Morrison's space in the abdominal cavity. Surgical anatomy of the liver and biliary tract. Surgical anatomy of the liver and biliary tract

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The hepatic mass fills the right dome of the diaphragm and extends to the left of the body midline below the heart (Fig. 1 A). The most typical shape of the anterior surface of the liver, namely its decreasing volume to the left of the falciform ligament, is very convenient for laparoscopic access to extrahepatic biliary structures. The apex of the lateral segment of the left lobe of the liver may have the form of a fibrous continuation, which is an embryonic remnant (Fig. 1 B). Less common is enlargement of the right lobe of the liver downwards, which may cause additional difficulties (Fig. 1 B). The edge of the liver is directed from above to the left and below to the right, leaving part of the anterior wall of the stomach and pylorus open on the left and the proximal part of the transverse colon on the right. The tip of an unchanged gallbladder may protrude between the colon and the lower edge of the liver.

When studying the anatomy of the liver in three projections, one must always correlate it with the anatomy of neighboring organs. The relationship between the liver and the diaphragm is determined by the commonality of their embryonic origin - the transverse septum (Fig. 2 A). The areas of the liver not covered by peritoneum are the result of the transition of the parietal peritoneum from the lower surface of the diaphragm to the liver. This feature of the distribution of the peritoneum forms a diamond-shaped crown above the liver, called the coronary ligament.

The border of attachment of the “ligaments” is located on the upper surface of the liver far above and posteriorly, forming a deep suprahepatic pocket on the right. In the center of this area is the confluence of the inferior vena cava with the main hepatic veins. Anteriorly, the coronary ligament passes into the falciform ligament, the head portion of the ventral mesentery. Along the edges, left and right, the anterior and posterior surfaces of the coronary ligament come together at an acute angle and form triangular ligaments.

When the surgeon transects the left triangular ligament to mobilize the lateral segment of the left lobe of the liver, he must be aware of the proximity of the hepatic veins and the inferior vena cava. Access to these vessels, if damaged, will be extremely difficult due to their deep localization. Small veins running from the posterior surface of the liver directly to the inferior vena cava reflect the peculiarity of the evolutionary development of the vena cava from the dorsal part of the venous plexus of the liver. Note the location of the inferior left phrenic vein, which passes along the anterior semicircle of the esophageal opening of the diaphragm. This is a very common anatomy variant.

The organs of the upper floor of the abdominal cavity, when viewed on a CT scan slice, are located in the shape of a kidney or bean (Figure 2 B). The spine and large vessels fill the cavity, and the organs themselves are located posteriorly and to the sides, in the diaphragmatic recesses. The most posterior position is occupied by the kidneys.

In a sagittal section (Fig. 3), the abdominal cavity has a wedge shape due to the slope of the lumbar spine and adjacent lumbar muscles. The hepatorenal volvulus (Morrison's pouch) is the outermost space of the abdominal cavity. To the right and behind, the lower surface of the liver goes around the kidney with perinephric fiber, and in front of it is the hepatic angle of the colon.

A sagittal section of the right upper quadrant of the abdominal cavity (Fig. 4) shows that the inferior vena cava is located in the center of the abdominal cavity, and immediately in front of it is the hepatoduodenal ligament with the portal vein. On a frontal cholangiogram, the common bile duct usually runs along the right edge of the lumbar vertebrae. To view small details without overlapping images of underlying structures, the patient should be turned slightly to the right (Fig. 5).

If the liver is elevated, the hepatogastric omentum becomes visible, another derivative of the ventral mesentery, which extends from the lesser curvature of the stomach to the groove of the venous ligament and the porta hepatis (Fig. 6). The free edge of the omentum surrounds the bile ducts and forms the hepatoduodenal ligament. The place of contact between the anterior surface of the fundus of the stomach and the lower surface of the lateral segment of the left lobe of the liver is also visible. The initial section of the duodenum, previously closed by the edge of the liver, is visible, and the relative position of the intestine and the lower surface of the quadrate lobe, as well as the gallbladder, is visible. And finally, on the right, the relative position of the hepatic angle of the colon, the right lobe of the liver and the gallbladder is open.

When the stomach and duodenum are retracted, the root of the mesentery of the transverse colon and the boundaries of the omental bursa behind the lesser omentum become visible (Fig. 7). In the upper part of the bursa, the caudate lobe of the liver is visible, which is usually of considerable size. The fold of peritoneum between the liver and pancreas has the appearance of a ridge formed by the hepatic artery, passing through the retroperitoneal space of the omental bursa and turning into the hepatoduodenal ligament.

When the posterior layer of the parietal peritoneum is spread apart, the anatomical structures of the porta hepatis and their relationship with the pancreas are exposed (Fig. 8). The trunk of the celiac artery is usually divided into three branches, giving rise to the left gastric artery, hepatic and splenic arteries.

And let’s complete the review of the organs of the upper abdominal cavity with a rear view (Fig. 9). The right lobe of the liver extends posteriorly over the superior pole of the right kidney, so that the right adrenal gland is enclosed between the kidney, liver, and inferior vena cava. The inferior vena cava, for a greater or lesser extent, is located in the fossa separating the right and left lobes of the liver. To the left of the vena cava lies the caudate lobe of the liver.

The gastrohepatic omentum extends from the lesser curvature of the stomach to the hilum of the spleen and the groove of the venous ligament. The esophagus is located immediately to the left of the quadrate lobe, between the lower thoracic aorta posteriorly (behind the crura of the diaphragm) and the lateral segment of the left lobe of the liver anteriorly. The cone-shaped edge of the left lobe protrudes above the cardia of the stomach, reaching the anterior border of the spleen. The fourth section of the duodenum goes obliquely upward between the body of the pancreas in front (removed) and the aorta (removed) behind.

On the lower surface of the liver there is a deep central transverse groove formed by its gate (Fig. 10). The common bile duct, hepatic artery and portal vein - the main anatomical structures of the portal - are adjacent to the right side of the groove, and their branches go to the left side, located for a considerable distance outside the hepatic tissue. The plane drawn along the gall bladder bed and the inferior vena cava mainly separates the left and right lobes of the liver (the caudate lobe extends on both sides).

Near the end of the portal groove on the left side, the round ligament of the liver (a remnant of the umbilical vein) passes through a small depression. The extrahepatic portion of the round ligament below the umbilical notch lies along the free edge of the falciform ligament. From the left end of the portal, a groove of the venous ligament stretches obliquely posteriorly, which runs from the left branch of the portal vein to the inferior vena cava near the diaphragm. The hepatogastric omentum extends from the same groove, continuing to the porta hepatis and surrounding the main portal structures in the form of the hepatoduodenal ligament.

Between the omentum and the inferior vena cava is the caudate lobe of the liver. The caudate and right lobes are connected by a narrow isthmus - the caudate process, lying between the gate and the vena cava. It is the roof of the omental opening connecting the omental bursa and the abdominal cavity. The anterior edge of this opening is the hepatoduodenal ligament, and the posterior edge is the vena cava. The inferior inversion of the parietal peritoneum onto the liver crosses the inferior vena cava immediately inferior to the liver and partially follows the depression of the right adrenal gland on the inferior surface of the right lobe.

It is important for the laparoscopist surgeon to know the segmental structure of the liver (shown in the oblique caudal plane, Fig. 11). Knowledge of the normal anatomy of the bile ducts (which occurs in 70% of cases) is necessary to recognize possible anomalies, identify ductal branches that are not visualized on cholangiograms (due to damage or obstruction), and be more careful about the anatomical structures adjacent to the gallbladder bed. Each biliary segment contains the bile duct, a branch of the portal vein and a branch of the hepatic artery. The hepatic veins run between the segments.

The right and left lobes of the liver are separated by a plane passing through the gall bladder bed and the fossa of the inferior vena cava, and each lobe is divided into two segments. The median hepatic vein is located at the junction of both lobes. The right lobe is divided by an oblique transverse plane, running correspondingly to the right hepatic vein, into anterior and posterior segments. The left hepatic vein divides the left lobe into medial and lateral segments. Each of these large segments consists of an upper and lower part.

The caudate lobe, located behind the upper part of the medial segment, is in contact to varying degrees with both lobes. The terminal sections of the hepatic artery and portal vein are anastomosed with the initial sections of the hepatic vein at the level of the hepatic lobules. Portal vessels and ducts enter each segment from the side of the centrally located gate. The gallbladder bed is formed by the inferior surfaces of the right anterior and left medial segments, and the ducts and vessels passing through these segments are at risk of damage when cholecystectomies are performed.

The cholangiogram shows the normal structure of the biliary system (Fig. 12 A). The right and left hepatic ducts join at the porta hepatis to form the common bile duct (in 90% of cases outside the liver itself). The right hepatic duct is formed by the fusion of the anterior and posterior segmental ducts, which occurs close (~1 cm) to the junction of the right and left hepatic ducts.

The right anterior segmental duct is shorter and located below the posterior segmental duct. The frontal cholangiogram shows that the bifurcation site of the anterior duct is more medial than the posterior duct. In about a third of individuals, there is a subvesical duct, which passes close to the gallbladder bed and drains into the right anterior duct. Unlike other bile ducts, it is not accompanied by a branch of the portal vein. It is not connected to the gallbladder, but can be damaged during cholecystectomy.

The left lateral superior and inferior ducts usually join at or slightly to the right of the left segmental sulcus. Bile flows into the long and thin superior duct from the apex of the left lobe, which passes into the fibrous process. In a small number of people (= 5%), the bile ducts in this appendage may persist and be a source of bile leakage when the appendage is divided to mobilize the left triangular ligament of the liver.

From the upper and lower parts of the medial segment of the left lobe, bile flows into four small ducts. When the medial and lateral segmental ducts join near the porta hepatis, the left hepatic duct is formed. Bile from the caudate part of the medial segment goes in three directions. From the rightmost section, bile usually flows into the right ductal system, from the leftmost section into the left, and from the intermediate section, with approximately equal frequency, into one of the sides.

There are several options for the location of the bile ducts inside the liver. Typically, the main left and right bile ducts join at the center of the porta hepatis (in 10% of cases, within the hepatic parenchyma). In approximately 22% of individuals, the right posterior segmental duct can cross the interlobar fissure and empty into the left hepatic duct (Fig. 12 B).

In 6% of cases, the right anterior segmental duct passes to the left side (Fig. 12 B). If the right segmental ducts are located separately, they may be damaged during cholecystectomy. It is more correct to call these ducts aberrant than accessory, since they collect bile from normal areas of the liver, and are not some kind of additional ones. On the left side, in a quarter of cases, the duct of the medial segment flows into the lower branch of the duct of the lateral segment (Fig. 12 D).

Of the peripheral ducts, the right posterior superior duct has the most consistent location. The remaining subsegmental ducts in 22% of cases have alternative drainage options.

The course of the portal vein trunks when viewed from below corresponds to the segmental structure of the liver (Fig. 13). The portal vein divides outside the liver, near the right side of the portal, and the longer left trunk crosses the portal groove. The right trunk runs close posterior to the infundibular portion of the gallbladder and is most often damaged at this location. The right trunk of the portal vein usually divides into anterior and posterior branches, going to the two main segments of the right lobe in an anterosuperior and posteroinferior direction, respectively. Sometimes this division occurs at the site of the main bifurcation of the portal vein, which thus becomes a trifurcation. During cholecystectomy, the right trunk of the portal vein may be damaged near the porta hepatis.

The left trunk of the portal vein bends anteriorly and enters the liver parenchyma in the region of the groove of the round ligament. It then divides into two branches leading to the medial and lateral segments of the left lobe. Each segmental branch feeds the upper and lower sections of its segment. Proximal branches from the main right and left trunks of the portal vein extend to the caudate lobe. Some venous outflow from the gallbladder goes into the right portal trunk, but the main amount of blood flows directly into the hepatic bed of the gallbladder.

Wind G.J.
Applied laparoscopic anatomy: abdominal cavity and pelvis

Sergodeev I.V.

Applicant,

Chelyabinsk State University

MYTHOPOEIC SPACE OF JAMES DOUGLAS MORRISON (INTEXTUAL AND HYPERTEXTUAL RELATIONS)

annotation

The article examines the features of the implementation of the category of intertextuality in the mythopoetic space of J. Morrison. Two types of intertextuality are considered: intellectuality and hypertextuality. Some archetypes of J. Morrison's works are analyzed.

Keywords: myth, intextuality, hypertextuality.

Sergodeev I. V.

Chelyabinsk State University

MYTHOPOETIC SPACE OF JAMES DOUGLAS MORRISON (INTEXTUAL AND HYPERTEXTUAL LINKS)

Abstract

The article considers special aspects of intertextual category implementation in J. Morrison’s mythopoetic space. Two types of intertextuality are under consideration: intextuality and hypertextuality. Some archetypes of J. Morrison’s works are analyzed.

Keywords: myth, intextuality, hypertextuality.

Myth allows a person to look at himself not as a product of history, but as a product of mythical events that occurred outside of time. Myth also presupposes the existence of a primitive experience or, in other words, a return “to origins.” This attitude is inherent in the American poet J. Morrison. All of his work is imbued with images of death and disasters, which correlate with the plots of eschatological myths. J. Morrison's mythopoetics turns to the world of the author's thoughts and feelings, and at the same time immediately to a whole layer of world mythology, which creates some difficulties in the perception of his text.

The category of intertextuality is the text category that will facilitate the perception of the author’s poetic text and allow us to organize J. Morrison’s mythopoetic space into something whole. Speaking about the category of intertextuality, we will rely on the classification of various types of intertextual relations in postmodern literature developed by N. S. Olizko. According to this classification, the typology of intertextuality is constructed in two planes: horizontal (hypertextuality, metatextuality) and vertical (architetextuality, intextuality).

For a more complete understanding of J. Morrison’s mythopoetics, it is necessary to turn to the primary sources, that is, to myths. To do this, we will analyze the means of expressing intextuality in the mythopoetic space of J. Morrison. "Intextuality represents textual inclusions that introduce information into a given text about various precedent phenomena and reflect the “quotation nature of postmodern thinking” - the saturation of the works of postmodernism with various kinds of reminiscences.”

Ride the snake, ride the snake

To the lake, the ancient lake, baby

The snake is long, seven miles

Ride the snake…he’s old, and his skin is cold… (The End)

Intextuality in this passage is realized through references to mythological precedent phenomena, which are embodied in specific allusions: in the poetry of J. Morrison, the image of a Serpent or a Lizard often appears. This is an allusion to Native American mythology, specifically the Navajo "Snake Song":

He's coming to us

He's coming to us

His body is white

He's coming to us

With a black stripe

It is known that the poet is interested in Indian culture and mythology, reads a lot of literature, and spends a lot of time in the desert with the Indians. However, in the texts of J. Morrison there is no fully formed complex of mythology of Indian tribes, since the mythology of each individual tribe often differs from the mythology of any other. Different tribes have different cult images and clan totems, among which there is not always a place for the Snake, which plays an important role in the poet’s work. Consequently, the Serpent is not entirely an allusion to Indian mythology, but has more ancient roots. According to A. Golan, the appearance of the image of the Morrison Serpent refers to Neolithic mythology and the Nostratic proto-language. J. Morrison collects mythologies of various cults that go back to early agricultural culture, and combines them into the Serpent, and later into the Lizard: “I’ve always liked reptiles. I used to see the universe as a mammoth snake…” (Jim Morrison) In Neolithic mythology, the image of the snake is the source of evil, the image of the black god, the god of the underworld, the god of the earth, the god of thunder. In Egyptian mythology, the god of the underworld is called Serapis, in the Jewish tradition the word seraph (serpent) means “to burn, burn”; in Hittite rituals there is a moment of worship of the mountain, the home of the fiery serpent; in Indian mythology, Indra kills the dragon located on the mountain; in Slavic mythology, there is the serpent Gorynych, who lives on the mountain; in the American tradition, to which J. Morrison belongs, the serpent lives in a hole, that is, in the context of mythology, in the underworld.

Well, I'm the Crawlin' King Snake

And I rule my den (Crawling King Snake, folk song, 1920s)

The primitive idea gives the Serpent the functions of destroyer and creator, and the underworld is located both underground and in heaven. The ring into which the serpent is coiled symbolizes the cyclical life-death cycle. In the mythopoetic space of J. Morrison, this plays a very important role. The shaman, through the initiation rite, enters a trance, “dies” and acquires a new quality. J. Morrison tries to do the same in his work: “Why the desire for death. Desire for Perfect Life.” (Jim Morrison)

Ride the snake, ride the snake

To the lake, the ancient lake, baby (The End)

The image of water is also one of the central images of the poet. In mythology, water is associated with both death and life: beyond the sea there is an other world and life arises from water. “There is an internal conditionality of such descriptions, which indicates a connection with archetypes; the meeting of sea and land can be considered as an important experience of experiencing the border, the threshold between the infinite and the finite.”

Let's swim to the moon

Let's climb to the tide

Penetrate the evening that the

City sleeps to hide (Moonlight Drive)

In mythology, the image of the moon can act as a symbol of the world of the dead and as one of the forms of the black god or Morrison's Serpent. The poet wants to cross the sea to join it. Thus, J. Morrison “dies” in order to be transformed. The poet's work is eschatological in nature: it is not death itself that is important, but absolute repetition, which leads to cosmogony. “The cosmogonic myth can be reproduced on the occasion of death, because this is a new situation that can be correctly perceived in order to make it creative.”

This statement can be proven through intertextual relations, namely through hypertextuality. “Hypertextuality is a type of intertextuality that allows us to consider each work of an individual author, on the one hand, as a link in one narrative chain, and on the other, as a hypertext that serves as an effective means of realizing intertextual connections within the work of a particular writer.”

J. Morrison writes a number of poems in which he identifies himself with the ancient god:

I'm a guide to the Labyrinth

Monarch of the protean towers

on this cool stone patio (The Opening of the Trunk)

In this passage, the labyrinth is an image of the change of day and night, subordinate to the black god. In many traditions, the home of the sun is the underworld, which is similar to the underground lake among the Indians and the River Styx, which is also located in the underworld among the Greeks. The sun appears in the sky by the will of the black god, that is, it is a symbol of the Serpent, an integral attribute of which is also a stone. The poet puts together a mosaic of his mythopoetic space and complements the narrative chain traced in his texts by asserting: he is the guide in the Labyrinth, the monarch of the stone palaces. Comparing this passage with the previous ones, hypertextual connections are visible especially clearly - there is a qualitative transition of J. Morrison from a poet who describes the reality surrounding him to a poet who himself is the creator of this reality. This process can be clearly traced in the poetic development of J. Morrison from his early works to his later ones. For a more vivid illustration, let us turn to another poem by J. Morrison, where he directly declares his divine nature:

'I'm the Lizard King

I can do anything..."(Celebration of the Lizard)

Thus, in his mythopoetic space, the poet J. Morrison resorts to primitive experience and “resurrects” ancient myths, the synthesis of which serves as the foundation of his work. He, as it were, creates his own universe and, like a shaman, transforms in it, he himself takes the place of the Creator Serpent, doomed to an endless series of transformations, which is expressed in the endless process of creativity itself.

This article provides an overview of the most common echo signs of tumors and tumor-like formations that can be detected by ultrasound in the liver, as well as differential diagnostic options.

It must be remembered that it is impossible to unequivocally judge the nature of the formation in the liver detected during ultrasound diagnostics. The doctor, during an ultrasound, can detect mainly indirect echo signs that indicate the benignity or malignancy of the existing process. A final, accurate judgment can be formed after a biopsy.

If a formation is detected, a control ultrasound examination should be carried out after 1-1.5 months, then after 3 months, if there is no growth - after 6 months, then once a year.

Benign liver tumors characterized by slow growth and lack of metastasis, some may (rarely) become malignant.

Liver adenoma. It is more common in women, and a single formation is determined with a predominant localization in the right lobe, but with glycogenosis and in patients taking hormonal drugs, it can be represented by several formations. May develop during pregnancy. It can be hepato- and cholangiocellular.

Echo signs: repeats the echo structure of the liver (consists of hepatocytes with a high glycogen content), often homogeneous, but can be moderately heterogeneous; echogenicity may be reduced, isoechoic, or moderately increased; sometimes a thin hypoechoic rim is determined along the periphery, less often a moderately hyperechoic one, the so-called. “pseudocapsule” (atrophy of the surrounding parenchyma with subsequent fibrous changes due to compression by the tumor node), the contours are correspondingly smooth and clear. Adenoma may be avascular (predominantly), or with slightly pronounced intranodular vascularization. It can reach large sizes (10 cm or more), there is a risk of malignancy (approx. 10%). Slow growth dynamics. It is necessary to differentiate with metastasis, focal nodular hyperplasia, malignant hepatoma (verification is possible with an ultrasound-guided biopsy).

Hemangioma . Many experts believe that this is not a tumor, but a vascular anomaly (a malformation of the vascular system). The most common focal pathology of the liver (up to 80-85% according to different authors). In terms of incidence, the ratio of women to men is approx. 5:1. Often located directly next to the hepatic vessels. It can be capillary and cavernous. It is mostly asymptomatic, but when large in size it can compress adjacent structures and organs. In case of injury with a rupture, it results in profuse intra-abdominal bleeding (puncture, especially if located superficially, can also be complicated by bleeding). If the hemangiomas are multiple (hemangiomatosis), then the liver may be enlarged, and upon examination the patient may additionally have intradermal hemangiomas. The size can reach 3-4 cm, occupying a segment, sometimes the entire lobe of the liver. Very rarely malignant.

A ) Capillary hemangioma looks like a hyperechoic formation with a fine-grained homogeneous echo structure, round or ovoid in shape, with a smooth or sometimes finely scalloped contour, with clear boundaries (due to the fibrous capsule), behind or without acoustic effects or slight dorsal pseudo-enhancement. Sometimes you can detect a small, often single area of ​​reduced echogenicity along the periphery, and with CDK a vessel is identified in this place (the so-called vascular “pedicle”, rarely found with hemangioma sizes up to 1.5 cm). Occasionally, heterogeneity of the structure (including due to calcifications) and blurred contour may occur - it is necessary to differentiate with hyperechoic metastasis.

b) Cavernous hemangioma has in its structure small and larger anechoic or hypoechoic vascular cavities with thin walls (can contain both liquid and clotted blood), there may be foci of calcification and hypoechoic areas of hyalinization. Atypical variants may be anechoic with an echopositive peripheral rim.

Hemangiomas are either avascular (capillary, more often) or hypovascular (more often cavernous; monophasic low-amplitude blood flow, which is characteristic of venous blood flow, can be recorded in them).

With fatty hepatosis, the hemangioma may appear hypoechoic, with an unclear contour. It is necessary to differentiate from metastasis.

Focal nodular hyperplasia liver , or focal nodular hyperplasia. An uncommon pathology (approx. 3%) can be found in women who have been taking oral contraceptives for a long time. This is a benign process in the form of an area of ​​regeneration (can be in the form of one node or several) in the absence of changes at the level of liver cells.

There is evidence in the literature of two anatomical variants - focal nodular hyperplasia of the solid type and telangiectatic type (the latter with more pronounced intranodular vascularization). With small sizes it is practically not visualized. According to some authors, it is more often found in segments 5, 6 and 7. It may be located close to the capsule, forming a protrusion of the liver contour. Usually the focus is of moderately reduced echogenicity (with a predominance of regenerative processes), but can be isoechoic or moderately hyperechoic (less often). The echo structure reveals a diffuse, small-focal heterogeneity of the formation, reminiscent of changes in cirrhosis, as well as centrally located hyperechoic scar connective tissue (detection frequency 20-47%), in the form of a stellate structure or like a “wheel with spokes” (repeats the course of the feeding vessels , typically determined by CDK, in the form of a central feeding artery and smaller branches diverging from the center to the periphery, the peripheral resistance index is often reduced due to arteriovenous shunts). The peripheral sections are represented by practically unchanged hepatocellular tissue. The capsule or hyperechoic rim is not identified. Rarely, a moderately hypoechoic rim may be present (better visualized against the background of fatty infiltration). The contours are often smooth, but can be clear or fuzzy. The vascularization of the structure is determined, sometimes with a change in the vascular pattern (see above). The shape is both irregular, oblong and round. Verification - puncture biopsy (but may be accompanied by bleeding, as with hemangioma). With prolonged growth it can reach large sizes (up to 20 cm). It is necessary to differentiate with a neoplasm of a malignant nature, Riedel's lobe (a protruding area of ​​unchanged parenchyma of the right lobe).

Leiomyoma And fibroma - I did not find echo signs characteristic of localization in the liver parenchyma in the literature.

Histiocytosis - the appearance in the liver parenchyma of small (10-12 mm) irregularly shaped foci with uneven and unclear contours. It can occur against the background of leptospirosis, toxoplasmosis, mononucleosis, cytomegalovirus infection, tuberculosis, typhoid fever, etc. Accompanied by hepatosplenomegaly, enlarged hepatic, mesenteric or retroperitoneal lymph nodes. Upon recovery, the lesions either disappear or fibrosis develops in their place and can calcify.

Liver infarction - an area of ​​parenchyma of moderately reduced echogenicity and irregular shape with “angularity” of contours is determined in any segment of the liver.

Congenital and the majority acquired cysts they look like a round or oval anechoic formation with smooth and clear contours, and also have distal pseudo-enhancement and thin lateral shadows (indirect signs of wall smoothness). Several cysts are regarded as multicystic (in the absence of a family history of polycystic disease). Vascularization in the cavity of simple cysts (without septations) is not detected. If there is a complication in the form of hemorrhage into the wall or cavity, echo-positive inclusions in the cavity are visualized. With malignancy, an area of ​​thickening and unevenness of the cyst wall is determined, sometimes with a loss of clarity of the border (invasion into the liver tissue). Also, along the internal contour, parietal vegetations of irregular shape can be determined, both with and without signs of vascularization. Congenital cysts do not have their own wall, but purchased have. They need to be differentiated from anechoic metastases.

Polycystic liver disease - multiple cysts of both lobes of different sizes with an enlarged liver. According to some authors, these are cysts that occupy 60% of the parenchyma or more, and if up to 30% in one lobe, there may be multicystic disease. Other authors tend to take into account family history - if there is polycystic liver disease in the family history, then before the age of 40 there is one cyst, and after 40 years there is three - polycystic disease. And if there is no family history of polycystic disease, then the presence of 20 or more cysts can be regarded as polycystic disease.

At the 3rd stage, the cystic formation becomes heterogeneous due to septations (formation of daughter cysts), and may have the appearance of a “honeycomb”.

Subsequently, a focus of calcification with an acoustic shadow remains in the liver; the liquid component is either absent or slightly expressed, in the form of a “sickle”.

Alveolar echinococcus - less common. In type 1, these are hyperechoic foci with an uneven contour, with a tendency to infiltrate into the surrounding tissue. The structure of the outbreak may have the appearance of a “blizzard” or a mesh.

In type 2, as a result of partial necrosis, hypoechoic areas with a vague contour appear; along the periphery there may be a hypoechoic belt (in this case, a zone of peripheral vascularization).

Type 3 has the appearance of a cyst.

Liver abscess- a bacterial process, in most cases as a manifestation of obstruction of the intrahepatic bile ducts. It can occur as a result of abdominal infection (for example, amebiasis), spread of the infectious process to the parenchyma from distant foci, as well as suppuration of a pre-existing formation - cyst, hematoma, tumor disintegration. It can be single and multiple, acute and chronic.

IN infiltrative stage in the liver, an inconspicuous hypoechoic homogeneous area with unclear boundaries appears and may have an irregular shape. At this stage, reverse development is possible and after a few days no changes are detected.

With partial purulent melting tissue, more often a hypo-anechoic zone appears centrally with an uneven contour and with multiple randomly located areas of lower echogenicity, or with anechoic content, or with heterogeneous hyperechoic content.

In progress complete meltdown An anechoic formation with distal pseudo-enhancement is determined, with a thin, up to several millimeters, hypoechoic belt around (a zone of reactive inflammation that delimits altered and healthy tissue).

If the pus in the abscess is thick, then the formation has a heterogeneous structure of medium or increased echogenicity and with unclear contours (difficult to distinguish from a tumor).

If the contents have vertical artifacts like reverberation, then these are from gas bubbles during anaerobic infection; they are located in the upper part and move when the position of the body changes. The contents can be stratified into an anechoic part and an echogenic suspension (also shifts when the body turns). Over time, a hyperechoic thickened wall may form along the periphery of the abscess, with possible subsequent calcification. There may be partitions inside.

With treatment, the cavity gradually decreases, and the hypoechoic belt disappears. Subsequently, a zone of fibrosis remains, and in the longer term, a focus of calcification.

Sometimes cobweb-like hypoechoic branches into the surrounding tissue are visible.

The size of the hematoma may increase with continued bleeding with the appearance of heterogeneity in the structure (liquid blood and clots).

Without damage to large vessels, the hematoma looks different - after 1-2 days, an area of ​​moderately increased echogenicity appears with an unclear contour in which, over time, hypoechoic areas appear (hemorrhagic impregnation, characteristic of blunt trauma, at this stage it is necessary to differentiate with liver cancer). If the outcome is favorable, after 7 days this area may no longer be detected.

With a subcapsular hematoma, an anechoic strip with a sharp end appears, with the dynamics of changes close to those described above for vascular damage.

Choledochal cyst- can be congenital or acquired. It can be located on any part of the common bile duct and can be visualized both directly at the wall of the latter and at some distance from it. It is necessary to distinguish between the cyst itself and the cystic (local) expansion of the bile duct, which in a transverse section can be visualized as a cyst, and in a longitudinal section stretches into an anechoic tubular structure with an area of ​​local increase in diameter or saccular protrusion of one of the walls. The cyst is often associated with the bile duct (this connection may not be detected by ultrasound, but can be seen by CT, preferably with contrast). Has echo signs of a simple cyst located in the area of ​​the porta hepatis, or near this area. It is necessary to differentiate with: duodenal diverticulum, cholangiocarcinoma, subcapsular cyst of the head of the pancreas, disease and Caroli syndrome (congenital pathology, manifested in Caroli disease by local dilation of the large hepatic ducts - left and right, segmental; and Caroli syndrome is usually associated with dilation small bile ducts with concomitant fibrosis of the liver parenchyma), with biliary papillomatosis (epithelial tumor in the lumen of the bile duct, if it blocks the lumen, prestenotic dilatation of the duct can be detected).

Liver calcification - may occur after echinococcosis, tuberculosis, toxoplasmosis; calcification of hematoma, hemangioma, metastasis after chemotherapy. Differentiate with aerobilia, intrahepatic bile duct calculus.

Liver lipoma - a round formation with an even and clear contour, with a homogeneous echo structure of increased echogenicity, may slightly increase in size during dynamic observation, or does not change its size for a long time.

Focal liver fibrosis - local increase in echogenicity (unevenly) of the liver parenchyma with dimensions greater than 5 cm, irregular shape. In the area of ​​fibrosis, the vascular pattern may be deformed.

Echo signs of local and focal forms of fatty infiltration of the liver . Local form - a large area, up to 10 cm, or can occupy the entire lobe. Focal form - a small area or areas. Against the background of unchanged or slightly increased echogenicity of the liver parenchyma, an area of ​​increased echogenicity is visualized with an irregular shape and a clear, less often with a fuzzy contour. The structure of the liver architecture is not changed in this area.

An area of ​​absence of fat, irregular shape and reduced echogenicity may appear against the background of a general increase in echogenicity with a diffuse form of steatosis, with an unclear contour.

Echo signs of pseudolipoma (synonyms in the literature: fetal lipoma, brown lipoma(?), benign hibernoma) - a round, encapsulated formation consisting of remnants of embryonic adipose tissue (areas with large rounded fat cells separated by linear sections of stroma). It may look like a lobulated, small-sized nodule with varying degrees of echopositivity. In the literature I came across indications that areas of necrosis followed by calcification may appear in the echo structure. May be located next to the liver capsule.

Echo signs of lymphostasis in the liver . The draining capillaries of the deep network of lymphatic vessels of the liver are located along the so-called. triad (branches of the portal vein, hepatic artery and intrahepatic bile duct), forming a plexus. Even with a slight increase of 3-7 mm Hg. Art., when the normal pressure in the portal vein system is exceeded, the liquid part of the blood escapes into the surrounding lymphatic capillaries, which expand and with ultrasound one can detect a strip of hypoechoic parenchyma along the portal veins, sometimes over a significant extent of the vessels - the so-called. hypoechoic “muff”.

Liver lymphoma - hypoechoic multiple foci of small size, irregular shape, with unclear and uneven contours against the background of diffuse changes in the liver.

Metastases in the liver parenchyma.

They can affect the parenchyma diffusely - multiple hypo- or hyperechoic small foci.

But local metastases are quite common:

- isoechoic - difficult to diagnose, may not have a clearly defined hypoechoic rim. May be suspected in case of: local protrusions of the liver contour; when the natural course of the liver vessels changes; or when, with CDK, a local change in the vascularization of the parenchyma is noted. It is necessary to differentiate from focal nodular hyperplasia of the liver and cancer.

- hypoechoic - often a homogeneous echo structure. It is necessary to differentiate with areas of preserved parenchyma with fatty infiltration of the liver, with focal nodular hyperplasia of the liver, with liver abscesses in the infiltration phase, with adenomas, with hepatocellular liver cancer.

- mixed echogenicity - Occurs in patients with long-term disease. For example, hypoechoic metastasis with an echopositive central part (described in the literature as a “target” type); or central necrosis of echogenic metastasis (bull's eye type). Differential diagnosis must be carried out with liver abscess and cavernous hemangioma; in children with adenoma (with accumulation of glycogen in its central parts).

With CDK in metastases, vascularization can be enhanced, and with Dopplerography, the peak systolic blood flow velocity in the common hepatic artery is increased (normal up to 79-105 cm/sec), its diameter can be increased (normal up to 5-5.5 mm), the peripheral index resistance (RI) decreases (normal to 0.7-0.74). Standard indicators of blood flow are taken from the works of Kuntsevich G.I., 1998.

If the patient received a course of chemotherapy, a change in the echo structure of metastases is possible due to the appearance of hyperechoic inclusions with subsequent calcification, and the size may decrease, sometimes significantly (no longer visualized).

If metastasis has occurred in the lymph nodes of the portal of the liver, in the para-aortic and lymph nodes located near the celiac trunk, then they enlarge, become almost spherical, hypoechoic and homogeneous (without differentiation of the medulla); with CDK, diffuse vascularization can be detected in them.

Portal vein thrombosis , less often splenic vein , can occur against the background of primary and metastatic tumor lesions of the liver, pancreas, stomach, but can also occur against the background of cirrhosis. Accordingly, a blood clot in the vein, with signs of its expansion, splenomegaly, and ascites, will be detected. Sometimes a blood clot in the portal vein or its branches may be a sign of tumor growth in the vein wall.

Thrombosis of the inferior vena cava can occur when the tumor is located in close proximity to it.

Primary liver cancer. The literature indicates that chronic hepatitis B and C greatly increase the risk of developing primary liver cancer.

Hepatocellular cancer can be represented by a single formation; multiple separately located foci in the liver parenchyma or a conglomerate of nodular formations is described in the literature; local change in the echo structure in any segment or lobe; changes in the contours of the liver. If there is only a local change in the echo structure of the parenchyma, with a tumor size of up to 35 mm, then it can be difficult to distinguish it from other focal liver lesions. With such sizes, the formation is often hypoechoic, but it can also be isoechoic (the most difficult to differentiate), and with larger sizes, the echogenicity of the formation is often increased.

Nodal form can be represented by one nodular formation, with the following options for echo signs:

- echogenicity- reduced, average, increased, mixed;

- contours- clear or unclear, smooth or uneven (scalloped, finely lumpy);

- internal echo structure may be quite homogeneous; heterogeneous due to areas of reduced, medium or increased echogenicity with sizes up to 7-12 mm or larger rounded areas with smooth contours; in the literature there is a comparison of “several formations in one larger one”; may contain centrally located hyperechoic linear inclusions of a horizontal orientation without acoustic effects;

- hypoechoic rim along the outer contour (some authors call it Halo) with different thicknesses: from 1 mm to 8 mm, more often expressed in formations that are heterogeneous in structure.

At diffuse form the liver often has smooth contours, its size is increased evenly. Uneven or tuberous contours occur when areas of the parenchyma adjacent to the capsule are affected, and they may have a normal echo structure. The pressure in the portal vein system and intrahepatic bile ducts may rapidly increase.

Options:

In most areas of the liver parenchyma, nodular formations of various echo structures are detected, causing deformation of the branches of the hepatic and portal veins;

A diffuse large-focal heterogeneity of the echo structure of the liver is determined, with deformation of the vascular pattern, the symptom of “vascular amputation” can be determined, the vascular pattern is diffusely depleted;

Echopositive nodules with unclear boundaries are visualized over the entire area of ​​the echo section of the liver (a rare variant is multicentric primary liver cancer).

Cholangiocellular carcinoma liver - one or more nodular formations are identified, most often hyperechoic, but they can also be of mixed echogenicity, irregularly round in shape with uneven and unclear contours. It is possible to detect an expansion of the corresponding intrahepatic bile duct in the area located in front of the site of stenosis by tumor masses.

Rare liver tumors. Cystadenoma intrahepatic bile ducts, hemangiosarcoma, teratoma- have not been sufficiently studied in ultrasound diagnostics. Hemangioendothelioma- occurs in newborns, is combined with cutaneous hemangiomas, echographically resembles a hemangioma, and is prone to malignancy. At rhabdomyosarcoma a hypoechoic formation with a clear contour and heterogeneous structure is determined (sometimes due to cystic inclusions).

Postcholecystectomy syndrome.

Develops after removal of the gallbladder, with a frequency of up to 25%. The symptoms are dominated by pain, sometimes even more pronounced than before surgery, as well as nausea and bitterness in the mouth. May develop within several months after cholecystectomy. In the majority of cases, the cause is a disease of the bile ducts itself (less often, a disease of nearby organs):

Stenosis of the papilla of Vater (hypertension of the sphincter of Oddi and stenotic papillitis);

Choledocholithiasis is recurrent (detected more than 3 years after surgical treatment) and residual (remaining stones in the common bile duct, less than 3 years after surgical treatment);

Combination of choledocholithiasis and stenosis of the papilla of Vater;

Primary and secondary pancreatitis;

Gastritis, duodenitis;

Parafaternal diverticulum;

Late complications after surgery (narrowing, stricture of the ducts).

Postcholecystectomy syndrome often develops:

In patients who had a previous cholecystectomy, long-existing cholelithiasis, or cholelithiasis with atypical symptoms and small stones in the gallbladder;

In patients with a history of episodes of obstructive jaundice;

In patients with frequent exacerbations of pancreatitis.

Additional research methods used:

Fibrogastroduodenoscopy;

Endoscopic retrograde cholangiopancreatography (ERCP).

Conservative, if the main cause is diseases of adjacent organs (diet, antispasmodics, enzyme preparations);

Endoscopic papillosphincterotomy (small stone in the bile duct, mild stenosis of the papilla of Vater);

Surgical intervention, if there are large bile duct stones, stenoses and strictures of the terminal part of the common bile duct, the so-called false gallbladder;

Combined - papillosphincterotomy followed by surgery.

The purpose of ultrasound examination is to early identify obstructions in the patency of the biliary tract (stenoses, strictures, stones).

The effectiveness of ultrasound increases when the diameter of the common bile duct increases to 8-10 mm or more. A hyperechoic inclusion with an acoustic shadow (calculus) can be visualized in the lumen of the common bile duct. Also in the lumen, clots of putty-like bile can be found in the form of medium and moderately increased echogenicity of inclusions without an acoustic shadow (or with unexpressed acoustic attenuation). Small stones may not cause dilatation of the bile duct and its diameter is less than 8 mm.

Most often, stones are located in the terminal part of the common bile duct. Visualization of this area can be reduced by endoprostheses, staples, and ligatures after surgery (they may also have an acoustic shadow).

Papillitis (stenotic duodenal papillitis) is associated with a narrowing of the ampulla of the major duodenal papilla, as well as the terminal section (about 1 cm long) of the common bile duct, due to inflammatory processes and fibrotic changes against the background of hypertension of the sphincter of Oddi. Ultrasound can reveal indirect signs - expansion of the common bile duct with concomitant expansion of the intrahepatic bile ducts or without expansion of the latter (depending on the duration of the process and the degree of stenosis).

Additionally, to identify partial obstructions in the patency of the terminal section of the common bile duct (the diameter of the common bile duct in the hilum area is 7-10 mm), drug tests with choleretics are used, which increase the volume of bile secretion and even with a small degree of obstruction, the bile ducts cannot cope with the evacuation of fresh portions of bile , which will be manifested by dilatation of the common bile duct proximal to the site of obstruction. Before this, we conduct an ultrasound examination and measure the internal diameter of the common bile duct in the hilum area (normally less than 7 mm). Then the patient takes a choleretic drug (do not eat or drink after taking the drug). The control study can be repeated after 2.5-3 hours: we measure the diameter of the common bile duct in the same place. If the diameter increases by 2 mm or more, the test is considered positive.

Drugs used:

Dehydrocholic acid, at the rate of 10 mg per 1 kg of body weight;

Oxafenamide, at the rate of 12.5 mg per 1 kg of body weight;

Cyclalon, at the rate of 5 mg per 1 kg of body weight (but no more than 4 tablets for an adult, no more than 2 tablets for children).

If the test is positive, the patient requires hospitalization. Additionally, MRI and ERCP can be used.

Pneumobilia, aerobilia - air in the bile ducts. On ultrasound, along the bile ducts in the liver, hyperechoic structures of an elongated linear shape are determined, behind which a reverberation effect is determined (glare, flickering as opposed to an acoustic shadow). Air (gas) also appears in the extrahepatic bile ducts.

Pneumobilia can be detected:

In patients who have undergone papillosphincterotomy (the penetration of gas from the duodenum into the common bile duct occurs due to the fact that in the duodenum the pressure is higher than in the common bile duct; and if the contents of the duodenum are refluxed into the common bile duct, then there is a high risk of developing cholangitis);

When applying biliodigestive anastomoses (choledochoduodenoanastomosis, cholecystogastroanastomosis, cholecystojejunostomosis);

With Mirizzi syndrome (Mirizzi), when a partial narrowing of the common hepatic duct is formed due to inflammation and compression from outside a calculus located in the cystic duct or in the neck of the gallbladder. This, in turn, leads to the formation of a stricture of the common hepatic duct or to the formation of a bedsore from a stone in the cervix with the development of a vesicocholedochal fistula. Pneumobilia in this case may appear in the event of the formation of a vesico-intestinal fistula (usually with the duodenum);

For cholangitis caused by anaerobic flora;

With insufficiency of the sphincter of Oddi.

Pneumobilia must be differentiated from calcifications in the liver (they do not follow the course of the intrahepatic bile ducts, which are located parallel to the branches of the portal vein; calcifications are not linear, but often round, have an acoustic shadow in contrast to the reverberation effect), with stones of the intrahepatic bile ducts.

False gallbladder is an excessive stump of the cystic duct and is not common. During ultrasound, a formation similar to a gallbladder is visualized in the bladder bed; it can reach 2-4 cm in length; over time (months and years), stones can form in the stump. Stump stretching may be associated with biliary hypertension and atony of the bile ducts after cholecystectomy. An inflammatory process may develop in the stump.

Mechanical jaundice.

Synonyms: subhepatic, obstructive, extrahepatic cholestasis.

The main symptoms of obstructive jaundice:

Pain syndrome localized in the epigastric region and right hypochondrium may increase gradually or occur suddenly;

Discolored stool;

Dark urine;

Jaundice staining of the sclera of the eyes, mucous membranes and skin;

Itchy skin;

Additionally: nausea, less often vomiting, liver enlargement.

Laboratory diagnostics: an increase in the level of direct (mainly) bilirubin in the blood, cholesterol, and alkaline phosphatase activity is detected.

It develops as a result of an obstruction to the flow of bile, usually within 3-5 days (not hours).

Objectives of ultrasound in cases of suspected obstructive jaundice:

Determination of the genesis of jaundice (mechanical or parenchymal). We carry out research on patients in any case, incl. and without preliminary preparation of the gastrointestinal tract.

An attempt to clarify the nature - benign (for example, a stone), or malignant.

Block level definition.

Causes of obstructive jaundice.

Benign:

Choledocholithiasis (up to 30%);

Papillostenosis, stricture of the distal part of the common bile duct (6-7%);

Papillitis (4-5%);

Acute and chronic pseudotumor pancreatitis (up to 3%);

Cysts of the common bile duct (2-3%), most often congenital;

Cholecystitis, cholangitis (1-2%);

Enlarged lymph nodes in the area of ​​the porta hepatis, parafaterial diverticulum of the duodenum (located in close proximity to the papilla of Vater).

Malignant, tumorous:

Pancreatic head cancer (up to 70%);

Cancer of the major duodenal papilla (up to 15%);

Tumor of the gallbladder and bile ducts (up to 10%);

Liver tumor: hepato- and cholangiocellular cancer (up to 3%);

Metastases in the area of ​​the porta hepatis (3-5%, most often from the pancreas, stomach).

Four block levels:

Distal block - the level of the pancreas and duodenum, most often;

Middle block - including the level of the confluence of the cystic duct;

High block, proximal - at the level of the portal of the liver;

Intrahepatic block.

A pathognomonic echo sign of obstructive jaundice is dilation of the intrahepatic bile ducts, at least in one lobe. Whether the common bile duct will be dilated depends on the level of the block (the higher the block, the less dilated the common bile duct is).

Depending on the degree of expansion of the intrahepatic bile ducts, you can find:

The ultrasound symptom of a “double-barreled shotgun”, a “hunting rifle” according to other authors, when the diameter of the dilated intrahepatic bile ducts is close to or equal to the diameter of the branches of the portal vein (anechoic tubular structures are located nearby, parallel) of the corresponding level - lobar, segmental. This can be a moderate expansion, or up to 10-12 mm maximum, more often observed with a benign cause of obstructive jaundice, but also with a malignant one with gradual expansion.

Subsequent expansion of the intrahepatic bile ducts leads to the formation of so-called anechoic bile ducts. “worm-shaped structures”, “bile lakes”, “stellate structures” - they no longer have a regular tubular appearance and a course parallel to the branches of the portal vein, they are much more expanded, up to 14 mm or more, with an uneven diameter. More often they can be detected during a tumor process.

If, with the detected ultrasound symptom of a “double-barreled shotgun”, echo-positive walls of the bile ducts can be seen, then “bile lakes” and other more expanded areas of the ducts are determined without obvious echo signs of the walls (since they are significantly stretched and thinned).

Distal block.

Echo signs of a tumor of the major duodenal papilla and distal common bile duct. It is difficult to distinguish between the terminal section of the common bile duct (about 1 cm long) and the major duodenal papilla (its area) with ultrasound. The echo picture may be the same in both tumor locations.

What you can find:

Dilation of the intrahepatic bile ducts (ultrasound symptoms of “double-barreled shotgun”, “bile lakes”), dilation of the main bile duct along its entire length (7-9 cm), because the block is located at the very end. Sometimes the tortuosity of the common bile duct is determined. The common bile duct ends with a prestenotic dilatation (some authors have a “drumstick” symptom). The gallbladder is enlarged (like dropsy), the main pancreatic duct is enlarged, if it opens together with the common bile duct (not always).

Additional studies: duodenoscopy, ERCP, MRI are indicated.

Level of the head of the pancreas. Adenocarcinoma, cystadenoma (less commonly), pseudocyst localized in the head region; pseudotumorous pancreatitis, acute pancreatitis with an enlarged edematous head - can compress the common bile duct, which runs along the posterior surface of the head of the pancreas in the groove.

Ultrasound can detect dilation of the intrahepatic bile ducts, dilation of the main bile duct up to the projection of the head of the pancreas. It ends with a cone-shaped or cylindrical stump. The stump is adjacent to the formation, or a formation compressing it is visualized next to it. The gallbladder is enlarged if the tumor does not invade the cystic duct. The duct of Wirsung is dilated, but not necessarily.

For such patients, the following additional research methods are indicated: ERCP, MRI CP. Differential diagnosis should be carried out between pseudotumor pancreatitis and a tumor of the head of the pancreas.

Middle block.

Incl. the place where the cystic duct enters the main bile duct.

Tumor of the proximal common bile duct (immediately below the junction of the cystic duct). The echo pattern may be similar to a distal block. But the above-described changes in the head of the pancreas are not detected. Dilation of the intrahepatic bile ducts. The gallbladder is enlarged. The distal parts of the common bile duct are not visible (deserted). It is possible to obtain direct images of the tumor, but is rare. If the tumor is located above the confluence of the cystic duct, then the gallbladder is not enlarged (collapsed, may look hepatized). Additional studies: MRI CP, percutaneous transhepatic CG.

High block.

This is the level of the hilum of the liver (for example, metastases to the lymph nodes in the hilum area, tumor in the hilum area). Echo signs: dilation of the intrahepatic bile ducts, the hepaticocholedochus is visible very briefly (0.5-1 cm in length), then not visible (collapsed). The gallbladder is reduced in size, hepatized, collapsed. Sometimes it is possible to visualize the tumor itself. Additional studies: MRI CP, percutaneous transhepatic CG.

Intrahepatic block.

Tumor of the liver itself (cholangio- and hepatocellular cancer). The intrahepatic bile ducts are dilated in the healthy lobe or in part of the liver - compensatory. The remaining sections of the biliary tree are either not visible or narrow. Small gallbladder. Additional research - MRI.

In conclusion we indicate: Obstructive jaundice, ... block level.

Traumatic injuries to the abdominal cavity.

Indications for ultrasound are blunt abdominal trauma.

During an ultrasound examination, indirect and direct signs of damage to the abdominal organs and retroperitoneal space can be identified.

The test is aimed at detecting fluid in the abdominal cavity (partial FAST protocol).

Advantages of ultrasound examination:

Liquid detection accuracy;

A small amount of time spent on research;

Possibility of repeating the study several times in a short period of time;

Non-invasive.

The disadvantage is that it is often impossible to determine the type of liquid.

We carry out ultrasound examinations for emergency indications, without prior preparation.

To more accurately interpret the detected changes, it is necessary to clarify when the injury occurred (hours passed or days after the injury?).

We use a 2.5-5 MHz convex sensor to examine the abdominal cavity. We examine all organs, measure sizes, determine the echo structure of the parenchyma, the contours of organs (including the integrity of the capsule), displacement during breathing, measure diameters and determine the presence of blood flow (CDC, EDC mode) in the great vessels, determine the presence of fluid in the abdominal cavity. Do not forget about the polypositional principle during the study (displacement of free fluid).

To track the dynamics of detected changes, we carry out repeated studies several times a day, as well as the next day - in agreement with the surgeon and gynecologist.

The examination can be complicated by the patient’s serious condition, the lack of preliminary preparation of the gastrointestinal tract, as well as the addition of intestinal paresis. Therefore, in the standard ultrasound examination protocol it is necessary to indicate which areas in the abdominal cavity are not visualized and for what reason (gas in the intestines, gas in the abdominal cavity, or other reasons).

We search for liquid:

In the pericardial cavity, the sensor (3.5-5 MHz) is installed in a transverse or oblique position under the xiphoid process with an inclination of the scanning plane in the cranial direction;

In the right upper quadrant of the abdomen (in the hepatorenal space - Morrison's pouch, as well as in the right subphrenic space), incl. using intercostal approaches along the intercostal spaces and along the axillary lines;

In the right lower quadrant of the abdomen (between the intestinal loops and the right kidney);

In the left upper quadrant of the abdomen (in the left subphrenic space and the space between the spleen and kidney - in the splenorenal recess);

In the left lower quadrant of the abdomen (between the intestinal loops and the left kidney);

In the suprapubic region (around the bladder, in the protocol it is necessary to note whether the bladder cavity is visualized, as well as in the pelvic pockets).

Fluid in the right upper quadrant of the abdomen first accumulates in the Morrison's pouch and then spreads through the right lateral canal into the pelvis.

Fluid in the left upper quadrant of the abdomen first accumulates in the left subphrenic space, then in the splenorenal recess, and then descends through the left lateral canal into the pelvis. But if the victim lies on his back for a long time, then the Morrison's pouch is the most likely place for fluid accumulation, regardless of the location of the injury (due to the small space of the left lateral canal).

A pathological amount of fluid in the pericardial cavity can appear with pericarditis or as a result of trauma and is visualized as an echo-negative (homogeneous or heterogeneous) strip between the hyperechoic pericardium and the average echogenic myocardium. Pericardial fluid in a volume of up to 30 ml is of physiological origin, its main function is lubrication, and is visualized posteriorly and below the left ventricle.

Average amount of fluid - extends to the apex of the heart (the thickness of the strip posterior to the left ventricle is 1 cm or more).

A significant amount of fluid surrounds the heart on all sides during both phases of the cardiac cycle. Rapid accumulation of fluid in the pericardial cavity in a volume of 100-200 ml causes cardiac tamponade.

Fluid in the pericardial cavity must be differentiated from the pericardial fat pad, which may be visualized as a hypo- or anechoic stripe anterior to the right ventricle, but with the patient in the supine position, it does not move posterior to the heart, as fluid would.

Most often, with blunt abdominal trauma, damage occurs to the spleen (about 75%), then the liver (20%), damage to the intestines and mesentery occurs in 5%, bladder in 1.6%, and pancreas in less than 0.5%.

When examining the upper quadrants of the abdomen, fluid can be detected between the diaphragm and the liver, the diaphragm and the spleen, between the liver and the kidney, the spleen and the kidney in the form of anechoic or hypoechoic crescent-shaped strips of varying thickness. A strip of 0.5 cm thick in Morrison's pocket corresponds to approximately 0.5 liters of liquid. If liquid is detected in 2-3 pockets, then its volume is at least 1 liter. Free fluid moves easily during polypositional examination.

You can also detect fluid in the pleural sinus, which is separated from the liver (or from the spleen) by the diaphragm in the form of a uniformly curved echo-positive homogeneous linear structure (normally, a mirror reflection artifact can be found at the site of the pleural sinus).

We must remember that fluid in the stomach can simulate a false hematoma on the left. Also, the left lobe of the liver may protrude far beyond the midline to the left and be visualized above the spleen as a moderately hypoechoic elongated structure.

Damage to the structure of organs can occur both with capsule rupture and without rupture.

When injured, the liver can change its shape and size. More often, the hematoma is located along the line of the conventional blow, and if it is located subcapsularly, it can be visualized as a local protrusion of the contour.

With blunt liver injury, the onset of changes in its echo structure is noticeable after 1-2 days, in the form of a homogeneous or heterogeneous area of ​​increased echogenicity, with unclear boundaries. After 7 days, this area may no longer be detected - the echo structure is completely restored.

In this case, differential diagnosis must be made with liver cancer - with trauma, the echo picture changes within a few days, with cancer it does not change.

If there are phenomena of destruction of the parenchyma, then with blunt trauma the zone of changes may be similar to cavernous hemangioma. With further development of the process (if resorption has not occurred within 7 days), on the 10th day the clarity of the contour increases, the echogenicity unevenly decreases (in the form of hypo- and anechoic areas) and gradually the hematoma takes on the appearance of an anechoic liquid formation with smooth contours, with acoustic distal pseudo-amplification, i.e. looks like a cyst.

Options for the outcome of hematoma:

There may be a merging of smaller hematomas into one larger one;

An inflammatory process and suppuration may develop;

May break into the abdominal cavity.

Treatment of hematoma is ultrasound-guided puncture and drainage.

The spleen is easily damaged by injury, it is rich in blood vessels, and also contains part of the blood in the form of a depot. A subcapsular hematoma often forms in the spleen, which is visualized as an echo-negative elongated subcapsular strip with a 2nd contour. If the capsule ruptures, it is possible to detect discontinuity of the contour in this place and hypo- and anechoic accumulations of blood located in the adjacent tissue. There are also hematomas located inside the parenchyma. During their development, splenic hematomas go through the same stages as in the liver (described above). Sometimes the hematoma is multi-chambered, more often in the case of large sizes.

The pancreas is rarely damaged in abdominal trauma. The hematoma can be located subcapsular or in the parenchyma. If in the parenchyma, then the echo picture is similar to acute pancreatitis. Visualization of the injury area improves significantly 3 days after injury. Later, pseudocysts may form at the site of the hematoma, incl. multi-chamber, usually 4-5 weeks after injury. Such pseudocysts can reach several centimeters in size, with a heterogeneous echo structure, with typical dorsal pseudoenhancement. When a hematoma is organized, a decrease in its size, heterogeneity of the echo structure, clear contours, and a hyperechoic rim along the periphery (due to fibrin threads in the sediment and in the forming walls) are observed. Over time, calcifications may form inside the established hematoma.

Additional studies - CT, MRI, ultrasound-guided puncture.

In the kidneys and adrenal glands, hematomas can form during injury, as well as in other parenchymal organs. In the first 3-5 hours, an increase in the organ is observed, later areas of reduced echogenicity with hyperechoic structures appear - this is hemorrhagic impregnation of the tissue. After 3-7 days, an involution of these changes occurs: the size decreases, the contour becomes clearer, the parenchyma in this area becomes more homogeneous. Further, either lysis is possible - a cyst is formed, or an organization with fibrous-sclerotic changes and possible calcification in the future. With subcapsular injuries, the capsule is not damaged and the hematoma is visualized as a crescent-shaped echo-negative strip under the capsule of medium or increased echogenicity. But if the capsule is not clearly defined, then the hematoma must be differentiated from free fluid near the outer contour of the organ. To do this, you need to change the position of the patient's body - the subcapsular hematoma will not move.

There may be hematomas in the pararenal tissue (usually they are clearly defined).

If a hematoma is located in the area of ​​the upper pole of the kidney, it must be differentiated from a hematoma or tumor of the adrenal gland (especially in the case of heterogeneity of the echo structure). There is a transcapsular rupture of the kidney with or without damage to the pelvic region, which is determined in the form of a local disturbance of the contour with visualization of the rupture line and a clearly demarcated accumulation of fluid (urohematoma) in the posterior pararenal space. Such patients require emergency surgical treatment.

An established hematoma is visualized as the formation of a heterogeneous solid-cystic structure, in which calcifications can be detected; the contours can be clear or indistinct. It is necessary to differentiate an established hematoma from kidney cancer. Additional studies - MRI, CT.

In case of injury, the adrenal gland becomes enlarged, round in shape (if there is no rupture), and when the injury is from several hours to 3 days old, it has the appearance of an average or reduced echogenicity of the formation at the upper pole of the kidney, without distal pseudo-enhancement. At this stage it is necessary to differentiate from an adrenal tumor. A hematoma always changes dynamically. Possible changes are the formation of cystic cavities after 4-5 days, later calcifications may form.

If the intestine or mesentery is damaged, fluid is detected in the interloop spaces in the form of echo-negative accumulations of a characteristic triangular shape.

When examining the lower quadrants of the abdomen and suprapubic region using longitudinal and transverse scanning, it is possible to detect fluid in the pelvic cavity: in large quantities near the outer contours of the bladder, in small quantities in the pouch of Douglas and the area of ​​the uterine appendages in women, in the space between the rectum and bladder in men.

A necessary condition is an adequately filled bladder (if not filled, catheterization with the introduction of 200-300 ml of sterile saline solution).

Any amount of free fluid in trauma patients can be considered hemoperitoneum, except in female patients of reproductive age. In such patients, the detection of fluid collection in the pouch of Douglas with an anteroposterior dimension of less than 3 cm may be physiological. But if fluid is found in other places, it is most likely hemoperitoneum.

Complications after surgical interventions.

An ultrasound examination can detect foreign bodies in the abdominal cavity that are not detected by x-ray examination. In particular, of textile origin (so-called textiles) - napkins, tampons. But it must be borne in mind that currently napkins for the abdominal cavity (for example, TELASORB) can be used, which contain a sewn-in radiopaque plate and loop - they are visible on radiography.

There are so-called “dry” foreign bodies - without effusion. Clinical manifestations of such a foreign body are erased or absent. It is often detected as a finding during a survey ultrasound examination. Such patients have a history of surgery. On examination, it may be visualized as a hyperechoic crescent-shaped stripe (referred to as a “shell-like” structure in some ultrasound manuals) with intense acoustic shadowing behind. The width of the acoustic shadow coincides with the size of the crescent strip. May resemble a stone in the abdominal cavity.

If there are clinical manifestations - pain, fever, changes in blood tests, then the foreign body is surrounded by fluid due to a pronounced exudative reaction. Ultrasound reveals a volumetric formation of various shapes, with clear or unclear contours, a heterogeneous echo structure due to hypoechoic (initial stage) and then medium echogenicity of the periphery and with hyperechoic inclusions in the center, which have an acoustic shadow (these are already signs of the formation of an abscess around the napkin) .

Differential diagnosis of “dry” foreign bodies must be carried out:

1. With intestinal loops filled with gas. The difference is that the shadow from the gas in the intestines is gray, “glare” (an artifact of reverberation from oscillating gas bubbles in the intestines), and the acoustic shadow behind the napkin is black, intense. We must remember that an intense acoustic shadow is also observed from barium in the intestines. In such cases, a survey radiography of the abdominal cavity can help, in which barium is always visible, and the textile napkin is not detected (unless it contains sewn-in radiopaque materials).

2. With large stones in the gall bladder, as well as with the so-called. “porcelain” gallbladder (with chronic cholecystitis, calcium salts are deposited in the walls of the bladder and ultrasound visualizes a hyperechoic anterior wall of the gallbladder with an intense acoustic shadow).

3. With other calcifications in the abdominal cavity, such as:

Stones in the intestines (for example, petrified fecal stones);

Calcification of the walls of the abdominal aorta (usually in the bifurcation area, against the background

atherosclerosis in elderly patients) and its branches, incl. aneurysmal dilatations;

Calcification of the walls of cysts and tumors;

Calcifications in the spleen (previous histoplasmosis, tuberculosis, malaria,

sickle cell anemia, infarction and hematoma of the spleen), liver and pancreas

Calcifications in the seminal vesicles and prostate gland;

Ovarian teratoma, calcification of uterine fibroids;

Calcifications in mesenteric lymph nodes;

Calcification of post-traumatic hematoma.

Heart attacks, hematomas and lymph nodes may contain calcifications in the form of separate hyperechoic fragments that produce acoustic shadows behind them, like vertical stripes.

All calcifications are visible on X-ray examination.

Foreign bodies with effusion must be differentiated from abscesses and abdominal cysts. The foreign body will have an acoustic shadow from the napkin itself in the center of such a formation, and the abscess and cyst will have a distal pseudoenhancement effect.

Purulent-septic diseases of the abdominal cavity.

Liver abscesses.

Secondary: suppuration of a pre-existing formation (cyst, hematoma, tumor decay).

There are single and multiple. Depending on the course - acute and chronic.

Routes of infection spread: through the portal vein (usually multiple abscesses), through the hepatic artery (usually single abscesses), through the bile duct, from surrounding tissues (in case of liver injury).

Stages of process development:

Initial, infiltrative stage - a zone of reduced echogenicity is determined in the liver area, not clearly separated from the surrounding parenchyma, the contour is unclear, irregular in shape, homogeneous echo structure, reverse development is possible - after a few days there are no changes;

If the pathological process continues, then a melting zone is formed - reduced echogenicity, heterogeneous echo structure, irregular shape, unclear contour, the appearance of central or eccentrically located areas with lower echogenicity and uneven contour;

Finally, the stage of complete melting develops - an echo-negative formation with distal acoustic enhancement, surrounded by a thin halo, up to several mm thick (zone of reactive inflammation, demarcation zone, distinguishes diseased and healthy tissue).

If there is thick pus in the abscess cavity, then it is difficult to distinguish from a tumor - the formation of a heterogeneous echo structure, medium or increased echogenicity, the contours are unclear (but the vessels inside are not visible).

Differential diagnosis - with an abscess the picture changes within 2-5 days, with a tumor it is stable. Puncture is best, because... When a tumor disintegrates, it can also fester.

There may be gas in the abscess cavity - linear hyperechoic structures, with reverberation, occupy the highest position and move when the patient’s body position changes. Treatment - puncture, drainage - the cavity collapses, then a scar forms in this place.

Paravesical abscess - forms near the gallbladder, this is a complication of acute cholecystitis. Echo signs: a formation of round or oval shape, 2-5 cm in size, low echogenicity, homogeneous or heterogeneous structure is determined near the gallbladder. It can be located in the parenchyma of the visceral surface of the liver or in paravesical tissue. It is necessary to differentiate from gallbladder diverticulum. Some such abscesses communicate with the gallbladder.

With a diverticulum, the spread of the gallbladder wall and this formation is determined.

Subhepatic abscess - can form after cholecystectomy, surgery on the stomach, or other organs. Most often located under the right lobe of the liver, in the subhepatic space. Echo signs: oval or round formation, hypo-anechoic, with distal acoustic enhancement, heterogeneous structure, size 2-5 cm or more (up to 15 cm).

Biloma is an accumulation of bile in the area of ​​the bed (in the groove) of the removed gallbladder, often has the appearance of a trifoliate or bifoliate. It is necessary to differentiate with a tumor of the hepatic flexure of the colon and a tumor of the small intestine. If there is a tumor of the intestine, then the ultrasound symptom of a lesion of a hollow organ (HCO) is often determined - a formation with a hypoechoic periphery (intestinal wall) and a hyperechoic center (lumen).

Subphrenic abscess is most often a postoperative complication, or a complication of other purulent processes in the chest and abdominal cavity (purulent pleurisy, peritonitis, destructive pancreatitis). It is difficult to determine in the left subdiaphragmatic space, the gas bubble of the stomach and intestines interfere. Pay attention to the space between the dome of the diaphragm and the liver on the right or the spleen on the left. Echo signs: formation of various shapes (initially a narrow crescent, later it can thicken significantly, pushes aside the organ and becomes rounded or fusiform), hypo- or anechoic, homogeneous or not, may contain gas bubbles with a reverberation effect. It is important to distinguish a subdiaphragmatic abscess from the accumulation of fluid between the diaphragm and the organ, as well as from effusion into the pleural cavity. You need to turn the patient and the fluid will flow out, but the abscess will remain in place. We also take into account the clinic, data from laboratory research methods.

Abscess of the pelvic cavity. The study must be carried out with a full bladder and carefully examine it from all sides; if there is a formation near the bladder, then it may be a peri-vesical abscess (if there are ultrasound signs of an abscess and clinical picture). It is necessary to differentiate with bladder diverticulum or tumor.

Interintestinal abscesses are difficult to see on ultrasound - they are small, often multiple and surrounded by dilated and fluid-filled loops of intestine. It is important to distinguish an abscess from a loop of small intestine with very sluggish peristalsis during paresis. If the abscess is more than 3-4 cm, then it is clearly visualized and it is important to monitor whether there is peristalsis in it.

Abscess of the omental bursa is a complication of purulent-destructive pancreatitis. It is located anterior to the pancreas, between the anteriorly pushed stomach and the pancreas. Visualized as a formation of round, oval, or irregular shape. We find the pancreas and look at its upper contour, above it is the wall of the stomach. Normally, they are tightly adjacent to each other. The abscess has quite characteristic echo signs depending on the stage (see above). It is important to distinguish this formation from a stomach filled with heterogeneous fluid - the stomach has 5 layers in the wall, of which 3 parallel layers are well differentiated, but an abscess does not have such differentiation of the wall. Peristalsis can also be observed in the stomach. In difficult cases, you can give the patient a drink of water, which will increase the volume of the stomach and improve the differentiation of its wall.

If, during exacerbation of chronic pancreatitis and acute pancreatitis, a thin echo-negative strip appears between the stomach and pancreas, then it may be a harbinger of the development of pancreatic necrosis. This is an effusion of inflammatory infiltrate into the omental bursa.

Appendiceal infiltrate is accompanied by pain in the right iliac region, a rise in body temperature, and leukocytosis in a blood test. Echo signs: in the right iliac region, at the site of a palpable formation (infiltrate), a round or oval formation is determined, with a hypoechoic periphery (edematous wall) and a hyperechoic center (lumen of the process). The contours are initially fuzzy and blurry. In dynamics, a decrease in size occurs due to a decrease in tissue infiltration, the hypoechoic periphery also decreases (less swelling of the wall), the contours become clearer. Initially, ultrasound is repeated after 3-5 days (after 5 days, the size of the infiltrate may decrease by 2-3 times). After 10-14 days, we look once a week until the ultrasound picture stabilizes (there is no decrease in size over time) and clinical manifestations. Having acquired clear contours, the formation becomes similar to a symptom of damage to a hollow organ.

Complications of infiltration: anechoic inclusions appear in the peripheral zone, increase in size, blurred contours - periappendiceal abscess.

Soft tissue infiltrates in the area of ​​postoperative scars. Echo signs: in the thickness of the abdominal wall or under it (sometimes deep), the formation of an elongated fusiform shape, slightly increased echogenicity, a homogeneous structure, with a fairly clear contour is determined. In dynamics, it decreases, until it disappears. If it suppurates, it increases in size, is round in shape, anechoic foci (pus) and other signs of an abscess appear.

Seroma is a limited accumulation of serous fluid in the area of ​​surgical intervention. Has echo signs of liquid formation.

Ascites, intra-abdominal bleeding, peritonitis - in all cases we see fluid in sloping areas of the abdominal cavity, already with 50 ml, first along the posterior-inferior surface of the liver, Morrison's pouch. This is a thin hypoechoic stripe. As the volume increases, the liquid surrounds the liver and spleen on all sides, and loops of intestine can “float” in it. If the structure of the fluid is homogeneous, it is most likely ascites; if it is heterogeneous, it is likely blood (clots, fibrin) or pus.

Pancreatic necrosis is a complication of destructive pancreatitis.

Echo signs: the pancreas is enlarged in size, the contour is unclear, uneven, echogenicity is reduced in areas or diffusely, the structure is heterogeneous due to hypo- and hyperechoic inclusions. An anechoic reactive effusion into the peripancreatic tissue is detected. The structure of the stromal elements of the gland is preserved. This can happen with acute pancreatitis and with exacerbation of chronic pancreatitis.

If the above-described changes in the gland tissue + effusion into the omental bursa (in front of the gland, under the stomach) are detected, then the diagnosis of pancreatic necrosis is likely. It is reliable when the tissue around the gland is involved in the process: with longitudinal scanning, linear areas of reduced echogenicity, a fairly homogeneous echo structure, with moderately indistinct contours, are visible on both sides of the tail of the pancreas. If these linear areas of reduced echogenicity increase significantly, the contours become even more erased, then an abscess of the retroperitoneal space in which the pancreas is located (between the posterior layer of the peritoneum and the transverse fascia, which lines the posterior part of the abdominal cavity) can form.

Characteristic echo signs of pancreatic necrosis:

Changes in the pancreas;

Effusion into the omental bursa;

Involvement of parapancreatic tissue in the inflammatory process.

Abstract: ultrasound examination for urgent conditions of the kidneys and urinary system

I I believe that “considering” information critical to finding a solution requires the ability to see _not in the literal sense, but rather in the sense of the word that artists use...

BETTY EDWARDS, THE ARTIST INSIDE YOU

Despite the active introduction of modern diagnostic technologies into clinical practice, in many medical institutions ultrasound is the main method for detecting nephrological diseases. This is due to the relatively low cost of the technology, non-invasiveness, absence of ionizing radiation, and high accuracy of detecting morphological changes. The kidneys are located in the lumbar region on both sides of the spine, retroperitoneally. They have fibrous, fatty and fascial capsules. The thickness of the fibrous capsule is 0.1-0.2 mm. In relation to the spinal column, the kidneys are located at the level of the 12th thoracic, 1-2 (sometimes 3) lumbar vertebrae. The left kidney is located 2-3 cm above the right and reaches the 11th rib with its upper pole. The 12th rib crosses the left kidney in the middle, while the right one crosses the border of the upper and middle third. More often, the upper edge of the right kidney is located at the level of the 11th intercostal space, and its hilum is below the 12th rib, while the upper edge of the left kidney is located at the level of the 11th rib, and its hilum is at the level of the 12th rib. The posterior surfaces of the kidneys at the top are adjacent to the lumbar part of the diaphragm, behind which are the costophrenic sinuses of the pleura, below - to the psoas major muscle, the quadratus lumborum muscle and the aponeurosis of the transverse abdominal muscle.

The adrenal glands are located above and on the anteromedial side of the upper poles of the kidneys.

Medial to the right kidney is the inferior vena cava, medial to the left is the abdominal aorta.

The anterior surface of the right kidney has fields of contact with the descending part of the duodenum (at the gate), the right lobe of the liver (almost 2/3 of the surface, the space between the kidney and liver is called Morrison's pouch), and the right flexure of the colon. The anterior surface of the left kidney is in contact with the spleen, the fundus of the stomach, the tail of the pancreas (at the gate), the left flexure of the colon and the jejunum. Anterior to the left kidney is the omental bursa..jpg" width="679" height="467"> 3 large renal calyces flow into the renal pelvis, with an ampullary - 2. Each of them is formed due to the connection of 2-3 small renal calyces, the total the number of which is often 8-10, but can range from 4 to 19. The volume of the chest is greater in men than in women.

The retroperitoneal space (retroperotonium) is located between the posterior layer of the parietal peritoneum, in front and the transverse fascia behind, extending from the diaphragm to the level of the edge of the pelvic bones. The retroperitoneum is divided by the layers of the renal fascia into three sections, which are named according to their relationship to the kidney - anterior pararenal, perirenal and posterior pararenal. The perirenal (around the kidney) section is delimited from other sections of the retroperitoneal space by the perirenal fascia and contains the kidneys, renal vessels, ureter, adrenal glands and adipose tissue. The perirenal fascia fuses posteriorly and medially with the muscular fascia m.psoas,m.Guadratus lumborum. It then spreads behind the kidney in a layer of two layers, which is divided into a layer covering the anterior surface of the kidney in the form of the anterior perirenal fascia (Gerota's fascia) and a thickened posterior layer (Zuckerkandl's fascia). The latter continues further in the form of the lateroconal fascia, then merges with the parietal peritoneum. The thickness of the fascia is approximately 1 mm, in some places 3 mm. There is no communication between the right and left perirenal sections in most cases due to the fusion of the anterior perirenal fascia along the midline with the dense connective tissue surrounding the large vessels. Sectional studies, however, have shown that fluid can pass through the midline at the level of 3-4 lumbar vertebrae through a narrow canal ranging in size from 2 to 10 mm. The perirenal section is filled with perirenal tissue: adipose tissue separated by a network of connective tissue plates. There are several groups of connective tissue plates:

Group 1: between the kidney capsule and the perirenal fascia;

Group 2: the plate surrounding the outer surface of the kidney and fused with its capsule is called the renal-renal septum;

Group 3: between the anterior and posterior fascia;

Group 4: plates located between the groups described above;

Such a complex organization of the perirenal region helps prevent the spread of diseases from one side to the other. However, it is believed that free communication between the perirenal and pararenal sections and the spread of liquid and gas in tumor and inflammatory conditions beyond the perirenal section are possible.

Topographic anatomy of the ureters and bladder. Ureter, ureter is a paired organ located in the retroperitoneal space and subperitoneal tissue of the small pelvis. Accordingly, it is divided into the abdominal section and the pelvic section. The length of the ureter in men is 30-32 cm, in women it is 27-29 cm. The right ureter is shorter than the left by about 1 cm. About 2 cm of the length of the ureter falls on the intravesical part, and the ratio is the length of the intramural and submucosal segments. There are three narrowings in the ureter, the location of which is important when the stone passes through the ureter: at the junction of the pelvis into the ureter - in the ureteropelvic segment (UPS), at the intersection with the iliac vessels at the entrance to the small pelvis and near the urinary ureter. The lumen of the ureter in narrowed areas has a diameter of 2-3 mm, in expanded areas it is 5-10 mm.

The projection of the ureter on the anterior abdominal wall corresponds to the outer edge of the rectus abdominis muscle, on the lumbar region - the line connecting the ends of the transverse processes of the vertebrae. The ureter is surrounded by fiber and layers of retroperitoneal fascia; through the fascia it is quite closely connected to the parietal peritoneum by connective tissue bridges. In the retroperitoneal space, the ureter lies on the psoas major muscle with its fascia; above the middle of this muscle, the ureter crosses the testicular vessels in men and the ovarian vessels in women, located posterior to them. At the terminal line of the pelvis, the right ureter crosses the external iliac artery, the left ureter crosses the common iliac artery, located anterior to them. Inwardly from the right ureter is the inferior vena cava, outwardly - the inner edges of the ascending colon and cecum, anteriorly and upwardly - the descending part of the duodenum, anteriorly and inferiorly - the root of the mesentery of the small intestine. Medial to the left ureter is the abdominal aorta, lateral to the inner edge of the descending colon, in front and supero-small intestine, in front and below is the root of the mesentery of the sigmoid colon, the intersigmoid recess of the peritoneum. In the pelvic region, the ureter, adjacent to the side wall of the male pelvis, crosses the iliac vessels, approaching the bladder, bends anteriorly and inwardly, passes between the posterior wall of the rectum outward from the vas deferens, crossing the latter at a right angle, then goes between the bladder and seminal bubbles and in the bottom area pierces the wall of the bladder from top to bottom and from outside to inside

Located on the lateral surface of the female pelvis, the ureter goes anterior to the internal iliac artery and the uterine artery extending from it, then at the base of the broad ligament of the uterus at a distance of about 1.5-2.5 cm from the cervix it once again crosses the uterine artery, passing behind it. The ureter then goes to the anterior wall of the vagina and flows into the bladder at an acute angle.

Bladder,vesica urinaria, has the shape of an ovoid with a capacity of 200-250 ml in men, 300-350 ml in women. The capacity of the bladder can reach 500-600 ml, in pathological conditions - 1 liter or more. The urge to urinate occurs when the bladder volume is 150-350 ml. The bladder consists of an apex, a body and a neck, which passes into the urethra. In the bottom area, the vesical triangle (Lieto) is distinguished, which is a smooth section of the mucosa, devoid of a submucosal layer, the apex of which is the internal opening of the urethra, and the base is formed by the interureteric fold - a transverse ridge connecting the mouth of the ureters. The prostate gland is adjacent to the bottom of the bladder, surrounding the neck of the bladder and the beginning of the urethra. In women, the bottom of the bladder is located on the urogenital diaphragm. Posterior to the bladder is the uterus and in the subperitoneal space is the vagina.

One of the complications of acute, predominantly purulent pyelonephritis, as well as chronic pyelonephritis, is paranephritis, an inflammatory process in the perinephric tissue. Depending on the location, paranephritis is distinguished: anterior, posterior, and superior. lower and total. Diagnosis of paranephritis sometimes presents significant difficulties. Timely detection of o. paranephritis is often crucial in preserving the kidney. In case of paranephritis, a hypo- or anechoic focus without clear contours is found near the kidney, which is often mistaken for a formation unrelated to the kidney or a tumor, especially when the inflammatory process is latent. It should be borne in mind that when about. paranephritis, kidney mobility is sharply limited or absent. In chronic paranephritis, ultrasound examination reveals a heterogeneous echostructure of fatty tissue, gas bubbles and liquid. Gerota's fascia becomes indistinct or thickened, and sometimes becomes displaced.

In the anterior pararenal section of the retroperitoneal space there is the pancreas, the retroperitoneal section of the 12th finger. intestines, retroperitoneal segments of the ascending and descending colon, roots of the mesenteries of the small and transverse colon. When Fr. In pancreatitis, fluid rich in proteolytic enzymes can spread upward to the dome of the diaphragm posterior to the abdominal esophagus and diaphragmatic esophageal ligament, allowing the formation of mediasthenic pseudocysts. Exudate can spread down into the iliac region, into the prevesical, perivesical and presacral spaces, it may spread along the rectum, round ligament or vas deferens and femoral canal. A small amount of fluid in the anterior pararenal space during o. pancreatitis may be mistaken for anterior paranephritis.

Quite often whenWhen the kidney capsule ruptures, blood spreads into the perinephric tissue. CT is considered the method of choice in this case; however, ultrasound examination also clearly shows subcapsular hematomas and violations of the integrity of the renal parenchyma. Energy mapping (ED) helps in assessing renal perfusion and identifying avascular areas. This is particularly helpful in the search for segmental infarcts when the segmental renal vessels cannot be clearly differentiated. A subcapsular hematoma on ultrasound appears as a crescent-shaped collection of an- or hypoechoic fluid under the kidney capsule. With deep ruptures of the parenchyma, the leakage of urine leads to the appearance of a formation that is heterogeneous in structure (urohematoma) with an anechoic liquid component (urine) and low-echoic clots. With intracavitary hematoma, clots can also appear in the pelvis, ureter and bladder. Indications for ultrasound examination in case of kidney injury are macrohematuria (more than 5 red blood cells in the visual field), hypotension (systolic pressure less than 90 mm Hg), as well as the presence of associated injuries.

Gap The bladder can be extraperitoneal, when there is no damage to the peritoneum covering the bladder, and intraperitoneal, when, due to a rupture of the bladder wall and peritoneum, urine enters the abdominal cavity. Ultrasound examination of an extraperitoneal rupture visualizes a fluid formation delimited by the peritoneum and the wall of the bladder. The wall of the bladder appears collapsed, and in some cases a rupture site can be found in it. With an intraperitoneal rupture in the abdominal cavity, free acoustically transparent liquid (urine) is detected; the bladder can empty almost completely into the abdominal cavity. When bleeding from the wall of the bladder (as well as from the upper urinary tract), clots are found in its lumen, which look like low-echoic structures that move when the patient’s body position changes. If the clot is fixed, it may be indistinguishable from a papillary bladder tumor. With CDK, the presence of vascularization can be detected in the tumor, which is not typical for a clot.

RENAL COLIC (acute obstructive uropathy)

Among the causes of renal colic, urolithiasis makes up 66.3%, gynecological diseases (infiltrates in the parametrium, space-occupying formations compressing the ureter) - 16%, pyelonephritis - 6.4%, kidney tumors - 4.3%, kidney tumors - 4.3 %, kidney injury with a blood clot in the ureter - 0.5%, etc. 3.8%.

The term “colic” refers to severe, sometimes cramping pain that occurs during acute obstruction of a tubular organ. Renal colic is an acute painful attack caused by a sharp disruption of the outflow of urine and hemodynamics in it. Renal colic, which occurs during acute obstruction of the upper urinary tract as a manifestation of acute congestive kidney, occurs in 1-2% of the population. In the structure of urgent pathology, renal colic ranks second after acute appendicular pain. The onset of an attack is often provoked by physical activity and excessive fluid intake. Characterized by lower back pain, nausea, and bradycardia. Patients are restless, constantly looking for a body position that will relieve pain, and this differs from patients with pathology of the abdominal organs, for whom a state of absolute immobility brings relief. Changing the patient's body position and "wild dancing" allows in some cases to unblock the ureter and relieve renal colic. This is usually accompanied by the disappearance of pain and the appearance of cloudy, flaky, dark urine. In urine analysis: red blood cells, protein, salts. Then the ureter can be blocked again and the attack repeats again. The strength of the attacks, as a rule, decreases as the stone moves downwards; in some cases, an imaginary recovery may occur.

There are certain features in the clinical picture with different localization of stones. Ureteral stones of any location are characterized by pain in the region of the costovertebral angle, which is associated with the expansion of the renal collecting system and stretching of the renal capsule, as well as swelling of the perinephric tissue. (see echograms No. 1,2,3)

With obstruction of the ureteropelvic segment, pain may radiate forward and into the upper quadrant of the abdomen.

Concretions in the upper third of the ureter cause pain along the ureter and lead to testicular hypersensitivity.

As the stone moves down, in the middle third of the ureter, the pain shifts to the middle lateral and lower quadrant of the abdomen.

With a calculus of the third ureter, pain radiates to the sacrum or testicle in men and the labia majora in women.

Stones in the intramural ureter cause dysuria, pain in the tip of the penis and above the pubis. For ultrasound examination in the last 2 levels, it is desirable to use a vaginal or rectal sensor. Ultrasound examination identifies stones as hyperechoic structures in the lumen of the ureter, often producing an acoustic shadow. The ureter above the stone is in most cases dilated, its diameter, as a rule, does not exceed the transverse size of the stone. It is better to begin an ultrasound examination of the ureter in renal colic with an examination of its third orifice and pelvic region; this can easily be done with a full bladder. Then it is necessary to inspect the v/3 and c/3 ureters. An ultrasound examination of the ureter may detect not only stones, but also salt conglomerates. They appear as elongated stones with a length to thickness ratio of more than 2:1. The passage of salts through the ureter occurs quite quickly, already 2-3 hours after the onset of the attack it is clearly visible in the ureter. Such a “calculus” seems to dissolve when it enters the bladder, leaving behind only salts in laboratory urine tests.

Renal colic must be differentiated from acute abdominal syndrome and neurological pathology. The most common reasons are: o. appendicitis, o. pancreatitis, o. cholecystitis, viral hepatitis, o. intestinal obstruction, o. endometritis, ovarian apoplexy, ectopic pregnancy, lumbar osteochondrosis, lumbodynia, etc. If diagnosed untimely, renal colic can be complicated by pyelonephritis and bacteremic shock. Therefore, improving methods for diagnosing renal colic is very important. An ultrasound examination must be done as soon as possible after the patient visits a medical institution. Since renal colic is an acute form of acute congestive kidney. the main symptom is the expansion of the renal cavity system at the height of clinical manifestations. You can observe an increase in the size of the kidney. an increase in the hydrophilicity of the parenchyma, which explains the presence of venous stasis in it, sometimes a halo of sparseness around the kidney due to edema of the perinephric tissue. In the case of an erased picture of renal colic in the presence of a “valve” stone, dilatation of the maxillary sinus and ureter may be minimal. To identify “hidden” obstruction, a diuretic stress test is used, which is recommended as 40 mg of furosemide and about 0.5 liters of fluid with repeated testing when pain increases and there is a pronounced urge to urinate or intravenous administration of 2-4 ml of a 1% Lasix solution. This achieves increased expansion of the ureter, determination of the level of the block and visualization of the calculus.

Difficulties arise in the presence of incomplete obstruction and the consequence of this is a slightly dilated CL and ureter. If it is impossible to perform a study with a diuretic load, a study with a full bladder is recommended. Recently, to clarify the severity and presence of obstruction, the Doppler method has been used. An increase in vascular resistance is expressed in a decrease in the diastolic component on the Dopplerogram in the parenchymal vessels of the kidney and an increase in the resistance index, which was discussed in research papers. To diagnose obstruction, a resistance index value of more than 0.7 and a difference in values ​​between the healthy kidney and the kidney on the obstructed side of more than 0.1 were used. These results work only in the presence of complete obstruction, while in case of incomplete obstruction the results remain questionable. Another factor that reduces the advantages of Doppler diagnostics is the increase in peripheral resistance indices in the vessels of the kidney with age. Also, non-obstructive conditions that cause dilatation of the cervical joint can be combined with stone obstruction. Another criterion widely used in the diagnosis of obstruction is the absence or change in the characteristics of the ureteral discharge on the side of the obstruction. The release of urine into the bladder is accompanied by the formation of a moving stream, which can be recorded using Doppler technology. With complete obstruction, there is a complete absence of ureteral emissions on the affected side; with incomplete obstruction, emissions may be slow or weakened compared to the healthy side

Timely Ultrasound diagnosis of acute congestive kidney allows urgently to provide the necessary assistance and prevent the transition to the serous stage O. pyelonephritis into purulent. If purulent pilonephritis (kidney abscess) is detected, urgent surgical intervention is necessary: ​​open surgery or puncture of the abscess under ultrasound control and its drainage. With purulent pyelonephritis, anechoic foci are detected in the parenchyma of the kidney, which, depending on their volume and nature, can be an aposteme, carbuncle or abscess (see example). Such a terrible disease as pyonephrosis can occur. The echo picture of pyonephrosis is characterized by the presence in the lumen of the dilated collecting cavities of floating echogenic inclusions (thick pus, microliths, clots, gas bubbles). With CDK and ED, there is depletion or complete absence of the vascular bed with purulent pyelonephritis. With ID of the renal arteries in an acutely congestive kidney, usually caused by obstruction of the upper urinary tract by a stone and complicated by purulent pyelonephritis, it sharply increasesS/D,IR,PI (on WedS/Dequals 5.1+0.8;IR-0/81+0/01;PI-1.89+0.12) . However, an increase in Doppler indices is also observed in hypertension, diabetes mellitus, and other pathological conditions of the kidney. A carefully collected medical history before an ultrasound helps here.

All tubulo-interstitial diseases, systemic diseases with kidney damage, congenital forms of nephropathy, vascular diseases, obstructive lesions of the upper urinary tract can lead to the development of nephrosclerosis, and, consequently, to renal failure - a decrease in renal function, leading to disruption of homeostasis. Depending on the speed of their development and severity of manifestations, they speak of acute or chronic renal failure.

Acute renal failure. The pathogenesis of acute renal failure is based on cortical ischemia with increased blood flow to the medulla. By opening the shunts, blood flow is discharged through the renal pyramids, bypassing the cortex. Due to vasoconstriction, peripheral vascular resistance increases, which causes changes in Doppler examination. In patients with acute renal failure, a typical echo picture is revealed, which is characterized by: an increase in the size of the kidney, thickening of the parenchyma, increased echogenicity, compression of the renal sinus, significant expansion of the pyramids, which are contoured against the background of the echogenic renal parenchyma. Assessment of the thickness and echogenicity of the renal parenchyma and its cortex are of great importance in terms of prognosis of acute renal failure. Normally, the thickness of the parenchyma should be more than 1.0 cm. It is measured from the outer edge of the renal pyramids to the renal capsule. The echogenicity of normal renal parenchyma should be slightly lower than that of the liver. A sharp increase in echogenicity will indicate the development of an intrarenal form of acute renal failure. At the stage of oligoanuria, maximum expansion of the renal pyramids is observed. At this stage, compression of the renal sinus and depletion of cortical blood flow are also significantly expressed, which is expressed by the lowest values ​​of the resistance index in the renal vessels. With anuria, the resistance index can reach 1.0. Systolic blood flow velocity also changes. The acceleration time of the arterial flow decreases, the blood flow is pulsating in nature, the time of effective blood supply to the kidneys is sharply reduced. Due to the increase in parenchymal edema, the volume of the kidney increases, the shape of the cross section approaches round, the thickness of the cortical layer is maximum, the diameter of the pyramid is minimal. In the stage of polyuria, a gradual expansion of the renal sinus occurs with the appearance of dilated calyces, and the thickness of the parenchyma decreases. The blood flow velocity in the renal arteries increases slightly, however, the diastolic blood flow velocity increases, the resistance index decreases, and the perfusion of the cortical layer improves.

Conclusion. The use of ultrasound diagnostics of kidney diseases undoubtedly has great prospects both in expanding the scope of their application and in deepening existing knowledge in this area. Using ultrasound data, it becomes possible not only to establish a diagnosis, but to predict the course of the pathological process, and judge the effectiveness of conservative and surgical treatment.

Literature:

, "Ultrasonography Dopplerography in

diagnosis of kidney diseases" 2005

, R. Owen, S. I Pimanov “Ultrasound research in

"Abdominal echography" 2006

. "Diagnostic ultrasound.

Uronephrology"