Sonografie der großen Gefäße Nebennieren und MILZ Dr. Dieter Lungenschmid/Dr. Thomas Trieb www.radiologieinnsbruck.at
Abdomensonographie Große Gefäße Aorta Echoreiche Gefäßwand Nicht komprimierbar Darstellung der Gefäßabgänge Aorta abdominalis Tr. coeliacus (A. gastr. sinistra, A. hepatica, A. lienalis) A. mesenterica superior Aa. renales A. mesenterica inferior Iliakalgefäße
Abdomensonographie Große Gefäße Vena cava Echoärmere Wand, rechts der Aorta Komprimierbar Doppelschlagphänomen Zuflüsse Lebervenen
Abdomensonographie Große Gefäße Vena porta Echoreiche Wand, rechts der Aorta Zuflüsse V. lienalis V.mes. sup. = Confluens V. porta
Aorta abdominalis V. Cava inferior
MILZ
Size And Location Intraperitoneal located in the Lt. hypochondrium between fundus of stomach and diaphragm Bare area anterior to Lt. kidney Ovoid in shape 11 cm in length; 7 7 cm in breadth 4 4 cm in thickness Weighs 150-200g Varies 80-300 gms
Structure Red Pulp - Venous sinuses serving as blood reservoir, resembles a lymph gland White Pulp - Malpighian corpuscles / lymph tissue
Abdomensonographie Milz Indikation: Erkennen von Größen- und Formveränderungen Nebenmilz Hämatome, Abszesse, Zysten Aussage: Sehr gute Methode zur Größenbestimmung Veränderungen ab 0,5 cm erkennbar
Abdomensonographie Milz Auffinden: Intercostaler Längsschnitt 10.ICR links (keine tiefe Inspiration, bei subcostaler Darstellung tiefe Insp.) Halbmondförmig Maße: 4 x 7 x 11cm, wenn max. Längsdurchmesser > 11cm dann erfolgt Bestimmung der Tiefe und Breite Echogenität: Ähnlich der Leber
Nebenmilz
Size And Location Intraperitoneal located in the Lt. hypochondrium between fundus of stomach and diaphragm Bare area anterior to Lt. kidney Ovoid in shape 11 cm in length; 7 7 cm in breadth 4 4 cm in thickness Weighs 150-200g Varies 80-300 gms
Indications Splenomegaly Palpable splenic mass Cranial abdominal organomegaly Lethargy, collapse Anemia, abnormal RBC s
Ultrasound Technique Left side of body Head of spleen Under border of rib cage on left Body & tail of spleen Along left body wall Ventral or lateral to left kidney Scan sagittal & transverse
Anatomy Size of normal spleen variable Assessed subjectively Enlarged spleen may cross midline or extend caudally to the bladder Parenchyma Homogenous, finely textured
Spleen Longitudinal Spleen Lt Kidney Adrenal
Splenic Hilium Longitudinal Splenic hilum
Longitudinal Spleen Diaphragm
Normal Spleen
Anatomy Capsule Smooth, regular, VERY echogenic Splenic veins Only other structure normally visualized Poorly visualized except near hilus Whale tail Enlargement subjective Hilus Check for lymphadenopathy
Splenic Hilus
Diffuse splenomegaly Congestion Torsion Inflammation/septicemia Neoplasia Pathology Lymphosarcoma Mast cell tumor Phenothiazine tranquilizers & barbiturate anaesthetics Extramedullary hematopoesis
Pathology Focal or multifocal splenic lesions Hematoma Infarcts Cysts Abscess Nodular hyperplasia Neoplasia Hemangioma Hemangiosarcoma
Diffuse Splenomegaly Diffuse increase in echogenicity uncommon Neoplastic (mast cell or lymphosarcoma) Diffuse decrease in echogenicity more common Congestion Extra-medullary hematopoesis Lymphosarcoma Inflammation/ septicemia Torsion Normal echogenicity can occur with lymphosarcoma & mast cell tumor
Non Homogenous
Focal/Multifocal Lesions More common than diffuse Anechoic Cysts Hematoma/neoplasia Hypoechoic Neoplasia Abscess Acute infarct Nodular hyperplasia
Focal/Multifocal Lesions Hyperechoic Neoplasia Abscess Chronic infarct Nodular hyperplasia Mixed echogenicity Neoplasia Hematoma Abscess Nodular hyperplasia
Splenic Mass
Splenic Mass
Splenic Infarct
Torsion Definitive diagnosis by ultrasound Characteristic appearance Severe, diffuse splenomegaly Hypoechoic Coarse & lace-like Venous blood flow absent on Doppler +/- hyperechoic venous thrombi Lymphosarcoma can appear similar Normal blood flow
Torsion
Neoplasia Lymphosarcoma Diffuse or focal/multifocal Hypoechoic or hyperechoic Can appear normal Hematoma, hemangioma, hemangiosarcoma Unable to differentiate Focal Hypoechoic, hyperechoic or mixed
Lymphosarcoma
Hemangiosarcoma
Neoplasia Other neoplasms Mast cell tumor, leiomyoma, etc. Presence of peritoneal effusion not a good indication of malignancy Metastasis Lungs, liver, lymph nodes (splenic, hepatic, gastric)
Echogenic Focal Lesions Focal fat deposits Especially cats Surround hepatic veins (myelolipomas) Fibrosis & calcification Secondary to hematoma, chronic infarcts or granulomas (histoplasmosis) Primary or metastatic neoplasia
Definitive Diagnosis Ultrasonic appearance of most splenic diseases non-specific Consider history, signalment, clinical signs Fine needle aspirate useful Biopsy generally not performed
Rupture Free fluid within the abdomen Often echoic (due to blood cells) May be anechoic Most likely a tumor Cannot rule out hematoma
Thrombosis
Splenic Thrombus
Myelolipoma
Figure 7. Severe splenic laceration in a 35-year-old man after an assault. McGahan J P et al. Radiographics 2001;21:S191-S199 2001 by Radiological Society of North America
Figure 8. Severe splenic laceration in a 29-year-old man involved in a motor vehicle accident. McGahan J P et al. Radiographics 2001;21:S191-S199 2001 by Radiological Society of North America