Table Of ContentDynamic Radiology of the Abdomen
Normal and Pathologic Anatomy
MORTON A. MEYERS
Dynamic Radiology
of the Abdomen
Normal and
Pathologie Anatomy
with a contribution in ultrasonography by
Elias Kazam
638 figures including 14 color plates
Springer Science+Business Media, LLC
1976
Morton A. Meyers, M.D.
Professor of Radiology
Cornell University Medieal College
New York, New York
Elias Kazam, M.D.
Assistant Professor of Radiology
Cornell University Medieal College
New York, New York
Library of Congress Cataloging in Publieation Data
Meyers, Morlon A.
Dynamie radiology of the abdomen.
Ineludes bibliographieal referenees and index.
1. Abdomen-Radiography. I. Kazam, Elias. 11. Title.
RC944.M48 617' .55'07572 76-18722
All rights reserved.
No part of this book may be translated or reprodueed in any form without
written permission from Springer-Verlag.
ISBN 978-1-4757-3957-2 ISBN 978-1-4757-3955-8 (eBook)
DOI 10.1007/978-1-4757-3955-8
© 1976 by Springer Science+Business Media New York
Originally published by Springer-Verlag New York Inc. in 1976.
Softcover reprint of the hardcover 1st edition 1976
To my wife, Bea, There are some things which cannot be learned
and my children, Richard and Amy 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 (1898-1961),
Oeath in the Afternoon
Preface
This book provides a systematie applieation of anatomie and
dynamie prineiples to the praetieal understanding and diagnosis
of intraabdominal diseases. Anatomie sections and injeetion
studies form a basis for understanding the eharaeteristie features
of many eommon and uncommon diseases and their spread and
loealization in the abdomen. These relationships and speeifie
eriteria provide a rational system for accurate radiologie analysis
in plain films, eonventional eontrast studies, ultrasonography,
and computerized transaxial tomography (CTT). This informa
tion leads to the uncovering of clinieally deeeptive diseases, the
evaluation of the effeets of disease, the antieipation of eompliea
tions, and the determination of 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 CTT seans at eorresponding levels. The
seetions, whieh are approximately 3.8 em (1.5 in.) thiek, were
obtained from fresh eadavers frozen in dry iee for 48 hours, in
order to maintain the true intimate anatomie relationships. The
aeeompanying text of the atlas stresses normal gross rela
tionships, eommon variants, and the basis of their radiologie
identifieation, partieularly in plain films. The subsequent ehap
ters deal with the diagnosis and the pathways of spread of
infeetion, malignaneies, and traumatie and inflammatory effu
sions within the intra- and extraperitoneal spaees. Emphasis is
plaeed on the specifie loealizing features based on the anatomie
planes and reeesses and the dynamies of extension of disease.
Sagittal and coronal as weIl as horizontal anatomie seetions
support the findings in eonventional radiologie proeedures,
ultrasonography, and eomputerized transaxial tomography
throughout. Correlation with the clinieal findings and manage
ment underscores the value of the radiologie observations.
Diagnostie eriteria whieh are easily applied are established for
the eharaeteristie features of speeifie disease processes ranging
from loealized abseesses to dis semina ted metastases.
Many of the insights detailed in this book have been made
only in the past few years. The applieation of peritoneography as
a clinieal diagnostie study, for example, first indieated the dy
namie cireulation of fluid states within the peritoneal reeesses
and permitted an insight into the spread of infeetion and
malignaneies. Similarly, the signifieanee of the anatomie and
radiologie definition of the extraperitoneal spaees, the small
vii
bowel mesentery and other peritoneal refleetions, the haustral
eontours of the large intestine, and the eontiguity of eertain
organ relationships has only reeently been appreciated.
Acknowledgments
I first learned my basie gross anatomy as a medieal student at
The State University of New York Upstate Medieal Center in
Syraeuse. It is a partieular pleasure to thank Dr. Donald Good
man, Chairman of the Department of Anatomy, for permission
to reproduee many of the anatomie seetions skillfully prepared
by Mr. Lou Rimmler. Alfred S. Berne, M.D., an intelleetually
demanding radiologist who has always stressed anatomie and
pathologie eorrelation, has provided eontinued support and en
eouragement.
Many of the illustrations have been reprodueed, with permis
sion of the publishers, from articles of mine whieh have first
0/
appeared in Radiology and The American Journal Roentgenology,
Radium Therapy and Nuclear Medicine. David H. Stephens, M.D.,
Robert R. Hattery, M.D. and Patriek F. Sheedy 11, M.D., Mayo
Clinie, Roehester, Minnesota, and Stuart S. Sagel, M.D. and
J.
Robert Stanley, M.D., Washington University Sehool of
Medicine, St. Louis, Missouri, have graciously allowed me the
use of some of their material of eomputerized transaxial tomogra
phy of the abdomen.
A grant from E. R. Squibb and Sons made possible mueh of
the art work neeessary for the graphie exposition of the ana
tomie relationships.
Last, I would like to thank the editorial staff of Springer
Verlag, New York, for their helpful suggestions and eonsistent
cooperation through the preparation of this work.
Morton A. Meyers, M.D.
viii
Foreword by Richard H. Marshak, M.D.
Few books present so fresh an approach and so clear an
0/
exposition as does Dynamie Radiology the Abdomen: Normal and
Pathologie Anatomy.
This well-doeumented, clearly written, and beautifully illus
trated 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 accurate radiologie analysis. The eharaeteristie radio
logie features of intraabdominal diseases are shown to be easily
identified, expanding the praetieal applieation of the term "pat
tern recognition." It eertainly is of praetieal value in daily clini
eal experienee and will be of considerable help for furt her ad
vanees.
The traditional dissectional method of learning anatomy dis
turbs the intimate relationships of struetures. The sectional anat
omy presented in this book is the framework for understanding
the findings in eonventional radiology-in plain films and rou
tine eontrast studies-as weIl as in ultrasonography and com
puterized tomography of the abdomen.
This is not just a review of others' experienees, but a erystal
lization of the author's contributions over the past several years.
Dr. Meyers' coneept of dynamie cireulation within the peritoneal
eavity is a breakthrough in our understanding of the spread of
intraabdominal disease, partieularly abseesses and malignaneies.
Peritoneography, the opaeifieation of the largest lumen in the
body, offers a potential yield of vast diagnostie information. The
precise definition of the three extraperitoneal spaees represents a
eharting of previously unexplored territory. Awareness of the
renointestinal and duodenoeolie relationships, the spread of
pancreatitis along mesenterie planes, and the pathways of extra
pelvie spread of disease again underscores the praetieal impor
tanee of anatomie features. The approach to the mesenterie and
antimesenterie borders of the small bowel and to the haustral
pattern of the colon adds a new dimension to the interpretation
of abdominal radiology.
This book eonfirms Dr. Meyers' reputation as one of the au
thorities in normal and pathologie radiologie anatomy of the
abdomen.
Riehard H. Marshak, M.D.
Clinieal Professor of Radiology
Mount Sinai Sehool of Medieine
New York City
ix
Foreword by Lloyd M. Nyhus, M.D.,
F.A.C.S.
Dr. Morton A. Meyers indeed has developed adynamie text
relating to radiologie aspeets 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 confined to those arising from a
purely radiologie study of the abdomen. The inclusion of obser
vations based on injeetion studies both in the eadaver and in vivo
has given this work a noteworthy eomprehensiveness.
The insights provided by both the atlas of full-page color
anatomie cross seetions of the abdomen and pelvis and the
exeellent anatomie-radiologie eorrelations found in the text
make the book indispensable. The atlas establishes the basis for
intimate anatomie relationships which are then applied to the
practieal areas of clinieal diagnosis and treatment of intraabdomi
nal pathology. Presentations of these diagnostic and therapeutie
eonsiderations are enhanced by illustrated discussions relative to
the new techniques of ultrasonography and eomputerized trans
axial tomography.
Dr. Meyers' presentation of this timely information is valua
ble, but what makes this 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 this important
field. I believe the special approach given to this subjeet 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 from the gastrointestinal tract will
not find it here. What they will find is major help in the
understanding of, and indeed, therapeutie approach to a number
of common intraabdominal problems, including infeetion and
malignancy.
Lloyd M. Nyhus, M.D., F.A.C.S.
Warren H. Cole Professor and
The Abraham Lineoln School of Medieine
University of Illinois at the Medical Center
Chieago, Illinois
xi
Direet Invasion from Contiguous Primary
Contents Tumors 48
Intraperitoneal Seeding 54
Anatomie Features 55
Prefaee vii Pathways of Aseitie Flow 56
Seeded Sites 57
Foreword by Poueh of Douglas (Reetosigmoid Junetion):
Riehard H. Marshak, M.D. ix Radiologie Features 58
Lower Small Bowel Mesentery (Terminal Ileum and
Foreword by Ceeum): Radiologie Features 59
Sigmoid Colon: Radiologie Features 69
Lloyd M. Nyhus, M.D. xi
Right Paraeolie Gutter (Ceeum and Aseending
Colon): Radiologie Features 71
Normal Anatomie Relationships
Embolie Metastases 71
and Variants xvii
Metastatic Melanoma 71
Breast Metastases 75
Bronehogenie Careinoma 79
Chapter 1 Renal Carcinoma 80
Intraperitoneal Spread of Infeetions
Referenees 80
General Introduetion 1
Anatomie Considerations 2 Chapter 3
The Posterior Peritoneal Attaehments 2 Peritoneography: Normal and
Detailed Anatomy of the Right Upper Quadrant 3
Pathologie Anatomy
The Right Subhepatie Spaee 3
The Right Subphrenie Spaee 6
The Left Subphrenie Spaee 7 General Introduetion 83
The Lesser Sae 8
Safety of Intraperitoneal Water-Soluble
Radiologie Features 10 Contrast Media 84
The Spread and Loealization of Intraperitoneal Investigational Evidenee 84
Abseesses 1 0 Clinieal Evidence 85
Pelvie Abseesses 11 Historical Development of Peritoneography 85
Right Subhepatie and Subphrenie Abseesses 12
Indieations and Contraindications 86
Lesser Sae Abseesses 21
Left'Subphrenie Abseesses 23 Teehnique of Peritoneography 87
Summary 33
Adjunet to Peritoneoscopy 89
Management 33
Findings on Peritoneography 90
Referenees 34
Right Upper Quadrant 91
Liver: Right Lobe 91
Liver: Left Lobe 95
Chapter 2 Gallbladder 97
Intraperitoneal Spread of Stomaeh and Supporting Mesenteries 97
Left Upper Quadrant 101
Malignaneies
Spleen 101
Tail of Pancreas 101
General Introduetion 37
Colon 103
Pelvie Area 104
Direet Invasion from Noneontiguous
Urinary Bladder 104
Primary Tumors 38
Female Pelvic Organs 109
Invasion along Mesenterie Refleetions 38
Careinoma of the Stomaeh 39 References 110
Careinoma of the Panereas 43
Careinoma of the Colon 44
Invasion by Lymphatie Permeation and Extension 47
xiii
