Percutaneous diagnostic and bile diverting interventions in patients with obstructive jaundice. Traumatic injuries of the abdominal cavity

The date: 29.06.2020

Ultrasound semiotics of biliary tract lesions

Normal ultrasound scan of the biliary tract

The gallbladder is located under the right costal arch and is mainly covered by the liver. Below it is the transverse colon and the right flexure of the colon. These three structures - the liver, costal arch, and colon - serve as landmarks for ultrasound examination of the gallbladder. The liver is used as an ultrasound window, and the costal arch and colon make it difficult to examine the gallbladder. The window for imaging the gallbladder is very small

The biliary system, examined by echography, is represented by the bile ducts and the gallbladder. The bile ducts are subdivided according to anatomical and functional characteristics: intrahepatic and extrahepatic. Intrahepatic ducts include lobular, subsegmental (of various grades), segmental, lobular. The extrahepatic ones include the common hepatic duct, the common bile duct (common bile duct), and the gallbladder duct. The intrahepatic bile ducts are located in the hepatic triad and accompany the intrahepatic branches of the portal vein and hepatic artery. The intrahepatic bile ducts have thin walls, represented mainly by connective tissue with predominantly elastic fibers, a thin muscle layer and endothelium. Their inner diameter is very small and begins to gradually increase in the direction of the common bile duct. At the same time, some thickening of their walls is noted. Small lobular ducts, merging with each other, form subsegmental, then segmental, lobar and finally, the common hepatic duct. In most cases, the length of the common hepatic duct does not exceed 1.5-3 cm.The gallbladder duct, which has a small (up to 1-2 mm) inner diameter and variable length (from 2 to 6 cm), thin walls and several kinks, flows into the common hepatic duct in the gates of the liver, forming together with the latter a common bile duct. The structure of the walls of the extrahepatic bile ducts is somewhat different from that of the intrahepatic ones, due to the greater amount of elastic connective tissue in their composition. The common bile duct is located in the hepato-duodenal ligament, occupying in most cases the upper - lateral position with the transition to the lower - lateral surface of the ligament in its middle third, however, in some cases, the common bile duct can be located along the medial surface of the ligament in place of the hepatic artery. The common hepatic duct may be so narrow that it is barely visible along a nearby artery. Its normal clearance should not exceed 6 mm. After resection of the gallbladder, it partially takes over the reservoir function and can expand up to 9 mm, which is not a sign of pathology. The bile duct, dilated to a borderline value (obstructive jaundice), can no longer be distinguished from neighboring vessels by the size of the inner diameter, but only by its position anterior to the portal vein. It is very important to display the image of the bile duct in the longitudinal direction to exclude intraductal calculi.

The technology for examining the biliary system involves scanning in several planes - longitudinal, transverse and oblique. Mutually perpendicular slices allow visualizing various departments and structures along their length and diameter, which is important for making a correct diagnosis. In addition to the most common access to the structures of the biliary system - from under the right costal margin - there is access to visualization of the gallbladder neck, the main lobar and common hepatic duct through the intercostal spaces along the anterior axillary line on the right.

In addition to static studies that provide information about morphology, functional studies can also be carried out. Due to the fact that such studies involve the assessment of dynamic phenomena, they significantly expand the diagnostic capabilities, allowing you to obtain information about the functions of the organ.

Any novice specialist with an ultrasound examination of the gallbladder faces certain difficulties. It should be borne in mind that in addition to the lack of experience, the constitutional characteristics of the patient also affect the quality of the examination:

· Small cross-section of the gallbladder;

· The imposition of gases formed in the lumen of the large intestine on the cut of the gallbladder;

· Contraction of the gallbladder;

· Features of the topography of the gallbladder;

· Under the costal arch;

· To the left of the midline;

· Along the midline;

· Transversely;

Omission or dystopia in the right iliac region;

Partial or complete immersion in the hepatic parenchyma;

In the anterior abdominal wall, falciform ligament, anterior to the liver and retroperitoneally.

Rice. 1.One of the options for the image of the anatomical and topographic relationship of the gallbladder (GB), duodenum (DUO) and pancreas with oblique scanning along the right costal arch.

The best for the study of the biliary system are the frequencies of the sensors 3.5-5 MHz or multi-frequency and broadband sensors, which allow obtaining the highest quality image in a wide range of frequencies. Frequencies of the order of 3.5 MHz allow obtaining the best image at a great depth - from 12-15 to 22-24 cm. Frequencies of the order of 5 MHz provide good image quality at a shallow depth of 4-5 to 10-12 cm.

Preparing a patient for an ultrasound examination of the biliary system is of great importance, especially if there are any abnormalities in the structure, location, size of the organ or in the presence of pathology. The main conditions for achieving high information content of research is the observance of the rules of nutrition and the study regime. For a successful ultrasound scan, the patient must comply with the following diet: exclusion from the diet for one and a half to two days of vegetables, fruits, black bread and dairy products that cause intestinal distention undesirable for the study, limiting the amount of plant juices per day before the study. The gallbladder is examined on an empty stomach; before the procedure, the patient should also not drink coffee and smoke (factors that provoke the contraction of the bladder). As with the examination of the liver, the patient's right arm is raised up. Also, ask him to "puff up his belly." In cases where the study is not carried out in the morning or in patients with insulin-dependent diabetes mellitus, it is possible to eat unsweetened tea and dried white bread. If the patient has a dysfunction of the intestine or any disease of the intestines or organs of the digestive system, it is advisable to carry out medical correction before the study. Regardless of the presence or absence of acute and chronic dysfunctions or diseases, all patients are shown the appointment of cleansing enemas on the day preceding the study, if there are no contraindications for the nature of the disease and the patient's condition.

To obtain a satisfactory image of the gallbladder in most cases, in addition to the appropriate preparation of the patient, it is sufficient to scan in three planes from the side of the right hypochondrium - oblique, longitudinal and transverse. In oblique scanning, the transducer slides along the costal arch. With this arrangement and giving the sensor different angles of inclination from 0 ° to 90 °, it is possible to study the gallbladder in transverse and oblique sections

Position the transducer in a cross-sectional position under the right costal arch approximately at the midclavicular line. Point the transducer upwards into the liver tissue, then tilt it slowly from top to bottom. You will first see the portal vein

Figure 2 - Probe tilted downward: liver, vena cava and portal vein (Vp)

(2), then the gallbladder appears as an anechoic formation with smooth contours and distal acoustic enhancement (Fig. 3).

Fig. 3 The sensor is tilted even lower. A section of the gallbladder is visible (Gb).

On ultrasound examination, the gallbladder has an anechoic structure, distal acoustic enhancement and smooth contours. The gallbladder is located in most cases in the main interlobar sulcus along the ventral surface of the liver. In the gallbladder, several sections are distinguished - the bottom, the body, the neck (including the Hartmann's pocket "- an expansion in the cervical part of the gallbladder, usually facing the gate of the liver.) The walls of the gallbladder consist of several layers (mucous, muscular, subserous and serous membranes Normally, the gallbladder cavity contains liquid bile.After eating, there is a gradual contraction of the gallbladder, leading to a change in its shape, size and wall thickness.

In longitudinal scanning, the sensor is positioned along the long axis of the body near the midclavicular line under the right costal arch.

Rice. 4. Sections of the gallbladder. F - bottom, Kp - body, KI - neck, I - funnel

The thickness of the wall of the gallbladder is not the same in all departments - for example, in the region of the neck, the walls have a large visible thickness due to the difficulty of differentiating them from the surrounding adipose tissue. The image of the shape of the gallbladder depends on the direction and level of the cut. With a longitudinal section, in most cases, the shape of the gallbladder resembles a pear-shaped, less often ovoid, with a narrowing in the neck. The length of the gallbladder in adults normally ranges from 60 to 100 mm. Cross-section - usually does not exceed 30 mm. The area of the maximum cut of the gallbladder along the length usually does not exceed 15-18 square meters. cm. In cross-section, the gallbladder usually has a rounded shape. The image of the gallbladder also depends on the class of the ultrasound device used for the study.

Rice. 5. Visualization of the gallbladder in longitudinal section: lateral section of the gallbladder (Gb). Its typical location on the visceral surface of the liver is visible (L);

Light areas of the ultrasound reflection behind the gallbladder are due to the presence of gases in the duodenum;

In addition to these techniques, it is also advisable to use access through the intercostal space along the anterior axillary and midclavicular lines. In these cases, the sensor is located along the intercostal space and by changing the angle of its inclination there is a possibility of good acoustic access to the right lobe of the liver, the gate, the bed of the gallbladder. Such access is especially effective in obese patients and with severe flatulence. The limitation is usually the presence of pulmonary emphysema in the patient.

Using a planimetric technique, the maximum longitudinal sectional area is measured by scanning points along the circumference of the gallbladder.

Rice. 6 Planimetry of the gallbladder to determine the maximum longitudinal sectional area.

Rice. 7 Ultrasound planimetry of the gallbladder to determine the maximum cross-sectional area. L - liver, GB - gallbladder.

Abnormalities in the development of the gallbladder

Several groups of conditions belong to gallbladder anomalies:

1) shape anomalies (kinks, partitions);

2) anomalies of position (“intrahepatic”), interposition, inversion, dystopia, rotation);

3) quantity anomalies (agenesis, doubling, diverticula):

4) size anomalies (hypogenesis, giant gallbladder).

The duct of the gallbladder (d. Cysticus) in the overwhelming majority of cases is not visualized due to its small diameter and peculiarities of its location - against the background of the gate of the liver. In those cases when it is possible to differentiate the duct of the gallbladder, its echographic picture is represented by a tubular structure with thin hyperechoic walls, "merging" with the surrounding adipose tissue. Of all the intrahepatic bile ducts, normally only the main lobar ducts are usually visualized, detected anterior to the bifurcation of the portal vein. They also have highly echogenic walls and a small diameter - from 1 to 4 mm. Differentiating the ducts from other tubular structures usually does not present significant difficulties if all signs are taken into account, including exploration "over the course" - ie. tracing the further course of the tubular structure in both directions. Modern methods of color and pulsed Doppler studies make it possible in most cases to easily differentiate these structures by the presence or absence of the color signal of the Doppler spectrum.

Rice. 8. Echographic image of a transverse section of the hepato-duodenal ligament at the level of the liver hilum in the position of oblique scanning, the view of “Mickey Mouse's head”. RK - right kidney, GB gallbladder, CBD - common bile duct. HA-hepatic artery, PV - portal vein, IVC - inferior vena cava.

The extrahepatic bile ducts are well visualized almost throughout, with the exception of the retroduodenal section. However, the quality of their visualization directly depends on the quality and class of the ultrasound diagnostic device and the echo-negative lumen, with a diameter of 4 mm to 6-8 mm. Of the features of the location, it should be noted the retroduodenal location of the middle third of the common bile duct, which leads to difficulties in visualization during the study. At the same time, the terminal part of the common bile duct, located in the thickness of the head of the pancreas or along its posterior surface, is usually visualized quite clearly.

In recent years, new methods of ultrasound research have been developed, for example, endoscopic ultrasound diagnostics - an ultrasound examination of the biliary system using specialized transducers, which are a combination of an endoscopic probe with an ultrasound transducer. Such techniques make it possible to obtain images of the extrahepatic bile ducts from the access through the duodenum, which is especially important for a more accurate diagnosis of choledocholithiasis with the localization of calculi in the retroduodenal part of the common bile duct or its tumor lesion. The same version of the study includes a direct study of the common bile duct using an ultrathin ultrasound probe inserted directly into the lumen of the duct through its mouth from the side of the Vater's nipple.

Article I.

Article II.

Article III.

Section 3.01

Sonographic signs of bile stasis

A dilated duct (greater than 9 mm in diameter) always becomes visible anterior and lateral to the portal vein. Even when the distal segment of the common bile duct is obstructed by duodenal gas, proximal intrahepatic obstruction (eg, in liver metastases) can be distinguished from distal obstruction (eg, nipple calculus, omentum lymphadenopathy, or pancreatic cancer). In proximal obstruction, neither the gallbladder nor the common bile duct is distended.

Rice. 9. CBD dilated common bile duct; STONE gallstone in the area of Vater's nipple; SHADOW distal acoustic stone shadow.

Small intrahepatic bile ducts are parallel to the branches of the portal vein and are not normally visible. They become visible along the portal veins when the bile ducts dilate with obstruction and the double-barreled gun symptom appears.

Rice. 10. Echographic picture of one of the variants of cholelithiasis - small stones in the intrahepatic ducts of the left lobe of the liver.

In the differential diagnosis of mechanical (duct dilatation) and parenchymal (no duct dilatation) jaundice, the efficiency of sonography reaches 90%. It is characteristic that severe obstruction of the biliary tract causes a tortuous expansion of the intrahepatic bile ducts (66), which can take the form of antlers.

Gallbladder enlargement

A large gallbladder discovered during the study may turn out to be one of the variants of the norm. In general, the causes of an increase in the gallbladder can be: starvation, atony (for example, with diabetes mellitus, old age, dropsy of the gallbladder, empyema of the gallbladder).

Rice. 11. Echographic picture of one of the variants of complications of cholelithiasis, dropsy of the gallbladder against the background of infringement of the only calculus in its neck.

If the examination reveals that the cross-section of the gallbladder exceeds 4 cm, then there is a reasonable suspicion of the presence of some kind of pathology.

Cholestasis can increase the viscosity of bile, leading to the precipitation of cholesterol or calcium crystals. This so-called sludge. It can also occur after prolonged fasting without obstruction of the biliary tract. Thick (up to putty) bile also sometimes interferes with correct diagnosis, because either it simulates conglomerates of small and, less often, medium-sized calculi (in extremely rare cases, an acoustic shadow or weakening effect behind the clot can be detected - in the absence of real calculi in it), or "sticks together" the calculi. what you need to make additional sections, turn the patient, shake the area under study.

The ultrasound criteria for gallbladder sludge are:

Hyperechoic sediment
Education level
Mobility

Gallbladder sludge should be differentiated with gallbladder "sand", ray thickness artifact, gallbladder empyema, acute and chronic cholecystitis. When the entire cavity of the gallbladder is filled with sludge, the phenomenon of echogenic bile occurs with the absence of a free cavity.

Fig. 14. Echogenic gallbladder. The gallbladder is completely filled with echogenic sludge (S1). There is no distal acoustic shadow. L - liver.

For biliary obstruction, decompression of the biliary tree can be done by placing a biliary stent during ERCP. In addition, a percutaneous transhepatic catheter can be inserted into the bile duct.

Gallbladder shape options

Assessing the shape of the gallbladder is more informative than determining the size. With the accumulation of experience, one's own impression arises about the options for the shape of the gallbladder. Most often, it is in the shape of a pear. In addition, there are options for a round, oblong gallbladder, a bladder with kinks. When bent at the bottom, the bubble takes the shape of a "Phrygian cap". This is the name of a tall cone-shaped cap, the top of which is bent forward.

Fig 15. "Phrygian cap": bend of the gallbladder in the bottom;

Section 3.01

Calculous and acalculous cholecystitis, gallbladder polyps

The prevalence of cholestasis is about 15%, with older women being affected more often. Clinical manifestations: episodes of severe, colicky pain caused by contractions of the gallbladder. The cause is stones that interfere with the patency of the bile ducts, which leads to an increase in pressure inside the gallbladder. Pain often occurs after a meal and persists for 1-4 hours (residual symptoms may occur within 24 hours). Vomiting is common, and jaundice may develop if the duct is blocked. The appearance of a fever indicates the development of a complication.

About 80% of gallstones do not manifest clinically and are detected only in connection with the complications they cause (cholecystitis, cholangitis, colitis, obstructive jaundice).

Gallstones are formed in the gallbladder due to changes in the composition of the secreted bile. Depending on their composition, gallstones can transmit sound almost entirely, float in the gallbladder (cholesterol stones) or, if the calcium content is high, reflect sound to such an extent that only the front surface is visible. Gallstones are the most common abnormal finding on ultrasound examination of the upper abdomen. The number of stones and their size vary widely. The classic ultrasound signs of a stone are the reflection of the echo signal from it in the anechoic cavity of the gallbladder, the distal acoustic shadow and the mobility of the stone when the patient's position changes.

Single stones are usually clearly identified on examination. On the contrary, with the simultaneous presence of large, medium and small stones, it is usually not possible to correctly estimate the size and number of stones, since small and medium stones fall into the shadow of larger ones. There are cases when the gallbladder is almost completely filled with calculi - in this situation, the cavity of the gallbladder is not detected and the stones are so closely adjacent to each other that it is impossible to determine their number and size (the situation is further aggravated by shrinking of the gallbladder)

The smallest stones are able to form the so-called "sand" of the gallbladder. Unlike sludge, it is a sediment with particles that give a distal acoustic shadow.

Rice. 18. Sand of the gallbladder. An echogenic sediment that produces an acoustic shadow.

As mentioned earlier, stones with a high cholesterol content are capable of transmitting ultrasonic rays to some extent and have a distinguishable structure; with a large proportion of calcium, the surface of the stone reflects ultrasound more strongly. However, it is not possible to reliably assess the composition of the stone based on the research data.

The calculus is best differentiated when it is surrounded by fluid on three sides. Moving calculi and calculi located in the body and the bottom, usually come to light without complications.

The most difficult to find stones of the funnel and the bottom of the gallbladder, as well as stones located in the sclerosed gallbladder. In addition, the area of the gallbladder funnel is often not fully inspected, and ultrasound phenomena can sometimes be observed that resemble a distal acoustic shadow behind the stone.

Rice. 19. Stone of the funnel of the gallbladder, giving a distal acoustic shadow (v). Stones of such localization are easy to miss.

This is due to the presence of a significant amount of connective and adipose tissue in this place around the neck of the gallbladder, which prevents a clear separation of the stone and in itself can create a weakening or acoustic shadow effect.

Rice. 20. Stone at the bottom. In some cases, a stone can be mistaken for gas in the colon.

At the same time, a novice specialist can, among other things, confuse gas in the duodenum with a gallbladder stone.

Rice. 21. Cholesterol gallbladder stone (v) with inhomogeneous structure. Small residual cavity. S - distal acoustic shadow, Lu - gases in the duodenum.

The reasons for a false-positive diagnosis of a gallbladder stone are considered to be: gas in the duodenum, the marginal shadow behind the cyst, an artifact in the neck of the gallbladder, polyps.

A stone is diagnosed if an echogenic structure, unlike a polyp, is displaced along the wall of the gallbladder when the position of the patient's body changes. Some stones remain fixed to the wall of the gallbladder due to inflammation or are fixed in the neck, making it difficult to differentiate from polyps. An acoustic shadow behind such a formation indicates a stone. The marginal effect of the gallbladder wall must be carefully differentiated from the shadow formed by the gallstone to exclude misdiagnosis.

Often there are polyposis changes in the wall of the gallbladder. Cholesterol polyps are visualized as semicircular hyperechoic protrusions of cholesterol deposits, the size of which does not exceed a few millimeters. Polyps have no distal acoustic shadow.

Fig. 22. Cholesterol polyps (v). Hyperechoic outgrowths into the gallbladder cavity, not giving a distal acoustic shadow.

Polyps should be monitored and their growth rate determined to rule out malignancy.

Adenomas and gallbladder cancer. Gallbladder adenomas are rare. As a rule, they are larger (> 5 mm), smooth or uneven protrusions of moderate echogenicity. Large adenomas (> 10 mm) are often difficult to distinguish from cancer.

Rice. 23. Cancer of the gallbladder. Inhomogeneous thickening of the wall, blurring of the zone bordering on the liver, the tumor grows into the liver. In addition, cholecystolithiasis is noted.

Most often, the wall of the gallbladder changes with its inflammation - cholecystitis.

In the wall of the gallbladder, three layers are distinguished: mucous, muscular and serous membranes. Under favorable research conditions, it is possible to see all three - the hyperechoic inner and outer layers and the hypoechoic middle layer. The image of the gallbladder also depends on the class of the ultrasound device used for the study. So, on most portable devices and some middle-class devices, the wall of the gallbladder is represented by a fairly uniform thin line of moderately increased echogenicity. In contrast, on modern diagnostic devices, average and. especially, of the upper classes, the same wall is visualized already in the form of a fine structure of medium or slightly increased echogenicity, in which in some cases (especially in the phase of incomplete contraction) several layers can be distinguished.

Rice. 24. Gallbladder contracted after eating. Characterized by well-distinguishable layers of the wall (v) with a small cavity.

Even a novice specialist can determine pathological changes in the gallbladder regarding the thickness and echogenicity of its wall. Changes in the wall of the gallbladder with characteristic signs of acute edema and structural disturbances of the wall - all this is one of the most important echographic signs in an acute inflammatory process in the gallbladder. With pronounced edema, the wall thickens from 3-4 mm to 6-25 mm or more.

Rice. 25. Acute cholecystitis. Gangrene of the wall of the gallbladder.

Moreover, with the defeat of all layers of the wall, a periprocess develops around the gallbladder with the involvement of the surrounding structures (perivesical tissue, omentum, intestinal loops), which further increases the wall thickness. In the latter case, it is often impossible to distinguish between the altered wall itself and the tissues and structures involved. Due to this, the external contour of the gallbladder is often indistinct. The inner contour can also become uneven, especially in severe cases - due to local limited detachment of the mucous membrane. The echogenicity of the wall also undergoes significant changes - areas of increased and decreased echogenicity appear, reflecting a violation of the internal structure of the gallbladder wall

Fig. 26. Acute cholecystitis. Inhomogeneous, partially hypoechoic thickening of the wall (^).

Ultrasound criteria for acute cholecystitis are: tenderness to palpation in the right hypochondrium, thickening and heterogeneity of the gallbladder wall, hypoechoic rim.

In chronic cholecystitis, the wall thickness in most cases increases, it becomes heterogeneous and hyperechoic. However, ultrasound examination performed for chronic cholecystitis does not in all cases provide an unambiguous idea of the presence or absence of this disease.

Fig. 27. Chronic cholecystitis. The wall of the gallbladder is thickened and hyperechoic.

This is due, firstly, to less significant, compared with acute cholecystitis, changes in the echographic picture; secondly, with a less clear clinical picture, which sometimes does not allow one to clearly navigate in terms of the alleged changes in the echographic picture; thirdly, with the frequent discrepancy between the echographic picture and the clinic in various phases of the disease; fourth, with various variants of the disease: calculous and acalculous, hypertrophic and atrophic and other variants of chronic cholecystitis; finally, with a variety of pathological processes leading to the formation of a similar echographic picture

Fig. 28. Chronic cholecystitis. Significant thickening of the hyperechoic wall (v).

At the same time, the classic ultrasound criteria for chronic cholecystitis are considered to be: a decrease in the gallbladder, thickening of the wall, hyperechogenicity of the wall.

As complications of cholecystitis detected sonographically, it is necessary to indicate: dropsy, detachment of the mucous membrane, empyema, gangrene of the gallbladder, perivisical abscess, cholangitis, the formation of a vesicousto-intestinal or ductavo-intestinal fistula, adhesions in the gallbladder zone, calcification of its wall.

"Porcelain" gallbladder develops against the background of chronic cholecystitis with calcification of the gallbladder wall. A typical ultrasound picture is characterized by a distal acoustic shadow behind the gallbladder, while the posterior wall of the bladder is clearly visible, in the cavity of which a light suspension is determined.

Fig. 29. "Porcelain" gallbladder. Calcification of the gallbladder wall, perceived as a thin ring (^). In this case, the visible hyperechoic posterior wall of the gallbladder and the visualized cavity are typical.

In chronic cholecystitis, changes in the surrounding tissues occur with a frequently recurring inflammatory process and, as a consequence, acute cholecystitis. In these cases, there can be observed: displacement to the gallbladder of the loops of the intestine and the omentum; increased echogenicity of the gallbladder bed and moderately pronounced diffuse changes in the liver parenchyma (like chronic nonspecific hepatitis); abnormal location of the gallbladder; occasionally, in the case of a fistula, a communication between the cavity of the gallbladder and the lumen of the intestine, etc.

Differential diagnosis of chronic cholecystitis both in the phase of remission and in the phase of exacerbation, as well as the differential diagnosis of acute cholecystitis, must be carried out with a number of conditions leading to a thickening of the wall of the gallbladder and a change in the state of its cavity. These include: benign cholecystopathies; primary and secondary malignant lesions; secondary changes in the walls and cavity of the gallbladder in chronic heart failure, renal failure, hepatitis, liver cirrhosis, pancreatitis, hypoalbuminemia, portal hypertension, myeloma. fasting, etc. The main principle of the correct formulation of instrumental diagnosis is also taking into account all the revealed echographic signs, features of anamnestic and clinical and laboratory data of a particular patient and dynamic observation.

If removal of the gallbladder is indicated, laparoscopic or open cholecystectomy, wave lithotripsy, or ERCP may be performed. Moreover, the composition of bile can be changed with drugs and some stones can be dissolved.

At the present stage, there are many instrumental methods that allow assessing the state of the abdominal cavity organs, the abdominal space, as well as the pelvic organs: plain radiography, radiographic contrast study, magnetic resonance imaging and computed tomography, radioesotopic and endoscopic studies. However, these methods have a number of significant disadvantages.

Ultrasound examination is especially valuable in pediatric practice, because it has high information content, sensitivity, painlessness for the patient, it is non-invasive, does not require special preparation of the patient, the introduction of contrast agents and does not cause ionizing radiation. With its help, the state of not only narenchymal, but also hollow organs is assessed, the level of blood flow is monitored, and diagnostic or therapeutic

gradually became the main method for studying children with acute, recurrent abdominal pain, for identifying the causes of diseases that are not accompanied by pain, as well as for dynamic monitoring of children and determining the effectiveness of treatment.

In the diagnosis of diseases biliary system, both functional and pathological in nature, echography is the most accurate and safe method with which it is possible to identify not only anatomical changes in the gallbladder, but also to assess its contractile ability in dynamics. With the help of ultrasound, the state of the intra- and extrahepatic bile ducts is determined, which makes it possible to judge their inflammatory state, dyskinesias, and also to identify with high accuracy the origin of jaundice in degas, starting from the neonatal period ™.

For an echographic examination of the gallbladder, a 12-hour night fast is required, after which it has a maximum filling. This allows you to get an idea of its true size, shape, state of the walls, progression and gives information about the initial parameters for determining the contractile function.

Normally, the gallbladder on echograms has a g-shaped or oval shape, located under the liver between the right and

his left lobes. The bottom of the bladder in older children may protrude slightly from under the edge of the liver. The lumen of the bladder in the normal state is anechogenic, its anterior wall is not visualized, the distal amplification of signals is observed behind the posterior chene; with a large gallbladder along the posterior wall, an edge artifact can be determined, which does not change when the position of the body is displaced. Compaction of the wall of the gallbladder is visualized as a strong echo-dense this al. It is possible to speak about thickening of the sgenic when the thickness of its linear shape exceeds 2 mm.

When assessing the size of the gallbladder, the maximum length and width are taken into account. The size of the gallbladder is associated with age. For comparison, standard tables are used for the gallbladder, liver, pancreas, kidneys, adrenal glands and spleen, developed at the echography department of the Institute of Pediatrics of the Russian Medical Academy of Sciences of the Russian Federation.

The options for the development of the gallbladder are

changes in its shape in the form of kinks, constrictions, partitions, giving the bubble the appearance of an hourglass, a hook. The most gross anomaly of the bubble is its multiple S-shaped deformation. Bladder deformities are often congenital in nature, but they can also be acquired as a result of inflammation, due to the development of adhesions that deform the bladder.

To assess the lability of developmental anomalies, it is necessary to change the position of the body, inflate the abdomen and return the patient to the starting position.

Gallbladder liquor

assessed by comparing the size of the bladder before and 50 minutes after giving a choleretic breakfast (chicken egg yolk, xylitol). The calculation of the volume of the gallbladder is carried out using tables Polyak EZ, used in radiology. Normal contraction of the gallbladder is in the range of 33-66%; contractility of less than 33% indicates hypokinesia, and more than 66% indicates gallbladder hyperkinesia.

With acute cholecystitis ultrasound examination reveals a thickening and unevenness of the gallbladder wall; in the early stages of the disease, an echo-free layer is revealed inside this wall, which can be intermittent or continuous, the origin of the echo-free layer is associated with the presence of edema. The presence of wall layering (double contour) on echograms is a specific sign in inflammation. With dynamic observation during therapy, one can observe the disappearance of this echo-free layer and the alignment of the walls. It is believed that the presence of a thickened uneven wall, even without such lamination, is a sign of acute inflammation.

Ultrasound examination of the gallbladder with chronic cholecystitis a sharp compaction and thickening of the organ wall is determined; in some cases, the echo from the wall is intermittent with bulging into the lumen of the organ. These data are fully consistent with the results of morphological studies, since a thickened sclerosed wall reflects ultrasound much more strongly than an unchanged one. IV Dvoryakovsky notes two types of changes in the gallbladder wall in children with chronic cholecystitis: either thickening (up to 4-5 mm) or induration (strong linear impulse). This is a reflection of two degrees of the inflammatory process: hypertrophic and atrophic cholecystitis. With exacerbation of chronic cholecystitis, swelling of the mucous membrane of the bladder occurs, which leads to its even greater thickening on the echogram due to the bulging of low-amplitude uneven echo signals into the lumen of the gallbladder.

As a rule, children with chronic cholecystitis also have a decrease in the contractile function of the gallbladder. A decrease in the contractile and evacuation function of the gallbladder is considered one of the main factors leading to the precipitation of bile sediment and to cholelithiasis.

In some cases, children showed weak or located in the form of a slide near the back wall floating echoes from the contents of the gallbladder, the origin of which is associated with the presence of sediment or flakes of bile, consisting of pigment granules and crystals of cholesterol, their chemical composition is calcium bilirubium.

With gallstone disease echographically a stone,

located in the lumen of the gallbladder, is determined in the form of a strong reflected pulse, the size and shape of which corresponds approximately to the size and shape of the stone. Stones are single and multiple. Due to the strong reflection of ultrasound from the stone, the effect of an ultrasonic shadow is created - an acoustic path. The presence of an acoustic shade depends not only on the size of the stone, but also on its quality composition. So, stones with a high cholesterol content do not create a significant shadow effect. An important distinctive feature of the stone is its movement from the neck to the bottom of the bladder, associated with a change in the position of the patient's body.

Stones are best visualized when surrounded by bile. When the calculus is clamped by the walls of the gallbladder or there are so many stones that they completely fill the lumen of the bladder, displacing bile, then their recognition is very difficult. The only criterion indicating the presence of calculus can be an acoustic shadow that appears behind

a strong arcuate echo originating from the bed of the gallbladder.

Stones located in the common bile duct or in the cystic duct pose the same problem for finding them as in a contracted gallbladder, since such a stone is usually wedged between the walls of the duct and is not surrounded by bile. The diagnostic sign will be the finding of an acoustic shadow in the area of localization of the cystic or common bile duct. Visualization of an enlarged bile duct can help in making the diagnosis.

Intrahepatic bile ducts, if they are not changed, they are not visible on the echograms. However, when their walls are compacted, as well as when their lumen expands more than 1 mm, they begin to appear against the background of impulses from the liver parenchyma in the form of multiple strong paired signals of a linear configuration, indicating the presence of cholangitis and cholestasis.

Differentiation of these structures from the hepatic and portal veins is not difficult, since the hepatic veins, in contrast to the ducts, are always vertical.

When expanding common bile duct it becomes similar in size to the portal vein. As a result, the echogram shows two adjacent anechoic structures, called the "shotgun symptom".

The difference between the common bile duct and the portal vein presents a certain difficulty. Firstly, the Valsalva test can help here - holding the breath on a deep breath, causing the expansion of the ney. Secondly, the common bile duct is located longitudinally, and the portal vein is transverse; thirdly, it never crosses the midline and anatomically the duct is located in front of the vein.

With the help of ultrasound, it is possible to carry out differential diagnostics of heiasis of jaundice. The main diagnostic criterion in determining the level of obstruction is the presence of dilated intrahepatic ducts. Dilation of the common bile duct usually indicates an obstruction located below the liver. With a normal duct, the site of obstruction is most likely in the area of the liver vorog and its origin may be associated with a tumor or cirrhotic process in the liver or a tumor of the gallbladder. If, with the most careful examination, the expansion of the ducts is not detected, then the origin of jaundice is associated with intrahepatic diseases (hepatitis, cirrhosis).

The liver is an ideal organ for ultrasound examination, as it has a significant size, easy access, is located immediately under the abdominal wall, and passes well

ultrasound. When conducting ultrasound of the liver, all sections of the parenchyma, portal and hepatic veins, hepatic artery, common bile duct, diaphragm mobility should be assessed.

The liver parenchyma is homogeneous, of medium echogenicity and is a standard for comparing the density of the parenchyma of such organs as the pancreas, kidneys, and spleen.

When examining the liver, attention is paid to its size, shape, clarity and evenness of the contour, the relationship with other organs. The most accurate way to judge the size of the liver is the longitudinal section of the right lobe along the mid-clavicular line and the left lobe along the midline.

The ultrasound method is very informative in assessing the pathological conditions of the liver parenchyma. The method is most accurate in recognizing volumetric processes, cystic organ damage. To facilitate the interpretation of echograms obtained in patients with diffuse liver diseases, they have to be compared with the data of other examination methods.

At acute viral hepatitis the pathological process involves the parenchyma, the reticuloendothelial system and the stroma of the liver. In this case, alternative, exudative and proliferative processes occur, leading to the formation of foci of necrosis, dystrophy, infiltration and sclerosis, which differ acoustically from each other and from the unchanged parenchyma. The echogram is characterized by the appearance of pulses of the correct shape, medium or low amplitude, which do not merge with each other, i.e. diffuse medium- and large-dispensary compaction of the organ. Changes in the signals coming from the borders of the liver are due to the subkaisushfny location of the lesion.

significant differences in the nature of morphological changes in the organ. However, with hepatitis B, the predominant localization of pathological changes is noted in the right lobe of the liver, and with hepatitis A - in the left lobe.

At chronic hepatitis echographically in all patients there is an increase in the liver, especially in the area of the left lobe. The surface of the organ is flat, no signs of ultrasound absorption by the parenchyma are observed.

An increase in the echogenicity of an organ occurs due to the registration of multiple, differing from each other in size

(fatty liver) - outlined polyetiological characterized by increased

hepatosis

good shape,

and the amplitude of the lesions. The liver parenchyma on echograms has a "motley" color.

The number of small and large areas of compaction in different patients is not the same, but is in direct proportion to the phase of activity of the process. An increase in the number of small areas of compaction, apparently associated with the emergence in the phase of exacerbation of necrosis and regeneration of hepagocytes. Against the background of increased echogenicity of the liver, veins are clearly visualized - moderately dilated portal and normal caliber, but hepatic veins are of greater length.

Liver cirrhosis is a diffuse process characterized by chronic destruction of the normal hepatic parenchyma with its replacement by fibrous tissue and regeneration nodes. During cirrhosis, three stages can be traced: initial, formed and terminal. The initial stage, compared with chronic hepatitis. It is characterized by a more homogeneous structure of the liver. At the same time, small vessels expand, which creates a fine-mesh pattern. The absorption of ultrasound by the parenchyma increases, as a result of which the part of the liver presenting to the diaphragm is not so clearly visible. The portal vein is dilated in all parts, the hepatic veins remain normal. The splenic vein and hepatic artery expand significantly. The spleen is significantly enlarged, the echogenicity of its parenchyma remains normal.

When cirrhosis is formed, the size of the liver remains normal, the contour of the liver is even. In the liver parenchyma, multiple areas of compaction are determined, against which the severity manifests itself, caused by the expansion of small vessels and bile ducts. The absorption of ultrasound by the parenchyma is significant. The portal vein expands, its walls become thickened, the hepatic veins are narrowed due to heterogeneity of the liver parenchyma. The spleen enlarges, its parenchyma diffusely thickens. The splenic vein is enlarged, curved in the area of the vines.

At the terminal stage of cirrhosis, a decrease in the size of the liver is observed, its contour is often uneven. The level of echogenicity decreases, approaching almost normal, which can be explained by the maximum replacement of the usual liver parenchyma with connective tissue and thereby a decrease in the reflecting structures. The absorption of ultrasound by the parenchyma increases, small vessels, bile ducts, as well as the portal vein and hepatic artery expand. The spleen is significantly enlarged, its parenchyma is diffusely compacted, the splenic vein is dilated, bent into the area of the hilum.

Fatty

morphologically

nosological

accumulation of fat in the hepatocyte. Echographically determined by an increase in the liver, as well as an increase in the echogenicity of the liver parenchyma, since ultrasound is reflected from multiple fatty tissue surfaces. This diffuse fine-grained hardness gives the impression that the liver is filled with sand. The vascular pattern of the organ, as a rule, does not suffer. In most patients with the most pronounced increase in echogenicity, the effect of increased absorption of ultrasound by the liver parenchyma is observed.

Echographic studies have expanded the diagnostic capabilities of lesions pancreas. Since with pancreatitis there may be clinical symptoms that are common with the symptoms of damage to other digestive organs, which makes it difficult to diagnose damage to the pancreas, the ultrasound method acquires special diagnostic value. It allows you to assess the structure of an organ, its size in various parts (head, body, tail), the originality of the form, the unevenness of its contours.

On echograms, the pancreas appears to be an echogenic cord located under the left lobe of the liver. The echogenicity of the parenchyma is equivalent to that of the liver parenchyma. Usually in the area of the body, less often the head, a tubular anechoic structure is visible - the Wirsung duct. Its width should not exceed 2 mm in children of all age groups, but usually it appears as a single line or duct not exceeding 1 mm in the lumen. An important criterion for assessing the gland is its size, which is clearly age dependent.

Acute pancreatitis its edematous form can be both an independent disease and a reactive state against the background of another pathology of the digestive system. Destructive forms of pancreatitis occur as an acute surgical pathology and are very rare in children.

In acute inflammation, the pancreas is visible on echograms as a sharply enlarged formation. The contour of the gland can be disturbed, and therefore, it does not seem to be separated from the surrounding organs. The echogenicity of the parenchyma is reduced, which makes it difficult to determine the border between it and the splenic vein, and difficulties arise in its measurement. The Wirsung duct often widens, its lumen can reach 4 mm. In the parenchyma of the gland, fluid formations may appear: pseudocyst, abscess, hematoma. With the development of fluid formation, it can protrude beyond the edge of the gland and be located in the area of the lesser omentum or the anterior perihepatic space. In some cases, a small amount of ascitic fluid can be observed.

With an ultrasound examination, the picture reactive pancreatitis corresponds to that in acute: there is an increase in the pancreas, but more often - of one section (usually the tail), an expansion of the Wirsung duct, a decrease in echogenicity (diffuse or local). The contour of the gland remains flat.

Conditionally, changes in the pancreas in patients with various allergic manifestations can be attributed to reactive pancreatitis. Echographically, in this case, a diffuse or local increase is observed. More often in the area of the tail or head, the echogenicity of the parenchyma is not changed, but the walls of the parenchymal vessels are compacted. The latter are visible as multiple echo signals (with an increase - paired), concentrated in the tail region, less often ~ along the entire volume of the gland.The presence of such vessels with sealed walls creates a motley picture of the parenchyma, which can be mistaken for a picture of chronic pancreatitis, which often happens. These are areas of sclerosis - they will have a paired linear configuration. chronic pancreatitis the proliferation of connective tissue is revealed. Leading to the development of fibrosis and gradual atrophy of the parenchyma of the gland. The spread of the inflammatory process in the gland leads first to an increase in ss, and then, as atrophic processes develop in it, to a decrease.

IN depending on the activity of the process, chronic pancreatitis is divided into three phases: exacerbation, subsiding, remission.

IN phase of exacerbation echographically in most cases, there is a diffuse or less often local enlargement of the pancreas. Its contour is clear, somewhat uneven. From the parenchyma are recorded echo signals are either multiple or large single, also hyperechoic, well distinguished against the background of the parenchyma. The origin of strong echoes is associated, but apparently, with the presence of fibrosis in the tissue of the gland.

IN the phase of the abatement of the pathological process, a moderate increase in the gland is observed. Strong multiples are recorded from the parenchyma. echo signals, which in shape and quantity can be of two types: diffuse small and large single, concentrated mainly in one section, more often the head. The parenchyma of the gland becomes more echogenic than with an exacerbation.

IN the phase of remission of chronic pancreatitis, the size of the gland corresponds to the age norm or may be slightly smaller.

The overall echogenicity of the parenchyma is significantly increased due to the presence of multiple hyperechoic echoes, which can be small or large. Expansion of the duct may be observed.

The state of the pancreas was studied by the method of echography. hemorrhagic vasculitis. Have

the vast majority of patients revealed changes in the form of: 1) a decrease in the echogenicity of its parenchyma associated with edema, 2) heterogeneity of the parenchyma due to edema and induration, and 3) diffuse compaction of the pancreatic parenchyma. glands with a pronounced vascular pattern. At the same time, differences in the nature and frequency of pancreatic lesions did not depend on the presence or absence of abdominal syndrome. The involvement of the pancreas in the pathological process with hemorrhagic vasculitis occurs in most patients. This can be considered as its capillarotoxic lesion and indicates the need for ultrasound examination in all degas with hemorrhagic syndrome.

Echographic evaluation stomach, its pyloric section

carried out after a 12-hour fast. Normally, with such preparation, the contents in its lumen are not visualized. The wall of the stomach, including the pyloric section, consists of five layers: two hyperechoic - serous and mucous layers, a hypoechoic muscle layer and two dividing layers. The inner layer is divided by a swampy apechogenic canal. The total thickness of the stomach wall should not exceed 4-5 mm.

The contours of the duodenum are normally not visualized and become visible approximately 30 minutes after the start of acoustic contrasting of the stomach with a 5% glucose solution. If during an ultrasound examination on an empty stomach it is possible to visualize in the stomach the contents associated with its hypersecretion, thickening of its walls, expansion of the lumen of the pyloric section, as well as the contours of the 12-perspective intestine, which are echo signs gastroduodenitis, it is necessary to carry out gastroduodenoscopy to clarify the diagnosis.

If you suspect acute appendicitis the study is carried out after a cleansing enema, in the position of the child on his back, while the right iliac region, the right lateral canal and the small pelvis are sequentially examined. The inflamed appendix is visualized as an echo-positive hypoechoic formation, with longitudinal scanning - cylindrical, and with transverse scanning, round. The diameter of the appendix increases from 10 to 30 mm, depending on the type of inflammation, its wall becomes thickened, layered. When pressed, the sensor determines the rigidity of the formation.

There is an increase in regional lymph nodes, in some patients - a small amount of fluid in the small pelvis.

Echography is widely used in study of the urinary system in children, since the method is highly informative, it is relatively simple and compares favorably with the radiographic one in that it does not depend on the function of the organ and allows the study of the night in cases where the administration of contrast agents is contraindicated. However, the echographic and X-ray logical methods of studying the kidneys should not replace, but complement each other.

With the help of echography, it is possible to determine in patients such congenital anomalies in the development of the kidneys as doubling, aplasia, hypoplasia, polycystic, renal fusion (horseshoe-shaped, bisque-shaped, S and L-shaped). Most often, these diagnostic "findings" are made using ultrasound. In the same way, dystopic kidneys are successfully determined, pathological mobility of the kidneys is revealed. In inflammatory diseases, ultrasound examination is used very successfully. At acute pyelonephritis the enlarged kidney is determined, the echogenicity of the parenchyma is reduced or increased, the cortical and medullary layers do not differ. The walls of the collecting system are thickened, their echogenicity is reduced due to edema of the mucous membrane and its infiltration with inflammatory cells. The most common echographic sign in acute pyelonephritis is the thickening of the walls of the pelvis.

As the pathological process in the kidney subsides, the echographic picture is normalized. Sometimes, as a result of an acute infection, a focal formation is formed - acute bacterial nephritis. A typical echographic finding in this case is the presence of a hypoechogenic formation without distal enhancement. A complication of acute pyelonephritis can be the development of an abscess, which appears as a clear hypoechoic formation with unevenly thin or thick walls. Hypoechoic signals are recorded from the content, the origin of which is associated with the presence

inflammation of the parenchyma and renal pelvis, leading to a progressive deterioration in the function of the nocturnal. Echographic changes are detected only with a long-term current process and, as a rule, are nonspecific. Multiple hyperechogenic signals are recorded from the parenchyma, the cause of which may be sclerotic and fibro-hyaline formations. The walls of the collecting system are sealed, the central echo signal does not represent a single complex, but, as it were,

fragmented. The sizes of the kidneys are within normal limits. In the presence of obstruction, signs of expansion of the collecting system appear.

In the outcome of glomerular, tubular, vascular and stromal changes in kidney disease develops

secondary wrinkling of the kidney. The kidney decreases in size,

becomes dense, its surface is fine-grained. On the echograms, the kidney is reduced, the contour of the ss is uneven, indistinct, it does not stand out among the surrounding tissues. The parenchyma is diffusely unevenly compacted, but against the background of this compaction, even more hyperechoic echoes of a linear configuration can be determined. The central complex does not clearly stand out against such a background of the parenchyma.

On the echograms of the kidneys with acute glomerulonephritis

a significant increase in the kidneys is determined, their contour may be uneven. The echogenicity of the cortical layer is sharply reduced. The pyramids with a hypoechoic structure are clearly demonstrated against such a background. The decrease in echogenicity of the cortical layer as a result of edema can be explained by the appearance of multiple reflective structures. The collecting system does not suffer.

With chronic glomerulonephritis dystrophic changes in the tubules and stroma of the kidneys dominate the changes in the glomeruli. The echographic picture in chronic glomerulonephritis in remission in most patients is normal, in some cases there is a slight compaction of the cortex. With exacerbation, echocargina is identical to that found in acute glomerulonephritis.

Hydronephrosis is a kidney disease characterized by an expansion of the calyx-pelvic system, atrophy of the renal parenchyma as a result of impaired outflow of urine and a mrofessory deterioration of all major renal functions.

The course of hydronephrosis is divided into 3 stages: I - expansion of only the pelvis (pyelectasis); II - expansion of not only the pelvis, but also the calyx (hydrocalicosis); III - expansion of the collector system, a sharp atrophy of the kidney parenchyma, the transformation of this into a thin-walled sac. All these changes are clearly identified by echography.

Urolithiasis disease quite a common disease in children. Most often, calculi are localized in the cups and pelvis. With ultrasound, stones are well defined if they are located in the kidney parenchyma. In this case, against the background of the parenchyma poor in echo signals, an intense compaction is visualized, creating an acoustic shadow.

The detection of a stone in the pelvis is much more difficult echographically, since this structure appears to be dense on the echogram.

education. In this case, the main features of the stone are acoustic shade and, if the stone is of considerable size. - local expansion of the pelvis.

With increased urinary excretion of phosphates, urates, oxalates. which is quite often observed in children, during ultrasound examination, the emphasis of the pyramids is noted with a thin hyperechoic corolla; the compaction of the walls of the collecting system with visualization of small hyperechoic inclusions - salt crystals.

Ultrasound examination of the bladder is carried out when it is full, since under this condition it is possible to see the entire organ, assess its shape, the condition of the walls and identify any intracavitary inclusions, as well as the presence of vesicoureteral and vesicoureteral reflexes. After urination, no urine should remain in the bladder and therefore the lumen should not be visible. With the help of ultrasound, it is possible to determine the residual urine in the bladder with the calculation of its quantity. In the presence of residual urine in an amount exceeding 12-15 ml, we can talk about hypotension of the bladder. Echographic evaluation pelvic organs in girls is carried out necessarily at the maximum filling of the bladder. Attention is drawn to the presence of free fluid, which healthy children should not have, only a small amount of it (2-6 mm) is allowed in the Douglas space in girls. When examining the genitals in girls, the location of the uterus, its shape, size, the severity of the angle between the body and the cervix, the thickness of the myometrium, the M-echo of the uterus, depending on the stage of the physiological cycle, as well as the location, contours, echogenicity and echostructure of the ovaries are determined.

With the help of echography, it seems possible to reliably judge the puberty of girls, developmental anomalies, the presence of inflammatory and volumetric processes.

Ultrasound diagnostics in the present state of its development in the future will retain and expand its place in the diagnosis of almost any pathology.

Signed to print:

Order No. 10378 Circulation -100 copies. Screen printing.

N.V. Viktorov, T.Yu. Viktorov.

Medical center "Art-Med", Moscow.

Basic principles of the method and physical characteristics

Ultrasound- high-frequency vibrations lying in the range above the frequency band perceived by the human ear (more than 20,000 Hz). Radiated into the patient's body, ultrasonic vibrations are reflected from the examined tissues, blood, as well as surfaces, such as boundaries between organs, and, returning to ultrasound scanner, are processed and measured after their preliminary delay to obtain a focused image. The resulting data is fed to the monitor screen, allowing an assessment of the state of internal organs. Even though ultrasound cannot effectively penetrate media such as air or other gases, as well as bones, it finds wide application in the study of soft tissues. Usage ultrasonic gels and other liquids, while improving the performance of the sensors, increases the range of applications for various medical examinations.

The speed of ultrasonic waves in the soft tissues of the human body averages 1.540 m / s and is practically independent of frequency. Sensor is one of the main components of diagnostic systems that converts electrical signals into ultrasonic vibrations and produces electrical signals, receiving reflected echoes from the patient's internal tissues. An ideal sensor should be effective as an emitter and sensitive as a receiver, have good characteristics of the pulses emitted by it with strictly defined parameters, and also receive a wide frequency range reflected from the examined tissues.

In electronic sensors, ultrasonic vibrations are excited by applying high-voltage pulses to the piezo crystals that make up the sensor (the piezoelectric effect was discovered by Pierre and Marie Curie in 1880). The number of times the crystal vibrates per second determines the frequency of the sensor. With an increase in frequency, the wavelength of the generated oscillations decreases, which is reflected in the improvement of resolution, however, the absorption of ultrasonic oscillations by the tissues of the body is proportional to the increase in frequency, which entails a decrease in the penetration depth. Therefore, sensors with a high vibration frequency provide better image resolution when examining not deeply located tissues, just as low-frequency sensors allow examining deeper organs, yielding to high-frequency ones. image quality... This disagreement is the main determining factor in the use of sensors.

In the daily clinical practice Various designs of sensors are used, which are discs with one element, as well as combining several elements located around the circumference or along the length of the sensor, producing various image formats that are necessary or preferable for diagnostics various organs.

Five types of sensors are traditionally and mainly used

Mechanical sector sensors.
Phased scan sensors.

These five main types of sensors differ according to

the method of forming ultrasonic vibrations;
radiation method;
the image format they create on the monitor screen.

Image formats obtained with various sensors

Mechanical sector sensors

* Areas with the best resolution are highlighted with a dark background.

For diagnostic purposes usually use sensors with frequencies: 3.0 MHz, 3.5 MHz, 5.0 MHz, 6.5 MHz, 7.5 MHz. In addition, in recent years, devices equipped with high-frequency sensors 10-20 MHz.

Applications of sensors

3.0 MHz (convex and sector) are used in;
3.5 MHz (convex and sectorial) - in abdominal diagnostics and studies of the pelvic organs;
5.0 MHz (convex and sector) - in;
5.0 MHz short focus can be used for breast examinations;
6.0-6.5 MHz (convex, linear, sector, annular) - in cavity sensors;
7.5 MHz (linear, sensors with a water attachment) - when examining superficially located organs - the thyroid gland, mammary glands, lymphatic system.

Basic Image Adjustment Options

Gain- "amplification" of the detected signal by changing the ratio of the amplitudes of the input and output signals. (Excessively high gain levels result in a blurred image that becomes "white").
Dynamic range(dynamic range) - the range between the recorded signals with the maximum and minimum intensity. (The wider it is, the better signals are perceived that differ little in intensity).
Contrast- characterizes the ability of the system to distinguish between echoes with small differences in amplitude or brightness.
Focusing- is used to improve the resolution in a specific area of interest. (Increasing the number of focal areas improves the image quality but decreases the frame rate.)
TGC- gain compensated for depth.
Frame average(frame averaging) - allows you to smooth the image by superimposing a certain number of frames on top of each other per unit of time or to make it rigid, bringing it closer to real time.
Direction- changes the orientation of the image on the screen (from left to right or from top to bottom).

When carrying out diagnostics, along with useful information, quite often appear image artifacts and also some acoustic phenomena are observed.

Image artifacts

Reverberation. It is observed when an ultrasonic wave hits between two or more reflective surfaces, partially experiencing multiple reflections. In this case, non-existent surfaces will appear on the screen, which will be located behind the second reflector at a distance equal to the distance between the first and the second. This most often occurs when the beam passes through liquid-containing structures.
Mirror artifacts. This is the appearance in the image of an object located on one side of a strong reflector on the other side. This phenomenon often occurs near the diaphragm.
"Comet Tail". This is the name of the small echo-positive signals that appear behind the gas bubbles and are caused by their own oscillations.
Refraction artifact. It appears if the path of ultrasound from the sensor to the reflective structure and back is not the same. In this case, an incorrect position of the object appears on the image.
Effective reflective surface artifact. It consists in the fact that the real reflective surface is larger than that displayed in the image, since the reflected signal does not always return all the way to the sensor.
Beam thickness artifacts. This is the appearance, mainly in liquid-containing structures, of wall reflections due to the fact that the ultrasound beam has a specific thickness and part of this beam can simultaneously form an image of an organ and an image of adjacent structures.
Ultrasound velocity artifacts. The average speed of ultrasound in soft tissues of 1.54 m / s, for which the device is programmed, is slightly higher or lower than the speed in a particular tissue. Therefore, slight image distortion is inevitable.
Acoustic shadow artifact. Occurs behind highly reflective or strongly absorbing ultrasound structures.
Distal pseudo-amplification artifact. Arises behind structures that are weakly absorbing ultrasound.
Side shadow artifact. Occurs when a beam falls tangentially on a convex surface of a structure, the speed of ultrasound in which is significantly different from the surrounding tissues. Refraction and sometimes interference of ultrasonic waves occurs.

Basic terms used to describe the acoustic characteristics of formations and pathological processes

anechoic;
hypoechoic;
isoechoic;
hyperechoic;
cystic formation;
solid education;
solid cystic formation;
echo dense formation with acoustic shadow;
diffuse lesion;
nodular (focal) lesion;
diffuse nodular lesion.

Echogenicity- characteristic of tissues, reflecting their ability to form an echo.
Homogeneous structure- the area that forms a homogeneous echo.

Some ultrasound symptoms of pathological processes and formations

Hallo. It is a rim of reduced echogenicity around the formation, for example, liver metastasis.
Bull's eye symptom. A volumetric formation of uneven acoustic density with a hypoechoic rim and a hypoechoic area in the center looks similar, it is observed with metastases in the liver.
Symptom of "pseudotumor". Against the background of pronounced fatty infiltration of the liver, a hypoechoic area of unchanged parenchyma, which is usually located near, may appear as an additional formation.
Symptom "rail". Occurs with pronounced dilatation of the intrahepatic bile ducts, when the liver vein and duct are presented in the form of parallel tubular structures.
Symptom "double-barreled". It looks like a significantly enlarged common bile duct and portal vein in the projection of the hepatic hilum.
The symptom of "snow flakes". Multiple small formations of increased echogenicity in the lumen of the gallbladder, appearing immediately after a change in the position of the patient's body, observed in chronic cholecystitis.
A symptom of a "blizzard". Areas of increased echogenicity in the liver with fuzzy contours of an indefinite shape and of various sizes, observed in cirrhosis. Also, multiple heterogeneous oval-shaped formations, increased echogenicity, located in the uterine cavity with cystic drift or in the ovaries with luteal cysts.
Symptom of "pseudo-kidney". It manifests itself in tumor lesions of the gastrointestinal tract. With transverse scanning, the image of the affected area of the intestine resembles a kidney - the peripheral zone is low-echogenic, and the central one has increased echogenicity.

Terms for describing the location of anatomical structures

cranial (upper);
caudal (lower);
ventral (anterior);
dorsal (lower);
medial (median);
lateral (lateral);
proximal (description of structures located close to their place of origin or attachment);
distal (description of structures located far from their place of origin or attachment).

The study evaluates

location and interposition of organs and their parts;
their shape and size;
contours;
structure (with an assessment of sound conductivity);
the presence or absence of additional education;
state of intra- and peri-organ vessels.

Basic scan planes

sagittal(longitudinal) - scanning plane when the long axis of the sensor is oriented in the direction of the patient's head - legs;
frontal- scanning plane, when the sensor is located on the lateral surface of the patient's body while orienting its long axis head - legs;
transverse- scanning plane, when the long axis of the sensor is oriented perpendicular to the long axis of the patient's body.

3.1. TREATMENT AND DIAGNOSTIC MEASURES PREFERRED TO PERCUTANEOUS TRANSHEADENAL INTERVENTIONS.

According to most surgeons, preparation of a patient for transhepatic bile diverting interventions in patients with obstructive jaundice should be short-term and include the following points:

clarification of the diagnosis and determination of the severity of the patient's condition;
determination of indications and contraindications for percutaneous transhepatic interventions;
infusion therapy and other measures aimed at correcting existing pathological changes and preventing possible complications of transhepatic interventions;
actually preoperative preparation.

CLARIFICATION OF DIAGNOSIS AND DETERMINATION OF THE SEVERITY OF THE PATIENT'S CONDITION.

The leading role in the diagnosis in patients with jaundice currently belongs to ultrasound examination (US) of the organs of the hepatopancreato-duodenal zone. If a patient is suspected of having obstructive jaundice, an ultrasound scan should be performed in the next few hours from the moment the patient is admitted to the surgical hospital. At the same time, as a rule, it is possible to ascertain the presence or absence of biliary hypertension without special preparation of the patient. In case of insufficient information content, the study is repeated the next day.

With an ultrasound examination, the following questions must be answered:

the presence of signs of biliary hypertension;
the level of obstruction of the biliary tract;
preference for performing cholecysto- or cholangiostomy;
the presence of a safe trajectory of the puncture of the biliary system.

To identify signs of biliary hypertension, it is better to measure hepaticoholedochus at several points, since its diameter is not the same throughout and reaches the greatest value in the region of the pancreas head. From a diagnostic point of view, the most appropriate gradation proposed by Laing and Jeffre (1983): the internal diameter of the common bile duct up to 5 mm is the norm, possible expansion - 6 - 7 mm, 8 mm or more is considered as pathological dilatation. The diameter of the right and left lobar ducts, measured at a distance of 2 - 3 cm from the hepatic hilum, does not exceed 2 - 3 mm, expansion up to 5 mm is pathological. Segmental ducts are rarely visualized and their diameter usually does not exceed 1 mm.

Abnormal enlargement of the Wirsung duct is said to be when the inner diameter exceeds 2.5 mm in the head and more than 1 mm in the tail.

The main sign of the presence of biliary hypertension is the identification of dilated bile ducts, located parallel to the branches of the portal vein and, as a rule, in front of them.

In the literature, this feature has various names:

multiple tubes sign. - symptom of multiple tubes;
double barrell gun sign. - a symptom of parallel channels or a symptom of a double-barreled gun;
double tracking sign. - a symptom of double channels.

Depending on the duration of the obstruction and the level of the block of the biliary system, ultrasound examination shows various variants of dilatation of the bile ducts. With non-prolonged obstructive jaundice, a symptom of double or parallel canals is more often observed (Fig. 3.1).

With prolonged obstruction (more than two weeks) of the bile ducts, multiple stellate tubular structures are often visualized (Fig. 3.2). This form of the bile ducts arises as a result of the "continued" type of proliferation of the bile ducts, characterized by a pronounced lengthening and curvature of the bile ducts, as a result of which they acquire increased tortuosity [Kordzaya D., 1990].

The degree of dilatation of the extrahepatic bile ducts depends on the duration of jaundice [Datsenko B.M. et al., 1991].

The information content of ultrasound in detecting biliary hypertension is quite high - up to 96 - 98%. (Table 3.1).

Table 3.1. The informative value of ultrasound in elucidating the nature and causes of jaundice, the level of obstruction of the bile ducts.

	Research sensitivity
author	The nature of jaundice	Block level	Mechanical reason jaundice
B.A. Agaev et al. 1989	96%	*	80%
Vasiliev V.E. et al. 1989	60%	*	33,2%
Zatevakhin I.I. et al. 1989	48,6%	*	46,5%
Nasirov F.N., Arefiev A.E. 1988	97,7%	97,7	41,1%
Nesterenko Yu.A. et al. 1986	88%	*	67%
L.M. tailor et al. 1986	98,4%	100	83,7%
Ermolov A.S. et al. 1995	71%	67%	38%
Ashfarov A.A., Gadiev S.I. 1995	94%	82,7%	64,7%
Lapkin K.V. et al. 1995	*	*	93,1%
Weill F.S. 1978	96 - 97%	90%	57%

Note: * - no data.

Errors in determining the nature of jaundice are rare and are due to the following reasons:

lack of experience of the doctor conducting the ultrasound;
examination in the early stages after the onset of jaundice (after 1 - 2 days), when in a number of patients the bile ducts are not yet dilated;
the intermittent nature of jaundice in the case of a valve stone of hepaticoholedochus;
abnormal structure or atypical position of the branches of the portal vein and hepatic artery, which can be mistaken for ectazed ducts (Fig. 3.3, 3.4).

If it is difficult to differentiate the vessels from the bile ducts, an ultrasound of the portal vein should be performed, along the entire length - from the confluence of the superior mesenteric and splenic veins to the gate of the liver. It is possible to use the Valsalva test, in which the veins change their diameter, but the bile ducts do not. However, the most informative method in such situations is Doppler ultrasound.

Registration of the spectrum of blood flow in the investigated area makes it easy to distinguish blood vessels from ducts (Fig. 3.5).

Highly informative ultrasound and in determining the level of occlusion of the bile ducts (Table 3.1).

Shim Chan-Sup (1995) proposed a convenient for practical application scheme for echographic diagnostics of the levels of occlusion of the biliary tract (Fig. 3.6).

They identified 5 levels of the most frequent blockade and their typical signs:

Level 1 - occlusion of the intrahepatic ducts (Fig. 3.7):

expansion of the ducts inside the liver;
the difference in the caliber of the bile ducts of the left and right lobes (depending on the site of obstruction);

Level 2a - occlusion in the area of the liver hilum (Fig. 3.8);

the difference in the caliber of the ducts of the left and right lobes is absent or weak.

Level 2c - occlusion of the extrahepatic part of the common hepatic duct (Fig. 3.9);

expansion of the extrahepatic duct;
there is no increase in the size of the gallbladder.

3a level - occlusion of hepaticoholedochus (Fig. 3.10);

enlargement of the gallbladder;
the expansion of the Wirsung duct is absent.

3c level - damage to the pancreas (Fig. 3.11);

expansion of the Wirsung duct.


Rice. 3.9. Occlusion of the extrahepatic segment of the common hepatic duct (level 2c) 1 - liver; 2 - calculus of the extrahepatic segment of the common hepatic duct; 3 - dilated hepatic duct.	Rice. 3.10. Occlusion of hepaticoholedochus (3a level) 1 - dilated common hepatic duct; 2 - dilated cystic duct; 3 - dilated common bile duct; 4 - block of common bile duct.

The proposed scheme most fully reflects the signs of obstruction of the biliary tract, depending on the level of obstruction. However, it is necessary to remember about the possibility of an extended occlusion, involving several levels (Fig.3.12) and various anatomical developmental options (Fig.3.13) and anomalies (Fig.3.14) of the biliary system, which can determine the atypical nature of the ultrasound picture (fig. 4.3).


Rice. 3.12. Extended occlusion of hepaticocholedochus. 1 - tumor of the common hepatic duct and common bile duct; 2 - calculus of the common bile duct.	Rice. 3.13. Variant of the structure of the biliary system: extrahepatic confluence of the lobar ducts; the inflow of the cystic duct into the right lobar duct. 1 - left lobar duct; 2 - right lobar duct; 3 - cystic duct; 4 - co-fluence of the lobar ducts; 5 - common bile duct.

The cause of obstruction of the biliary tree by ultrasound can be established in 33 - 93% (Table 3.1).

The accuracy of diagnosis increases when ultrasound is performed after special preparation of the patient, including the appointment of a special non-gas-forming diet, polyenzyme drugs, activated carbon and a cleansing enema. Zinevich V.P. et al. (1989) to improve visualization of the terminal part of the common bile duct fill the stomach and duodenum with 500 - 600 ml of warm liquid. Through the formed "acoustic window" examine the patient in the position on the right side.

However, it should always be assessed whether it is worthwhile to conduct a second ultrasound scan and at the same time delay the examination period, or limit it to the statement of biliary hypertension and, if possible, the level of obstruction, which is almost always sufficient to determine the patient's treatment tactics. As practice shows, differentiation into tumor and non-tumor jaundice is more important for solving tactical issues.

Diagnosis of pancreatic tumors is based on visualization of the tumor formation in its projection.

The break of the terminal part of the enlarged common bile duct at the level of the upper edge of the head or inside it is extremely suspicious for a tumor. If with the help of ultrasound it is not possible to find a calculus or a tumor of the pancreas at the site of the "break" of the common bile duct, then this circumstance rather suggests a primary tumor of the bile duct or large duodenal nipple.

In the differential diagnosis of intraductal tumors from sludge masses, the use of Doppler sonography can be of significant help (Fig. 3.15).

Based on ultrasound data, the diagnosis of choledocholithiasis is recommended only in cases of direct visualization of stones in the bile ducts. In all other cases, it is only legitimate to make an assumption about choledocholithiasis and argue its likelihood by the absence of a tumor in the head of the pancreas and pseudotumorous pancreatitis, dilation of the bile ducts and the presence of stones in the gallbladder (although their absence does not exclude choledocholithiasis).

Difficult echographic diagnosis of benign stricture of the common bile duct, as well as differentiation between chronic pseudotumorous pancreatitis and pancreatic tumor.
With stenosis of previously imposed biliodigestive anastomoses, as a rule, it is possible to identify an enlarged bile duct approaching the intestinal wall (Fig. 3.16).

When diagnosing the causes of obstructive jaundice, 20% or more erroneous conclusions are encountered, especially when it comes to changes in the distal common bile duct and obstructive jaundice of non-calculous origin [Nesterenko Yu.A. et al., 1987].

Errors in topical diagnosis are allowed for large tumors that germinate the pancreas, common bile duct, and duodenum. Under these conditions, it is impossible to determine correctly the organ from which the tumor originates [LM Tailor]. et al., 1986].

see completely:

Ivshin V.G., Yakunin A.Yu., Lukichev O.D .. Percutaneous diagnostic and bile-diverting interventions in patients with obstructive jaundice. Tula: Grif and K, 2000. - p. 312.

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

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 the ultrasound scan, can detect mainly indirect echo signs, testifying in favor of the benignity or malignancy of the existing process. A final, accurate judgment can be made after the biopsy.

If an education is found, a control ultrasound study must 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 masses characterized by slow growth and lack of metastasis, some may (rarely) become malignant.

Liver adenoma. It is more common in women, while 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 happens hepato- and cholangiocellular.

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

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

but ) Capillary hemangioma looks like a hyperechoic formation with a fine-grained homogeneous echo structure, round or ovoid in shape, with an even or sometimes with a fine-festooned contour, with clear boundaries (due to the fibrous capsule), behind or no acoustic effects, or slight dorsal pseudo-enhancement. Sometimes it is possible to find a small, more often a single area of reduced echogenicity along the periphery, and with CDC, a vessel is determined in this place (the so-called vascular "leg", with hemangioma sizes up to 1.5 cm it is rarely found). Occasionally, there may be a heterogeneity of the structure (including due to calcifications) and an indistinct contour - 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 (may contain both liquid and coagulated blood), foci of calcification and hypoechoic areas of hyalinization are possible. Atypical variants can be anechoic with an echo-positive peripheral rim.

Hemangiomas are either avascular (more often capillary), or hypovascular (more often cavernous, in them it is possible to register a monophasic low-amplitude blood flow, which is characteristic of venous blood flow).

With fatty hepatosis, the hemangioma may look hypoechoic, with an indistinct outline. It is necessary to differentiate with metastasis.

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

In the literature, there are data on two anatomical variants - focal nodular hyperplasia of solid and telangiectatic type (the latter with more pronounced intranodular vascularization). At small sizes, it is practically not visualized. According to some authors, it is more often found in 5,6 and 7 segments. It can be located close to the capsule, forming a protrusion of the contour of the liver. Usually, the focus is moderately reduced echogenicity (with a predominance of regenerative processes), but it can be isoechoic or moderately hyperechoic (less often). In the echo structure, a diffuse small-focal heterogeneity of the formation is determined, resembling changes in cirrhosis, as well as a centrally located hyperechoic cicatricial connective tissue (detection rate 20-47%), in the form of a stellate structure or as a "wheel with spokes" (repeats the course of the supply vessels , in a typical case, determined at CDC, 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 defined. Occasionally, a moderately hypoechoic rim may be present (better visualized against the background of fatty infiltration). The contours are often even, they 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 in hemangioma). With prolonged growth, it can reach large sizes (up to 20 cm). It is necessary to differentiate with a malignant neoplasm, Riedel's lobe (a protruding section of the unchanged parenchyma of the right lobe).

Leiomyoma and fibroma - I did not find echo signs in the literature typical for localization in the liver parenchyma.

Histiocytosis - the appearance in the liver parenchyma of small (10-12 mm) foci of irregular shape with uneven and indistinct contours. May occur against the background of leptospirosis, toxoplasmosis, mononucleosis, cytomegalovirus infection, tuberculosis, typhoid fever, etc. It is accompanied by hepatosplenomegaly, an increase in hepatic, mesenteric or retroperitoneal l / u. With recovery, the foci either disappear, or fibrosis develops in their place, and can be calcified.

Liver infarction - a section of the parenchyma of moderately reduced echogenicity and irregular shape with "angular" contours is determined in any segment of the liver.

Congenital and most acquired cysts look like a round or oval anechoic formation with smooth and clear contours, and also have distal pseudo-amplification and thin lateral shadows (indirect signs of wall smoothness). Several cysts are considered multicystic (if there is no family history of polycystic disease). Vascularization in the cavity of simple cysts (without septa) is not detected. In case of complications in the form of hemorrhage into the wall or into the cavity, echo-positive inclusions in the cavity are visualized. With malignancy, a site of thickening and unevenness of the cyst wall is determined, sometimes with a loss of clarity of the border (invasion of the liver tissue). Also, along the inner contour, parietal vegetations of an irregular shape can be determined, both with signs of vascularization, and without. Congenital cysts do not have their own wall, but acquired have. They need to be differentiated with 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% and in one lobe, there may be multicystosis. Other authors tend to take into account the family history - if there is polycystic liver disease in the family history, then up to 40 years there is one cyst, and after 40 years of 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.

At the 3rd stage, the cystic formation becomes heterogeneous due to partitions (the formation of daughter cysts), it can look like 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 "crescent".

Alveolar echinococcus - less common. In type 1, these are hyperechoic foci with an uneven outline, with a tendency to infiltrate into the surrounding tissue. The source structure can have the form of a "snow storm" or mesh.

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

The third type 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 an abdominal infection (for example, amebiasis), the spread of the infectious process to the parenchyma from distant foci, as well as with suppuration of a pre-existing formation - cysts, hematomas, tumor decay. It can be single and multiple, acute and chronic.

IN infiltrative stage in the liver, an inconspicuous hypoechoic homogeneous area with indistinct boundaries appears, it may have an irregular shape. At this stage, a reverse development is possible and after a few days changes are not detected.

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

In stage complete melting an anechoic formation with distal pseudo-amplification is determined, with a thin, up to several millimeters, hypoechoic girdle around (the zone of reactive inflammation, delimits the altered and healthy tissue).

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

If the content with vertical artifacts of the type of reverberation is from gas bubbles during anaerobic infection, they are located in the upper part and move when the position of the body changes. The content can stratify into an anechoic part and an echogenic suspension (it also displaces when the body is turned). Over time, along the periphery of the abscess, a hyperechoic thickened wall may form, with possible calcification in the future. There may be partitions inside.

During treatment, the cavity gradually decreases, the hypoechoic belt disappears. Subsequently, there remains a zone of fibrosis, in the more distant future - a focus of calcification.

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

The size of the hematoma can 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 with a fuzzy outline appears in which, over time, hypoechoic areas appear (hemorrhagic impregnation is characteristic of blunt trauma, at this stage it is necessary to differentiate with liver cancer). With a favorable outcome, after 7 days, this area may no longer be detected.

With subcapsular hematoma, an anechoic band with a sharp end appears, with the dynamics of changes close to that described above in case of vascular damage.

Common bile duct cyst- can be congenital and acquired. It can be located on any part of the common bile duct and 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) enlargement of the bile duct, which in a cross section can be visualized as a cyst, and in a longitudinal section it 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 traced during CT, better with contrast). Has echo signs of a simple cyst located in the area of the gate of the liver, or near this area. It is necessary to differentiate with: duodenal diverticulum, cholangiocarcinoma, subcapsular cyst of the pancreatic head, disease and Caroli syndrome (congenital pathology manifested in Caroli disease by local expansion of large hepatic ducts - left and right, segmental; and Caroli syndrome is usually associated with enlargement 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, then pretenotic expansion 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 rounded 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 - a local increase in echogenicity (unevenly) of the liver parenchyma with dimensions of more 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 liver infiltration ... The local form is a large area, up to 10 cm, or it 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, increased echogenicity is visualized in an area of irregular shape and a clear, less often with an indistinct contour. The structure of the liver architectonics is not changed in this area.

The appearance of an area of absence of fat, irregular shape and reduced echogenicity against the background of a general increase in echogenicity with a diffuse form of steatosis, with an indistinct contour, is possible.

Echo signs of pseudolipoma (synonyms in the literature: fetal lipoma, brown lipoma (?), benign hibernoma) is a rounded, encapsulated formation consisting of remnants of embryonic adipose tissue (areas with large rounded fat cells separated by linear sections of the stroma). It may look like a lobular, with varying degrees of echo-positiveness, a small nodule. In the literature, I met an indication that areas of necrosis with subsequent calcification may appear in the echo structure. It can be located next to the liver capsule.

Echo signs of lymphostasis in the liver ... The discharge capillaries of the deep network of the lymphatic vessels of the liver are located along the so-called. triads (branches of the portal vein, hepatic artery and intrahepatic bile duct), forming a plexus. Even if it is insignificant, by 3-7 mm Hg. Art., when the normal pressure in the portal vein system is exceeded, the liquid part of the blood is released into the surrounding lymphatic capillaries, which expand and ultrasound can detect a strip of hypoechoic parenchyma along the portal veins, sometimes along a significant length of the vessels - the so-called. hypoechoic "clutch".

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

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 well-defined hypoechoic corolla. May be suspected in case of: local protrusions of the liver contour; when the natural course of the vessels of the liver changes; or when a local change in the vascularization of the parenchyma is noted with CDC. It is necessary to differentiate with focal nodular hyperplasia of the liver and cancer.

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

- mixed echogenicity - are found in patients with long-term disease. For example, hypoechoic metastasis with an echo-positive central part (described in the literature as a “target” type); or central necrosis of echogenic metastasis (bovine-eye type). Differential diagnosis should be carried out with liver abscess, with cavernous hemangioma; in children with adenoma (with accumulation of glycogen in its central parts).

With CDC in metastases, vascularization can be enhanced, and with Doppler sonography, the peak systolic blood flow velocity in the common hepatic artery is increased (the norm is up to 79-105 cm / sec), its diameter can be increased (the norm is up to 5-5.5 mm), the peripheral resistance (RI) decreases (the norm is up to 0.7-0.74). The normative indicators of blood flow are taken from the works of G.I. Kuntsevich, 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 pronounced (stop being visualized).

If metastasis has occurred in the lymph nodes of the liver gate, in the paraaortic and l / y located near the celiac trunk, then they increase, become almost spherical, hypoechoic and homogeneous (without differentiation of the medulla); with CDC, diffuse vascularization can be determined 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 a vein is determined, with signs of its expansion, splenomegaly, ascites. Sometimes a blood clot in the portal vein or its branch can be a sign of tumor invasion of the vein wall.

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

Primary liver cancer... There is an indication in the literature that chronic hepatitis B and C greatly increase the risk of developing primary liver cancer.

Hepatocellular carcinoma can be represented by a single entity; 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, 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 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 for differentiation), and with large 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, medium, increased, mixed;

- contours- clear or indistinct, even or uneven (scalloped, small knobby);

- internal echo structure can 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 even contours; in the literature there is a comparison "several formations in one larger"; may contain centrally located hyperechoic linear inclusions of horizontal direction 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 structures heterogeneous in structure.

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

The options are:

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

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;

Echo-positive nodules with fuzzy boundaries are visualized over the entire area of the liver echo-section (a rare variant is multicentric primary liver cancer).

Cholangiocellular carcinoma liver - one or more nodal formations are determined, often hyperechoic, but there may be mixed echogenicity, irregular rounded shape with uneven and indistinct contours. You can find the expansion of the corresponding intrahepatic bile duct in the area located in front of the site of stenosis by its tumor masses.

Rare liver tumors. Cystadenoma intrahepatic bile ducts, hemangiosarcoma, teratoma- studied in ultrasound diagnostics are insufficient. Hemangioendothelioma- occurs in newborns, is combined with cutaneous hemangiomas, echographically resembles a hemangioma, prone to malignancy. At rhabdomyosarcoma a hypoechoic formation with a clear contour, heterogeneous structure (sometimes due to cystic inclusions) is determined.

Postcholecystectomy syndrome.

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

Stenosis of the Vater's papilla zone (hypertension of the sphincter of Oddi and stenosing papillitis);

Recurrent choledocholithiasis (detected more than 3 years after surgical treatment) and residual (left stones in the common bile duct, less than 3 years after surgical treatment);

Combination of choledocholithiasis and stenosis of the Vater's papilla zone;

Pancreatitis, primary and secondary;

Gastritis, duodenitis;

Parafateral diverticulum;

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

Postcholecystectomy syndrome often develops:

Patients who have had a long-standing cholelithiasis or cholelithiasis with atypical symptoms and small stones in the gallbladder before cholecystectomy;

In patients with a history 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 calculus in the bile duct, slightly pronounced stenosis of the Vater papilla);

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

Combined - papillosphincterotomy followed by surgery.

The task of ultrasound examination is to early detection of a violation of the patency of the biliary tract (stenosis, stricture, calculi).

The effectiveness of ultrasound increases with an increase in the diameter of the common bile duct to 8-10 mm or more. In the lumen of the common bile duct, a hyperechoic inclusion with an acoustic shadow (calculus) can be visualized. Also, clots of putty bile can be found in the lumen 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 widening of the bile duct and its diameter is less than 8 mm.

Most often, calculi are located in the terminal section of the common bile duct. The visualization of this area can be reduced by endoprostheses, staples, ligatures after surgery (they can also have an acoustic shadow).

Papillitis (stenosing duodenal papillitis) is associated with narrowing of the ampulla of the large 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 age of the process and the degree of stenosis).

In addition, to identify partial violations of the patency of the terminal section of the common bile duct (the diameter of the common bile duct in the area of the gates 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 the expansion of the common bile duct proximal to the site of obstruction. Before that, we conduct an ultrasound study and measure the inner diameter of the common bile duct in the area of the gate (normally less than 7 mm). Then the patient takes a choleretic (do not eat or drink after taking the drug). A 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 sample is considered positive.

Applied drugs:

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;

Tsikvalon, 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 needs hospitalization. Additionally, MRI, 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 the reverberation effect is determined (flashing, flickering in contrast to the acoustic shadow). Air (gas) also looks in the extrahepatic bile ducts.

Pneumatic vehicles 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 the pressure in the duodenum is higher than in the common bile duct; and if the contents of the duodenum are thrown into the common bile duct, then there is a high risk of developing cholangitis);

When imposing biliodigistivny anastomoses (choledochoduodenoanastomosis, cholecystogastroanastomosis, cholecystojejunoanastomosis);

With Mirizzi syndrome (Mirizzi), when a partial narrowing of the common hepatic duct is formed due to inflammation and compression from the outside by 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 pressure ulcer from a stone in the neck with the development of a vesicocholedocheal fistula. Pneumobilia in this case may appear in the case of the formation of a gallbladder fistula (more often with a duodenum 12);

With cholangitis caused by anaerobic flora;

In case of insufficiency of the sphincter of Oddi.

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

The pseudo-gallbladder is an excessive cystic duct stump, which is not common. With ultrasound in the bed of the bladder, a formation similar to the gallbladder is visualized, it can reach 2-4 cm in length, over time (months and years) stones can form in the stump. Stretching of the stump is possibly associated with biliary hypertension and atony of the bile ducts after cholecystectomy. An inflammatory process can develop in the cult.

Obstructive jaundice.

Synonyms - subhepatic, obstructive, extrahepatic cholestasis.

The main symptoms of obstructive jaundice:

Pain syndrome with localization in the epigastric region and the right hypochondrium, may increase gradually, or occurs suddenly;

Discolored stools;

Dark urine;

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

Itchy skin;

Additionally: nausea, less often vomiting, enlarged liver.

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 obstacle to the flow of bile, more often in 3-5 days (not hours).

Tasks of ultrasound for suspected obstructive jaundice:

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

An attempt to clarify the character - benign (for example, calculus), or malignant.

Determination of the block level.

The 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 pseudotumorous pancreatitis (up to 3%);

Common bile duct cysts (2-3%), often congenital;

Cholecystitis, cholangitis (1-2%);

Enlarged lymph nodes in the area of the liver hilum, parafaterial diverticulum of the duodenum (located in close proximity to the Vater's papilla).

Malignant, neoplastic:

Pancreatic head cancer (up to 70%);

Cancer of the greater 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 gate of the liver (3-5%, more 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 cystic duct confluence;

High block, proximal - at the level of the hepatic hilum;

Intrahepatic block.

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

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

US symptom of "double-barreled", "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 side by side, parallel) of the corresponding level - lobar, segmental. This can be moderate expansion, or up to 10-12 mm as much as possible, 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 anechoic so-called. "Worm-like structures", "bile lakes", "stellate structures" - they no longer have the correct tubular appearance and parallel to the branches of the portal vein of the course, much more expanded, up to 14 mm or more, with an uneven diameter. More often they can be found in the tumor process.

If with the detected ultrasound symptom of a "double-barreled" one can consider the echo-positive walls of the bile ducts, then the "bile lakes" and other more dilated sections of the ducts are determined without obvious echo-signs of the walls (since they are significantly stretched, thinned).

Distal block.

Echo signs of a tumor of the large 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 large duodenal papilla (its area) with ultrasound. The echo pattern can be the same for both tumor localizations.

What can be found:

Expansion of the intrahepatic bile ducts (ultrasound symptoms of "double-barreled", "bile lakes"), expansion of the main bile duct throughout (7-9 cm), because the block is located at the very end. Sometimes the tortuosity of the course of the common bile duct is determined. The common bile duct ends with a pretenotic dilatation (some authors have a symptom of a "drumstick"). The gallbladder is enlarged (like dropsy), the main pancreatic duct is expanded, if it opens together with the common bile duct (not always).

Additional studies: shown duodenoscopy, ERCP, MRTH.

Pancreatic head level. Adenocarcinoma, cystadenoma (less often), pseudocyst localized in the head region; pseudotumorous pancreatitis, acute pancreatitis with an enlarged edematous head - can squeeze the common bile duct, which runs along the posterior surface of the pancreatic head in the sulcus.

With ultrasound, it is possible to detect an expansion of the intrahepatic bile ducts, an expansion of the main bile duct up to the projection of the head of the pancreas. It ends with a conical or cylindrical stump. The stump is adjacent to the formation, or next to it the formation compressing it is visualized. The gallbladder is enlarged if the tumor does not invade the cystic duct. The Wirsung duct is widened, but not necessarily.

Such patients are shown as additional research methods: ERCP, MRTCPG. Differential diagnosis should be carried out between pseudotumorous pancreatitis and a tumor of the head of the pancreas.

Middle block.

Incl. the place of confluence into the main bile duct of the cystic duct.

Tumor of the proximal common bile duct (immediately below the confluence 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 found. Dilation of the intrahepatic bile ducts. The gallbladder is enlarged. The distal parts of the common bile duct are not visible (desolate). It is possible to get a direct image of the tumor, but rarely. If the tumor is located above the confluence of the cystic duct, then the gallbladder is not enlarged (collapsed, may look like hepatized). Additional studies: MRTCPG, percutaneous transhepatic hCG.

High block.

This is the level of the liver hilum (for example, metastases to the lymph nodes in the hilum, tumor in the hilum). Echo-signs: expansion of the intrahepatic bile ducts, hepaticoholedochus is visible very shortly (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: MRTCPG, percutaneous transhepatic hCG.

Intrahepatic block.

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

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

Traumatic injuries of the abdominal cavity.

Indications for ultrasound examination are blunt abdominal trauma.

During an ultrasound study, it is possible to identify indirect and direct signs of damage to the abdominal organs and retroperitoneal space.

The study is aimed at detecting fluid in the abdominal cavity (incomplete FAST protocol).

Benefits of ultrasound examination:

Liquid detection accuracy;

A small amount of time spent on research;

Possibility of repeated repetition of the study in a short period of time;

Non-invasiveness.

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

We conduct an ultrasound study for emergency indications, without preliminary preparation.

For a more accurate interpretation of the detected changes, it is necessary to clarify when the injury was received (hours have passed or days after the injury?).

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

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

The study can complicate the serious condition of the patient, 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 intestine, gas in the abdominal cavity, or other reasons).

We carry out the search for liquid:

In the pericardial cavity, while 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 pocket, as well as in the right subphrenic space), incl. using intercostal approaches along the intercostal spaces and along the axillary lines;

In the lower right quadrant of the abdomen (between the bowel 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 the kidney - in the splenorenal pocket);

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

In the suprapubic area (around the bladder, it is necessary to note in the protocol whether the bladder cavity is visualized, as well as in the pockets of the small pelvis).

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

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

An abnormal amount of fluid in the pericardial cavity may appear during pericarditis or as a result of trauma and is visualized as an echo-negative (homogeneous or inhomogeneous) strip between the hyperechoic pericardium and the average echogenicity of the myocardium. Pericardial fluid in a volume of up to 30 ml has a physiological origin, its main function is lubrication, it is visualized posteriorly and below the left ventricle.

The 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.

The fluid in the pericardial cavity must be differentiated from the pericardial fat pad, which can be visualized as a hypo- or anechoic streak anterior to the right ventricle, but in the supine position, it does not move posteriorly from the heart, as the fluid would displace.

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

When examining the upper quadrants of the abdomen, fluid can be found 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 sickle-shaped stripes of various thicknesses. The 0.5 cm strip in Morrison's pocket corresponds to approximately 0.5 liters of liquid. If the liquid is found in 2-3 pockets, then its volume is not less than 1 liter. Free fluid easily moves during polypositional examination.

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

It must be remembered that the liquid in the stomach can mimic a false hematoma on the left. Also, the left lobe of the liver can 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 rupture of the capsule and without rupture.

In case of injury, the liver can change its shape and size. More often, the hematoma is located along the line of the conditioned impact, and with a subcapsular location, 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 indistinct boundaries. After 7 days, this area may no longer be detected - complete restoration of the echo structure.

In this case, the differential diagnosis must be carried out with liver cancer - with trauma, the echo pattern changes in 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 look like a cavernous hemangioma. With the further development of the process (if there was no resorption within 7 days) on the 10th day, the clarity of the contour increases, the echogenicity decreases unevenly (in the form of hypo- and anechoic areas) and gradually the hematoma takes the form of an anechoic fluid formation with smooth contours, with acoustic distal pseudo-amplification, i.e. looks like a cyst.

Options for the outcome of a hematoma:

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

Inflammation and suppuration may develop;

Can break into the abdominal cavity.

Hematoma treatment - ultrasound-guided puncture and drainage.

The spleen is easily damaged by trauma, it is rich in blood vessels, and also contains part of the blood in the form of a depot. In the spleen, a subcapsular hematoma is often formed, which is visualized in the form of an echo-negative elongated subcapsular stripe that has a 2nd contour. When the capsule ruptures, it is possible to detect the discontinuity of the contour in this place and the hypo- and anechoic accumulations of blood in the adjacent tissue located in the same place. There are also hematomas located inside the parenchyma. During their development, spleen 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 injuries. The hematoma can be located subcapsularly, or in the parenchyma. If in the parenchyma, then the echo pattern is similar to acute pancreatitis. The visualization of the damaged area is significantly improved 3 days after the injury. Later, pseudocysts can form at the site of the hematoma, incl. multi-chamber, usually 4-5 weeks after injury. The size of such pseudocysts can reach several centimeters, with an inhomogeneous echo structure, with a typical dorsal pseudo-amplification. When organizing a hematoma, there is a decrease in its size, heterogeneity of the echo structure, clear contours, a hyperechoic rim along the periphery (due to fibrin filaments in the sediment and in the forming walls). Over time, calcifications may form inside an organized hematoma.

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

In the kidneys and adrenal glands, with trauma, hematomas can form, 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 tissue impregnation. After 3-7 days, the involution of these changes occurs: a decrease in size, the contour becomes clearer, the parenchyma in this area becomes more uniform. Further, either lysis is possible - a cyst is formed, or an organization with fibrosclerotic changes and possible calcification in the future. In case of subcapsular lesions, the capsule is not damaged and the hematoma is visualized in the form of a sickle-shaped echo-negative strip under the medium or increased echogenicity of the capsule. But if the capsule is not clearly defined, then the hematoma must be differentiated with free fluid at the outer contour of the organ. To do this, it is necessary 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 delineated).

When a hematoma is found in the region 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 CHS, it is defined as a local violation 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 urgent surgical treatment.

An organized hematoma is visualized as the formation of a heterogeneous solid-cystic structure, in which calcifications can be found, the contours can be clear and indistinct. It is necessary to differentiate an organized hematoma with kidney cancer. Additional studies - MRI, CT.

The adrenal gland is enlarged with trauma, rounded (if without rupture), with the age of damage from several hours to 3 days, it looks like an average or reduced echogenicity of the formation at the upper pole of the kidney, without distal pseudo-amplification. At this stage, it is necessary to differentiate with an adrenal tumor. The hematoma always changes over time. Possible changes - the formation of cystic cavities in 4-5 days, later calcifications may form.

In case of damage to the intestine or mesentery, fluid is found in the inter-loop spaces in the form of echo-negative accumulations of a characteristic triangular shape.

When examining the lower quadrants of the abdomen and the suprapubic region using longitudinal and transverse scanning, it is possible to reveal fluid in the pelvic cavity: with large amounts in the external contours of the bladder, with small amounts - in the Douglas space and the uterine appendages in women, in the space between the rectum and bladder in men.

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

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 accumulation of fluid in the Douglas pocket with an anteroposterior dimension less than 3 cm may be physiological. But if fluid is found in other places, it is most likely hemoperitoneum.

Complications after surgery.

An ultrasound scan allows you to detect foreign bodies in the abdominal cavity, which 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 at present, abdominal wipes (for example, TELASORB) can be used, which contain an embedded radiopaque plate and a loop - they are visible on X-ray.

There are so-called. "Dry" foreign bodies - no effusion. Clinical manifestations of such a foreign body are erased or absent. It is often found as a find during a survey ultrasound examination. In the history of these patients, surgery. On examination, it can be visualized as a hyperechoic crescent stripe (referred to as a "shell-like" structure in some SPL guides) with an intense acoustic shadow behind. The width of the acoustic shadow is the same as the size of the crescent-shaped stripe. May resemble a stone in the abdomen.

If there are clinical manifestations - pain, fever, changes in the blood test, then the foreign body is surrounded by liquid due to a pronounced exudative reaction. During ultrasound, a volumetric formation of various shapes is determined, with clear or indistinct contours, a heterogeneous echo structure due to the 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) ...

The differential diagnosis of "dry" foreign bodies must be carried out:

1.With gas-filled bowel loops. The difference is that the shadow from the gas in the intestine is gray, “glittering” (artifact of reverberation from oscillating gas bubbles in the intestine), and the acoustic shadow behind the napkin is black and intense. It must be remembered that an intense acoustic shadow is also observed in the intestines from barium. In such cases, plain X-ray 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 gallbladder, as well as with the so-called. "Porcelain" gallbladder (in chronic cholecystitis, calcium salts are deposited in the walls of the bladder, and ultrasound visualizes the hyperechoic anterior wall of the gallbladder with an intense acoustic shadow).

3.With other abdominal calcifications such as:

Intestinal stones (eg, petrified fecal stones);

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

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

Calcification of the walls of cysts and tumors;

Calcifications in the spleen (previously transferred histoplasmosis, tuberculosis, malaria,

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

Calcifications in the seminal vesicles and in the prostate gland;

Ovarian teratoma, calcification of uterine fibroids;

Calcifications in the mesenteric lymph nodes;

Calcification of post-traumatic hematoma.

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

All calcifications are visible on X-ray examination.

Foreign bodies with effusion must be differentiated from abscesses, 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 pseudo-amplification 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. Downstream - acute and chronic.

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

Development stages of the process:

The initial, infiltrative stage - in the liver area, a zone of reduced echogenicity is determined, indistinctly separated from the surrounding parenchyma, the contour is indistinct, irregular 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, the contour is indistinct, the appearance of central or eccentrically located areas with a lower echogenicity and an uneven contour;

In conclusion, the stage of complete melting develops - an echo-negative formation with distal acoustic amplification, around a thin Halo, up to several mm thick (zone of reactive inflammation, demarcation zone, delimits the diseased and healthy tissue).

If there is thick pus in the abscess cavity, then it is poorly distinguishable from the tumor - the formation of a heterogeneous echo structure, medium or increased echogenicity, the contours are indistinct (but the vessels are not determined inside).

Differential diagnosis - with an abscess in 2-5 days, the picture changes, with a tumor it is stable. A puncture is best, because swelling during decay can also suppurate.

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

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

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

Subhepatic abscess - can form after cholecystectomy, surgery on the stomach, and other organs. It is more 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, 2-5 cm and more (up to 15 cm).

Biloma is an accumulation of bile in the area of the bed (in the furrow) of the removed gallbladder, often in the form of a three- or two-leaved. It is necessary to differentiate with a tumor of the hepatic flexure of the colon, a tumor of the small intestine. If there is a tumor of the intestine, then the ultrasound symptom of a hollow organ lesion (PPO) is more often determined - a formation with a hypoechoic periphery (intestinal wall) and a hyperechoic center (lumen).

Subphrenic abscess is more 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 subphrenic space, the gas bubble of the stomach, intestines interferes. 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 (at first a narrow crescent, later it can significantly thicken, pushing back the organ and becoming rounded or spindle-shaped), hypo- or anechoic, homogeneous or not, may contain gas bubbles with a reverberation effect. It is important to distinguish a subphrenic abscess from fluid accumulation between the diaphragm and an organ, as well as from pleural effusion. It is necessary to turn the patient and the liquid will flow, and the abscess will remain in place. We also take into account the clinic, the data of laboratory research methods.

Abscess of the pelvic cavity. The study must be carried out with a filled bladder and carefully examine it from all sides, if there is a formation near the bladder, then it may be a peri-vesicular abscess (in the presence of ultrasound signs of an abscess and clinic). It is necessary to differentiate with a bladder diverticulum, a tumor.

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

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

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

Appendicular infiltration 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 (process lumen). The contours are initially indistinct, blurred. In dynamics, a decrease in size occurs due to a decrease in tissue infiltration, the hypoechoic periphery also decreases (less wall edema), 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 will be no decrease in size over time) and clinical manifestations. Having acquired clear contours, the formation becomes similar to a symptom of a defeat of a hollow organ.

Complications of infiltration: anechoic inclusions appear in the peripheral zone, an increase in size, indistinct contours - a para-appendicular abscess.

Soft tissue infiltrates in the area of postoperative scars. Echo signs: in the thickness of the abdominal wall or under it (sometimes deeply), the formation of an elongated spindle-shaped form, slightly increased echogenicity, a homogeneous structure, with a fairly clear contour is determined. In dynamics - its decrease, up to its disappearance. If it suppurates, it increases in size, round in shape, anechoic foci (pus) and other signs of an abscess appear.

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

Ascites, intra-abdominal bleeding, peritonitis - in all cases we see fluid in the sloping places of the abdominal cavity, already from 50 ml, first along the posterior-lower surface of the liver, Morrison's pocket. This is a thin hypoechoic streak. As the volume increases, the fluid surrounds the liver, spleen, and the bowel loops can “float” in it. With a homogeneous structure of the fluid - most likely ascites, with a heterogeneous - blood (clots, fibrin) or pus.

Pancreatic necrosis is a complication of destructive pancreatitis.

Echo signs: the pancreas is enlarged, the contour is indistinct, uneven, echogenicity is reduced in areas or diffusely, the structure is heterogeneous due to hypo- and hyperechoic inclusions. Anechoic reactive effusion into parapancreatic tissue is determined. The structure of the stromal elements of the gland is preserved. This can be with acute pancreatitis and with exacerbation of chronic pancreatitis.

If the above-described changes in the tissue of the gland + effusion into the omental bursa (anterior to the gland, under the stomach) are found, 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 on both sides of the tail of the pancreas, linear areas of reduced echogenicity, a fairly homogeneous echo structure, with moderately fuzzy contours are visible. If these linear areas of reduced echogenicity increase significantly, the contours become even more blurred, then an abscess of the retroperitoneal space in which the pancreas is located (between the posterior peritoneum and the transverse fascia that lines the posterior abdominal cavity) may form.

Typical echo signs of pancreatic necrosis:

Pancreas changes;

Omental effusion;

Involvement of parapancreatic fiber in the inflammatory process.