SONOGRAM ABBREVIATIONS

Ad Adrenal gland

Ao Aorta

D Diaphragm

GBl Gallbladder

IVC Inferior vena cava

K Kidney

L Liver

P, Pa Pancreas

PPs Pancreatic pseudocysts

R Ribs

Sp Spleen

St Stomach

KEY WORDS

Gaucher’s Disease. One of the group of “storage” diseases in which fat and proteins are abnormally deposited in the body, typically in the liver, spleen, and bone marrow.

Myeloproliferative Disorder. Term referring to chronic myeloid leukemia, myelofibrosis, and polycythemia vera—a spectrum of hematologic conditions associated with a large spleen. Sometimes one entity will change into another.

Pancreatic Pseudocyst. Fluid collection produced by the pancreas during acute pancreatitis.

Pheochromocytoma. A hormone-producing tumor that generally arises from the adrenal glands.

Portal Hypertension. A rise in the pressure of the venous blood flowing into the liver through the portal venous system, causing an increase in the size of the portal, splenic, and superior mesenteric veins and of the spleen. If portal hypertension is severe, additional vessels known as collaterals develop at multiple points within the abdomen (see Fig. 6-7).

Splenomegaly. Enlargement of the spleen.

Subphrenic Abscess. An abscess lying under the left or right diaphragm. Such abscesses commonly follow a surgical procedure in the area, for example, an operation on the stomach.

The Clinical Problem

SPLENOMEGALY

The most frequent left upper quadrant mass is an enlarged spleen. Splenomegaly occurs in a wide variety of disease states.

1. Infectious diseases such as tuberculosis, malaria, infectious mononucleosis (“mono”), and subacute bacterial endocarditis are often accompanied by an enlarged spleen. (The spleen is occasionally the site of an abscess, particularly with subacute bacterial endocarditis or any other bacteremic state.)

2. Myeloproliferative disorders such as myelofibrosis may be characterized by splenomegaly.

3. Splenomegaly occurs when the veins draining the spleen are obstructed, as in portal hypertension or splenic vein thrombosis. Both pancreatic cancer and pancreatitis can cause splenic vein thrombosis.

4. Metastases may occur in the spleen; however, the spleen is not often the site of neoplastic involvement.

5. Lymphoma and leukemia may involve the spleen directly or cause splenomegaly as a secondary phenomenon because blood production is disorganized.

6. Storage disorders such as Gaucher’s disease may cause splenomegaly.

FLUID-FILLED MASSES

A left upper quadrant fluid-filled mass is quite common and may be (1) a renal mass such as hydronephrosis or a large renal cyst, (2) a splenic cyst, (3) an adrenal cyst, or (4) a pancreatic pseudocyst.

NEOPLASMS

Neoplastic masses in the left upper quadrant include (1) retroperitoneal sarcomas; (2) adrenal tumors, which are usually small (e.g., metastases, pheochromocytoma) but occasionally become large; and (3) pancreas and kidney cancers, which can spread into the left upper quadrant and cause a palpable abdominal mass.

The surgical approach is dictated by the origin and nature of the mass. Cysts may be treated conservatively or by cyst puncture rather than by surgery.

ABSCESSES

The left subdiaphragmatic region is a common site for abscess collections, particularly in postoperative patients after removal of the spleen or stomach operations.

Anatomy

SPLEEN

The spleen is the predominant organ in the left upper quadrant. It lies immediately under the left hemidiaphragm and may be difficult to see because of gas in the neighboring lung and ribs. It lies superior to the left kidney and lateral to the adrenal gland and the tail of the pancreas. The left lobe of the liver is often in contact with the spleen.

The splenic texture is more echogenic than the liver or kidney. A group of high-level echoes in the spleen’s center at its medial aspect represents the splenic hilum at the entrance of the splenic artery and vein.

ADRENAL GLANDS

See Chapter 16 for information pertaining to the adrenal glands.

Technique

LEFT SIDE VIEW (CORONAL)

The left-side-up position (right lateral decubitus) is the preferred position for investigating the left upper quadrant (Fig. 12-1). Angle the transducer somewhat obliquely so that it passes between the ribs. Place a pillow or a wedge under the patient to improve access to the left kidney (see Chapter 18). To identify your location, find the left kidney; the spleen will be superior to it. There should normally be nothing between the spleen and the left hemidiaphragm. Make sure the scan plane allows visualization above the diaphragm as well.

TRANSVERSE VIEWS

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