parenchyma hematoma

    • Size: enlarge

    • Contour: smooth

    • Anechoic area in parenchyma




  1. Kidney

  1. USG of normal kidney

    • Size: length 10-12cm, thick 3-4cm

    • Renal sinus echo: high level echo

    • Renal parenchyma thick: 1.5-2.5cm

  1. USG of common diseases of kidney

  1. Kidney stone

Strong echo in the renal sinus with acoustic shadow, if it has Secondary hydronephrosis, the renal calices and pelvis showed irregular anechoic area.


  1. Hydronephrosis

① Clinical manifestation:

It can be caused by stone, tumor, infection and so on. The patients can have renal colic, hematuresis and fever.

② USG:


    • dilated renal sinus ≥1cm

    • collecting system: anechoic space

    • moderate and marked hydronephrosis: kidney enlarge

    • marked hydronephrosis: renal parenchyma atrophia

    • hydroureter

③ Differential diagnoses:

Drink too much water, filling of bladder, pregnancy or drugs can cause physiological renal sinus dilated, but it usually <8mm. With polycystic kidney disease or multiple renal cysts identification: the anechoic area of hydronephrosis is communicating with each other, while the renal cysts are not.

Small parts Sonography


  1. Thyroid

  1. USG of normal thyroid

    • Shape: lobus lateralis sinister and dexter, isthmus at front.

    • Clear contour, regular borderline,

    • Echo: medium intensity or a litter low level echo

    • Texture echo: homogeneous

  1. USG of common diseases of thyroid

  1. Thyroid nodule

    • Solid nodules: including cancer, adenomas and cystic nodules.

    • Admixture nodules: including adenomas cystic degeneration or adenoma hemorrhage.

  1. Thyroid diffuse lesions

    • Including simple goiter, nodular goiter, hyperthyroidism, and thyroiditis and so on.

    • By glandular echo and color flow distribution can make discrimination.




  1. Breast

  1. USG of normal breast

Three type:

    • Diffuse homogeneous type: breast tissue was uniformity detailed echo

    • Micro-vesicles: 1~ 2mm vesicle area opaca in breast diffusely

    • Mixed type

  1. USG of common diseases of breast

  1. Cyclomastopathy

    • Bilateral breast: symmetry increase mildly

    • Glandular organ structure: disorder

    • Echo: diffuse increased

    • Texture echo: uneven

    • Hypoechoic nodules or cysts in breast




  1. Fibroadenoma of breast
    • Round or oval, lobulated when large


    • Smooth boundary, has peplos

    • Low level echo, homogeneous

    • CDFI: no or a litter blood flow




  1. Breast cancer

    • Mass: heterogeneous hypoechoic, irregular form, no peplos, angular margin, crab-foot extension.

    • CDFI: multiple vessles demonstrated




Figure 14 Breast tumor

A, Benign fibroadenoma: elliptical, wider than tall and completely encompressed by a thin, echogenic capsule.

B, Malignant nodule: hypoechoic mass with angular margin and spiculation surround it.

Gynecologic and Obstetric Ultrasound

  1. Uterus

  1. USG of normal uterus

    • Position: The uterus lies in the true pelvis between the urinary bladder and the rectosigmoid colon posterioly.

    • Size: the adult uterus is 7~8 cm in length, 4~5 cm in width and 2~3 cm in anteroposterior diameter.

    • Shape: inverse pear-shaped appearance.
    • Sonography: The normal endometrial cavity is seen as a thin echogenic line. The sonographic appearance of the endometrium varies during the menstrual cycle. The endometrium is composed of a superficial functional layer and a deep basal layer. The functional layer thickens throughout the menstrual cycle and is shed with menses. The menstrual phase endometrium consists of a thin echogenic line. During the proliferative phase, the endometrium thickens, reaching 2 to 4 mm. The endometrium in secretory phase measures 7 to 10mm.





  1. USG of common diseases of uterus

  1. Leiomyoma

① Clinical manifestation:

Leiomyomas (fibroids) are the most common neoplasm of the uterus. Women with leiomyomas can experience pain and uterine bleeding. Leiomyomas may be classified as intramural, submucosal and subserosal.

② USG:


    • the uterus may be enlarged

    • distorted and irregular external contour of the uterus

    • localized leiomyomas are most commonly hypoechoic or heterogeneous in echotexture

    • leiomyomas impinge on the endometrium, distorting the cavity



Fig 15 Uterus leiomyoma

A hypoechoic nodus (arrow) in the anterior wall of uterus; BL:bladder

③ Differential diagnoses:


  • adenomyosis: diffuse uterine enlargement with a normal contour, normal endometrial texture

thickening of the posterior myometrium, with the involved area being slightly more anechoic than normal myometrium

  • Endometrial carcinoma: The most common clinical presentation is uterine bleeding. Sonographically, a thickened endometrium, which has a heterogeneous echotexure with irregular or poorly defined margins.

  1. Ovary

  1. Normal Ultrasonography of Ovary

    • Position: Uterine location influences the position of the ovaries. The normal ovaries are usually identified laterally or posterolaterally to the anteflexed midline uterus. Their craniocaudad axes are paralleling the internal iliac vessels, which lie posteriorly and serve as a helpful reference.
    • Size: the adult ovary is 4×3×1cm


    • Shape: the ovaries are ellipsoid in shape

    • Sonography: the normal ovary has a relatively homogenous echotexure with a central, more echogenic medulla. Well-defined, small anechoic or cystic follicles may be seen peripherally in the cortex. The appearance of the ovary changes with age and with the phase of the menstrual cycle.

  1. USG of common diseases of ovary

  1. Ovarian cystadenoma

① Clinical manifestation:

Ovarian cystadenomas are the most common, comprising 45% of all benign ovarian neoplasms. The peak incidence of cystadenoma is in third to fifth decades women. Ovarian cystadenomas are classified into serous and mucinous cystadenomas. Approximately 20% of serous cystadenomas are bilateral. Their sizes vary greatly, but in general, they are smaller than mucinous tumors. Mucinous cystadenomas are often huge and less frequently bilateral.

② USG:


    • Serous cystadenomas are usually large, thin-walled, unilocular cystic masses that may contain thin septations. Papillary projections are occasionally seen.

    • Mucinous cystadenomas can be huge multiloculated cystic masses, measuring up to 15 to 30 cm. Mutiple thick septae are present and low-level echoes caused by the mucoid material may be seen in the dependent portions of the masse. Papillary projections are less frequently seen than in the serous cystadenomas.





Fig 16 Ovarian mucinous cystadenoma

A huge multiloculated cystic mass with multiple septae of ovary



  1. Normal early pregnancy


The whole gestational period is 40 weeks (menstrual age). Early pregnancy or the first trimester of pregnancy is the first 12 weeks. Ultrasound is a readily available, noninvasive, and safe means of evaluating fetal health, determining gestational age, and assessing the intrauterine environment.

  1. USG of normal early pregnancy

    • uterus enlargement

    • gestational sac: a round or oval shape intradecidual sac which can be detected at 5 weeks of gestational age(GA) using transvaginal sonography(TVS)

    • embryo: visualized from 6 to 7 weeks of GA using TVS, clear crown-rump length (CRL) is shown from 8 weeks of GA.

    • fetal heart: heart tube beating can be seen as early as 6 weeks of GA, clear embryonic cardiac cavity can be seen at 12 weeks of GA.

    • fetal movement: happen from 9 weeks of GA, and active fetal movement can be seen from 12 weeks of GA.

    • placenta: can be seen at 8 to 9 weeks of GA, hyperechoic compared with uterus

    • yolk sac: the first structure to be seen normally within the gestational sac and can be seen till 11 weeks of GA






Fig 17 Early pregnancy (TVS)

1. exocoelom and amnion(arrow) 2.yolk sac 3.embryo 4. amniotic sac




  1. Ectopic pregnancy

① Clinical manifestation: Pain, abnormal vaginal bleeding, and a palpable adnexal mass ,amenorrhea, adnexal tenderness, and cervical excitation tenderness

② USG:


    • Enlarged uterus without gestational sac in the cavity

    • Adnexal mass

    • Free fluid in the recto-uterine fossa

New technique

  1. Harmonic imaging

Variation of the propagation velocity of sound in fat and other tissues near the transducer results in phase aberration that distorts the ultrasound image. Tissue harmonic imaging provides an approach for reducing the effects of phase aberrations, reducing the noise and clutter. Because harmonic beam do not interact with superficial structures and are narrower than the originally transmitted beam, spatial resolution is improved and clutter and side lobes are reduced.


  1. 3-D ultraousnd

Dedicated 3-D scanners used for fetal, gynecologic and cardiac scanning may employ hardware-based image registration, high density 2-D array, or software registration of scan planes as a tissue volume is acquired. 3-D ultrasound permits collection and review of data obtained from a volume of tissue in multiple imaging planes as well as rendering of surface features.

  1. Contrast enhanced ultrasound

The principle requirements for an ultrasound contrast agent are that it should be easily introducible into the vascular system, be stable for the duration of the diagnostic examination, have low toxity, and modify one or more acoustic properties of tissues which determine the ultrasound imaging process. The new generation of ultrasound contrast agents has extend their capabilities, redefining the role of ultrasound in resolving the vascular questions that were until now left to CT and MRI. Contrast agents as blood pool agents can help delineate vascular structures and enhance Doppler signals from small volumes of blood. More excitingly, contrast agents make it possible for ultrasound to achieve entirely new objectives, the most striking of which is the ability for the first time to image organ and lesion perfusion in real time.



  1. Interventional ultrasound

  1. ultrasound-guided biopsy

Ultrasound-guided needle biopsy is an important diagnostic technique in radiology practices throughout the world. It has become an accurate, safe, and widely accepted technique for confirmation of suspected malignant masses and characteristics of many benign lesions in various intra-abdominal locations. It also decreases patient’s costs by obviating the need for an operation, decreasing the duration of hospital stay, and decreasing the number of examination necessary during a diagnostic evaluation.

Traditionally, ultrasound-guided needle biopsy has been used for the biopsy of large, superficial, and cystic masses. Currently, however, because of improvements in instrumentation and biopsy techniques, small, deeply located, and solid masses can also undergo accurate biopsy.



Indications: Suspected malignancy before nonsurgical treatment, such as chemotherapy and radiation therapy.

Contraindications: Relative contraindications to needle biopsy include uncorrectable coagulopathy, lack of a safe biopsy route, and an uncooperative patient.

  1. Ultrasound-guided drainage

Percutaneous aspiration and drainage procedures have gained wide acceptance in clinical practice because of their safety, simplicity, and effectiveness. Modalities such as ultrasound and CT allow for precise needle placement for superficial and deep abdominal fluid collections or abscesses.

Indications:

① Percutaneous catheter drainage of pyogenic abscesss and cysts

② Percutaneous cholecystostomy

③ Percutaneous transhepatic cholangiography and drainage


Contraindications:

Contraindications to image-guided percutaneous catheter drainage include lack of safe route, bleeding diathesis and uncooperative patient.



  1. Intraoperative sonography

Intraoperative sonography (IOS) is a dynamic and growing imaging technique providing important real-time diagnostic information to the radiologist and the surgeon. It identifies and characterizes lesions seen on preoperative imaging and discovers new lesions not detected by preoperative imaging or surgical inspection and palpation. The ultimate goal is to correlate preoperative images, surgical inspection and palpation, and IOS findings to determine the most appropriate surgical procedure.

Indications and applications: detection of occult masses; determinination of relationships and vascular abnormalities; characterization of masses; guidance for intervention





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