115

Downloaded from www.ajronline .org by 180.191.22.20 2 on 02/07/14 from IP address 180.191.22.20 2. Co yrig!" #$$%. &or ersonal 'se only( all rig!"s reser)ed
0illiam

&allibili"yof *+ lora"ory ,a aro"omyin De"e-"ionof .e a"i-and $e"ro eri"oneal /asses

P. .arbin112

2ose !

2a-3 0i""enberg1 4. &err'-Ci52r.1

Pe"er #. /'eller1

,eslie

0. 6""inger7

4!e re-en" wide a)ailabili"yof sonogra !yand -om '"edbody"omogra !y!as added a new dimension"o "!e diagnosisof abdominalmasses. $e-en"lyin si+ a"ien"s e+ lora"oryla aro"omyfailed "o re)eal a mass demons"ra"edby reo era"i)e-ross8 se-"ionalimaging and s'bse9'en"ly-onfirmedin "!e os"o era"i)e eriod by ree+am8 ina"ionwi"! or wi"!o'" er-'"aneo'sneedling.4!ree of "!e si+ a"ien"s!ad re)io's an-rea"i-inflamma"orydiseasew!i-! may !a)e limi"ed "!e s'rgi-ale)al'a"ionof "!e re"ro eri"one'm.Prior "o "!e ad)en" of -ross8se-"ionalimaging5"!ere were few a)ail8 able dire-" means for dis-o)eringerrors in in"raabdominals'rgi-al diagnosis.0!ile

e+ lora"ory radiologis"s

la aro"omyis ob)io'sly-r'-ial for -onfirma"ion s!o'ld be reminded "!a" i" is no" infallible.

of abdominal

masses5

*+ lora"ory
diagnosis assessing ally5

la aro"omy

is an im or"an"5
masses. a--'ra-y fails I" is -ommonly of radiologi"o -onfirm

widely

'sed5

"r's"ed
as a "r'"! "e-!ni9'es. was

me"!od

for "!e

of abdominal "!e diagnos"ie+ lora"ion

'sed imaging a mass "!a"

s"andardfor 6--asion8 by ei"!er

abdominal

redi-"ed

!ysi-ale+amina"ionor radiologi-s"'dies.In s'-! -ases5 f'"!er s"'dy may -ease and medi-als'r)eilan-emay be rela+ed.0i"!in an 1 8 mon"! eriod5 si+ a"ien"s
in o'r !os i"al 'nderwen" s'rgi-al e+ lora"ion of "!e abdomen w!i-! failed "o

re)eal
imaging

a mass
wi"!

"!a"

was

no" only
or -om

sonogra !y

-onfirmed
da"a new

in "!e os"o era"i)e

by sonogra !y "!e reo era"i)e

demons"ra"ed by reo era"i)e-ross8se-"ional "omogra !y:C4; b'" was s'bse9'en"ly '"ed <e-a'seof "!e 'ni9'e-ross8se-"ional eriod.
and C45 "!eseme"!ods diagnosisof s'rgi-al !a)e -learlyaddeda disease.4!is re or"

now ro)ided dimension"o

resen"s
im li-a"ions

"!e er"inen"
of "!e

fea"'res
false8nega"i)e

of "!ese

-ases

and dis-'sses

some

less ob)io's

la aro"omy.

$e-ei)ed
re)ision /ar-!

6-"ober
1 75 1980.

1 =5

1 979(

a--e "ed .ar)ard .os i"al5

af"er /edi-al <os"on5

Case $e or"s
Case 1

>De ar"men"of $adiology. %-!ool5/assa-!'se""s?eneral /# 02114.

# =08year8oldman was "ransferredfrom ano"!er .e !ad been well 'n"il 7 days beforeadmission
s!a3ing ser'm -!ills5 bilir'bin na'sea5 and and al3aline )omi"ing. !os !a"ase #" a lo-al le)els

!os i"al
w!en !os i"al5 and !e

wi"! se sis
de)elo ed da"a ele)a"ed

and !y o"ension.
fe)er ser'm "o 78.9@A17=BC5 normal gl'"amire)ealed

2Presen" addressC$ome $adiology?ro' 5 700 w. ="! %".5 $ome5 ?# 701 =1 . #ddressre rin" re9'es"s"o 0. P. .arbin. 7De ar"men"of %-!ool5/assa-!'se""s /# 02114. #2$ 175C11581215
07=18807D/80/1751801

labora"ory a slig!"ly

%'rgery5 ?eneral

.ar)ard .os i"al5

/edi-al <os"on.

o+ala-e"i-a-id "ransaminase:%?64;. Des i"e in"ra)eno'san"ibio"i-"!era y5se "i- s!o-3 ens'ed.P!ysi-ale+amina"ionwas 'nremar3ablee+-e "for mild rig!" ' er 9'adran" "enderness.<lood -'l"'reswere osi"i)e for ?ram8 osi"i)e-o--i in airs. 6n !os i"al day 25 sonogra !i-e+amina"iondemons"ra"eda 9.5 + 7 + 8 -m -om le+mass in)ol)ingmos"
of "!e os"erior ar" of "!e rig!" lobe of "!e li)er :fig. 1 #;. .e a"iar"eniogra !y erformed

2'ly

1980 15 E00.00

F #meri-an

$oen"gen

$ay %o-ie"y

7 !r af"er "!e sonogra !i-

e+amina"ion

was in"er re"ed

as normal.

11=

.#$<IG

*4

#,.

#2$C1755

2'ly 1980

#f"er dis-'ssionswi"! "!e o era"ings'rgeon5e+ lora"oryla a8 ro"omywas erformedon "!e same day and re)ealeda normal
a earing eri"oneal -a)i"y5 li)er5 and gallbladder. 4!e en"ire li)er

Case 7 # 528year8oldman was admi""edbe-a'se of in-reasingabdomi8 nal ain. 4!ree mon"!s before admission5!e !ad been e)al'a"ed for "!e same ain a" ano"!er!os i"alw!ere sonogra !yand an8
giogra !y !ad bo"! demons"ra"ed an a)as-'lar mass in "!e s' erior

and rig!" '

er

9'adran"

were e+ lored

and al a"ed

b'" no needle

was in"rod'-ed in"o "!e li)er. 4!e abdomen was -losed. 4wo days af"er s'rgery5 a 9H4- s'lf'r -olloid !e a"i- s-in"igram Downloaded from www.ajronline .org by 180.191.22.20 2 on 02/07/14 from IP address 180.191.22.20 2. Co yrig!" #$$%. &or ersonal 'se only( all rig!"s reser)ed
demons"ra"eda large defe-" in "!e os"eriorrig!" !e a"i- lobe and a -on-omi""an"=7?a s-in"igramwas in"er re"edas s!owing roba8 bly abnormal' "a3e in "!e same region. 6n os"o era"i)eday 75 C4 re)ealeda large low8densi"ymass in "!e os"eriorrig!" !e a"ilobe :fig. 1 <;. # diagnos"i-fine8needleas ira"ionof "!e !e a"imass erformed'nder C4 g'idan-eyieldedabo'" 5 ml of fran3 's5 and ?ram s"ain re)ealed?ram8 osi"i)e-o--i.4!e a"ien"

ar" of "!e re"ro eri"one'm.,a aro"omydis-loseda re"ro eni"oneal mass "o "!e rig!" of "!e -elia- a+is( o era"i)ebio sy of "!e mass and s'rro'ndinglym ! nodes re or"edlyre)ealed +an"!ogran'lom8 a"o's inflamma"ion.4!e a"ien"was "old "!a" -an-erwas no" e+-l'ded..is ain !ad im ro)edsin-e "!e s'rgery5b'" !e en"ered "!is !os i"al for defini"i)ediagnosisand "rea"men". P!ysi-ale+amina"ionand labora"oryda"a5 in-l'dinga ser'm amylase5were all wi"!in normal limi"s. %onogra !yre)ealed a =87

ini"ially

ref'sed

re ea"

s'rgi-al

e+ lora"ion

b'"

s'bse9'en"ly

-on8

sen"ed.&i)e days af"er as ira"ion5an abs-essin "!e rig!" lobe of "!e li)er was e)a-'a"ed)ia a s'b-os"alin-ision.4!e a"ien" was dis-!arged7 wee3s la"er in good -ondi"ion.

-m

!y oe-!noi-

mass

wi"!

diff'se

low8le)el

in"ernal

e-!oes

in "!e

s' eriorre"ro eri"oneal "i-al "o "!e reo era"i)e

radiologifindings were

region :fig. sonogram

-aref'lly

7#;. 4!e mass a eared from "!e o"!er !os i"al.

re)iewed wi"! "!e a"ien"1s

iden8 4!e
s'n8

Case 2 # 1 98year8oldgirl was admi""edwi"! ersis"en"fe)er. #" age 4 years a -!oledo-!al-ys" was diagnosedand s'bse9'en"lyre8

geon. *+ lora"oryla aro"omywas erformed5b'" a "!oro'g!e+8 lora"ionof "!e re"no eni"oneal5re"ro!e a"i-5 eniaor"i-5and lesser sa- regionsfailed "o re)eal a mass. 4wo wee3s la"er5 a re ea" sonogra !i-e+amina"iondemons"ra"ed"!e same =87 -m re"ro er8
i"oneal mass :fig. 7<;. 4wo days la"er5 needle as ira"ion 'nder

se-"ed. 4!ree wee3s before admission5 -ommon d'-" e+ lora"ion was -arried o'" a" ano"!er !os i"al and se)eral in"ra!e a"i-d'-"
-al-'li were# -!oledo-!ojej'nos"omywas remo)ed. erformed.#"

sonogra !i-g'idan-eyielded 4 ml of "!i-35 brown5 'r'len"ma"e8 nial. Cy"ologi-e+amina"ionre)ealedinn'merable olymor !on'8 -lear le'3o-y"esb'" no malignan"-ells. D'ring a 1 mon"! os"o 8 era"i)eo'" a"ien")isi"5 "!e a"ien"a earedwell and re or"ed
infre9'en" abdominal ain. .e did no" re"'rn for f'r"!er follow8' .

leas" one large -al-'l's remainedin "!e rig!" !e a"i-d'-" sys"em

as demons"ra"edon os"o era"i)e-!olangiograms. %!e was an ema-ia"ed5sallow yo'ng female wi"! a dis"ended abdomenand a "ender enlargedli)er. %er'm bilir'bin was 7.4 mgI
dl5 and w!i"e blood -ell -o'n" was 1 45700. # 48"'be -!olangiogram

re)ealed
rig!" !e a"i-

a a"en"
d'-".

-!oledo-!ojej'nos"omy
?ray s-ale sonogra !y

and a -al-'l's
:fig. 2#; dis-losed

in "!e
a fo-al

Case

485 -m ane-!oi- area in "!e s' erior as e-" lobe wi"! -!ara-"eris"i-sof an abs-ess.
,a aro"omywas -arriedo'" "!e ne+" day5 de"e-"edon "!e li)er s'rfa-e.4wen"y se ara"e
in"o "!e area of "!e rig!" !e a"ilobe failed

of "!e rig!" !e a"ib'" no mass was needle as ira"ions

"o yield any abnormal

# 508year8old sea5 )omi"ing5

in-l'ded e"!anol

man was admi""ed-om laining and 1 7.5 3g weig!"loss o)er

ab'se5 d'odenal 'l-er5 and

of wea3ness5na'8 4 mon"!s..is"ory
an e isode of lef" leg

ma"erial.

&e)er s i3es re-'rredwi"! in"ermi""en"!y o"ension.6n os"o 8 era"i)e day 75 re ea" sonogra !ys!owed"!e !y oe-!oi-fo-'s 'n-!anged.Inder sonogra !i-g'idan-e5 er-'"aneo'sneedle as ira"ionwas erformedand yielded20 ml of 'r'len"ma"erial. #f"er -ons'l"a"ionwi"! "!e a""endings'rgeon5"!e a"ien"was "ransferred"o "!e fl'oros-o ys'i"e w!ere er-'"aneo's-a"!e"er

"!rombo !lebi"isfollowedby liga"ionof "!e inferior)ena -a)a. P!ysi-ale+amina"ionand labora"oryda"a were 'nre)ealinge+-e " for modera"eele)a"ionof "!e ser'm amylaseon re ea"edde"ermi8 na"ions. #n ' er gas"roin"es"inalseries re)ealed "!i-3enedgas"riand d'odenalfolds. %onogra !i-e+amina"iondemons"ra"eda = + 7 + 7.5 -m se'do-ys"in "!e an-rea"i-!ead wi"! an es"ima"ed )ol'me of 700 ml :fig. 4#;. #r"eniogra !yalso o'"lineda =87 -m a)as-'larmass in "!e an-rea"i-!ead -onsis"en"wi"! a se'do8 -ys". *ndos-o i-re"rograde-!olangio an-rea"ogra !yre)ealed -!angesof -!roni- an-rea"i"isand e+"ra)asa"ionof -on"ras"ma8 "erial in"o a -ys"i- mass in "!e an-rea"i-!ead.

inser"ion

and

abs-ess

drainage

were

-arried

o'".

Con"rol

s o"

radiogra !saf"er -on"ras"inje-"ionof "!e er-'"aneo'sly la-ed -a"!e"erdis-loseda ra-emose a""ern of -on"ras"ma"erial s read8 ing "!ro'g!o'"a well defined 8.0 -m segmen"alarea in "!e s' er8 ola"eralas e-" of "!e rig!" !e a"i- lobe :fig. 2<;. 4!e im ression

4wel)e days af"er admission5

"a3en "o drain "!e an-rea"iin "!e !ead of "!e an-reas
os"erior wall of "!e s"oma-!

e+ lora"ory
se'do-ys". a longi"'dinal
and

la aro"omy

was 'nder8

#f"er al a"ionof a mass in-ision was made in "!e

fl'id lo-'la"ion was

a small

was "!a" of an e)ol)ing

area of !e a"i-

ne-rosis5

b'" no" a well

en"ered.

I" was ossible

"o as ira"e

abo'"

75 ml of dar3 brown was 'nder"a3enin8 "!ro'g! "!e os"erior

fl'id.

lo-'la"edabs-ess.# se-ond-a"!e"erwas inser"ed"o a-!ie)e im ro)edde enden"drainage.P's :1 5 ml; drainedfrom "!e "wo -a"!e"erse)en"'allygrew se)eral ?ram8nega"i)eorganismsin-l'd8 ing *n"eroba-"eriaand Pse'domonas. 4!e a"ien" was re"'rned"o "!e o era"ingroom1 = !r af"er "!e ro-ed'rebe-a'seof ersis"en"se sis and !y o"ension(f'r"!er

.owe)er5

a" "!a" oin"5 "!e s'rgeon

was no" -on)in-ed

"!a" !e !ad

as ira"ed"!e major -ys". &'r"!er e+ lora"ion -l'ding a d'odeno"omywi"! needle as ira"ion

d'odenal wall5 b'" no large amo'n" of fl'id

-o'ld

be as ira"ed.

4!e

s'rgeon
"!e region of "!e rig!"

belie)ed

"!a" i" wo'ld "!e a"ien"

af"er an-rea"ia se-ond s'rgery5

be 'nwise -on"in'ed
!ead

"o -'" "!ro'g! "o -om lain

:fig.

an-rea"iof abdominal
again w!i-! was 4<;

"iss'e in order "o drain any o"!er -ys"i- -a)i"y.

li9'ified 'r'len" ma"erial was s'-"ioned from

Pos"o era"i)ely5
ain. re)ealed 4wo wee3s a 7 -m la aro"omy5

!e a"i!e a"i)ealed

lobe. %!e s'bse9'en"lydied from renal5 res ira"ory5and fail're on !os i"alday 44. Pos"mor"eme+amina"ionre8 a f'lminan"ne-ro"iJinginfe-"ionin "!e eni!e a"i-s a-es

sonogra !ise'do-ys"

e+amina"ion

-onfirmed

by a C4 e+amina"ion

:fig.
la aro"omy

4C;.

6ne
was

mon"!
erformed

af"er
and

"!e
a

w!i-! eroded

"!e an"erior

eri"one'm

and abdominal

m's-'la"'re.

original

4!e rig!" lobe of "!e li)er was s ongy5wi"! a !oney-ombedgross a earan-eon se-"ioning.Go well definedabs-ess-a)i"y was delinea"ed.

large -ys"i- mass was fo'nd in "!e an-rea"i-!ead and drained )ia a -ys"i- gas"ros"omy.4!e a"ien" re-o)eredsa"isfa-"orilyand was dis-!argedfree of ain 2 wee3s af"er "!e se-ond e+ lora"ion.

#2$C1755

2'ly

1980

&#,,I<I,I4K

6&

*DP,6$#46$K

,#P#$646/K

117

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#
&ig. 1 8Case 1.
#5

<
Preo era"i)e sagi""al sonogram"!ro'g! rig!" rig!" !e a"i- lobe :arrows;. !e a"ilobe. ,arge mass :arrows;
in os"erior rig!" lobe. <5 Pos"o era"i)e C4 s-an of li)er.

,arge5 low densi"y mass in os"erior

>L>"
!5

>

#
s o"

&ig.

2.8Case

2. #5 .e a"i-

sonogram5

rig!"

in"er-os"al

)iew.

Poorly

margina"ed

<

area

of diminis!ed

e-!o

"e+"'re

in rig!"

!e a"i-

lobe

:arrows;.

<5 Con"ras"

radiogra !

d'ring

fl'oros-o i-ally

g'ided

needle

as ira"ion

and -a"!e"er

drainage.

%egmen"al

ra-emose

area of -on"ras"

a--'m'la"ion.

Case

-m.

6ne

wee3

la"er5

sonogra !y

demons"ra"ed

"!e

same

"wo

-ys"s.

# 298year8oldman wi"! a long !is"oryof e"!anolab'se and re)io'se isodesof an-rea"i"iswas admi""edbe-a'seof in"er8 mi""en"' er abdominal ain and 22.5 3g weig!"loss o)er "!e re)io'syear. C4 re)ealed"wo large lef" ' er 9'adran"-ys"s w!i-!werein"er re"ed as an-rea"i- se'do-ys"s:fig. 5#;( "!e an"erior-ys" was 1 2 + 9 + 1 0 -m and "!e os"erior57 + 7 + 8

4!e findingswere a" w!i-!a large

<e-a'se diffi-'l". of "!e #f"er were

dis-'ssed lef" ' er

"ension drainage and

wi"! "!e s'rgeon 9'adran"-ys"isiJe of "!e -ys"5

rior "o la ano"om5 mass was e)iden".

e+ lora"ion was mos"

was ossible
masses

"o f'r"!er
fo'nd.

of "!e -ys" "!ro'g! e+ lore "!e lef" ' er

Ins e-"ion of "!e in"erior

a -ys" gas"ros"omy5i" 9'adran"and no o"!er

of "!e de-om ressed

-ys"

re)ealed

no se "a"ions

or "iss'e.

118

.#$<IG

*4

#,.

#2$C1755

2'ly 1980

Downloaded from www.ajronline .org by 180.191.22.20 2 on 02/07/14 from IP address 180.191.22.20 2. Co yrig!" #$$%. &or ersonal 'se only( all rig!"s reser)ed

I.

&ig. 7.8Case

inferior

)ena

7. #5 Preo era"i)e -a)aCP N or"al

"rans)ersesonogram )ein. <5 Pos"o era"i)e

of s' erior "rans)erse

e igas"risonogram.

region. $e"ro eri"onealmass :=87 -m; os"erior %ame mass as on reo era"i)es"'dy.

"o li)er. /

mass(

aor"a(

Pos"o era"i)ely5

"!e

a"ien"

re-o)ered

sa"isfa-"orily

and

was

free

Dis-'ssion
*+ lora"ory -l'si)ee)al'a"ion !a)e "ermedi" la aro"omy >"!e is generally -onsidered masses. for a"ien"s "!e -on8 %ome wi"!

of ain. 6n "!e day of dis-!arge51 0 days af"er s'rgery5re ea" C4 demons"ra"eda 7 + 8 -m se'do-ys"near "!e an-rea"i-"ail "!a" -orres ondede+a-"ly"o "!e os"eriorlylo-a"ed -ys" seen on "!e
reo era"i)e s"'dy :fig. %<;. Go f'r"!er follow8' da"a was a)ailable.

>

for s's e-"edabdominal final diagnos"i-s"e 1

>

Case

fe)erof 'n3nownoriginO1 P. Ke" do-'men"a"ionof "!e a-8 -'ra-yof la aro"omyin "!e de"e-"ionof abdominalmasses is no" readilya)ailablein "!e li"era"'re.# "!oro'g!sear-! man
of "!e "!e rig!" s"ri-"'re

# 788year8old
4rans!e a"iing

was

admi""ed
!e a"i-

wi"!
d'-". re)ealed

ja'ndi-e
%'rgi-al

and
ear8 e+ lora"ion was

r'ni"'s.
and

re)ealed
nega"i)e e+ lora"ion. %'rgi-al

li""le informa"ion
obser)a"ions e+ lora"ion of

-on-erning
abdominal

false8 osi"i)e
masses 'sed by as

or false8
s'rgi-al an end

-!olangiogra !y -ommon ' er and

demons"ra"ed 9'adran"

a malignan"8a a malignan"

s"ri-"'re of d'-"

bio sy !e a"i-

-ommon erformed.

is also "!e diagnos"isonogra !yand

fre9'en"ly

a -!oledo-!ojej'nos"omy

Pa"!ologieno-ar-inoma 6)en in-l'ding

re9'iring

e+amina"ion
-onsis"en" ne+" 2 se)ere "!e

dis-losed
wi"! mon"!s5 bile

a modera"ely
d'-" origin.

differen"ia"ed
de)elo ed

ad8

oin"for assessing imaging.#l"!o'g!

ra !y !a)e

a--'ra-y of radiologi-om '"ed body "omog8 a--'ra-yin "!e de8

n'mero's an-rea"i"is

-om li-a"ions and abs-ess "!e a"ien"

demons"ra"ed

-onsiderable

ne-ro"iJing

forma"ion

"wo
and

s'rgi-al
an-rea"i-

ree+ lora"ions
abs-ess.

for drainage
.owe)er5

of rig!"

'

er

"e-"ion ob)io'sly nega"i)e "o de"ermine "ional !ere5

"!a"

of

abdominal remainsan ra"e. 4!e "!e

massesO288P5s'rgi-ale+ lora"ion a ro ria"emeas'reof "!eirfalse8 )alidi"y of 'sing 'n ro)en. an 1 8 mon"!

is no"

9'adran"

-on"in'ed

e+ lora"ory ra"e si+ in"er)al5

wi"!o'"

la aro"omy of -rossse-8 re or"ed -ases

"o be febnile and bo"! sonogra !y:fig. ons"ra"eda = + 5 + 4 -m abs-essin s a-e of "!e re"ro eri"one'm.# fo'r"! b'" e+ lora"ionof "!e re"no eni"one'm
small
drained.

=#; and C4 :fig. =<; dem8 "!e lef" an"erior ararenal o era"ionwas erformed5 was diffi-'l"..owe)er5a
ma"erial re-'rred. =D; on "!e $e ea" reo era"i)e was fo'nd sonogna !i"!e same lef" s"'dies. and

false8 osi"i)e remains o)er

la aro"omy

diagnos"i4!e

imaging en-o'n"ered
e+ lora"ory

demons"ra"e
limi"a"ions and

-olle-"ion

of "!i-35 fe)er :figs. abs-ess

serosang'ino's and -!ills =C and delinea"ed

raises o"!er #ll

la"ed

9'es"ions me"!ods si+

masses

-on-erning of de"e-"ing in)ol)ed

and ea-!

i"s 'n-ri"i-al'se abdominalmasses. inflamma"ory

-ase warran"s

in e)al'a"ing or inflamma"ion8re8
dis-'ssion.

Pos"o era"i)ely and C4 e+amina"ions re"ro eni"oneal

demons"ra"ed

-ases

se ara"e

<e-a'seof !is oor -ondi"ion5 er-'"aneo'sdrainageof "!e ab8 s-ess was erformed'nder C4 g'idan-e.#bo'" 75 ml of "!i-3 's was as ira"edini"ially5and "!e er-'"aneo's-a"!e"er-on"in'ed"o drain 's for se)eralwee3s. $e ea" C4 demons"ra"edred'-"ionof "!e abs-ess..e im ro)ed-lini-allyand was dis-!arged7 mon"!s la"er.

In -ase be-a'se .owe)er5 re)iewed asses re-o)er

1 5 "!e !e a"i-abs-esswas no" de"e-"ed only "!e li)er s'rfa-ewas al a"edand in -ase 25 "!e a""endings'rgeon!ad "!e sonogra !i-da"a and madeabo'" in"o "!e li)er s'bs"an-ein"rao era"i)ely5ye" failed "o 'r'len"ma"erial.# re-en"-om re!ensi)ere)iew

robably ins e-"ed. ersonally 20 needle

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I
&ig. 4.8Case 4. #5 Preo era"i)e "rans)erse sonogram "!ro'g! an-rea"i-

region. Cys"i- mass := + 7 + 7.5 -m; near an-rea"i-!ead. "rans)ersesonogram.%ame -ys"i- mass as on reo era"i)e o era"i)eC4 s-an. Cys"i- mass :7 -m; in an-rea"i-!ead.

<5 Pos"o era"i)e s"'dy. C5 Pos"8

diffi-'l"yin e+ loring"!is "ory-!anges..owe)er5

regionw!en"!ere no re"ro eri"oneal

are inflamma8 inflamma"ory

-!angeswere en-o'n"eredin -ase 75 and no e+ lana"ion for "!is diagnos"i-error is readily a aren". Pan-rea"i- se'do-ys"a--o'n"edfor "!e massesno" de"e-"edby la aro"omyin -ases 5 and =. 0i"! "!e ad)en"
of abdominal sonogra !y5 an-rea"imore fre9'en"ly se'do-ys" forma"ion

as a -om li-a"ion
re-ogniJed as

of an-rea"io--'rring

inflamma"ory

disease
"!an was

is now
re)i8

o'sly re-ordedin s'rgi-alor a'"o syseries O1 781 8P. &'r8 "!er5 serial sonogra !i-e+amina"ions!a)e demons"ra"ed "!a" s on"aneo'sresol'"ionof an-rea"i- se'do-ys"is no"
'n-ommon reo era"i)e of !e a"iabs-ess O9P no"ed "!a" of nine a"ien"s 'ndergoing O1 7P. In )iew e)al'a"ion of "!e o"en"ial by sonogra !y s'rgi-aldiffi-'l"ies5 or C4 s!o'ld

be

-onsidered
for bo"!

in all s's e-"ed

diagnosis and

-ases
"rea"men"

of an-rea"ilanning.

se'do-ys"

s'rgi-ale+ lora"ionfor s's e-"ed-!olangi"is5fo'r !ad a !e a"i-abs-ess"!a" was no" re-ogniJedin"rao era"i)ely. 4!esefo'r abs-esseswere s'bse9'en"lydis-o)eredby ree+ lora"ionin "wo -ases and by a'"o syin "wo -ases. In bo"! -ases 1 and 25 signs of -on"in'ingse sis and "!e ersis"en-eof "!e radiologi-"eam res'l"edin re-alling"!e a"ien"for ree+amina"ionand needle as ira"ionof "!e s's8 e-"edlesions.Per-'"aneo'sneedleas ira"ionof s's8 e-"ed abdominalabs-ess!as been s!own a safe5 a--'ra"e meansof ro)idinga defini"i)ediagnosisO10812P.%ono8 gra !y5body C4 or -on)en"ionalfl'oros-o y-an all be

Geo las"ien-o'n"ered

disease
in "!is

did no" a--o'n"

series. #l"!o'g!

for any of "!e masses

"!e -ases demons"ra"e

"!e diffi-'l"yof s'rgi-aldiagnosisin "!e resen-eof re"ro8 eri"onealinflamma"orydisease5similar limi"a"ionsmay no" er"ain "o neo las"i-diseasesof "!e re"ro eri"one'm.Ge)8 er"!eless5"!e diffi-'l"yin dis"ing'is!inginflamma"oryfrom
neo las"imasses of "!e an-reas a" s'rgi-al e+ lora"ion is

well 3nown. 'nde"e-"ed

li)er 'se of er-'8

&'r"!er5neo las"id'ringe+ lora"ory

de osi"sin "!e li)er may go la aro"omyw!en only "!e

and al a"ed. s e-ialiJa"ion and "e-!nologi-al

'sed

for

as ira"ion

g'idan-e.

/ore

fre9'en"

0i"!

s'rfa-eis ins e-"ed in-reasingmedi-al

"aneo'sneedle as ira"ionin s's e-"ed may !el "o a)oid s'-! -os"ly diagnos"iIn "!e was o"!er fo'r a"ien"s5 -ases 78=5 mass a re"ro eri"oneal inflamma"ory

abdominal errors.
"!e w!i-! final

abs-ess
diagnosis "!e

in)ol)ed

ad)an-es5a--'ra"e-omm'ni-a"ionbe"ween !ysi-iansis essen"ial"o good a"ien" -are. #l"!o'g!"!e res'l"s of ea-! e+amina"ionin o'r si+ a"ien"swere dis-'ssed reo era8 "i)ely wi"! "!e s'rgeonin -!arge5"!e !ig! degree of -onfi8 den-e wi"! w!i-! ea-! diagnosiswas made by "!e radiolo8
gis" may no" !a)e been ade9'a"ely im ar"ed or so'g!". 4!e

an-reas es e-ially
gi-al

in "!ree. an-rea"iof

Pre)io'sre"ro eri"oneal inflamma"orydisease5

"!is ana"omi-

inflamma"ion5 of"en limi"s s'r8

and may

e+ lora"ion

-om ar"men"

re-l'de in-'rred

a -om le"ediagnos"i-sear-!. 4!e diagnos"iin -ases 78= may well refle-" "!e limi"a"ions

error and

-omm'ni-a"ionof a -onfiden-ele)el may !a)e -r'-ialim8 or"an-efor "!e o era"ings'rgeonw!o m's" de-idew!a"
in"rao era"i)e ro-ed'res are ne-essary "o r'le in or o'" a

120

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#
&ig. 5.8Case Pos"o era"i)e 5. #5 Preo era"i)e C4 s-an. 4wo adja-en" se'do-ys"s in lef" ' er 9'adran". C8i is larger an"erior -ys"( C82 is smaller os"erior -ys". <5

C4 s-an. Pos"erior

-ys" :C82;

is demons"ra"ed

as on reo era"i)e

s"'dy.

&ig.

=.8Case

=. #5 Preo era"i)e5

obli9'e5

sagi""al

sonogram

"!ro'g!

lef"

flan3. #bs-ess:= + 5 + 4 -m; an"erola"eral"o lef" 3idney. # N abs-ess( Q N lef" 3idney.<. Preo era"i)eC4 s-an. $e"ro eri"onealabs-ess :arrows; an"erola"eral"o lef" 3idney.C5 Pos"o era"i)e5obli9'e5sagi""alsonogram. %ame abs-essas on reo era"i)es"'dies.D5 Pos"o era"i)eC4 s-an again s!ows lef" re"ro eri"onealabs-ess:arrows;.

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?rossman

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'l"rasonogra !y5 "e-"ings a-e
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"omogra !y5

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4!e
s'rgi-al

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me"!od.In ea-! was erformedby

.owe)er5 as "!ese si+

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-onfiden-e5

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be 'rs'ed

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radiologieriod. 4!'s

findings

radiologis"sm's" be reminded"!a" w!ile e+ lora"ory ro"omy is li3ely "o -on"in'e"o be "!e mos" a--'ra"e
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m's"

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