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Core Curriculum, The: Ultrasound 1st Edition
© 2001 Lippincott Williams & Wilkins ←↑→ 4 Ultrasound of the Gastrointestinal Tract Patients are commonly referred for US examination of the abdomen because of vague and non-specific symptoms such as abdominal pain or abdominal distention. The gastrointestinal (GI) tract is a common site of disease in these patients . Rather than being “between the transducer and what we want to see,” the GI tract is what we want to see. Nonetheless, examination of the GI tract by US is challenging because of obscuring bowel gas and confusing artifacts. Imaging Technique In the setting of acute abdominal pain, US examination should include the GI tract as well as the solid organs of the abdominal cavity. In women, transvaginal US should be added if transabdominal US is not conclusive. Graded compression US is utilized to examine the intestinal tract . The patient is asked to localize the area of maximal pain or tenderness and attention is focused on that area. A linear array 7-to 10-MHz transducer is utilized. In large patients a 5-MHz linear or curved array transducer may be needed. Color Doppler US greatly aids in the detection of inflammation. Anatomy The GI tract has a recognizable “gut signature” that identifies bowel during US examination. Although the wall of the intestinal tract has 5 histologic layers, a 3-layer pattern is usually demonstrated by US (Fig. 4.1). The innermost mucosa and submucosa are seen as a distinct echogenic rind that surrounds the gut lumen. The inner circular and outer longitudinal layers of the muscularis propria produce a central hypoechoic muscle layer on US. The outer adventitia/serosa and surrounding fat produce an outer echogenic layer. Thus the usual gut signature shown by US is two echogenic layers separated by a hypoechoic muscle layer that define the wall of the GI tract. The lumen of the gut may contain fluid, food, stool, and air in varying combinations at different locations. Portions of the GI tract are identified by location, appearance, peristaltic activity, and luminal contents.
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Figure 4.1 Normal Gut Signature. The normal bowel usually has a 3-layer appearance with an echogenic inner layer of m Contents of the gut lumen are variable in appearance. A. The gastric antrum (arrow) is commonly visualized as it crosses and shows echogenic mucosal folds (long arrow). The distended bowel has a thinner hypoechoic muscle zone (short arrow P.154 The stomach is a large sac in the left upper quadrant and epigastrium. It commonly contains fluid and air and, if the patient has recently eaten, food. The antrum extends across the pancreas to the duodenum. The duodenal bulb is commonly just inferior to the gallbladder. The third portion of the duodenum is the only portion of the GI tract that extends posterior to the superior mesenteric artery (SMA) and vein (SMV). The jejunum and ileum occupy the central abdomen. The jejunum is identified by its regular folds, the valvulae conniventes, that produce a “keyboard” pattern seen when fluid is in the lumen (Fig. 4.2). The ileum lacks folds and has a flat featureless wall pattern. The normal appendix is a narrow tube approximately 10 cm in length (Fig. 4.3). It arises from the tip of the cecum approximately 3 cm below the ileocecal valve. The base of the appendix has a constant relationship to the tip of the cecum, but the remainder of the appendix is free and variably located. It may be behind or below the cecum, behind or in front of the distal ileum, in the pelvis, or occasionally in the left side of the abdomen. The great variability in location influences the clinical presentation of acute appendicitis.
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Figure 4.2 Typical Keyboard Pattern of Jejunal Folds. A fluid distended loop of jejunum (SB) shows the folds of the valvulae conniventes as a row of echogenic “piano keys” (arrows) extending from its wall.
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com/ebooks/CoreCurriculumTheUltrasoun. A normal appendix (longer arrow) is shown in long axis (A) and short axis (B).3 Normal Appendix..msdlatinamerica. This patient 4 of 38 12/19/2012 7:33 PM . Figure 4..Ultrasound of the Gastrointestinal Tract http://www.
or solid in consistency. A. whereas the ileum and colon are oval or elliptical (Fig.msdlatinamerica.156 In short axis section the appendix is round. Wall Thickening The normal bowel wall is 2-5 mm in thickness depending upon distention (Fig. 4. More precise diagnosis is made by detailed examination 5 of 38 12/19/2012 7:33 PM . Wall thickening is nearly always pathologic but is often a non-specific finding.. the appendix (arrow. Doppler routinely shows little or no signal from the gut wall. Increased signal is highly indicative of the increased vascularity of an acute inflammatory process or a neoplasm [3.com/ebooks/CoreCurriculumTheUltrasoun. In transverse section.4). semi-solid.. between cursors. haustral pattern. Stool commonly contains tiny gas bubbles that produce bright echoes at varying depths. Stool is heterogeneous in echotexture and liquid.1). +) is round and smalle P.155 P.Ultrasound of the Gastrointestinal Tract http://www.4 Ileum versus Appendix. 4. and stool content. Figure 4.4]. The colon is identified by its larger size.
4. reflecting active inflammation . 4. Dilatation of proximal bowel and hyperperistalsis may be evident . focal or diffuse.5.msdlatinamerica. and correlation with clinical findings . Circumferential thickening of the wall of affected bowel >5 mm is indicative of the presence of disease.com/ebooks/CoreCurriculumTheUltrasoun.6). 6 of 38 12/19/2012 7:33 PM . that exceeds 25 mm in thickness is more likely to be malignant. Differential diagnosis of thickening of the wall of the small bowel and colon is listed in Boxes 4. asymmetric wall thickening. Skip areas of normal bowel are seen between affected segments.2 .1 and 4.7). Figure 4. Crohn’s Disease US can demonstrate characteristic features of Crohn’s disease . and may extend intraluminally or be exophytic (Fig. Any wall thickening. Increased blood flow may be demonstrated in areas of wall thickening. Mesenteric lymphadenopathy appears as multiple oval hypoechoic masses.Ultrasound of the Gastrointestinal Tract http://www. Benign wall thickening produces a target or bull’s-eye appearance and is usually uniform and symmetric (Figs... The wall of the gastric antrum (arrow) as seen in short axis view is diffusely and symmetrically thickened by adjacent acute pancreatitis. Masses demonstrate focal. 4.5 Benign Gastric Wall Thickening. The distal ileum is nearly always involved. Strictures show marked thickening of the bowel wall with fixed narrowing of the lumen.
msdlatinamerica.157 Lymphoma of the Gastrointestinal Tract The GI tract is the most common site of extra-nodal involvement by non-Hodgkin’s lymphoma.. cecum.Ultrasound of the Gastrointestinal Tract http://www.com/ebooks/CoreCurriculumTheUltrasoun. Thickening up to 4 cm is common. The wall of the duodenum (arrows) is circumferentially thickened to >10 mm. Most commonly involved sites are the stomach. Figure 4.6 Wall Thickening Caused by Duodenitis. Profound circumferential thickening of the wall is characteristic. Thickening may be nodular and asymmetric. k. P. and remainder of the colon. 7 of 38 12/19/2012 7:33 PM . The stomach (s) is distended with fluid reflecting partial gastric outlet obstruction. small bowel.. right kidney. Peristalsis is characteristically preserved with a notable lack of bowel obstruction despite marked involvement. Enlarged mesenteric and retroperitoneal nodes are common.
Ultrasound of the Gastrointestinal Tract http://www.com/ebooks/CoreCurriculumTheUltrasoun. P.1: Causes of Wall Thickening of the Small Bowel Wall edema Malignancy Postoperative Lymphoma Cirrhosis/ascites Peritoneal carcinomatosis Hypoproteinemia Mesenteric ischemia/infarction Inflammatory bowel disease Thrombosis of mesenteric veins Crohn’s disease Thrombosis of mesenteric arteries Acute ileitis (Yersinia Campylobacter) Small bowel disease/malabsorption Extraintestinal inflammatory conditions Celiac disease Pancreatitis Whipple’s disease Endometriosis Benign intestinal tumors (adenoma. Bowel wall thickening on transabdominal sonography. 8 of 38 12/19/2012 7:33 PM . et al. Strunk H. lipoma) Adapted from Ledermann HP. The wall of the duodenum shows asymmetric thickening (between arrows) of the hypoechoic muscle layer.7 Wall Thickening Caused by Leiomyoma.158 Box 4. Börner N..msdlatinamerica. AJR Am J Roentgenol 2000.174:107–117. Surgical resection confirmed a small leiomyoma.. The lumen (long skinny arrow) is compressed and distorted by the mass. Figure 4.
Ultrasound of the Gastrointestinal Tract http://www. Box 4. Pericolonic inflammation produces poorly defined hypoechoic areas adjacent to the involved bowel. Most present with left lower quadrant pain. Thickening and inflammation of the colonic mesentery are sometimes evident. P. Acute Diverticulitis Acute diverticulitis of the colon is a common cause of acute abdominal pain in older patients. gas. Colitis Pseudomembranous (Clostridium difficile) colitis has become increasingly common in the hospital setting.. Bowel wall thickening on transabdominal sonography. The involved segment of colon shows concentric hypoechoic thickening.com/ebooks/CoreCurriculumTheUltrasoun. Börner N. et al. AJR Am J Roentgenol 2000. fever. Strunk H.174:107–117.. predominantly involving the muscle layer. Intraluminal gas is strikingly absent. causing antibiotic therapy-related diarrhea .msdlatinamerica.2: Causes of Wall Thickening of the Colon Inflammation Diverticulitis Inflammatory bowel disease Crohn’s disease Ulcerative colitis Pseudomembranous colitis Appendicitis Extracolonic inflammatory conditions Endometriosis Malignancy Colon carcinoma Lymphoma Peritoneal carcinomatosis Edema Postoperative Cirrhosis/ascites Hypoproteinemia Ischemia/infarction Ischemic colitis Colon infarction Adapted from Ledermann HP. Pericolonic abscesses are seen as loculated fluid collections containing anechoic or echogenic fluid and. Most patients (64-77%) have accompanying ascites. 9 of 38 12/19/2012 7:33 PM .159 Inflamed diverticuli commonly contain impacted fecaliths or gas and appear as bright echogenic foci with ring-down artifact adjacent to the thickened bowel. Echogenic or hypoechoic linear tracts in the colon wall or extending to bladder. sometimes. Gross edema of the submucosa is reflected in marked thickening and decreased echogenicity of the inner hyperechoic layer of the colon. and leukocytosis [9. Ischemic colitis and other forms of infectious and noninfectious colitis have similar findings .10]. vagina. or other bowel suggests fistulae and sinus tracts. The swollen submucosa may be folded into a gyral pattern.
US is particularly good at demonstrating fluid-filled. A 3-cm colon carcinoma causes a poorly defined. circumferential. hypoechoic. or eccentric thickening of the colon wall may also represent colon cancer (Fig.msdlatinamerica. Bowel Obstruction US may provide evidence of the presence and cause of bowel obstruction . somewhat spiculated mass (between arrows) on US examination. Figure 4.Ultrasound of the Gastrointestinal Tract http://www.. Colon Carcinoma Although US is not the method of choice for colon cancer detection. 4. tumors may be identified unexpectedly in patients presenting with acute or chronic symptoms . US evaluation of adynamic ileus is 10 of 38 12/19/2012 7:33 PM . Intraluminal gas is commonly seen eccentrically located around the tumor. or ill-defined contours (Fig.9).. On US the mass is usually hypoechoic with irregular. dilated bowel loops when the abdomen is gasless and difficult to evaluate on plain film radiography. Gas-filled bowel loops seriously impair US assessment. Colon cancer may present as a bulky mass up to 10 cm or more in size. Colonic obstruction may be evident with colon and small bowel dilatation.8).8 Colon Carcinoma. Segmental. lobulated.com/ebooks/CoreCurriculumTheUltrasoun. 4.
It may be so short that it. Hypertrophic Pyloric Stenosis The differential diagnosis of vomiting in the first two months of infancy includes hypertrophic pyloric stenosis (HPS).9 Colon Carcinoma.. Imaging is performed in the epigastrium along the edge of the liver. and gastroesophageal reflux. The fluid-filled antrum is tracked to the pylorus. excessive feeding must be avoided because overdistention of the stomach displaces the pylorus posteriorly and makes examination more difficult . P.10). malrotation with Ladd’s bands or midgut volvulus. A.msdlatinamerica. This irregular dumbbell-shaped mass (arrow) in the right upper quadrant of the abdomen constricting spiculated mass (arrow) of a colon carcinoma. and observation for peristalsis and fluid movement through the pylorus. This position places fluid in the antropyloric region for optimal visualization. duodenal atresia.Ultrasound of the Gastrointestinal Tract http://www. US is the examination of choice for HPS . The pylorus is carefully evaluated in transverse and longitudinal section for documentation of muscle thickness and length of the pyloric channel. 4. The length of the pyloric channel is short. Barium studies are preferred in the diagnosis of gastroesophageal reflux and confirmation of malrotation. Continuous distention of a loop of bowel with abrupt transition to non-distended bowel is evidence of bowel obstruction.com/ebooks/CoreCurriculumTheUltrasoun. pylorospasm. Normal Pylorus The normal pylorus is significantly more difficult to identify than the abnormally thickened pylorus (Fig. The infant can be fed glucose solution if the stomach is empty. limited because large amounts of gas are usually present in the bowel lumen. However. Figure 4. US may demonstrate a mass or stricture at the site of obstruction. The circular muscle may be so thin that it is difficult to measure. often <10 mm. is difficult to 11 of 38 12/19/2012 7:33 PM .. Muscle thickness <2 mm in transverse plane is unequivocally normal. The US examination is performed with fluid in the stomach and the infant in right posterior oblique position.160 Peristalsis is increased and luminal contents show an ineffective to-and-fro motion. too.
msdlatinamerica.com/ebooks/CoreCurriculumTheUltrasoun. measure. allowing passage of fluid through the pylorus into the duodenum. Peristaltic activity is observed to pass through the antrum and open the pylorus.Ultrasound of the Gastrointestinal Tract http://www.. 12 of 38 12/19/2012 7:33 PM ..
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resulting in gastric outlet obstruction and projectile nonbilious vomiting. Length of the pyloric channel greater than 12 mm is indicative of HPS.11B).10 Normal Pylorus.msdlatinamerica. HPS most often affects infants 2-6 weeks old. Gastric peristalsis through the antrum ends abruptly at the pylorus.162 must be taken to make measurement in true transverse plane to the pylorus. The thickness of the pyloric muscle returns to normal within 2-12 weeks after surgery. the condition presents at birth or as late as 5 months of age. Care P. Anisotropic effect causes increased echogenicity of the muscle band in transverse section at 6 and 12 o’clock positions. 4. The pyloric muscle is thickened and the pyloric channel is elongated (Fig. the abnormal pylorus resembles a bull’s eye with hypoechoic thickened muscle surrounding central echogenic submucosa.. HPS is usually treated surgically with longitudinal pyloromyotomy. A “tit” sign is produced by fluid extending into the contracted pylorus (Fig. Muscle thickness >3 mm is diagnostic of HPS . A “shoulder sign” may be seen as the bulging impression of hypertrophied muscle on the wall of the gastric antrum. On short axis images. In the United States.17]. Rarely.com/ebooks/CoreCurriculumTheUltrasoun. + fluid (f) from the stomach.11). 4.Ultrasound of the Gastrointestinal Tract http://www. Long axis view of the pylorus in another patient shows a short (8 mm) pyloric channe the pylorus.161 Hypertrophic Pyloric Stenosis Hypertrophy of the circular muscle of the pylorus constricts the pyloric channel. Oblique planes falsely increase the apparent muscle thickness . A. Muscle thickness is measured from the echogenic submucosa to the outer edge of the hypoechoic muscle band . Pyloric channel length is measured along the persistently contracted portion of the pylorus . P. Figure 4. The “antral nipple sign” describes the prolapse of folded pyloric mucosa into the fluid-filled antrum .. C. This artifact creates difficulty in muscle measurement [14. Transverse view of the pylorus shows thin (<2 mm) pyloric muscle (between cursors. Boys are affected five times more frequently than girls. No peristalsis or passage of fluid through the pylorus is observed. 14 of 38 12/19/2012 7:33 PM .
P. occasionally.com/ebooks/CoreCurriculumTheUltrasoun.msdlatinamerica.4 mm . The transducer is placed in the epigastrium below the xiphoid to visualize the gastroesophageal junction 15 of 38 12/19/2012 7:33 PM . Gastroesophageal Reflux Gastroesophageal reflux also presents with vomiting in infancy. but US may be utilized .8 mm with mean pyloric channel length of 14. Pylorospasm is treated with watchful waiting or. Longitudinal image of the pylorus in another pat prominent “shoulder sign” produced by the thickened pyloric muscle and a “tit” sign of fluid extending into the contracte Pylorospasm Pylorospasm is a cause of projectile vomiting in infancy and must be considered in the differential diagnosis of HPS. Transverse image of the pylorus shows the characteristic doughnut or bull’s more than 20 minutes of examination time. with antispasmodics .11 Hypertrophic Pyloric Stenosis. US findings of pylorospasm overlaps those of the HPS.163 The major clue to diagnosis of pylorospasm is the variability of the appearance and thickness of pyloric muscle visualized during the US examination . A recent study of 34 patients with pylorospasm reported mean thickness of the muscle wall as 3.. Most authors report the thickness of the muscle wall in pylorospasm is <3 mm.Ultrasound of the Gastrointestinal Tract http://www. These data have not been confirmed. B.. the pylorus never opened. A. Although the pyloric channel may be closed for a large portion of the examination. it is eventually observed to open. Figure 4. Barium esophagram is the diagnostic study of choice.
Both US and CT are used with high accuracy in the diagnosis of acute appendicitis [22. vomiting. Approximately 90% of affected infants present with obstruction in the first month of life.and technique-dependent and is not always possible. gas was seen in the lumen of 86% of normal patients and in only 15% of patients with acute appendicitis . The normal appendix is identified by first finding the cecal tip. It is oriented in the long axis of the body and is larger than adjacent small bowel. 4. When the appendix is air-filled it may be recognized by its proximal interface that is round and of short diameter. inner. tubular structure that arises from the tip of the cecum (Figs. Gas bubbles are usually present in semisolid stool within the cecum. The terminal ileum is medial to and smaller than the cecum (Fig. Fluid is seen refluxing into the distal esophagus from the stomach. CT is usually chosen for imaging diagnosis [21. In cross section. or parasites . In a study of 457 patients. Peak age is 10-30 years. Imaging diagnosis is indicated in any patient in whom the diagnosis is uncertain. Continued secretion of mucus causes luminal dilatation and increased intraluminal pressures causing pain and often progressing to ischemia and perforation. 4. tumors. in obese patients. hyperechoic. When the normal appendix is identified.com/ebooks/CoreCurriculumTheUltrasoun. The appendix may be seen anterior to the iliac vessels or overlying the iliacus muscle. Gas in stool produces a stippled pattern of small echoes at varying depths.164 The normal appendix is a small. Normal Appendix Visualization of the normal appendix is exceptionally operator. Studies indicate visualization of a normal appendix in 10-56% of patients with higher percentages reported in children [23. In men. A narrowed base of the small bowel mesentery predisposes to midgut volvulus..24]. US provides the capacity to offer an alternative diagnosis such as hemorrhagic ovarian cyst in patients who do not have appendicitis. Malrotation Malrotation of the midgut may obstruct the duodenum and result in a vomiting infant. 4.3. it should be examined from cecal junction to bulbous blind-ending tip. 4. The cecum is ellipsoid in shape in all imaging planes. Diagnosis is routinely made by careful clinical examination.msdlatinamerica. foreign bodies. The lumen may be collapsed or it may contain stool or air. occupying the shallow concavity of the iliac bone. Acute Appendicitis 16 of 38 12/19/2012 7:33 PM . However. The appendix has a typical target appearance with hypoechoic outer zone representing the muscularis propria and a thin. US is usually considered the imaging method of choice in children and in women with active menstrual cycles .3. lymph nodes. and in patients with symptoms longer than 2-3 days. Barium upper GI series confirms the malrotation and abnormal position of the ligament of Treitz. The duodenum is obstructed from volvulus or from peritoneal bands (Ladd’s bands) that cross the second or third portion of the duodenum. The stomach and proximal duodenum are dilated and fluid-filled. the appendix is rounder than the nearby ovoid ileum and cecum.23]. The SMV normally is positioned to the right of the SMA. The presence of fever is evidence of perforation.25]. Transverse examination in the epigastrium demonstrates the SMV lying anterior or to the left of the SMA . 4. The normal appendix is less than 6 mm in diameter and is at least partially compressible.4). approximately 20% of patients have an atypical presentation.Ultrasound of the Gastrointestinal Tract http://www.4A). It may contain gas or liquid and routinely demonstrates peristalsis. The appendix does not demonstrate peristalsis. blind-ended. Acute appendicitis most often results from obstruction of the lumen of the appendix by appendicoliths. and distal esophagus. submucosal layer surrounding the usually collapsed lumen (Figs.4). Acute Appendicitis Acute appendicitis is the most common cause of emergency abdominal surgery .. and leukocytosis. Fluid may be anechoic or mixed with gas bubbles . The normal appendix shows little or no flow on color Doppler . P. Gas within the lumen of the appendix is a normal finding. The cecum is usually the most lateral structure in the right lower quadrant. Classic presentation (50-60% of patients) is right lower quadrant abdominal pain with nausea. in older patients (>45 years).
Ultrasound of the Gastrointestinal Tract http://www. especially when the appendix is minimally dilated . 4. Periappendiceal mass with poorly defined borders represents phlegmon or abscess. Untreated appendicitis may result in a chronic walled-off abscess (Fig. 4.166 within the lumen of the appendix or within a periappendiceal inflammatory mass. US diagnosis of acute appendicitis is made when the visualized appendix exceeds 6 mm in diameter and is noncompressible (Fig. 4. Acute appendicitis resolves spontaneously in a small percentage of cases [31. These calculi may obstruct the appendix. 4. and in absence of appendicitis (14% of cases) . Adenopathy is found in association with nonperforating appendicitis (20% of cases).16). Identification of a blind-ended tip confirms an abnormal appendix . but their clinical course usually dictates conservative.17). The presence of an appendicolith in a patient with acute abdominal pain is 90% predictive of acute appendicitis and is associated with a 50% incidence of appendix perforation . They are seen P. Loculated fluid collections are usually abscesses associated with perforated appendicitis. 4. loculated fluid collections may also be seen with nonperforated appendicitis. Appendicitis may be confined to its tip (4-5% of cases) (Fig.13).12) [2.. The US criteria for acute appendicitis apply to acutely symptomatic patients with abdominal pain. 4. Appendicoliths appear as discrete echogenic nodules that cast acoustic shadows. however. the appendix does not exceed 10-12 mm in diameter. These patients have sonographic features of acute appendicitis. The most common tumors of the appendix are carcinoid tumor and adenocarcinoma.com/ebooks/CoreCurriculumTheUltrasoun. Appendicoliths are intestinal concretions that form around some indigestible hard substance in the gut. Measurements of the size of the P. In most cases of acute appendicitis. in some cases the appendix may be greatly enlarged up to 15-20 mm and may be misidentified as small bowel. 17 of 38 12/19/2012 7:33 PM . P. Tumors are an unusual cause of acute appendicitis (Fig.msdlatinamerica. perforating appendicitis (5% of cases). Gas may be present within the inflamed appendix released by gas-forming infection (15% of cases) . Mesenteric lymphadenopathy appears as multiple oval or round nodules isoechoic or hypoechoic to muscle. Gangrenous or perforating appendicitis shows loss of visualization of the echogenic submucosa due to necrosis (Fig. Gas with ring down and acoustic shadowing increases the difficulty of identifying the appendix but is commonly limited to only a portion of the appendix . The normal appendix shows little or no color Doppler signal in its wall.165 appendix are made from outer wall to outer wall. A focal mass or an unusual appearance to the appendix is a clue to diagnosis. Identification of an appendicolith is another criterion for a positive examination (Fig. Appendicoliths are variable in size (5-20 mm) and shape and occasionally are multiple.12).14) with normal appearing more proximal appendix . However.167 Edema of the periappendiceal tissues causes increased prominence of the echogenic surrounding fat (Fig. non-surgical treatment ..15).32]. Hyperemia in the wall of the appendix on color Doppler US is strong evidence of acute appendicitis. 4. Anechoic or hypoechoic fluid is commonly seen in the lumen because the appendix is obstructed .28].
Figure 4...12 Acute Appendicitis.com/ebooks/CoreCurriculumTheUltrasoun. Transverse image reveals an 8-mm diameter. non-compressible appendix (white arrow).Ultrasound of the Gastrointestinal Tract http://www. 18 of 38 12/19/2012 7:33 PM .msdlatinamerica. Also evident is increased prominence of the periappendiceal fat (A open arrow) representing inflammatory change and a hypoechoic periappendiceal mass (black arrow) representing a small contained rupture confirmed at surgery.
An obstructing appendicolith (white arrow..msdlatinamerica.Ultrasound of the Gastrointestinal Tract http://www. between cursors. +) casts an acoustic shadow (S) and obstructs and dilates the appendix (a) resulting in acute appendicitis. 19 of 38 12/19/2012 7:33 PM ..com/ebooks/CoreCurriculumTheUltrasoun.13 Appendicolith. Figure 4.
20 of 38 12/19/2012 7:33 PM . Figure 4.com/ebooks/CoreCurriculumTheUltrasoun...14 Acute Appendicitis Confined to Tip.Ultrasound of the Gastrointestinal Tract http://www.msdlatinamerica. Image in long axis of the appendix shows acute inflammation of the appendiceal tip (black arrow) with adjacent small phlegmon (white arrow).
A. Transverse image of the appendix (A) shows focal loss of visualization of the ech another patient shows long segment loss of visualization of the submucosa (white arrow) and a focal perforation ( 21 of 38 12/19/2012 7:33 PM .Ultrasound of the Gastrointestinal Tract http://www.15 Perforated Appendicitis.msdlatinamerica.. Figure 4..com/ebooks/CoreCurriculumTheUltrasoun.
Figure 4. A mucocele of the appendix may have a similar appearance.msdlatinamerica..Ultrasound of the Gastrointestinal Tract http://www.com/ebooks/CoreCurriculumTheUltrasoun. 22 of 38 12/19/2012 7:33 PM . A fluid-filled mass (f) with a calcified wall (arrow) located in the right lower quadrant was found at surgery to be a chronic appendiceal abscess..16 Chronic Appendiceal Abscess.
Patients may be asymptomatic or present with acute or chronic abdominal pain. It is a rare condition but is easily recognized by US. oblong.17 Adenocarcinoma Causes Acute Appendicitis. usually in the right lower quadrant of the 23 of 38 12/19/2012 7:33 PM . US shows a well-encapsulated.Ultrasound of the Gastrointestinal Tract http://www. Images in the long (A) and short (B) axis of the appendix (A) sh right lower quadrant pain.168 Mucocele of the Appendix Mucocele of the appendix describes a dilated lumen of the appendix caused by chronic obstruction with progressive accumulation of mucus within the lumen. tubular.com/ebooks/CoreCurriculumTheUltrasoun.. Figure 4.. Rupture of a mucocele of the appendix seeds the peritoneal cavity with mucin-producing cells resulting in pseudomyxoma peritonei . cystic mass.msdlatinamerica. A hypoechoic mass (M) obstruc P. The patient is unusually old to present with acute appendicitis.
or ectopic pancreas . polyp. The distal ileum telescopes into the ascending colon. Impairment of arterial supply leads to bowel necrosis. Compression of the entrapped mesentery impairs venous return. ileoileal. especially children older than 3 years. which is encircled by the wall of the intussuscipiens. Intussusception Intussusception occurs when a segment of bowel telescopes into the lumen of an adjacent. Other forms include ileoileocolic.. The intussusceptum has two components. The blood supply of the intussuscipiens is unimpaired and its wall does not become edematous. A thick. especially in children . but is more commonly echogenic with floating particulate matter. It is one of the most common causes of acute abdomen in infancy. inflammatory mass of appendicitis. The lead point may be a Meckel’s diverticulum. The mesentery of the intussusceptum is dragged into the intussusception between the entering limb and the returning limb. outer ring of the mass of the intussusception is formed by the returning limb. Nearly all cases in this age group are idiopathic.169 fat of its mesentery. US has replaced the barium enema as the diagnostic method of first choice. Only the blood supply of the intussusceptum is affected. In approximately 10% of cases in children. 24 of 38 12/19/2012 7:33 PM . US has high sensitivity (98-100%) and specificity (88-100%).18) . an inner entering limb and an outer returning limb.msdlatinamerica. a lead point is responsible for the intussusception. downstream segment of bowel. malignant tumor. enteric duplication cyst.Ultrasound of the Gastrointestinal Tract http://www.com/ebooks/CoreCurriculumTheUltrasoun. abdomen. The receiving loop (the intussuscipiens) contains the folded donor loop (the intussusceptum). enlarged lymph nodes. and offers the advantage of providing an alternate diagnosis when intussusception is not present. Internal fluid may be anechoic. and in nearly all adults. An understanding of the anatomy of intussusception is required to interpret the US findings (Fig. The center of the mass of the intussusception contains the entering limb surrounded by the echogenic P. 4. The wall of the mass is usually thin (<6 mm). Calcification may occur in the wall of the mucocele. Most cases are ileocolic (75-95%). occurring most often between the ages of 6 months and 2 years. hypoechoic. lipoma. and colocolic. The wall of the entering limb is usually of normal thickness. while the wall of the returning limb of the intussusceptum is thickened. The wall of the intussuscipiens is of normal thickness.. resulting in edematous thickening of the bowel wall of the returning limb.
On axial scans the appearance of intussusception changes from the apex to the base of the mass.msdlatinamerica. Figure 4. creating the appearance of a doughnut.19). outer ring surrounds a hypoechoic central mass.20). a thick. Intussusception creates a large abdominal mass (~5 × 3 cm) that is usually easily visualized by US .21). An appearance of three parallel 25 of 38 12/19/2012 7:33 PM .18 Anatomy of Intussusception. In axial plane. Sandwich sign (Fig. Intussusception Scanning the mass of the intussusception in different anatomic planes produces characteristic appearances described with vivid names. longitudinal refers to the long axis of the intussusception mass and axial refers to the short axis of the mass. Crescent in doughnut sign (Fig. 4. Axial scans show a hypoechoic center surrounded by a thick hypoechoic ring (doughnut sign). 4. Doughnut sign (Fig. At the leading edge of the intussusception (the apex).com/ebooks/CoreCurriculumTheUltrasoun. The changing appearance is caused by the progressive increase in volume of enclosed mesentery from apex to base. In the common ileocolic intussusception the mass is subhepatic in location. the arrangement of the entrapped mesentery and the exact plane of section determine the appearance of the intussusception. The central mass varies in appearance with location... At the trailing edge of the mass (the base). creating a crescent in doughnut appearance . The thicker outer ring is made up of the thickened wall of the returning limb of the intussusceptum and the thinner outer wall of the intussuscipiens. Diagram illustrates the anatomy of intussusception in long (left) and short (right) axis. In longitudinal plane. the volume of echogenic trapped mesentery increases. In the descriptions listed. hypoechoic.Ultrasound of the Gastrointestinal Tract http://www. the amount of crescenticshaped. As scan level progresses toward the base. echogenic mesentery is maximal. the amount of mesentery present is minimal. 4.
The intussusception mass may resemble a kidney. particularly if the mass is curved or the plane of imaging is slightly oblique. electrolyte solutions.22). Treatment by enema. which separates the central hypoechoic entering limb from the thickened edematous returning limb of the intussusceptum.24). 26 of 38 12/19/2012 7:33 PM . Enlarged lymph nodes produce focal oval or round hypoechoic masses within the entrapped echogenic mesentery.Ultrasound of the Gastrointestinal Tract http://www. 4.43]. Peritoneal fluid trapped between the serosal layers of the intussuscipiens and the everted limb of the intussusceptum is evidence of ischemia and need for surgical reduction .171 Gas bubbles trapped within the lumen produce hyperechoic dots with ring down or shadowing. has been shown to be effective [35. Rarely. The presence of color signal within the intussusception is a good predictor of reducibility by enema (Fig. The absence of blood flow on Doppler US does not correlate well with the presence of necrosis in the intussusception . 4. P. water-soluble contrast media.msdlatinamerica. The hyperechoic bands represent the P. The absence of color blood flow signal in the intussusception indicates that the chance for non-operative reduction is decreased and that surgical reduction may be needed. or air guided by fluoroscopy or US. Copious feces in the colon may resemble the appearance of intussusception. intussusception will reduce spontaneously . Pseudokidney sign (Fig.. Color flow US is useful in assessing the reducibility of intussusception . hypoechoic bands separated by two parallel hyperechoic bands has been termed the sandwich sign.170 entrapped mesentery. using barium. water. P.172 In older children and adults. 4. The enveloped mesentery produces an echogenic “renal sinus” within the hypoechoic thickened walls of bowel that resemble the “renal parenchyma” . a careful search should be made for a lead-point mass responsible for the intussusception (Fig. Differentiation is made by recognizing that the hypoechoic rim of colon wall surrounding the echogenic feces is thin (<5-6 mm) rather than thick .com/ebooks/CoreCurriculumTheUltrasoun.23)..
. 27 of 38 12/19/2012 7:33 PM .msdlatinamerica.. the mass of the intussusception (arrows) resembles a doughnut.19 Intussusception–Doughnut Sign.Ultrasound of the Gastrointestinal Tract http://www. Figure 4. In short axis view.com/ebooks/CoreCurriculumTheUltrasoun.
.20 Intussusception–Crescent in Doughnut Sign. In short axis view. the amount of trapped mesentery increases as (arrows). A and B..Ultrasound of the Gastrointestinal Tract http://www. as demonstrated in two patients.com/ebooks/CoreCurriculumTheUltrasoun. 28 of 38 12/19/2012 7:33 PM .msdlatinamerica. Figure 4.
.21 Intussusception–Sandwich Sign.msdlatinamerica. Trapped mesentery (arrow) is “sandwiched” between layers of the intussusception in long axis view. Figure 4. 29 of 38 12/19/2012 7:33 PM .com/ebooks/CoreCurriculumTheUltrasoun..Ultrasound of the Gastrointestinal Tract http://www.
Ultrasound of the Gastrointestinal Tract http://www..22 Intussusception–Pseudokidney Sign. 30 of 38 12/19/2012 7:33 PM ..com/ebooks/CoreCurriculumTheUltrasoun. Figure 4. The layers of the intussusception resemble a kidney in this oblique long axis view.msdlatinamerica.
The presence of blood flow is excellent evidence that the intussusception will be successfully reduced by enema (see Color Figure 4. Color Doppler image confirms blood flow within the loops of bowel involved in the intussusception. 31 of 38 12/19/2012 7:33 PM . Figure 4..Ultrasound of the Gastrointestinal Tract http://www.23).23 Intussusception–Potentially Reducible.com/ebooks/CoreCurriculumTheUltrasoun..msdlatinamerica.
well-defined oval or round masses (>5 mm size) in the mesentery in close proximity to mesenteric blood vessels. veins. 4-layer fold of peritoneum between the anterior abdominal wall and the intestinal tract. It extends from the right lower quadrant region of the terminal ileum to the left upper quadrant ligament of Treitz. It is made up of the hepatogastric and hepatoduodenal ligaments and forms a portion of the anterior boundary of the lesser sac. The small bowel mesentery is a fan-shaped structure that connects the jejunum and ileum to the posterior abdominal wall. Pathology revealed a benign mucinous cystadenoma. Disease of the Mesentery and Omentum Masses in the mesentery and omentum are usually easily demonstrated by US examination. its accordion folds suspend approximately 25 feet of small bowel . Mesenteric adenitis mimics acute appendicitis. Enlarged lymph nodes appear as hypoechoic. A colo-colonic intussusception in a 50-year-old woman was induced by this heterogeneous cecal mass (arrow) identified by US. Masses may arise from any component of the mesentery. lymph nodes. Whereas the root of the mesentery is approximately 15 cm in length. Lymphadenopathy Normal mesenteric lymph nodes are less than 5 mm in diameter .Ultrasound of the Gastrointestinal Tract http://www. The greater omentum extends from the greater curvature of the stomach as an apron-like.24 Intussusception Caused by a Leading Mass..msdlatinamerica.. inflammation. and a variable amount of fat. The normal mesentery is approximately 15 mm in thickness .com/ebooks/CoreCurriculumTheUltrasoun. or neoplasm. 32 of 38 12/19/2012 7:33 PM . Figure 4. lymphatic channels. especially in children. solid. The mesentery consists of two layers of peritoneum that encase arteries. Lymphadenopathy may occur with infection. A specific diagnosis can often be made based upon the US findings and clinical evaluation. The greater omentum crosses the transverse colon and descends in front of the viscera. The lesser omentum is a fold of mesentery that extends from the liver to the lesser curvature of the stomach. It is easiest to recognize when ascites is present and bowel loops are suspended in fluid.
msdlatinamerica.Ultrasound of the Gastrointestinal Tract http://www. Desmoids Desmoids are benign. they are locally aggressive and recur after surgical resection in 25-65% of cases.. fibrous neoplasms that arise from the fascial sheath of striated muscle .com/ebooks/CoreCurriculumTheUltrasoun. Confluent adenopathy forms round or cake-like hypoechoic masses that may be well defined and lobulated in contour or ill defined.. bread-like confluent adenopathy (Fig. Mural involvement of small bowel usually extends from its mesenteric border . 4. Desmoid tumors are also classified as aggressive fibromatosis. A mesenteric artery (arrow) is sandwiched between two homogeneous hypoechoic masses of lymphoma (l) (see Color Figure 4. Desmoid tumors are found in association with Gardner’s syndrome or as isolated lesions . 33 of 38 12/19/2012 7:33 PM . P. dense.25) . Although benign.173 Lymphoma Non-Hodgkin’s lymphoma more commonly involves the mesentery. Encasement of mesenteric vessels produces a “sandwich sign” of blood vessels between two layers of flattened.25 Sandwich Sign of Mesenteric Lymphoma. Figure 4.25). Lymphoma in the mesentery may appear as discrete enlarged lymph nodes. Retroperitoneal adenopathy is usually also present.
Lymphangiomas are congenital lesions produced by failure of lymphatic tissue to communicate with lymphatic drainage channels. Internal fluid may be anechoic. Mesenteric involvement appears as an ill-defined.26 Omental Cyst. Appearance varies from homogeneous and hypoechoic to heterogeneous and echogenic.Ultrasound of the Gastrointestinal Tract http://www. thin-walled cysts (Fig.. Lesions tend to progressively enlarge over time. hypoechoic. Figure 4. Desmoids appear as well-defined solid masses. Metastases to the mesentery are present in 40-80% of cases.174 Lymphangiomas appear as large.. P. A thin-walled. Echogenicity varies with cellular composition as well as inclusion of fat and blood vessels within the mass.26) that are usually multiloculated . unilocular. 4. 10-cm cyst (between cursors. or may contain internal echoes dispersed evenly through the fluid or 34 of 38 12/19/2012 7:33 PM . +) moved freely with the omentum within the peritoneal cavity. Mesenteric/Omental Cyst The most common cyst of the mesentery or omentum is a lymphangioma . retractile mass with stellate margins.msdlatinamerica.com/ebooks/CoreCurriculumTheUltrasoun. Mesenteric Carcinoid Tumor Carcinoid tumor is the most common malignant tumor of the jejunum and ileum.
Pancreatic Fluid Collections Pancreatitis-associated fluid collections commonly dissect into the small bowel mesentery and may extend into the omentum. The internal echoes are indicative of prior hemorrhage that was confirmed at pathological examination.. A large cystic lymphangioma (MASS) arising in the small bowel mesentery of 2-year-old boy presented as an abdominal mass. US shows an anechoic cyst with a multilayered thick wall similar in appearance to bowel wall . Cysts in the omentum are located adjacent to the anterior abdominal wall and displace bowel posteriorly.com/ebooks/CoreCurriculumTheUltrasoun. 35 of 38 12/19/2012 7:33 PM . Partial small bowel obstruction may be present. layering with fluid-fluid levels.msdlatinamerica. Most are unilocular. although some contain a few thin septations.Ultrasound of the Gastrointestinal Tract http://www. 4. internal debris. Cysts in the mesentery are seen between loops of bowel. Enteric cysts have thin smooth walls and contain anechoic serous fluid .. Internal echoes represent hemorrhage. Enteric Duplication Cyst The wall of an enteric duplication cyst contains all the elements of normal bowel wall. or fatty material (Fig.27).27 Cystic Lymphangioma. US reveals a cystic mass with internal echoes. Figure 4.175 Enteric Cysts Enteric cysts are lined by GI mucosa but lack the smooth muscle component in the wall that characterizes enteric duplication cysts . P.
. Radiology 1991.14:283-287. Stansberry S. AJR Am J Roentgenol 1999. Blumhagen J. Ahmadjian J.13:473-478. Rutgers P. J Clin Ultrasound 1990. Jeffrey RJ. 16. Fenton L. Sells L. 11.17:661-666. AJR Am J Roentgenol 1996. Ledermann H. AJR Am J Roentgenol 2000. Puylaert J. et al. Swischuk L. Ambrosino M. et al. Radiographics 1989. 8. AJR Am J Roentgenol 1988. Sonography of hypertrophic pyloric stenosis: frequency and cause of nonuniform echogenicity of the thickened pyloric muscle. Börner N. AJR Am J Roentgenol 1990. Taylor G. 7. et al. Radiology 1986.172:513-516. J Ultrasound Med 1995. Verbanck J. Ko Y. J Ultrasound Med 1994. Strunk H. Cohen H.317:666-669. Radiology 1994. Can sonography diagnose acute colonic diverticulitis in patients with acute intestinal inflammation? A prospective study. Lim J. Hayden CJ.msdlatinamerica. 19. Bret P. 15. Lim J. Internal contents are echogenic with floating debris and usually fluid-fluid levels. Mesenteric adenitis and acute terminal ileitis: US evaluation using graded compression.9:437-447. Dinauer P.150:1367-1370. Calcifications are common and produce focal echogenicities with acoustic shadowing. 2. Carrico C. Hernanz-Schulman M. et al. A prospective study of ultrasonography in the diagnosis of appendicitis. The value of sonography in the diagnosis of acute diverticulitis of the colon. 9. Quillin S. Bowel wall thickening on transabdominal sonography. Kleinman P. et al.174:107-117. Colorectal cancer: sonographic findings. J Ultrasound Med 1998. 5. Ultrasonography of pylorospasm: findings may simulate hypertrophic pyloric stenosis. Krauter D. Lambrecht S. Westra S. Sonographic pitfalls in imaging of the antropyloric region in infants. et al.176 12. P. References 1. 4. Downey D. et al. 13. Truong M.167:45-47.161:691-695. Wolf B. Cystic teratomas contain multiple tissue types that produce cystic and solid components. Staalman C. Fluid collections in the mesentery are found in association with findings of acute pancreatitis and fluid collections elsewhere in the abdomen. et al. Sonographic diagnosis of hypertrophic pyloric stenosis. 36 of 38 12/19/2012 7:33 PM . Zinn H.17:705-711. Spevak M. 6. AJR Am J Roentgenol 1992. AJR Am J Roentgenol 1998. Hypertrophic pyloric stenosis in the infant without a palpable olive: accuracy of sonographic diagnosis. Toi A. Debatin J. 14. Atri M. Lalisang R. J Clin Ultrasound 1989. The mesentery and omentum are uncommon locations. Ultrasound diagnosis of gastroesophageal reflux and hiatal hernia in infants and young children.Ultrasound of the Gastrointestinal Tract http://www. 180:61-64. Ambrosino M. Hernanz-Schulman M. Puylaert J. Wilson S. Sonographic appearance of benign and malignant conditions of the colon. Pseudocysts Pseudocysts are cystic masses with a thick fibrous wall that lacks a cellular lining .18:477-485. Wilson S. 3. Maclin L. Cystic areas are usually anechoic. 18.13:751-756.. They result from incomplete resolution of a mesenteric or omental abscess or hematoma and contain hemorrhagic or purulent debris.com/ebooks/CoreCurriculumTheUltrasoun. Sommer F. 10. 17. Gastrointestinal inflammation in children: color Doppler ultrasonography. Pseudocysts are thick walled and usually septated . Haller J. Pseudomembranous colitis: sonographic features. Impact of sonography on the diagnosis and treatment of acute lower abdominal pain in children and young adults. N Engl J Med 1987. Determining the site and causes of colonic obstruction with sonography.193:771-776. Lee et al.158:129-132. The antral nipple sign of pyloric mucosal prolapse: endoscopic correlation of a new sonographic observation in patients with pyloric stenosis.170:1451-1455. et al.163:1113-1117. et al. J Ultrasound Med 1994. Rutgeerts L. AJR Am J Roentgenol 1994. Color Doppler sonography of focal gastrointestinal lesions: initial clinical experience. Benign Cystic Teratoma Cystic teratomas are usually discovered in children.154:1199-1202. Siegel M.
Diagnosis of acute appendicitis in children: spectrum of sonographic findings.1:1-10. Intussusception in children: current concepts in diagnosis and enema reduction. Sonographic diagnosis of intestinal malrotation in infants: importance of relative positions of the superior mesenteric vein and artery. Swischuk L. AJR Am J Roentgenol 1994.192:269-271. Solbiati L. Birnbaum B. Radiology 1998. Radiology 2000. 31. Bae S. Radiology 1996. Lim H. del-Pozo G. 23.31:315-317. Bubbles in the belly: imaging of cystic mesenteric or omental masses. Mindelzun R.199:688-692. Lee W. High-resolution sonography of acute appendicitis. 43. Spontaneous isolated mesenteric fibromatosis.200:799-801. Sonographic diagnosis of acute appendicitis: interpretive pitfalls. Radiology 1992. et al.19:299-319. et al. Lin S. 34.190:31-35. Spontaneously resolving acute appendicitis: clinical and sonographic documentation. 201:221-225. John S. Radiologist 1994. Hollerweger A. Brant WE. J Ultrasound Med 1997. 197:493-496. 37 of 38 12/19/2012 7:33 PM . Balthazar E. Intussusception: ability of fluoroscopic images obtained during air enemas to depict lead points and other abnormalities. Ros PR. Rioux M. Desai RK. 25. Sonographic detection of the normal and abnormal appendix. Port R. Maher J.163:593-604. et al. 45.177 41.164:649-652. Stoupis C. 32.162:55-59. Verschelden P. Abbitt PL. Lee K. Gonzalez-Spinola J. Acute appendicitis: a practical approach. Rettenbacher T. 40. 24. Gomez-Anson B. Tejedor D.214:183-187.206:595-598. 30. P. Filiatrault D. Jeffrey RB.184:741-744. et al. 42. Radiographics 1994. 27. Nghiem HV. Lim H. Miller S. Radiology 1995. Radiology 1994. Migraine S. Dautenhahn L. White E. Albillos J. et al. Radiology 1987. Meyers M. Kim T. Atri M. 29. Radiology 1996. Tejedor D. Wong H. Gore R. Bret P. Cobben L. 21. Abdominal desmoids: CT findings in 25 patients. Radiology 1996. AJR Am J Roentgenol 1992. Puylaert J.159:69-72. 28.16:141-144.211:395-397.201:379-383. Kong M. Yee J. Forte MD. Normal anatomy and pathologic changes of the small bowel mesentery: US appearance.161:147-152. 36. 37. Oliphant M. 22. van Otterloo A. Madwed D.158:773-778. Appendicitis at the millennium. The peritoneal ligaments and mesenteries: pathways of intraabdominal spread of disease. Radiology 2000. et al. Jeffrey RB. Assessment of reducibility of ileocolic intussusception in children: usefulness of color Doppler sonography.191:781-785. The pseudokidney sign. Birnbaum B. et al. Swischuk P. Radiographics 1999. Radiology 2000. et al.215:337-348. Diseases Colon Rectum 1988. Acute appendicitis: CT and US correlation in 100 patients. Radiology 1999. Lim H. Macheiner P. Garel L. Abu-Yousef M. Rizzato G. 38.157:275-279. et al.14:729-737. Presence or absence of gas in the appendix: additional criteria to rule out or confirm appendicitis–evaluation with US. Landes A.149:53-58. Intussusception: trapped peritoneal fluid detected with US–relationship to reducibility and ischemia. Lee W. Radiology 1996. AJR Am J Roentgenol 1993. Intussusception in children: reliability of US in diagnosis. AJR Am J Roentgenol 1992. et al. Jain KA. Radiology 1987. Anderson D. et al.205:55-58. Albillos J. Factors related to detection of blood flow by color Doppler ultrasonography in intussusception. Winters W. Intussusception: US findings with pathologic correlation–the crescentin-doughnut sign. Spontaneous reduction of intussusception: verification with US. Appendicitis: usefulness of color Doppler US. 20. del-Pozo G. Tagliabue JR. Radiology 1994. 39. Intussusception: even Hippocrates did not standardize his technique of enema reduction. et al.. Focal appendicitis confined to the tip: diagnosis at US. 47. AJR Am J Roentgenol 1991. et al. Weinberger E. Sivit C.Ultrasound of the Gastrointestinal Tract http://www. Radiology 1994. 44. et al.. Mucocele of the appendix: imaging findings. AJR Am J Roentgenol 1987. Spontaneously resolving appendicitis: frequency and natural history in 60 patients.215:349-352. 46. et al. Radiology 1997. Derchi L. Lee S. 33. Eistein DM. et al. 35.com/ebooks/CoreCurriculumTheUltrasoun. Jr. Bleichen J. 26. McAlister W. Berne A.159:825-828. Jr. del-Pozo G. et al.msdlatinamerica. 48. AJR Am J Roentgenol 1992. Wilson S. Liddell R.
. Moser RJ. Olmstead W..164:327-332. Ros P.msdlatinamerica. et al. ←↑→ 38 of 38 12/19/2012 7:33 PM . Mesenteric and omental cysts: histologic classification with imaging correlation.Ultrasound of the Gastrointestinal Tract http://www. 49. Radiology 1987.com/ebooks/CoreCurriculumTheUltrasoun.
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