1979, British Journal of Radiology, 52, 990-992 Case reports ACKNOWLEDGMENTS
We are grateful to Professor Huntingford and Professor Turnbull for permission to report the details of this patient who was under their care. We should also like to thank Dr. Metreweli for helpful advice. REFERENCES BARTLEY, J. A., GOLBUS, M. S., FILLY, R. A. and HALL,
B. D., 1977. Prenatal diagnosis of dysplastic kidney disease. Clinical Genetics, 11, 375-378. GARRETT, W. J., GRUNWALD, G. and ROBINSON, D. E., 1970.
Prenatal diagnosis of fetal polycystic kidney by ultrasound. Australian and New Zealand Journal of Obstetrics and Gynaecology, 10, 7-9. GARRETT, W. J., KOSSOFF, G. and OSBORN, R. A., 1975. The
diagnosis of fetal hydronephrosis, megaureter and urethral obstruction by ultrasonic echography. British Journal of Obstetrics and Gynaecology, 82, 115-120. GEE, H. and ABDULLA, U., 1978. Antenatal diagnosis of fetal duodenal atresia by ultrasonic scan. British Medical Journal, 2,1265. 3. Transverse scan of the maternal abdomen showing similar transonic masses in twin 2. FIG.
scanning. A cross section of the upper fetal abdomen in their case showed double cystic structures corresponding to stomach and dilated proximal duodenum. This could represent a difficult differential diagnosis from bilateral hydronephrosis, and the possibility should be kept in mind, particularly if poly-hydramnios is present.
KAFFE, S., GODMILOW, L., WALKER, B. A. and HIRSCHHORN,
K., 1977a. Prenatal diagnosis of bilateral renal agenesis. Obstetrics and Gynaecology, 49, 478-480. KAFFE, S., ROSE, J. S., GODMILOW, L., WALKER, B. A., KERENYI, T., BERATIS, N., REYES, P. and HIRSCHHORN, K.,
1977b. Prenatal diagnosis of renal anomalies. American Journal of Medical Genetics, 1, 241-251. KEIRSE, M. J. N. C. and MEERMAN, R. H., 1978. Antenatal
diagnosis of Potter Syndrome. Obstetrics and Gynaecology, 52, No. 1 (Supplement), 64s-67s. LEE, T. G. and BLAKE, S., 1977. Prenatal fetal abdominal ultrasonography and diagnosis. Radiology, 124, 475-477. SANTOS-RAMOS, R. and DUENHOELTER, J. H., 1975. Diag-
nosis of congenital fetal abnormalities by sonography. Obstetrics and Gynaecology, 45, 279-283.
The features of the Mirizzi syndrome on ultrasound examination By K. C. Dewbury, B.Sc, M.B., F.R.C.R. Department of Radiology, Southampton General Hospital {Received June 1979)
The Mirizzi syndrome consists of the following four elements: 1. an anatomic arrangement of the cystic duct such that it lies almost parallel to the common hepatic duct; 2. impaction of a gall-stone in the cystic duct or neck of the gall-bladder; 3. partial mechanical obstruction of the common hepatic duct by the stone itself or the resulting inflammatory reaction; and 4. recurrent cholangitis or ultimately cholangitic cirrhosis due to the partial obstruction (Clemett and Lowman, 1965). This is an uncommon syndrome. We report the features on ultrasound examination in a patient we have recently seen.
FIG. 1. A longitudinal scan in the mid-line showing the dilated common duct (D) lying above the portal vein (P). The duct CASE REPORT A 71 -year-old female was admitted to hospital following an appears to stop (j) just above an echo density (C) with distal acoustic shadowing (S). episode of right upper quadrant pain, chills, fever and
990
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52, No. 624 Case reports
FIG. 2. A similar section showing the common duct (D) narrowing (I) down towards the calculus (C). S—Acoustic shadowing. P—Portal vein.
FIG. 4. Longitudinal scan showing a calculus (C) within a dilated common duct (D). S—Acoustic shadowing.
jaundice. Ten years previously gall-stones had been shown by an oral cholecystogram. The patient had refused cholecystectomy at that time. During the ten years she had remained fairly well, apart from infrequent episodes of right upper quadrant pain. As is the common practice in our hospital with jaundiced patients, she had an ultrasound examination within 48 hours of admission (Dewbury et al., 1979). This showed the presence of dilated intrahepatic bile ducts and a dilated upper common duct measuring 13mm in diameter (Fig. 1). This large duct appeared to stop just below the porta hepatis and 1 cm below this point an echo density with marked distal acoustic shadowing was seen. This appearance is typical of a calculus. At the time of examination it was assumed that this calculus was in the common duct. In retrospect it clearly is not in the duct, and in Fig. 2 the common duct can be seen narrowing as it approaches the calculus. The patient's jaundice deepened and before proceeding to laparotomy a fine needle percutaneous transhepatic cholangiogram was done. This shows the typical features of the Mirizzi syndrome (Fig. 3). A large, faintly calcified calculus can be seen adjacent to the common hepatic duct and causing a broad curved impression on its lateral aspect. The duct is considerably narrowed at this point, causing partial proximal obstruction with dilation of the intrahepatic ducts. At laparotomy the chronically inflamed gall-bladder and a large calculus were removed.
FIG. 3. Fine needle percutaneous cholangiogram. This shows a dilated upper duct system with narrowing of the common hepatic duct (D) at the level of a faintly opacified calculus (C). The calculus and surrounding inflammatory reaction causes a typical broad curved impression on the lateral aspect of the duct.
1979, British Journal of Radiology, 52, 992-993 Case reports
a positive diagnosis. In retrospect, the ultrasound features are characteristic.
COMMENT
To make the diagnosis of a calculus in the common bile duct at an ultrasound examination it is necessary to show the calculus within the duct, which is often possible (Fig. 4). The Mirizzi syndrome is uncommon and the author was not fully aware of its features. With this knowledge, and applying strict ultrasound criteria, it should be possible to make
REFERENCES CLEMETT, A. R., and LOWMAN, R. M., 1965. The Roentgen
features of the Mirizzi syndrome. American Journal of Radiology, 94, 480-483. DEWBURY, K. C , JOSEPH, A. E. A., HAYES, S., and MURRAY,
C , 1979. Ultrasound in the evaluation and diagnosis of jaundice. British Journal of Radiology, 52, 276-280.
Lipomatous tumour of the uterus: radiographic and ultrasonic appearance By L Murray Houser, M.D., C. H. Carrasco, M.D. and C. R. Sheehan, Jr., R.D.M.S. Department of Radiology, Pennsylvania Hospital, 8th and Spruce Streets, Philadelphia, Pennsylvania 19107 (Received March 1979)
Masses in the pelvis that are shown to contain fat on X-ray are usually thought to be ovarian in origin. An unusual lipomatous tumour of the uterus, seen on plain radiographs and on ultrasound, is presented. This is the first report of the pre-operative demonstration of such a tumour by X-ray or ultrasound.
and smooth muscle tissue. Most patients are postmenopausal, predominantly in their 50's and 60's although one was 23 years old. The size of the tumours vary from several millimetres to 32 cm in diameter. They may occur anywhere within the uterus, but are however, predominantly found in the corpus. Most are associated with ordinary fibroids. Grossly, they are rounded or oval and well encapsulated. The pure lipomas are soft and yellow, while the more fibrous tumours tend to be lighter in colour and firmer. Clinically, the symptoms are indistinguishable from those of ordinary fibroids. Histologically, the pure lipomas consist of mature fat cells in a spare connective tissue stroma. The
CASE REPORT
A 59-year-old white female was admitted for evaluation of a pelvic mass. She had been in good health until four days prior to admission when she noted pain in her right hip and a sensation of pressure in her pelvis. Physical examination revealed a large, hard, irregular pelvic mass extending upward to the level of the umbilicus. On the plain film of the abdomen there was a rounded mass in the pelvis measuring approximately 18 cm in diameter. The central portion of this was radiolucent and surrounded by a relatively uniform soft tissue density measuring 1—2 cm in thickness (Fig. 1). Abdominal ultrasound demonstrated a 16 cm mass with a strongly echogenic central portion, which was surrounded by a relatively echo-free' border (Fig. 2). The central portion of the mass was so attenuating that the back wall could not be seen. The radiographic and ultrasonic findings were interpreted as a soft-tissue pelvic mass with a fatty central core and assumed to represent a dermoid tumour of the ovary. At operation, the mass was found to be within the uterus and was thought to be a fibroid tumour. Total hysterectomy was performed. Gross examination of the uterus showed a large, spherical, firm mass, which on cut section was seen to be within the myometrium. It was well circumscribed and yellowish in colour. Microscopically, the tumour was composed predominantly of mature fat cells with some interposed fibrous elements and smooth muscle. The pathologic diagnosis was fibromyolipoma of the uterus. DISCUSSION
Lipomatous tumours of the uterus are relatively uncommon. Salm (1973) found seven cases 5200 speciments over a 25 year period, an incidence of 0.14%. Brandfass and Everts-Suarez (1955) summarized the world literature in a comprehensive review. They found 33 pure lipomas and 63 mixed tumours (fibromyolipomas, myolipomas and fibrolipomas) with varying amounts of fibrous
FIG.1.
Radiolucent central mass corresponds to fatty tumour. A thin rim of more radiodense material, representing the myometrium, surrounds it.
992
We are grateful to Professor Huntingford and Professor Turnbull for permission to report the details of this patient who was under their care. We should also like to thank Dr. Metreweli for helpful advice. REFERENCES BARTLEY, J. A., GOLBUS, M. S., FILLY, R. A. and HALL,
B. D., 1977. Prenatal diagnosis of dysplastic kidney disease. Clinical Genetics, 11, 375-378. GARRETT, W. J., GRUNWALD, G. and ROBINSON, D. E., 1970.
Prenatal diagnosis of fetal polycystic kidney by ultrasound. Australian and New Zealand Journal of Obstetrics and Gynaecology, 10, 7-9. GARRETT, W. J., KOSSOFF, G. and OSBORN, R. A., 1975. The
diagnosis of fetal hydronephrosis, megaureter and urethral obstruction by ultrasonic echography. British Journal of Obstetrics and Gynaecology, 82, 115-120. GEE, H. and ABDULLA, U., 1978. Antenatal diagnosis of fetal duodenal atresia by ultrasonic scan. British Medical Journal, 2,1265. 3. Transverse scan of the maternal abdomen showing similar transonic masses in twin 2. FIG.
scanning. A cross section of the upper fetal abdomen in their case showed double cystic structures corresponding to stomach and dilated proximal duodenum. This could represent a difficult differential diagnosis from bilateral hydronephrosis, and the possibility should be kept in mind, particularly if poly-hydramnios is present.
KAFFE, S., GODMILOW, L., WALKER, B. A. and HIRSCHHORN,
K., 1977a. Prenatal diagnosis of bilateral renal agenesis. Obstetrics and Gynaecology, 49, 478-480. KAFFE, S., ROSE, J. S., GODMILOW, L., WALKER, B. A., KERENYI, T., BERATIS, N., REYES, P. and HIRSCHHORN, K.,
1977b. Prenatal diagnosis of renal anomalies. American Journal of Medical Genetics, 1, 241-251. KEIRSE, M. J. N. C. and MEERMAN, R. H., 1978. Antenatal
diagnosis of Potter Syndrome. Obstetrics and Gynaecology, 52, No. 1 (Supplement), 64s-67s. LEE, T. G. and BLAKE, S., 1977. Prenatal fetal abdominal ultrasonography and diagnosis. Radiology, 124, 475-477. SANTOS-RAMOS, R. and DUENHOELTER, J. H., 1975. Diag-
nosis of congenital fetal abnormalities by sonography. Obstetrics and Gynaecology, 45, 279-283.
The features of the Mirizzi syndrome on ultrasound examination By K. C. Dewbury, B.Sc, M.B., F.R.C.R. Department of Radiology, Southampton General Hospital {Received June 1979)
The Mirizzi syndrome consists of the following four elements: 1. an anatomic arrangement of the cystic duct such that it lies almost parallel to the common hepatic duct; 2. impaction of a gall-stone in the cystic duct or neck of the gall-bladder; 3. partial mechanical obstruction of the common hepatic duct by the stone itself or the resulting inflammatory reaction; and 4. recurrent cholangitis or ultimately cholangitic cirrhosis due to the partial obstruction (Clemett and Lowman, 1965). This is an uncommon syndrome. We report the features on ultrasound examination in a patient we have recently seen.
FIG. 1. A longitudinal scan in the mid-line showing the dilated common duct (D) lying above the portal vein (P). The duct CASE REPORT A 71 -year-old female was admitted to hospital following an appears to stop (j) just above an echo density (C) with distal acoustic shadowing (S). episode of right upper quadrant pain, chills, fever and
990
VOL.
52, No. 624 Case reports
FIG. 2. A similar section showing the common duct (D) narrowing (I) down towards the calculus (C). S—Acoustic shadowing. P—Portal vein.
FIG. 4. Longitudinal scan showing a calculus (C) within a dilated common duct (D). S—Acoustic shadowing.
jaundice. Ten years previously gall-stones had been shown by an oral cholecystogram. The patient had refused cholecystectomy at that time. During the ten years she had remained fairly well, apart from infrequent episodes of right upper quadrant pain. As is the common practice in our hospital with jaundiced patients, she had an ultrasound examination within 48 hours of admission (Dewbury et al., 1979). This showed the presence of dilated intrahepatic bile ducts and a dilated upper common duct measuring 13mm in diameter (Fig. 1). This large duct appeared to stop just below the porta hepatis and 1 cm below this point an echo density with marked distal acoustic shadowing was seen. This appearance is typical of a calculus. At the time of examination it was assumed that this calculus was in the common duct. In retrospect it clearly is not in the duct, and in Fig. 2 the common duct can be seen narrowing as it approaches the calculus. The patient's jaundice deepened and before proceeding to laparotomy a fine needle percutaneous transhepatic cholangiogram was done. This shows the typical features of the Mirizzi syndrome (Fig. 3). A large, faintly calcified calculus can be seen adjacent to the common hepatic duct and causing a broad curved impression on its lateral aspect. The duct is considerably narrowed at this point, causing partial proximal obstruction with dilation of the intrahepatic ducts. At laparotomy the chronically inflamed gall-bladder and a large calculus were removed.
FIG. 3. Fine needle percutaneous cholangiogram. This shows a dilated upper duct system with narrowing of the common hepatic duct (D) at the level of a faintly opacified calculus (C). The calculus and surrounding inflammatory reaction causes a typical broad curved impression on the lateral aspect of the duct.
1979, British Journal of Radiology, 52, 992-993 Case reports
a positive diagnosis. In retrospect, the ultrasound features are characteristic.
COMMENT
To make the diagnosis of a calculus in the common bile duct at an ultrasound examination it is necessary to show the calculus within the duct, which is often possible (Fig. 4). The Mirizzi syndrome is uncommon and the author was not fully aware of its features. With this knowledge, and applying strict ultrasound criteria, it should be possible to make
REFERENCES CLEMETT, A. R., and LOWMAN, R. M., 1965. The Roentgen
features of the Mirizzi syndrome. American Journal of Radiology, 94, 480-483. DEWBURY, K. C , JOSEPH, A. E. A., HAYES, S., and MURRAY,
C , 1979. Ultrasound in the evaluation and diagnosis of jaundice. British Journal of Radiology, 52, 276-280.
Lipomatous tumour of the uterus: radiographic and ultrasonic appearance By L Murray Houser, M.D., C. H. Carrasco, M.D. and C. R. Sheehan, Jr., R.D.M.S. Department of Radiology, Pennsylvania Hospital, 8th and Spruce Streets, Philadelphia, Pennsylvania 19107 (Received March 1979)
Masses in the pelvis that are shown to contain fat on X-ray are usually thought to be ovarian in origin. An unusual lipomatous tumour of the uterus, seen on plain radiographs and on ultrasound, is presented. This is the first report of the pre-operative demonstration of such a tumour by X-ray or ultrasound.
and smooth muscle tissue. Most patients are postmenopausal, predominantly in their 50's and 60's although one was 23 years old. The size of the tumours vary from several millimetres to 32 cm in diameter. They may occur anywhere within the uterus, but are however, predominantly found in the corpus. Most are associated with ordinary fibroids. Grossly, they are rounded or oval and well encapsulated. The pure lipomas are soft and yellow, while the more fibrous tumours tend to be lighter in colour and firmer. Clinically, the symptoms are indistinguishable from those of ordinary fibroids. Histologically, the pure lipomas consist of mature fat cells in a spare connective tissue stroma. The
CASE REPORT
A 59-year-old white female was admitted for evaluation of a pelvic mass. She had been in good health until four days prior to admission when she noted pain in her right hip and a sensation of pressure in her pelvis. Physical examination revealed a large, hard, irregular pelvic mass extending upward to the level of the umbilicus. On the plain film of the abdomen there was a rounded mass in the pelvis measuring approximately 18 cm in diameter. The central portion of this was radiolucent and surrounded by a relatively uniform soft tissue density measuring 1—2 cm in thickness (Fig. 1). Abdominal ultrasound demonstrated a 16 cm mass with a strongly echogenic central portion, which was surrounded by a relatively echo-free' border (Fig. 2). The central portion of the mass was so attenuating that the back wall could not be seen. The radiographic and ultrasonic findings were interpreted as a soft-tissue pelvic mass with a fatty central core and assumed to represent a dermoid tumour of the ovary. At operation, the mass was found to be within the uterus and was thought to be a fibroid tumour. Total hysterectomy was performed. Gross examination of the uterus showed a large, spherical, firm mass, which on cut section was seen to be within the myometrium. It was well circumscribed and yellowish in colour. Microscopically, the tumour was composed predominantly of mature fat cells with some interposed fibrous elements and smooth muscle. The pathologic diagnosis was fibromyolipoma of the uterus. DISCUSSION
Lipomatous tumours of the uterus are relatively uncommon. Salm (1973) found seven cases 5200 speciments over a 25 year period, an incidence of 0.14%. Brandfass and Everts-Suarez (1955) summarized the world literature in a comprehensive review. They found 33 pure lipomas and 63 mixed tumours (fibromyolipomas, myolipomas and fibrolipomas) with varying amounts of fibrous
FIG.1.
Radiolucent central mass corresponds to fatty tumour. A thin rim of more radiodense material, representing the myometrium, surrounds it.
992
