o f the Abdomen

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Dynamic Radiology of the Abdomen

FIFTHEDITION

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Springer

New York Berlin Heidelberg Barcelona Hong Kong London Milan Paris Singapore Tokyo

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Morton A. Meyers

With Contributions by Stephen R. Baker, Alfred S. Berne, Chusilp Charnsangavej, Kyunghee C. Cho, Michiel A.M. Feldberg, Bruce Javors, Hiromu Mori,

Michael Oliphant, Catherine Roy, Maarten S. van Leeuwen, Ronald Wachsberg

Dynamic Radiology of the Abdomen

Normal and Pathologic Anatomy

F

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With 1133 Figures in 1796 Parts, 18 in Color

Springer

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To my wife, Bea,

and my children, Richard and Amy

There are some things which cannot be learned quickly, and time, which is all we have, must be paid heavily for their acquiring. They are

the very simplest things; and, because it takes a man’s life to know them, the little new that each man gets from life is very costly and the

only heritage he has to leave.

Ernest Hemingway Death in the Afternoon

The greatest thing a human soul ever does in this world is to see something. . . . To see clearly is poetry, prophecy,

and religion, all in one.

John Ruskin Modern Painters

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Preface to the Fifth Edition

The preface to the first edition of Dynamic Radiology of the Abdomen: Normal and Pathologic Anatomy stated that this book introduces a systematic application of anatomic and dynamic principles to the practical understanding and diagnosis of intraabdominal diseases. The clinical insights and rational system of diagnostic analysis stimulated by an appreciation of the dynamic intraabdominal relationships outlined in previous editions have been universally adopted. Literally thousands of scien- tific articles in the literature have attested to their basic precepts. Formulations and analytic approaches intro- duced in the first edition are now widely applied in clinical medicine so that many of the terminologies, def- initions, and concepts of pathogenesis have solidly en- tered the public domain. These insights lead to the un- covering of clinically deceptive diseases, the evaluation of the effects of disease, the anticipation of complica- tions, and the determination of the appropriate diagnostic and therapeutic approaches. Spanish, Italian, Jap- anese, and Portuguese editions have encouraged more widespread application of the principles which in turn has led to further contributions to our understanding of the features of spread and localization of intraabdominal diseases. These principles have been applied to the full range of imaging modalities—from plain films and conventional contrast studies to CT, US, MRI and endo–

scopic, laparoscopic, and intraoperative ultrasonography—leading to this fifth edition in 24 years.

In the pursuit of comprehending the pattern, all methods of investigation have been used, including (a) anatomic cross–sectioning of cadavers frozen to maintain relationships; (b) cadaver injections and dissections per- formed to determine preferential planes of spread along ligaments, mesenteries and extraperitoneal fascial com- partments; (c) selected clinical cases with the fullest

range of imaging studies including plain films, tomo–

grams, and conventional contrast studies; presacral ret–

roperitoneal pneumography and peritoneography; sin- ography which occasionally provided serendipitous display of normal and pathologic anatomy akin to an in vivo model; and computed tomography, ultrasonog- raphy, nuclear medicine studies, magnetic resonance imaging, and endoscopic ultrasonography; (d) peritoneos- copy; and (e) surgical operations, surgical pathology and autopsies.

The basic aims in writing this book have not changed from the first edition and it is produced in the same spirit as its predecessors. The quest of science has always sought the identification of a pattern of circumstances.

With this recognition, there follows insight and understanding into the nature and dynamics of events and thereby their predictability, management, and conse- quences. This book establishes that the spread and localization of diseases throughout the abdomen and pelvis are not random, irrational occurences but rather are governed by laws of structural and dynamic factors.

To satisfy these aims, special attention has been given to keeping the book current with clinical and techno- logical advances that have so dramatically altered the practice of abdominal imaging in the past several years.

Six completely new chapters have been added and vir- tually all others have been extensively updated and enlarged. This edition is expanded by more than 180 pages and more than 520 new illustrations.

Many of the new chapters are by international authorities who have pioneered advances in the crucial appreciation and precise recognition of a wide spectrum of intraabdominal diseases. An introductory chapter on general considerations underscores the book’s continu- ing thematic approach based upon anatomic relation-

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viii Preface to the Fifth Edition

ships, dynamic factors, and visual perception of the im- age. This is followed by a chapter on clinical embryology, emphasizing an understanding of disease entities which often are only first clinically apparent in the adult. The manifestations of intraperitoneal air, often subtle on plain films but nevertheless highly significant, are precisely described and illustrated. A new chapter is devoted to oncoradiology and the TNM staging of gastrointestinal cancers, delineating the normal anatomic mural components by sectional imaging and the extent of intramural and regional neoplastic spread. Other chapters deal with the discrete identification of the pathways of lymph node metastases in cancers of the gastrointestinal and hepatobiliary tracts and the pathways of regional spread in pancreatic cancer.

Developments in understanding the intraperitoneal spread of infections include the normal and pathologic anatomy of the lesser sac. Features of the significance of the gastropancreatic plica, the superior and lower reces- ses of the lesser sac, and the imaging features of the di- mensions and relationships of the foramen of Winslow are detailed. The clinical significance of the spread of infection via the perihepatic ligaments is greatly expanded.

Concepts of the pathways of dissemination of malignancies have been highly expanded and richly illustrated with the full range of imaging modalities. Normal and pathologic anatomy are made graphic by spiral CT with planar reconstructions, MR, endoscopic ultrasonog–

raphy and laparoscopic ultrasonography. The position and nomenclature of lymph node stations in gastric carcinoma as classified by the Japanese Research Society for Gastric Cancer have been updated and correlation is made with the TNM staging system. Further advances in the understanding of the intraperitoneal spread of malignancies include features of seeded perihepatic and subdiaphragmatic metastases, subcapsular liver metastases, spread to anterior mediastinal lymph nodes, implan- tation on the falciform ligament and within the inter- hepatic fissures, hepatic invasion by advanced gastric cancer, Sister Mary Joseph’s nodule, Krukenberg tumors of the ovaries, the pathogenesis and differential diagnosis of the omental cake and of peritoneal thickening and enhancement in peritoneal carcinomatosis; instrumen- tal, operative and needle track seeding; hematogeous metastases to the small bowel from metastatic melanoma, breast carcinoma and bronchogenic carcinoma. Devel- opments and advances in imaging the spread and localization of intraperitoneal malignancies are discussed and illustrated. The unifying perspective of the subperito- neal space of the abdomen and pelvis, establishing the discrete planes of subserous connective tissue and lym- phatics, is extended to the thoraco-abdominal contin-

uum; this holistic concept provides an explanation for what has long been thought of as illogical circumstances.

Numerous major developments have also refined our precise evaluation of the extraperitoneal fascia and spaces. A new section defines the compartmentalization of the anterior pararenal space, in keeping with pro- gressive application of embryologic/anatomic circumstances to clinical imaging. The section on the extraperitoneal paravesical pelvic spaces and their continuities with the abdominal spaces has been refined and expanded. Fundamental anatomic characteristics of the fascia and spaces are documented and their clinical rele- vance richly illustrated. These include the potential midline communication of the perirenal spaces, the in- ferior apex of the cone of renal fascia, the retromesen- teric plane, the attachment of the adrenal gland to the renal fascia superiorly, and the identification of the two lamellae of the posterior renal fascia. Further enlarged are the discussions and illustrations of the lumbar tri- angle pathway and its relationship to Grey Turner’s sign in pancreatitis and retrorenal hemorrhage; and of extension along the perihepatic ligaments and its relationship to Cullen’s sign. Occasional instances of splenic trauma leading to clinically masked extraperitoneal bleeding are explained. Staging of renal cell carcinoma is significantly updated, with comparison of Robson’s classification and the TNM system and the value of magnetic resonance imaging. Perirenal diseases beyond abscesses and hemorrhage have been expanded to include perirenal metastases, lymphoma, extramedullary hematopoiesis and retroperitoneal fibrosis. The anatomy of the iliopsoas compartment is clarified and the features of psoas abscess are illustrated. Controversies regarding rupture of abdominal aortic aneurysms with extension of hemorrhage to the extraperitoneal spaces are resolved.

Other additions include discussions of renocolic fis- tulas; the precise anatomy and importance of the ligament of Treitz; characteristic localizing features of scleroderma, carcinoid and Crohn disease of the small bowel; and the CT features and differential diagnosis of internal paraduodenal hernias.

While diagnostic criteria are emphasized throughout the book, there is also discussion of foreseeable compli- cations and appropriate management of many disease processes.

As in previous editions, great care has been taken with the layout to give prominence to selected illustrations and, most importantly, to position the figures as closely as possible to their citation in the text so that the reader’s time and effort are not wasted referring to pages some distance apart.

The color atlas details anatomic features of clinical significance.

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Preface to the Fifth Edition ix

The references have been considerably expanded and continue to include both classic articles and recent ci- tations. They are not restricted to the English language and, when pertinent, refer to the original descriptions.

A lengthy index with cross-references provides imme- diate access to the detailed material presented.

Many persons have contributed importantly to the fifth edition and I thank them sincerely. I wish to express my particular appreciation to Angel Arenas, M.D., Hos- pital Universitario “12 de Octubre,” Madrid, Spain; Yong Ho Auh, M.D., Asan Medical Center, Seoul, Korea; Emil Balthazar, M.D., New York University School of Medi- cine, New York City; James Brink, M.D., Yale University Medical School, New Haven, Connecticut; Gary G.

Ghahremani, M.D., Evanston Hospital—Northwestern University, Evanston, Illinois; Jay P. Heiken, M.D., Mal- linckrodt Institute of Radiology, St. Louis, Missouri;

Dean T. Maglinte, M.D., Methodist Hospital, Indiana-

polis, Indiana; Hiromu Mori, M.D., Oita Medical Uni- versity, Oita, Japan; Michael Oliphant, M.D., Crouse Hospital, State University of New York, Syracuse, New York; Richard C. Semelka, M.D., University of North Carolina Hospitals, Chapel Hill, North Carolina; Ann Singer, M.D., Cleveland Clinic Foundation, Cleveland, Ohio, and Francis Weill, M.D., University of Besançon School of Medicine, Besançon, France for their contributions. Additionally, I wish to express my gratitude to the contributing authors who have added luster to this edition.

I am distinctly grateful to Michiel A. M. Feldberg, M.D., Ph.D., University Hospital, Utrecht, Nether- lands, for his selfless cooperation and the stimulating pleasure of sharing intellectual enthusiasms.

I have submitted this fifth manuscript to Springer- Verlag, confident that their skills have produced another edition of high technical quality.

Morton A. Meyers, M.D.

Stony Brook, New York January, 2000

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Foreword to First Edition

Few books present so fresh an approach and so clear an exposition as does Dynamic Radiology of the Abdomen:

Normal and Pathologic Anatomy.

This well-documented, clearly written, and beauti- fully illustrated book details the answers not only to

“what is it?” but also “how?” and “why?” Such fundamental information regarding the pathogenesis of disease within the abdomen reinforces and simplifies ac- curate radiologic analysis. The characteristic radiologic features of intraabdominal diseases are shown to be easily identified, expanding the practical application of the term “pattern recognition.” It certainly is of practical value in daily clinical experience and will be of consid- erable help for further advances.

The traditional dissectional method of learning anat- omy disturbs the intimate relationships of structures.

The sectional anatomy presented in this book is the framework for understanding the findings in conventional radiology—in plain films and routine contrast studies—as well as in ultrasonography and computed tomography of the abdomen.

This is not just a review of others’ experiences, but a crystallization of the author’s contributions over the past several years. Dr. Meyers’ concept of dynamic circula- tion within the peritoneal cavity is a breakthrough in our understanding of the spread of intraabdominal disease, particularly abscesses and malignancies. Perito- neography, the opacification of the largest lumen in the body, offers a potential yield of vast diagnostic information. The precise definition of the three extraperitoneal spaces represents a charting of previously unex- plored territory. Awareness of the renointestinal and duodenocolic relationships, the spread of pancreatitis along mesenteric planes, and the pathways of extrapelvic spread of disease again underscores the practical importance of anatomic features. The approach to the mesenteric and antimesenteric borders of the small bowel and to the haustral pattern of the colon adds a new di- mension to the interpretation of abdominal radiology.

This book confirms Dr. Meyers’ reputation as one of the authorities in normal and pathologic radiologic anatomy of the abdomen.

1976 Richard H. Marshak, M.D.

Clinical Professor of Radiology Mount Sinai School of Medicine New York, New York

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Foreword to First Edition

Dr. Morton A. Meyers indeed has developed a dynamic text relating to radiologic aspects of abdominal disease.

But this statement, with its emphasis on radiology, is misleading. This book is an important reading source for surgeons. Dr. Meyers’ observations have not been confined to those arising from a purely radiologic study of the abdomen. The inclusion of observations based on injection studies both in the cadaver and in vivo has given this work a noteworthy comprehensiveness.

The insights provided by both the atlas of full-page color anatomic cross sections of the abdomen and pelvis and the excellent anatomic-radiologic correlations found in the text make the book indispensable. The atlas establishes the basis for intimate anatomic relationships which are then applied to the practical areas of clinical diagnosis and treatment of intraabdominal pathology.

Presentations of these diagnostic and therapeutic considerations are enhanced by illustrated discussions rela- tive to the new techniques of ultrasonography and computed tomography.

Dr. Meyers’ presentation of this timely information is valuable, but what makes this book invaluable is the vast personal experience he is able to bring to it. This is not “just another” book purporting to give us some- thing new in this important field. I believe the special approach given to this subject by Dr. Meyers is truly innovative. The radiologist and surgeon looking for the latest techniques in angiography for the diagnosis and treatment of massive bleeding form the gastrointestinal tract will not find it here. What they will find is major help in the understanding of, and indeed, therapeutic approach to a number of common intraabdominal prob- lems, including infection and malignancy.

1976 Lloyd M. Nyhus, M.D., F.A.C.S Warren H. Cole Professor

and Chairman, Department of Surgery The Abraham Lincoln School of Medicine University of Illinois at the Medical Center Chicago, Illinois

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Contributors

Stephen R. Baker, M.D.

Professor and Chairman Department of Radiology University Hospital C320

UMD New Jersey Medical School 150 Bergen Street

Newark, NJ USA

Alfred S. Berne, M.D.

Professor of Radiology SUNY Health Science Center 750 East Adams Street

Syracuse, NY USA

Chusilp Charnsangavej, M.D.

Professor of Radiology

Department of Diagnostic Radiology

The University of Texas M.D. Anderson Cancer Center 1515 Holcombe Boulevard

Houston, TX USA

Kyunghee C. Cho, M.D.

Professor of Radiology Department of Radiology University Hospital C320

Newark, NJ USA

Michiel A.M. Feldberg, M.D., Ph.D.

Professor of Radiology Department of Radiology University Hospital Utrecht Heidelberglaan 100

Utrecht 3584 CX Netherlands Bruce Javors, M.D.

Chief of G. I. Radiology Vice-Chairman

Department of Radiology

St. Vincents Hospital and Medical Center New York, NY

USA

Hiromu Mori, M.D.

Professor and Chairman Department of Radiology Oita Medical University Hasama-Machi

Oita 879-55 Japan

Michael Oliphant, M.D.

Chief of Radiology and Medical Director Department of Medical Imaging

Crouse Hospital 736 Irving Avenue Syracuse, NY USA

and

Clinical Professor of Radiology SUNY Health Science Center Syracuse, NY

USA

Catherine Roy, M.D.

Professor of Radiology Chef de Service

Service de Radiologie B

Les Hopitaux Universitaires de Strasbourg—BP426 F-67091 Strasbourg Cedex

France

Maarten S. van Leeuwen, M.D., Ph.D.

Department of Radiology University Hospital Utrecht Heidelberglaan 100

Utrecht 3584 CX Netherlands

Ronald Wachsberg, M.D.

Associate Professor of Radiology Department of Radiology University Hospital C320

Newark, NJ USA

o f the Abdomen

Dynamic Radiology of the Abdomen

Springer

Morton A. Meyers

Dynamic Radiology of the Abdomen

Normal and Pathologic Anatomy

F

E

To my wife, Bea,

and my children, Richard and Amy

Preface to the Fifth Edition

Foreword to First Edition

Foreword to First Edition

Contents

Contributors