Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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09.07.2019 Views

Hepatic Lymphoma (Left) Transverse abdominal ultrasound in a patient with lymphoma shows several hypoechoic masses in the lateral segment of the left lobe of the liver ſt. The more peripheral mass causes contour bulging of the liver capsule . (Right) Longitudinal color Doppler ultrasound performed in the same patient shows some vascularity st within the exophytic hypoechoic mass ſt. Diagnoses: Liver (Left) Transverse abdominal ultrasound in a patient with lymphoma shows multiple hypoechoic nodules ſt throughout the right lobe of the liver. (Right) Transverse color Doppler ultrasound in the same patient shows that the masses ſt are predominantly hypovascular and abut the portal veins . (Left) F-18 FDG PET in the same patient shows marked diffusely hypermetabolic uptake within the entire liver parenchyma ſt, caused by hepatic lymphoma. (Right) Power Doppler ultrasound in a patient with lymphoma shows an ill-defined, hypoechoic mass in the subcapsular portion of the right lobe of the liver ſt. No vascularity is detected within the mass. http://radiologyebook.com/ 259

Transjugular Intrahepatic Portosystemic Shunt (TIPS) Diagnoses: Liver TERMINOLOGY • Shunt between main portal vein and hepatic vein created with balloon-expandable covered metallic stent IMAGING • Goal of US: Detection of stenosis before shunt occludes or symptoms recur • Best imaging tool ○ US as primary TIPS surveillance tool ○ CTA/MRA indicated if US technically compromised or equivocal • Doppler US findings of TIPS malfunction ○ PV – Hepatofugal flow – Peak velocity < 35 cm/sec ○ Within shunt – Peak velocity < 90 cm/sec or > 200 cm/sec at any point – Temporal change in peak velocity > 50 cm/sec KEY FACTS TOP DIFFERENTIAL DIAGNOSES • Portal vein occlusion • Hepatic vein occlusion • Inferior vena cava occlusion PATHOLOGY • Stenosis usually secondary to intimal hyperplasia from hepatic venous side • Hepatic encephalopathy if portal flow bypasses liver CLINICAL ISSUES • Most common symptoms/signs of stent malfunction ○ Variceal hemorrhage ○ Signs of worsening portal hypertension with increasing ascites DIAGNOSTIC CHECKLIST • Low flow may be difficult to detect with US ○ Confirm angiographically (CTA, MRA, shunt venography) (Left) Graphic shows TIPS shunt creation. The hepatic vein is punctured within 2 cm of the inferior vena cava (IVC). A covered stent is placed between the hepatic venous end and the right portal vein, adjacent to its junction with the main portal vein. (Right) Spectral Doppler ultrasound of a TIPS with interrogation at the proximal (portal venous) portion of the shunt shows appropriate flow direction and velocity of 139 cm/sec. (Left) Spectral Doppler ultrasound (same patient) in the mid TIPS shows slight increase in velocity to 178 cm/sec, which is still within normal limits. Angle correction should always be used when evaluating TIPS for accurate velocity measurement. (Right) Anteroposterior supine portal angiogram in a 66-year-old man with a suspected TIPS stenosis based on Doppler ultrasound reveals multiple areas of intimal hyperplasia within the parenchymal portion of the shunt , consistent with stenosis. 260 http://radiologyebook.com/

Hepatic Lymphoma<br />

(Left) Transverse abdominal<br />

ultrasound in a patient with<br />

lymphoma shows several<br />

hypoechoic masses in the<br />

lateral segment of the left<br />

lobe of the liver ſt. The more<br />

peripheral mass causes<br />

contour bulging of the liver<br />

capsule . (Right)<br />

Longitudinal color Doppler<br />

ultrasound performed in the<br />

same patient shows some<br />

vascularity st within the<br />

exophytic hypoechoic mass ſt.<br />

Diagnoses: Liver<br />

(Left) Transverse abdominal<br />

ultrasound in a patient with<br />

lymphoma shows multiple<br />

hypoechoic nodules ſt<br />

throughout the right lobe of<br />

the liver. (Right) Transverse<br />

color Doppler ultrasound in<br />

the same patient shows that<br />

the masses ſt are<br />

predominantly hypovascular<br />

<strong>and</strong> abut the portal veins .<br />

(Left) F-18 FDG PET in the<br />

same patient shows marked<br />

diffusely hypermetabolic<br />

uptake within the entire liver<br />

parenchyma ſt, caused by<br />

hepatic lymphoma. (Right)<br />

Power Doppler ultrasound in a<br />

patient with lymphoma shows<br />

an ill-defined, hypoechoic<br />

mass in the subcapsular<br />

portion of the right lobe of the<br />

liver ſt. No vascularity is<br />

detected within the mass.<br />

http://radiologyebook.com/<br />

259

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