11 Sonografie von Gefäßen, NNT und Milz Gefäßverschlüsse im Abdomen, Nebennierenzumore, Milzvenenthrombose, Milzvergrößerung und Embolisation, Hepatosplenomegalie, Weitergabeskript

1. Sonografie der großen Gefäße
Nebennieren und MILZ
Dr. Dieter Lungenschmid/Dr. Thomas Trieb
www.RadiologieInnsbruck.at

3. 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

4. Abdomensonographie – Große Gefäße
•Vena cava
–Echoärmere Wand, rechts der Aorta
–Komprimierbar
–Doppelschlagphänomen
–Zuflüsse
•Lebervenen

6. Abdomensonographie – Große Gefäße
•Vena porta
–Echoreiche Wand, rechts der Aorta
–Zuflüsse
•V. lienalis – V.mes. sup. = Confluens – V. porta

7. Aorta abdominalis
V. Cava inferior

9. MILZ

11. Size And Location
•Intraperitoneal
Intraperitoneal
Intraperitoneal
Intraperitoneal located in the Lt.
located in the Lt.
located in the Lt.
located in the Lt.
hypochondrium
hypochondrium
hypochondrium
hypochondrium between fundus of
between fundus of
between fundus of
between fundus of
stomach and diaphragm
stomach and diaphragm
stomach and diaphragm
stomach and diaphragm
–Bare area anterior to Lt. kidney
Bare area anterior to Lt. kidney
Bare area anterior to Lt. kidney
Bare area anterior to Lt. kidney
•Ovoid
Ovoid
Ovoid
Ovoid in shape
in shape
in shape
in shape
•11
11
11
11 cm in length;
cm in length;
cm in length;
cm in length;
•7 cm in breadth
7 cm in breadth
7 cm in breadth
7 cm in breadth
•4 cm in thickness
4 cm in thickness
4 cm in thickness
4 cm in thickness
•Weighs 150
Weighs 150
Weighs 150
Weighs 150 -
-
-
-200g
200g
200g
200g
–Varies 80
Varies 80
Varies 80
Varies 80-
-
-
-300
300
300
300 gms
gms
gms
gms

12. Structure
•Red Pulp
Red Pulp
Red Pulp
Red Pulp -
-
-
- Venous sinuses serving as
Venous sinuses serving as
Venous sinuses serving as
Venous sinuses serving as
blood reservoir, resembles a lymph
blood reservoir, resembles a lymph
blood reservoir, resembles a lymph
blood reservoir, resembles a lymph
gland
gland
gland
gland
•White Pulp
White Pulp
White Pulp
White Pulp -
-
-
- Malpighian corpuscles /
Malpighian corpuscles /
Malpighian corpuscles /
Malpighian corpuscles /
lymph tissue
lymph tissue
lymph tissue
lymph tissue

13. Abdomensonographie – Milz
•Indikation:
–Erkennen von Größen- und Formveränderungen
–Nebenmilz
–Hämatome, Abszesse, Zysten
•Aussage:
–Sehr gute Methode zur Größenbestimmung
–Veränderungen ab 0,5 cm erkennbar

15. 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

16. Nebenmilz

17. Size And Location
•Intraperitoneal
Intraperitoneal
Intraperitoneal
Intraperitoneal located in the Lt.
located in the Lt.
located in the Lt.
located in the Lt.
hypochondrium
hypochondrium
hypochondrium
hypochondrium between fundus of
between fundus of
between fundus of
between fundus of
stomach and diaphragm
stomach and diaphragm
stomach and diaphragm
stomach and diaphragm
–Bare area anterior to Lt. kidney
Bare area anterior to Lt. kidney
Bare area anterior to Lt. kidney
Bare area anterior to Lt. kidney
•Ovoid
Ovoid
Ovoid
Ovoid in shape
in shape
in shape
in shape
•11
11
11
11 cm in length;
cm in length;
cm in length;
cm in length;
•7 cm in breadth
7 cm in breadth
7 cm in breadth
7 cm in breadth
•4 cm in thickness
4 cm in thickness
4 cm in thickness
4 cm in thickness
•Weighs 150
Weighs 150
Weighs 150
Weighs 150 -
-
-
-200g
200g
200g
200g
–Varies 80
Varies 80
Varies 80
Varies 80-
-
-
-300
300
300
300 gms
gms
gms
gms

18. Indications
•Splenomegaly
•Palpable splenic mass
•Cranial abdominal organomegaly
•Lethargy, collapse
•Anemia, abnormal RBC’s

19. 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

20. Anatomy
•Size of normal spleen variable
–Assessed subjectively
–Enlarged spleen may cross midline or extend caudally
to the bladder
•Parenchyma
–Homogenous, finely textured

21. Spleen
Spleen
Spleen
Spleen
Longitudinal
Lt Kidney
Adrenal
Spleen

22. Splenic Hilium
Splenic Hilium
Splenic Hilium
Splenic Hilium
Longitudinal
Splenic hilum

23. Spleen
Longitudinal
Diaphragm

24. Normal Spleen

25. 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

26. Splenic Hilus

27. Pathology
•Diffuse splenomegaly
–Congestion
–Torsion
–Inflammation/septicemia
–Neoplasia
•Lymphosarcoma
•Mast cell tumor
–Phenothiazine tranquilizers & barbiturate anaesthetics
–Extramedullary hematopoesis

28. Pathology
•Focal or multifocal splenic lesions
–Hematoma
–Infarcts
–Cysts
–Abscess
–Nodular hyperplasia
–Neoplasia
•Hemangioma
•Hemangiosarcoma

29. 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

30. Non Homogenous

31. Focal/Multifocal Lesions
•More common than diffuse
•Anechoic
–Cysts
•Hematoma/neoplasia
•Hypoechoic
–Neoplasia
–Abscess
–Acute infarct
–Nodular hyperplasia

32. Focal/Multifocal Lesions
•Hyperechoic
–Neoplasia
–Abscess
–Chronic infarct
–Nodular hyperplasia
•Mixed echogenicity
–Neoplasia
–Hematoma
–Abscess
–Nodular hyperplasia

33. Splenic Mass

34. Splenic Mass

35. Splenic Infarct

36. 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

37. Torsion

38. Neoplasia
•Lymphosarcoma
–Diffuse or focal/multifocal
–Hypoechoic or hyperechoic
–Can appear normal
•Hematoma, hemangioma, hemangiosarcoma
–Unable to differentiate
–Focal
–Hypoechoic, hyperechoic or mixed

39. Lymphosarcoma

40. Hemangiosarcoma

41. 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)

42. 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

43. Definitive Diagnosis
•Ultrasonic appearance of most splenic diseases
non-specific
•Consider history, signalment, clinical signs
•Fine needle aspirate useful
•Biopsy generally not performed

44. Rupture
•Free fluid within the abdomen
–Often echoic (due to ↑ blood cells)
–May be anechoic
•Most likely a tumor
•Cannot rule out hematoma

45. Thrombosis

46. Splenic Thrombus

47. Myelolipoma

48. 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

49. 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