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Even inhibitions buy lyrica 75 mg amex, irresponsible behaviour and grandiosity ac- when recognised and treated buy lyrica 75 mg lowest price, the condition carries a mortal- companied by biological symptoms (increased energy lyrica 150 mg line, rest- ity rate of 12–15%, through cardiac arrhythmia, rhabdomy- lessness, decreased need for sleep, and increased sex drive). The condition usually lasts for Psychotic features may be present, particularly disordered 5–7 daysafter the antipsychotic isstopped but may continue thinking manifested by grandiose delusions and ‘flight of longer when a depot preparation has been used. Fortunately ideas’ (acceleration of the pattern of thought with rapid those who survive tend to have no long-lasting physical speech). Hypomania is a less dramatic and less dangerous effects fromtheir ordealthoughcareisrequiredif, asisusual, presentation, butretainsthefeaturesofelation orirritability they need further antipsychotic treatment. Depressive episodes Comparison of conventional and may include any of the depressive symptoms described atypical antipsychotics above, and may include psychotic features. Tolerability, and thus compliance, appears to be better, Lithium in particular with less likelihood of inducing extrapyramidal effects and hyperprolactinaemia Lithium salts were known anecdotally to have beneficial (although the latter remains common with risperidone psychotropic effects as long ago as the middle of the and amisulpride). When an adequate dose of lithium is taken fect is probably to inhibit hydrolysis of inositol phosphate, consistently, around 65% of patients achieve improved so reducing the recycling of free inositol for synthesis of mood control. The existence of a ‘rebound effect’ (recurrence of and cholinergic neurotransmitters. The therapeutic and toxic plasma Lithium salts are ineffective for prophylaxis of bipolar af- concentrations are close (low therapeutic index). The search for is a small cation and, given orally, is rapidly absorbed alternatives has centred on anticonvulsants, notably carba- throughout the gut. High peak plasma concentrations are mazepine and sodium valproate and lamotrigine, and avoided by using sustained-release formulations which de- more recently the atypical antipsychotics. Lithium is also used to augment the action of antidepres- At first lithium is distributed throughout the extracellular sants in treatment-resistant depression (see p. The dose of lithium ions (Li ) delivered ter with a somewhat higher concentration in brain, bones varies with the pharmaceutical preparation; thus it is vital and thyroid gland. Lithium is easily dialysable from the for patients to adhere to the same pharmaceutical brand. The ion it is not metabolised, nor is it bound to plasma proprietary name must be stated on the prescription. Some patients cannot tolerate slow-release preparations The kidneys eliminate lithium. Like sodium, it is filtered because release of lithium distally in the intestine causes di- by the glomerulus and 80% is reabsorbed by the proximal arrhoea; they may be better served by the liquid prepara- tubule, but it is not reabsorbed by the distal tubule. In sodium deficiency lithium is retained in lowest dose of the preparation selected. Any change in the body, and thus concomitant use of a diuretic can reduce preparation demands the same precautions as does initia- lithium clearance by as much as 50%, and precipitate tox- tion of therapy. It ments are made at weekly intervals until the concentration is usually given 12–24-hourly to avoid unnecessary fluctu- lies within the range 0. A steady-state plasma of blood sampling is important, and by convention a blood concentration will be attained after about 5–6 days (i. Once the plasma con- and patients with impaired renal function will have a lon- centration is at steady state and in the therapeutic range, it ger t½so that steady state will be reached later and dose in- should be measured every 3 months. Lithium carbonate is effective treat- tion (plasma creatinine and electrolytes) should be ment in more than 75% of episodes of acute mania or hy- measured before initiation and every 3–6 months during pomania. In: Ayd F J, Blackwell B (eds) Adverse effects are encountered in three general Biological Psychiatry. It is also effective in combination with lith- goitre, hypothyroidism, acne, rash, diabetes insipidus ium. The latter two drowsiness, sluggishness and coarse tremor, leading on are metabolised to valproic acid which exerts the pharma- to giddiness, ataxia and dysarthria). Treatment syncope, oliguria, coma and even death may result if with valproic acid is easy to initiate (especially compared to treatment is not instigated urgently. Acute overdose may present without signs of of full blood count and liver function are recommended toxicity but with plasma concentrations well exceeding following reports of occasional blood dyscrasias or hepatic 2 mmol/L. Where not to be associated with the ‘rebound effect’ of relapse into toxicity is chronic, haemodialysis may be needed, espe- manic symptoms that may accompany early withdrawal of cially if renal function is impaired. Whole bowel irrigation may be an option for significant ingestion, but specialist Other drugs advice should be sought. Drugs that interfere with lithium excretion phylaxis of bipolar affective disorder, especially when de- by the renal tubules cause the plasma concentration to rise. Theophylline and sodium- control of acute manic symptoms, including both the gran- containing antacids reduce plasma lithium concentration. Diltiazem, verapamil, carbamazepine which can occur in an extremely agitated patient. However, and phenytoin may cause neurotoxicity without affecting atypical antipsychotics such as olanzapine, quetiapine and the plasma lithium level. Carbamazepine Other drugs that have been used in augmentation of Carbamazepine is licensed as an alternative to lithium for existing agents include the anticonvulsants oxcarbazepine prophylaxis of bipolar affective disorder, although clinical and gabapentin, the benzodiazepine clonazepam, and trial evidence is actually stronger to support its use in the the calcium channel blocking agents verapamil and treatment of acute mania. The first panic attack often occurs with- out warning but may subsequently become associated with The disability andhealth costs caused by anxietyare highand specific situations, e. Antici- comparablewiththose of other commonmedicalconditions patory anxiety and avoidance behaviour develop in re- such as diabetes, arthritis or hypertension. The condition must be ety disorders experience impaired physical and role function- distinguished from alcohol withdrawal, caffeinism, hyper- ing, more workdayslost due toillness, increased impairment thyroidism and (rarely) phaeochromocytoma. Our understanding of Patients experiencing panic attacks often do not know the nature of anxiety has increased greatly from advances in what is happening to them, and because the symptoms research in psychology and neuroscience. It is now possible are similar to those of cardiovascular, respiratory or neuro- to distinguish different types of anxiety with distinct biolog- logical conditions, often present to non-psychiatric ser- ical and cognitive symptoms, and clear criteria have been ac- vices, e. The last specialists, where they may either be extensively investi- decade has seen developments in both drug and psycholog- gated or given reassurance that there is nothing wrong. A ical therapies such that a range of treatment options can be carefully taken history reduces the likelihood of this tailored to individual patients and their condition. Anxiety does not manifest itself only as a psychic or men- tal state: there are also somatic or physical concomitants, Treatment. Anxiety symp- course of these two classes of agent in panic disorder is toms exist on a continuum and many people with a mild depicted in Figure 20. On with- ciated disability of many anxiety disorders means that most drawal of the benzodiazepine, even when it is gradual, in- patients who fulfil diagnostic criteria for a disorder are creased symptoms of anxiety and panic attacks may occur, likely to benefit from some form of treatment. In- deed, some patients find they are unable to withdraw and remain long-term on a benzodiazepine. Both divide anxiety into a series of but patients need help to stay on treatment in the first subsyndromes with clear operational criteria to assist in weeks. At any one time many patients may the likely course of events and the antidepressant should have symptoms of more than one syndrome, but making be started at half the usual initial dose to reduce the likeli- the primary diagnosis is important as this can markedly in- hood of exacerbation. The essential feature of social phobia is a marked and per- These are discrete periods of intense fear accompanied by sistent fear of performance situations when patients feel characteristic physical symptoms such as skipping or they will be the centre of attention and will do something 331 T viden ce- based treat en tsforan xiety disorders G X D F irst - l i e S S R S S R S S R cute p reven tion – if S S R sy chol ogical – treat en t feasibl e con sider ex osure p rop ran ol ol after therap y m ajortraum a.

An increase in free bupi- of epinephrine in local anesthetic solutions during vacaine might increase the risk of systemic toxicity buy lyrica 75 mg otc. Cardiovascular depression purchase 150mg lyrica visa, bradycardia purchase lyrica with visa, and arrhythmias are less Inhalational Anesthetics frequent with sevofurane than with halothane. In general, volatile anesthetics with relatively greater blood fow to vessel-rich appear to depress ventilation more in infants than organs contributes to a rapid increase in alveolar in older children. Sevofurane appears to produce anesthetic concentration and speeds inhalation the least respiratory depression. Furthermore, the blood/gas coefcients othane-induced hepatic dysfunction appears to be of volatile anesthetics are reduced in neonates com- much reduced in prepubertal children compared pared with adults, resulting in even faster induction with adults. Tere are no reported instances of times and potentially increasing the risk of acciden- renal toxicity attributed to inorganic fuoride pro- tal overdosage. Morphine sulfate, particularly in repeated preferred agent for inhaled induction in pediatric doses, should be used with caution in neonates anesthesia. The sevofurane, but both agents are associated with cytochrome P-450 pathways mature at the end of a greater incidence of agitation or delirium upon the neonatal period. Because relatively greater rates of biotransformation and of the latter, some clinicians switch to isofurane elimination as a result of high hepatic blood fow. Remifentanil clearance is increased in neonates and Nonvolatile Anesthetics infants but elimination half-life is unaltered com- Afer weight-adjustment of dosing, infants and pared with adults. Neonates and infants may be young children require larger doses of propofol more resistant to the hypnotic efects of ketamine, because of a larger volume of distribution compared requiring slightly higher doses than adults (but the with adults. Children also have a shorter elimina- “diferences” are within the range of error in studies); tion half-life and higher plasma clearance for pharmacokinetic values do not appear to be signif- propofol. Etomidate has ciably diferent from that in adults; however, recov- not been well-studied in pediatric patients younger ery following a continuous infusion may be more than 10 years of age; its profle in older children is rapid. Midazolam has the fastest increased weight-adjusted rates of infusion for clearance of all the benzodiazepines; however, mid- maintenance of anesthesia (up to 250 mcg/kg/min). Although the “propofol infusion syndrome” has been reported more ofen Muscle Relaxants in critically ill children, it has also been reported For a wide variety of reasons (including pharmacol- in adults undergoing long-term propofol infusion ogy, convenience, case mix, and convenience), muscle (>48 h) for sedation, particularly at increased doses relaxants are less commonly used during induction (>5 mg/kg/h). Its essential features include rhabdo- of anesthesia in pediatric than in adult patients. The elimination half- intravenous catheter, and administration of various life is shorter and the plasma clearance is greater than combinations of propofol, opioids, or lidocaine. In contrast, neonates, appear to be more All muscle relaxants generally have a faster sensitive to barbiturates. Neonates have less pro- onset (up to 50% less delay) in pediatric patients tein binding, a longer half-life, and impaired clear- because of shorter circulation times than adults. The thiopental induction dose for neonates is In both children and adults, intravenous succinyl- 3–4 mg/kg compared with 5–6 mg/kg for infants. Unproven doses of succinylcholine (2–3 mg/kg) than older (but popular) explanations include “easier entry” children and adults because of the relatively larger across the blood–brain barrier, decreased metabolic volume of distribution. Prolonged, heroic (eg, potentially including cardiopulmonary bypass) resuscitative Succinylcholine 0. When rapid muscle relaxation is required prior (the dose that produces 95% depression of evoked to intravenous access (eg, with inhaled inductions in twitches). With the notable exclusion of succinyl- patients with full stomachs), intramuscular succinyl- choline and possibly cisatracurium, infants require choline (4–6 mg/kg) can be used. Moreover, based on weight, older intramuscular succinylcholine to reduce the likeli- children require larger doses than adults for some hood of bradycardia. Some clinicians advocate intra- neuromuscular blocking agents (eg, atracurium, see lingual administration (2 mg/kg in the midline to Chapter 11). As with adults, a more rapid intubation avoid hematoma formation) as an alternate emer- can be achieved with a muscle relaxant dose that is gency route for intramuscular succinylcholine. Popular (and unproven) pediatric patients with intravenous access because explanations for this include “immaturity of the it has the fastest onset of nondepolarizing neuro- neuromuscular junction” (in premature neonates), muscular blocking agents (see Chapter 11). Larger tending to increase sensitivity (unproven), counter- doses of rocuronium (0. The relative immaturity of neonatal is the only nondepolarizing neuromuscular blocker hepatic function prolongs the duration of action for that has been adequately studied for intramuscular drugs that depend primarily on hepatic metabolism administration (1. Atracurium and cisatracurium do not depend on Atracurium or cisatracurium may be preferred hepatic biotransformation and reliably behave as in young infants, particularly for short procedures, intermediate-acting muscle relaxants. Nondepolarizing blockade can be reversed related 7% 4% Medication- with neostigmine (0. Sugammadex, a specifc antagonist for rocuronium and vecuronium, has yet to be released in the United States. Tis registry includes reports derived from approximately one million 66% of all medication-related arrests. Case was due to intravascular injection of a local anes- records of children experiencing cardiac arrests or thetic, most ofen following a negative aspiration death during the administration of or recovery from test during attempted caudal injection. Presumed anesthesia were investigated regarding any pos- cardiovascular mechanisms most ofen had no clear sible relationship with anesthesia. Nearly all patients etiology; in more than 50% of those cases the patient received general anesthesia alone or combined with had congenital heart disease. In a preliminary analysis that lar mechanism could be identifed, it was most ofen included 289 cases of cardiac arrest, anesthesia was related to hemorrhage, transfusion, or inadequate or judged to have contributed to 150 arrests. Nearly all permanent injury, but the majority (68%) had either patients who had airway obstruction or were dif- no or only temporary injury. Infants accounted tion (eg, pneumothorax, hemothorax, or cardiac for 55% of all anesthesia-related arrests, with those tamponade). The experimental Most (82%) arrests occurred during induction data in animals are consistently worrisome, but the of anesthesia; bradycardia, hypotension, and a low clinical data are (currently) inconclusive as to the Sp o 2 frequently preceded arrest. The most com- extent of the risk and whether one technique is safer mon mechanism of cardiac arrest was judged to be than another. Presurgical preparation programs—such as should anticipate that a longer-than-usual stay in the brochures, videos, or tours—can be very helpful in recovery room may be required. Unfortunately, outpatient and morning-of-admission surgery together with a busy operating room schedule ofen C. Laboratory Tests make it nearly impossible for an anesthesiologist to Few, if any, preoperative laboratory tests are cost break through the barriers presented by pediatric efective. For this reason, premedication (below) can ative laboratory tests in healthy children undergoing be helpful. Obviously, this places responsibil- the process of anesthesia and surgery by explaining ity on the anesthesiologist, surgeon, and pediatrician in age-appropriate terms what lies ahead. For exam- to correctly identify those patients who should have ple, the anesthesiologist might bring an anesthesia preoperative testing for specifc surgical procedures. Alternatively, in some centers, someone the child Innocent murmurs may occur in more than 30% of trusts (eg, a parent, nurse, another physician) may normal children. Tese are typically sof, short sys- be allowed to be in attendance during preanesthetic tolic ejection murmurs that are best heard along the preparations and induction of anesthesia.

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The upper and lower may traverse the inferior alveolar canal generic lyrica 150mg without prescription, which runs from compartments (joint spaces purchase cheap lyrica on line, above and below the disk) the mandibular foramen to the mental foramen buy discount lyrica on line, and can normally do not communicate. Due to its ring-like configuration, 50% of mandibular the best means of examining the osseous joint structures. This 43-year-old patient pre- sented with swelling and discomfort involving the man- dible for more than 20 years. The mass is at least, in part, multilocu- lated, a feature best seen on the more caudal of the two images. Although matrix calcification is not typical of an ameloblastoma, fragmented bone can be present, as in this case, due to the destructive nature of the lesion. Axial images (part 1) display a subcondylar fracture on the right, and a parasymphyseal fracture on the left. Coronal reformatted images (part 2) display well both fractures, with the subcondylar fracture grossly angulated (arrow) and, in addition, dislocation or subluxation of the left mandibular condyle (*). Close inspection of the condyles, evaluating for displacement/subluxation, is advised in all facial trauma. This should be supplemented by high resolution static images in both the open and closed position in the sagittal and coronal planes. T2-weighted im- ages can also be acquired to identify abnormal joint fluid or edema in the adjacent tissues. Anteriorly lies (when considered with the skull base), fractures of the mandible the nasal cavity. Coronal reformatted images goid plates (anteriorly) and the fascia and muscles of the display two fractures, one at the angle of the mandible on the right airway (posteriorly). The nasopharynx is separated from (black arrow) and one through the body on the left (white arrows), the oropharynx below by the soft palate. For a single fracture that involves the mandible, the angle of the mandible is the most common location. The mandibular condyle is located anterior to the mouth view, second column, the condyle translocates anteriorly external auditory meatus with its head articulating with the glenoid underneath the posterior band of the meniscus, with the meniscus fossa and articular eminence of the temporal bone. When the mouth (white arrow) now assuming a normal position (reduction of the dis- is closed (first column), the mandibular condyle lies centered in the location). In a fixed-type of dislocation (third row), the meniscus is glenoid fossa with the meniscus (black arrow) lying along its antero- seen anterior to the mandibular condyle in the closed-mouth view, superior aspect. With mouth opening, the condyle (C) translocates and remains dislocated (black *) anteriorly to the condyle in the anteriorly with the meniscus moving into the one o’clock position. The prevertebral (periver- torus tubarius, levator veli palatini muscles, and many tebral) space is bounded by the prevertebral fascia ante- minor salivary glands. The lateral pharyn- Infection involving the nasopharynx is usually second- geal recess (fossa of Rosenmüller) is formed by mucosal ary to either dental or tonsillar infection. Dental infection reflection over the longus colli and capitis muscles (flexors can spread to the masticator and prestyloid parapharyn- of the cervical spine), and is the site of origin for the vast geal spaces, in addition to causing osteomyelitis. The leva- lar infection can result in an abscess that can extend to tor veli palatini muscle is intrapharyngeal, just lateral to the retropharyngeal space or the prestyloid parapharyn- the torus tubarius. Eighty to seen in 4% of patients, and is a small midline cyst that lies 90% of patients have nodal involvement on presentation along the posterior nasopharyngeal wall. Involve- will have high signal intensity on T2, reflecting fluid, and ment of lymph nodes can be suggested on many different intermediate to high signal intensity on T1-weighted im- bases—by size criteria, with visualization of necrosis, and ages, dependent on the protein concentration. It is important to note that radiation therapy causes with Epstein-Barr virus infection. The lateral pharyngeal re- a substantial change in appearance of tissues in this region cess is the most common site of origin. Also note the middle the ostium of the eustachian tube, centered on (and obliterating) ear and mastoid fluid due to eustachian tube obstruction. Forty percent of these lesions occur in the head and neck, with the most common loca- tions being the orbit and nasopharynx. This tumor is lo- cally invasive, often with bone destruction and perineural tumor extension. Extrinsic muscles of the tongue include the genioglossus, hyoglossus, styloglossus, and palatoglossus muscles while intrinsic muscles include Fig. Mild mass effect upon, and dis- side of the oral cavity proper, below the mylohyoid muscle placement of, the oropharynx is noted. Prominent reactive upper cervical and mylohyoid muscles are innervated by the mylohyoid lymphadenopathy (not shown) was also present on the left. Other much less common malignant lesions include tonsils), the soft palate, and the oropharyngeal mucosa, non-Hodgkin lymphoma and minor salivary gland tumors. Half of all minor salivary gland tumors in this region are Infections in this area usually involve the mandible (due malignant. In regard to the tongue, squamous cell carci- to dental caries), salivary glands (with an obstructive cal- noma easily spreads along the intrinsic muscles. Extensive infection involving interpretation, it is important to assess spread in relation the sublingual and submandibular spaces, typically bilat- to the midline. Without midline extension, hemiglossec- eral (Ludwig angina), is a serious, potentially life-threat- tomy is a surgical option (Fig. It oral cavity tumor is squamous carcinoma of the lower is the result of dental caries and, if untreated, can lead to lip. More than 90% of malignant tumors involving the oral Within the oropharynx, tonsil carcinoma is the most cavity and oropharynx are squamous cell carcinomas. In this location in particular, some are associated with the human papilloma virus there is a very high incidence of nodal metastases at Fig. This polymicro- bial infection, which involves the soft tis- sues of the floor of the mouth, can spread rapidly in the absence of adequate antimi- crobial treatment, dissecting into the me- diastinum and causing chest pain (thus the name “angina”). In this patient, a 49-year- old substance abuser, the lesion was of odontogenic origin. On axial and coronal images there is an extensive phlegmon involving the floor of the mouth, with con- tiguous spread along connective tissue, fascia, and muscle planes. Note that the the tongue on the left, hyperintense on the coronal T2-weighted scan, tumor can be distinguished from normal adjacent tongue, even on intermediate signal intensity on the T1-weighted axial scan precon- the precontrast T1-weighted scan, with the latter demonstrating mild trast, and enhancing on the postcontrast scan with fat suppression. A small soft tissue lesion (*) is noted on the right, with intermediate signal intensity on the T2-weighted scan (slightly hyperintense to muscle) and mild contrast en- hancement (part 1). The jugulodigastric node on the left (black arrow) is normal by size criteria, but was partially necrotic on the adjacent section (not shown) and had restricted diffusion (also not illustrated). Regardless of specific location, bilateral lymph node involvemenThat presentation is common. The parotid gland is artificially divided into deep and superficial lobes by the facial nerve. The main duct of the parotid gland is Stensen duct, which runs anteriorly to pierce the buccinator muscle and open into the vestibule opposite the second maxillary molar. The main duct of the submandibular gland is Wharton duct, which opens at the top of a small papilla in the sub- lingual space. Eighty percent of salivary glands stones occur in larged submandibular glands bilaterally, in this patient with chronic Wharton duct (Fig. The majority of salivary gland stones are radi- present on the right, all likely in Stensen duct.

The triangular perivesical fatty triangle order 150mg lyrica with visa, surrounding the urachus and obliterated umbilical artery lyrica 75 mg mastercard, is partially demarcated by contrast media (white arrow) purchase lyrica with amex. The triangular perivesical fatty space around the urachus and obliterated umbilical arteries (arrows) is spared, outlined by a surrounding prevesical collection, some of which is opacified by contrast medium (*) leaking from the urinary bladder. Note the thickened, prominent perirectal fascia (perf) and posterior pelvic fascia (ppf). Largeamountofascites,eitherlocu- while the extraperitoneal prevesical collection lated or free, may form a molar tooth appearance in usually obliterates this fat (Figs. However, with collections of intraper- The umbilicovesical fascia that surrounds the itoneal fluid, the urinary bladder is displaced infer- urachus and obliterated umbilical arteries is not iorly rather than posteriorly and medially (Figs. Furthermore, the ‘‘root’’ portion is the umbilicovesical fascia becomes obvious when formed by accumulation of ascites in the bilateral there is adjacent prevesical fluid. The prevesical pararectal fossae or parasigmoidal fossae and collections surround but do not involve a trian- therefore located more superiorly. Additionally, gular segment of fat in the anterior abdominal ascites usually preserves the properitoneal fat wall, which represents the superior extension of 214 7. At this level, prevesical collections can extend directly through the thin transversalis fascia, along perforating branches of the inferior epigastric vessels, to come into direct contact with the rectus abdominis muscles (Figs. Fluid can then extend along these muscles into the 9 more superior portions of the rectus sheath. Simi- larly, rectus sheath hematomas can follow the same pathway into the prevesical space (Fig. In fact, when large collections involve both of these compartments, it can be difficult to determine whether the effusions originated in the prevesical 9 space or the rectus sheath. Large heterogeneous ganglioneuroma (*) courses within the prevesical space before it enters arising in the presacral space displaces the colon and the internal inguinal ring to become part of the sper- urinary bladder (ub) anteriorly and obliterates the matic cord. The prevesical collec- then, that prevesical fluid can extend along the vas tions usually obliterate the properitoneal fat deferens into the inguinal canal and subsequently except this triangular segment (Figs. Like the vas deferens, the distal portion of the Below the arcuate line, which lies approximately round ligament courses within the prevesical space as halfway between the umbilicus and pubic symphy- it enters the internal inguinal ring after hooking sis, the rectus abdominis muscles are lined poster- 22 around the proximal inferior epigastric vessels. As the external iliac vessels course below the ingu- This is because the posterior lamina of the apo- inal ligament to become the femoral vessels, they neurosis of the internal oblique muscle and the are enveloped by the femoral sheath, which consists aponeurosis of the transversus abdominis muscle, of a downward prolongation of transversalis fascia Abnormal Imaging Features 215 a b c Fig. This sheath is extension of contrast medium from the prevesical occupied by the femoral artery and vein laterally and space into the perivesical space or more frequently by the femoral canal medially. Since the external iliac vice versa is common in vivo, resulting in partial or vessels lie lateral to the peritoneum, within a com- complete obliteration of the perivesical fat (Fig. The prevesical space is continuous laterally with the Clinically, these effusions may be mistaken for extraperitoneal fat of the anterior abdominal wall, bladder wall thickening or perivesical tumor exten- which in turn is continuous with the properitoneal and sion. Thus, prevesical effusions can bladder may be mistaken for intraperitoneal fluid 9,10 extend laterally around the parietal peritoneum to within the cul-de-sac. When large collec- Perirectal Pathology tions involve both the abdominal and pelvic extraper- In contrast to the prevesical space where the most itoneal compartments, it can be difficult to predict common abnormal findings are related to spontaneous whether the effusions originated in the prevesical 5–10 or traumatic hematoma or other fluid collections, space or the retroperitoneum (Figs. Identifying fasciae and the resulting spaces is Perivesical Fluid Collections important for detecting and localizing pathologic pro- cesses and determining extent of the disease, thus influ- Perivesical collections are rarely seen without asso- encing clinical management and therapy. Perivesical collections are It is particularly helpful in the staging and manage- small since the fluid is within a relatively narrow ment of rectal cancer. Because the perirectal space is space around the urinary bladder confined by the mainly filled with adipose tissue, the extent of rectal umbilicovesical fascia. If the thin umbilicovesical fascia is impregnable, as tumor has reached the perirectal fascia, it is most likely text continues on page 219 216 7. Inflammatory changes are also seen in the adjacent right posterolateral abdominal wall, affecting the muscle (arrows), subcutaneous fat, and dermal layer (arrowheads) despite a ‘‘clean’’ posterior pararenal space. The urinary bladder also is compressed and displaced to the left by the prevesical fluid collection (*). Pelvic nodal metastatic disease from prostate cancer with edematous changes secondary to lymphatic blockage. Edematous changes are also present in the extraperitoneal space (wavy black arrows). Pancreatitis causing mild thickening of all extraperitoneal fasciae including the remote perirectal fascia. During pancreatitis (a, c, e) and after resolution of pancreatitis (b, d, f) at same corresponding levels. Thickening of the adjacent left anterior renal fascia (arrows) and right posterior renal fascia (arrowheads) is present. The umbilicovesical fascia (uvf), also not typically identifiable, is evident, closely apposed to the urinary bladder. The right obliterated umbilical artery (ua) and ductus deferens (dd) are also visualized. Pancreatitis causing mild thickening of all extraperitoneal fasciae including the remote perirectal fascia. How- spaces in the supine position, any fluid collection ever, thickening of the fascia alone that may be due to that develops in the pelvic extraperitoneal spaces, reactive inflammatory changes may not necessarily including a hematoma, can track into the presacral represent tumor involvement. Enlarged Primary or secondary bone tumor from the sacrum or lymph nodes may be often due to hyperplastic nature coccyx may also involve this space (Fig. It is because of these false positives that cross-sectional imaging has a high sensitivity but low specificity in the staging of 16 rectal cancer. Extension Across Fascial Planes Perirectal abscess and cellulitis are associated with Crohn disease and infectious proctitis in homosexual In many clinical situations, it is not uncommon to see fluid collections in one space migrate to males. In these cases, a more important anatomic another space illogically, beyond the boundaries consideration that may impact therapy is the levator ani muscle. For example, in the pel- approaches for supralevator abscess and the more vis, there may be posterior extension of a prevesi- common infralevator one are quite different. Since cal fluid collection into the perirectal space or pre- the perirectal fascia and space are located superior to sacral space (Figs. In the the levator ani, any abscess confined to the perirectal retroperitoneum, an anterior pararenal collection space which can be easily identified belongs to the may communicate with the perirenal space or pos- 20 terior pararenal space (Fig. Perirectal abscesses can result There are several hypotheses to explain these illogi- from the inferior migration of an abscess arising from a sigmoid diverticulitis, as the subperitoneal cal or paradoxical phenomena. First, there are likely space of the sigmoid mesocolon directly communi- individual variations in fascial anatomy among sub- cates with the perirectal space (Fig. Second, these fascial planes may be broken or ruptured directly due to trauma or digested as in a case of pancreatitis or Presacral Space Pathology disrupted by acute supprative infection. The acute and rapid accumulation of fluid collection may cause Hematomas can develop following fracture of the sacrum and coccyx (Fig. Since this space is the direct damage to the fascia allowing fluid collections 220 7. Prostate abscess causing mild thickening of all extraperitoneal fasciae including remote renal fascia. During abscess (a, c, e) and after resolution of abscess (b, d, f) at same corresponding levels. The transversalis fascia (white arrows) is evident as thin lines, posterior to the rectus muscles. Slight thickening of the urachus (wavy arrow) in the midline and obliterated umbilical arteries (ua, black arrows) on either side are evident.