Dynamic Radiologyof the AbdomenNormal and Pathologie Anatomy

Second Edition

Dynamic Radiologyof the AbdomenNormal and Pathologie AnatomySecond Edition

Morton A. Meyers, M.D.Professor and ChairmanDepartment of RadiologySchool of MedicineState University of New York at Stony Brook

With 1006 illustrations14 in full color

Springer Science+Business Media, LLC

Morton A. Meyers, M.D.Professor and ChairmanDepartment of RadiologySchool of MedicineState University of New York at Stony BrookStony Brook, New York 11794 U.S.A.

Production: Berta SteinerDesign: Caliber Design Planning, Ine.

Library of Congress Cataloging in Publication DataMeyers, Morton A.

Dynamic radiology of the abdomen.Includes bibliographies and index.1. Abdomen-Diseases-Diagnosis. 2. Abdomen-Radi­

ography. I. Tide. [DNLM: 1. Abdomen-Radiography.2. Abdomen-s-Anatomy and histology. WI 900 M615d]RC944.M48 1982 617'.5507572 81-23263

AACR2

@ 1976, 1982 by Springer Science+Business Media NewYorkOriginally published by Springer-Verlag NewYork Inc.in1982.

Softcover reprint of thehardcover 2ndedition 1982

All rights reserved. No part of this book may be translated or reproduced in any formwithout written permission from SpringerScience+Business Media,LLC

The use of general descriptive names, trade names, trademarks, etc. in this publication,even if the former are not especially identified, is not to be taken as a sign that suchnames, as understood by the Trade Marks and Merchandise Marks Act, may accordinglybe used freely by anyone.

9 8 7 6 5 4 321

ISBN 978-1-4757-3960-2 ISBN 978-1-4757-3958-9 (eBook)DOI 10.1007/978-1-4757-3958-9

To my wife, Bea,and my children, Richard and Amy

There are some things which cannot be learnedquickly, and time, which is all we have, mustbe paid heavily for their acquiring. They are thevery simplest things; and, because it takes aman's 1ife to know them, the little new that eachman gets from life is very costly and the onlyheritage he has to 1eave.

Ernest Hemingway (1898-1961) ,Death in the Afternoon

Contents

Prefaee IX

Prefaee to First Edition Xl

Forewords Xlll

1 Normal Anatomie Relationships and Variants I

2 Intraperitoneal Spread of Infeetions 20

3 Intraperitoneal Spread of Malignancies 55

4 The Extraperitoneal Spaees: Normal and PathologieAnatomy 105

5 The Renointestinal Relationships : Normal and PathologieAnatomy 186

6 The Duodenoeolie Relationships: Normal and PathologieAnatomy 223

7 Intestinal Effeets of Panereatitis: Spread along MesenteriePlanes 243

8 The Small Bowel: Normal and Pathologie Anatomy 264

9 The Colon: Normal and Pathologie Anatomy 285

10

11

Internal Abdominal Hernias 318

Pathways of Extrapelvie Spread of Disease 342

12 Dynamies of Plain-Film Analysis of the Abdomen 353

Index 375

vii

Preface

Sinee the publieation of the First Edition of Dynamie Radiology of the Abdomen:Normal and Pathologie Anatomy six years ago, literally hundreds of seientifie articlesin the literature have attested to its basic insights in the understanding andclinieal diagnosis of a speetrum of intraabdominal diseases. Based on radiologiecorrelations with anatomie and pathologie features , the observations have provenreadily applieable and highly accurate by ultrasonography and particularly com­puted tomography (CT) .

This edition is designed to provide a eomprehensive update of these prineiplesand their clinieal applieations, to include not only plain films and eonventionalcontrast studies, but also ultrasonography and CT. To aeeomplish these ends,some seetions have been eompletely rewritten and new seetions and ehaptershave been added. Over 503 illustrations have been added, many of them CTimages . The atla s of anatomie cross-sections in color has been retained, andthese as weIl as all CT images are now oriented aeeording to the eonventiongenerally adopted shortly after the First Edition was published, i.e., as if viewedfrom below with the subjects's right to the viewer's left. While a few of theCT illustrations are not of the highest quality, the reader will understand thatthey have been earefully seleeted for the particular abnormality they demonstrate.The rcferenees have been updated to eite not only classie articles, but seleetionsfrom the literature through 1981 .

Partieular appreeiation is expressed to the following for their cooperation:james L. Clements,jr. , M.D.,jaek Farman, M.D., Gary Ghahremani, M.D. , LeonLove, M.D. , Michael Oliphant, M.D. and Daniel Wise, M.D. A grant from KR.Squibb and Sons made possible mueh of the artwerk for the graphie expositionof the anatomie relationships.

Morton A. Meyers, M.D.

ix

Preface toFirst Edition

This book provides a systematie applieation of anatomie and dynamie prineiplesto the praetieal understanding and diagnosis of intraabdominal diseases. Ana­tomie seetions and injeetion studies form a basis for understanding the eharaeter­istie features of many eommon and uneommon diseases and their spread andloealization in the abdomen. These relationships and speeifie eriteria providea rational system for aecurate radiologie analysis in plain films, eonventionaleontrast studies, ultrasonography, and eomputed tomography (CT) . This infor­mation leads to the uneovering of clinieally deeeptive diseases, the evaluationof the effeets of disease, the antieipation of eomplieations, and the determinationof the appropriate diagnostie and therapeutie approaches.

The introductory atlas presents full color anatomie cross seetions of the abdo­men and pelvis, eomplemented by labeled traeings, and detailed CT seans atcorresponding levels. The seetions, whieh are approximately 3.8 em (1.5 in.)thick, were obtained from fresh eadavers frozen in dry iee for 48 hours, inorder to maintain the true intimate anatomie relationships. The aeeompanyingtext of the atlas stresses normal gross relationships, eommon variants, and thebasis of their radiologie identifieation, partieularly in plain films . The subsequentehapters deal with the diagnosis and the pathways of spread of infeetion, malig­naneies , and traumatie and inflammatory effusions within the intra- and extraperi­toneal spaees. Emphasis is plaeed on the speeifie loealizing features based onthe anatomie planes and reeesses and the dynamies of extension of disease.Sagittal and eoronal as well as horizontal anatomie seetions support the findingsin eonventional radiologie proeedures, ultrasonography, and eomputed tomogra­phy throughout. Correlation with the clinieal findings and management under­scores the value of the radiologie observations. Diagnostie eriteria whieh areeasily applied are established for the eharaeteristie features of speeifie diseaseprocesses ranging from loealized abseesses to disseminated metastases.

Many of the insights detailed in this book have been made only in the pastfew years. The applieation of peritoneography as a clinieal diagnostie study,for example, first indieated the dynamie eireulation of fluid states within theperitoneal reeesses and permitted an insight into the spread of infeetion andmalignaneies. Similarly, the signifieanee ofthe anatomie and radiologie definitionof the extraperitoneal spaees, the small bowel mesentery and other peritonealrefleetions, the haustral eontours of the large intestine, and the eontiguity ofeertain organ relationships has only reeently been appreeiated.

xi

Foreword toFirst Edition

Few books present so fresh an approach and so clear an exposition as doesDynamie Radiology of the Abdomen: Normal and Pathologie Anatomy.

This well-doeumented, clearly written, and beautifully illustrated book detailsthe answers not only to "what is it?" but also "how?" and "why?" Such funda­mental information regarding the pathogenesis of disease within the abdomenreinforces and simplifies accurate radiologie analysis. The eharaeteristie radio­logie features of intraabdominal diseases are shown to be easily identified, ex­panding the praetieal applieation of the term "pattern reeognition." It eertainlyis of praetieal value in daily clinieal experienee and will be of eonsiderable helpfor further advanees.

The traditional dissectional method of learning anatomy disturbs the intimaterelationships of struetures. The sectional anatomy presented in this book is theframework for understanding the findings in eonventional radiology-in plainfilms and routine eontrast studies-as weIl as in ultrasonography and eomputedtomography of the abdomen.

This is not just a review of others' experienees, but a erystallization of theauthor's eontributions over the past several years. Dr. Meyers' eoneept of dy­namie eireulation within the peritoneal eavity is a breakthrough in our under­standing of the spread of intraabdominal disease, particularly abseesses andmalignaneies. Peritoneography, the opaeifieation of the largest lumen in thebody, offers a potential yield of vast diagnostie information. The precise defini­tion of the three extraperitoneal spaees represents a eharting of previously unex­plored territory. Awareness ofthe renointestinal and duodenoeolie relationships,the spread of panereatitis along mesenterie planes, and the pathways of extrapel­vie spread of disease again underseores the praetieal importanee of anatomiefeatures. The approach to the mesenterie and antimesenterie borders of thesmall bowel and to the haustral pattern of the colon adds a new dimension tothe interpretation of abdominal radiology.

This book eonfirms Dr. Meyers' reputation as one of the authorities in normaland pathologie radiologie anatomy of the abdomen.

Riehard H. Marshak, M.D.Clinical Professor of RadiologyMount Sinai Sehool of MedicineNew York City

xiii

Foreword toFirst Edition

Dr. Morton A. Meyers indeed has developed adynamie text relating to radiologieaspeets of abdominal disease. But this statement, with its emphasis on radiology,is misleading. This book is an important reading souree for surgeons. Dr. Meyers'observations have not been eonfined to those arising from a purely radiologiestudy of the abdomen. The inclusion of observations based on injeetion studiesboth in the eadaver and in vivohas given this work a noteworthy eomprehensive­ness.

The insights provided by both the atlas of full-page color anatomie crossseetions of the abdomen and pelvis and the excellent anatomie-radiologie eorre­lations found in the text make the book indispensable. The atlas establishesthe basis for intimate anatomie relationships which are then applied to the praeti­eal areas of clinieal diagnosis and treatment ofintraabdominal pathology. Presen­tations of these diagnostie and therapeutie eonsiderations are enhaneed by illus­trated diseussions relative to the new teehniques of uhrasonography andeomputed tomography.

Dr. Meyers' presentation ofthis timely information is valuable, but what makesthis book invaluable is the vast personal experienee he is able to bring to it.this is not ''just another" book purporting to give us something new in thisimportant field. I believe the special approach given to this subject by Dr. Meyersis truly innovative. The radiologist and surgeon looking for the latest teehniquesin angiography for the diagnosis and treatment of massive bleeding from thegastrointestinal traet will not find it here. What they will find is major help inthe understanding of, and indeed, therapeutic approach to a number of eommonintraabdominal problems, including infeetion and malignaney.

Lloyd M. Nyhus, M.D., F.A.C.S.Warren H. Cole Professorand Chairman, Department of SurgeryThe Abraham Lincoln School of MedieineUniversity of Illinois at the Medical CenterChieago, Illinois

xv

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12.

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