Advanced-Imaging-of-the-Abdomen.pdf

Jovitas Skucas

Advanced Imaging

of the Abdomen

With 489 Figures in 1025 Parts

Jovitas Skucas, MD

Professor Emeritus, Department of Imaging Sciences, University of Rochester, Rochester, NY, USA

British Cataloging in Publication Data

A catalogue record for this book is available from the British Library.

Library of Congress Control Number 2005924309

ISBN-10:

1-85233-992-6

e-ISBN 1-84628-169-5

ISBN-13:

978-1-85233-992-0

Printed on acid-free paper.

Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted

under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or trans-

mitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of

reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency.

Enquiries concerning reproduction outside those terms should be sent to the publishers.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a speciﬁc

statement, that such names are exempt from the relevant laws and regulations and therefore free for general

use.

Product liability: The publisher can give no guarantee for information about drug dosage and application

thereof contained in this book. In every individual case the respective user must check its accuracy by con-

sulting other pharmaceutical literature.

Printed in the United States of America.

(BS/EB)

987654321

Springer Science + Business Media

springeronline.com

Preface

This book is an attempt to bridge the interface between referring clinicians and radiol-

ogists when faced with a patient suspected of having a complex or unusual abdominal

condition. The emphasis is on the choice of imaging procedures, expected diagnostic

yield, a discussion of pertinent imaging ﬁndings, and the possible differential diagno-

sis. The rapid proliferation of imaging techniques provides a bewildering array of

choices to the referring physician. Thus when faced with a suspected biliary abnormality,

should one suggest traditional endoscopic retrograde cholangiography, or is noninva-

sive and noncontrast magnetic resonance (MR) cholangiography or even contrast-aided

computed tomography (CT) cholangiography more appropriate? What is the role of CT

virtual colonoscopy? Is it limited to colon cancer screening or does it have a role in cancer

staging?

This book discusses imaging topics of those structures that fall in the purview of the

gastroenterologist, urologist, general surgeon, and related specialist. The anatomic limits

of the abdomen are somewhat stretched to include the esophagus superiorly, and the

aorta, inferior vena cava, and adjacent structures posteriorly. The emphasis is on new

imaging ﬁndings and innovations. This book also discusses the clinical aspects of a

disease needed to formulate a rational diagnostic approach, but basic research, results

of animal studies, and imaging research are not discussed as they are not pertinent to

clinical medicine. Because of space limitations, fetal imaging and choosing a contrast

agent are not discussed. Also, laboratory ﬁndings and therapeutic options are not dis-

cussed, except for those having a bearing on subsequent diagnostic studies.

This book is intended to be used as a reference for the atypical and unique presenta-

tion and newer diagnostic imaging modalities. Publications of unusual clinical and

imaging ﬁnding are accentuated, and common imaging studies of common disorders are

only mentioned in passing, if they are applicable.

Traditionally, radiology texts have used a pathologically oriented outline. Subse-

quently it became the custom to discuss disorders from an imaging point of view. An

attempt is made here to integrate clinical presentation with pertinent radiologic ﬁndings.

The material is organized primarily along anatomic organ systems, with some excep-

tions. For instance, disorders of the adnexa involve the peritoneal cavity, but they are

closely related to the female genital tract and thus are included in Chapter 12, Female

Reproductive Organs, rather than the peritoneum chapter. Within each organ system the

material is subdivided further along broad disorder categories, such as congenital,

inﬂammation, tumors, etc., but a pragmatic clinical approach is adopted. For example, a

PREFACE

history of trauma is usually known and thus imaging ﬁndings associated with acute

trauma are discussed in separate sections.

It has been said that “to steal from one author is plagiarism, if you steal from many,

it’s research” (1). With that deﬁnition in mind, this work, I hope, is research. The refer-

ences are rather wide-ranging, but to make the text more readable the number of refer-

ences is deliberately kept low and information that has diffused in the medical

community is not referenced further. The cited references serve both as an acknowl-

edgment to the original authors and as a guide to a more in-depth source on a particu-

lar topic.

An abbreviated format has been adopted in presenting published studies. Emphasis

is on sensitivity and speciﬁcity (or false-positive rate), realizing that these provide an

incomplete picture. Where applicable, the measurements given include a standard devi-

ation. To maintain brevity, little additional statistical analysis is provided.

It is assumed that the reader has basic knowledge of abdominal imaging. The techni-

cal details about performing and interpreting various imaging modalities are omitted

except when pertinent to new techniques and applications. Thus a statement such as

Tc99m-DTPA scintigraphy and color duplex US ...could reliably differentiate

minimal and not perfused renal allografts...

omits that scintigraphy consisted of analogue scans up to 60 minutes postinjection and

that time-activity curves over the ﬁrst 60 seconds after injection of 370 to 440 MBq of

technetium-99m-diethylenetriaminepentaacetic acid are obtained and classiﬁed by a

perfusion score, the time between renal and iliac artery peaks and washout of the

renogram curve; similarly, not mentioned is that color duplex ultrasonography (US) con-

sists of a perfusion study in all sections of the graft and vascular anastomoses by color-

coded duplex sonography and that maximal blood ﬂow velocity and resistive index in

the renal artery are determined by a pulsed Doppler device. Most of these details are

intuitive to the specialist performing such a test.

To avoid repetition, the more common imaging ﬁndings are not repeated for each

imaging modality. Thus if a lesion contains fat, it is stated as such; it is not stated that

this fat is hypodense with CT, hyperechoic with US, or hyperintense with T1-weighted

MR sequences. The exception is if a speciﬁc imaging appearance is unique.

Indications for magnetic resonance imaging (MRI) are still evolving. In addition, as

new imaging technology becomes available the imaging modality recommended for a

particular application today may not be optimal tomorrow. Thus multislice helical CT

techniques continue to expand application of CT angiography and interventional pro-

cedures, possibly at the expense of further rapid growth of MRI.

Numerous individuals contributed images to this book and their effort is gratefully

acknowledged. Over the years many ex-residents have provided me with interesting

studies from their daily practices and these are acknowledged. A special thanks goes to

Jolanta Galdikaite, an illustrator in Kaunas, Lithuania, for the line drawings.

Jovitas Skucas, MD

Reference

1. Attributed to the Hollywood ne’er-do-well Wilson Mizner (1876–1933). Quoted in Green J. Chasing the Sun:

Dictionary Makers and the Dictionaries They Make. New York: Henry Holt, 1996:19.

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