[Basic principles of ultrasonography and its relevance for internal medicine]. / Grundlagen der Sonographie und deren Relevanz für die Innere Medizin.

This article gives an overview of the technical possibilities and clinical applications of modern ultrasound. B-mode and Doppler imaging are already essential in daily routine. Advanced technology, such as harmonic imaging, improves image quality. Tissue harmonic imaging provides better resolution by reducing noise, whereas the introduction of contrast agents increases the perceptibility of focal lesions, e.g., liver tumors. Meanwhile the diagnostic accuracy of contrast-enhanced ultrasound imaging is comparable with CT imaging. Other tools, e.g., elastography, ameliorate the detection of liver fibrosis and tumors. Currently, application of three-dimensional and four-dimensional imaging is of low clinical relevance. Panoramic imaging provides images close to CT or MRI.

[Splenosis--important differential diagnosis in splenectomized patients presenting with abdominal masses of unknown origin]. / Splenose -- eine wichtige Differenzialdiagnose unklarer abdomineller Raumforderungen bei splenektomierten Patienten.

A 40-year-old female patient was admitted for work-up of multiple abdominal masses. The lymphoma-mimicking tumors were detected accidentally during an ultrasound course. The past medical history was unremarkable besides a status post-traumatic splenic rupture and splenectomy. The patient was asymptomatic, especially there were no complaints of fever, night sweats or weight loss. Laboratory tests did not show pathological results. Ultrasound of the abdomen revealed multiple hypoechoic mesenterial and peritoneal enlarged tumors as well as a subhepatic mass (30 x 20 mm). Transmission computed tomography (CT) showed a normal chest, excluded abnormal thoracal masses and confirmed the multiple abdominal nodules. Microparticles were trapped only by tissue with phagocytosis function as cells of the reticulohistiocytary system in liver and spleen. Uptake of (99 m)Tc-labeled microparticles is specific for splenic tissue. All abdominal masses were detectable by single photon emission computed tomography (SPECT) after intravenous administration of this radiotracer. Ultrasound-guided biopsy proved the presence of spleen tissue with follicular hyperplasia. In conclusion, we report a case of post-traumatic splenosis. In 16 - 67 % of patients who experienced traumatic splenic rupture autotransplanted spleen tissue can be detected. Splenosis therefore is an important differential diagnosis of abdominal masses in splenectomized patients.

[Painless jaundice after holidays in Tanzania]. / Schmerzloser Ikterus nach Urlaub in Tansania.

The side effects caused by malaria prophylaxis with mefloquine (Lariam) are well known. We describe the case of a 42-year-old female Caucasian patient suffering from painless jaundice and showing elevated liver, cholestasis and inflammation laboratory findings 7 days after returning from Tanzania. Acute cholecystitis was diagnosed by ultrasound. Treatment with parenteral nutrition and antibiotic therapy did not show any beneficial effect. Excluding the possibility of infectious diseases, the elevated laboratory and ultrasound findings were normalized after the discontinuation of the malaria prophylaxis.

Survival rate in patients with hepatocellular carcinoma: a retrospective analysis of 389 patients.

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. However, treatment options are limited and often inefficient. The aim of this study was to determine current survival rates for patients diagnosed with HCC and to identify prognostic factors, which will help in choosing optimal therapies for individual patients. A retrospective analysis of medical records was performed on 389 patients who were identified through the central tumour registry at our institution from 1998 to 2003. Clinical parameters, treatments received and survival curves from time of diagnosis were analysed. Overall median survival was 11 months. Liver cirrhosis was diagnosed in 80.5% of all patients. A total of 170 patients received transarterial chemoembolisation (TACE) and/or percutaneous ethanol injections (PEI) with a median survival rate of 16 months for patients receiving TACE, 11 months for patients receiving PEI and 24 months for patients receiving TACE followed by PEI. Independent negative prognostic parameters for survival were the presence of portal vein thrombosis, advanced liver cirrhosis (Child-Pugh score B or C) and a score of >2. This study will help to estimate survival rates for patients with HCC according to their clinical status at diagnosis and the treatments received.

[Transcutaneous perianal ultrasound (PAUS) for the imaging of fistulas and abscesses in Crohn's disease]. / Aktuelle Sonographie: Transkutaner, perianaler Ultraschall (PAUS) zur Diagnostik von Fisteln und Abszessen bei M. Crohn.

Pelvic MRI and transanal ultrasound constitute the gold standard for the imaging of perianal inflammatory lesions in Crohn's disease. Perianal ultrasound (PAUS), however, is rarely considered in recent literature. In contrast to the established methods, perianal ultrasound represents an easy, cost-effective and at the same time sensitive method for the imaging of perianal abscesses and fistulas. This article illustrates the performance of perianal ultrasound and shows typical images of pathological findings such as abscesses and fistulas. PAUS is especially useful for acute diagnostics to rule out perianal abscesses and for follow-up evaluation of fistula treatment. For example, complications such as abscesses can be detected in a timely manner.

[New concepts in ultrasound education in gastroenterology by simulator training]. / Neue Konzepte in der gastroenterologischen Sonographieausbildung durch Schulung am Ultraschallsimulator.

Ultrasound is one of the most important imaging methods in medicine. However, ultrasound education is complicated by varying quantities and qualities of specific pathologies resulting from distinct patient collectives. Furthermore, under current clinical conditions ultrasound educators as well as trainees frequently lack the time necessary for a sufficient ultrasound education. Finally, current ultrasound education materials including "gold standard" images are not ideally suited for teaching scanning three-dimensional pathologies. In a direct cross over study we recently proved, that the ultrasound simulator we developed simulated the real patient examination reliably and reproducibly. By using this simulator as well in the classical beginner and advanced level courses as in focused courses of abdominal emergencies for instance, ultrasound trainees are able to practice scanning of well defined pathologies under realistic conditions, which has not been possible before. Furthermore, the ultrasound simulator is well suited for a structured ultrasound training in single hospitals as well as in continuous medical education. Finally, objective, standardized ultrasound quality control has become possible with the simulator.

Malignant lymphoma accompanied by renal cell carcinoma - a not so rare coincidence?

We report a case of a patient who presented with a left sided inguinal swelling. Ultrasound examination clearly revealed a bilateral inguinal lymphoma. In addition, a renal cell carcinoma was diagnosed through ultrasound. The differences in texture between lymph nodes and renal tumour as well as the even concentric swelling of the lymph node sinus permitted a clear cut differentiation between the two entities. CT could not provide this clear distinction. Despite some controversy several case reports as well as a few retrospective studies showed an increased coincidence of renal cell carcinoma and malignant lymphoma. However, a pathophysiological connection has not yet been discovered. This report presents another case of synchronous appearance of renal cell carcinoma and malignant lymphoma and demonstrate the relevance of ultrasound in the discrimination between the two clinical entities. It is essential for physicians performing either sonography and/or CT to be aware of this coincidence to avoid misdiagnosis of lymphadenopathy in patients with renal cell carcinoma as metastasis and, vice versa, renal tumours in lymphoma patients as renal manifestation of the lymphoma.

Simulation of abdomen sonography. Evaluation of a new ultrasound simulator.

AIM: We developed and evaluated a simulator for the sonography of the abdomen in order to improve the teaching quality in sonography training. METHOD: Eleven medicine residents who had received 4 to 12 months full time sonography training performed ultrasound examinations of the right upper quadrant in 5 consecutive patients and in 5 simulator cases. The correctness of their findings and the time required for the examinations were measured. The subjective confidence in their findings and the handling of the ultrasound machines were rated on a visual analogue scale. RESULTS: During patient ultrasound examination 75 % (SEM 9%) of all pathologic findings were recognized by the residents, whereas 71 % (SEM 8%) of the pathologies of the simulator cases were found. This minimal difference was not significant in the paired, two sided t-test (p = 0.15). Severe pathologies did not escape detection. The time required for patient examination(10.57 min, SEM 3.25 min) was not significantly different (p = 0.53) to the time required for the simulator cases (9.59 min, SEM 2.98 min). The subjective confidence in the sonographic findings did not differ significantly (p = 0.39) between the real patient situation (68%, SEM 6%) and the simulation (64%, SEM 12 %). Only the handling of the ultrasound machines was judged to be significantly better (p=0.008) than the simulator (74%,SEM 7% vs. 61 %, SEM 12%). CONCLUSION: In this first direct crossover comparison between real patient sonography and simulator based scanning we proved that the simulator we developed simulates the real patient examination reliably and reproducibly.

[Ultrasound of acute abdomen]. / Sonographie des akuten Abdomens.

Ultrasound is an important tool in the diagnosis of acute abdominal pain, which is mainly caused by gastrointestinal diseases. This article gives an overview on the important differential diagnosis related to pain localization. Sonomorphological signs and their sensitivity and specificity are discussed. In contrast to other imaging methods ultrasound is hand guided. The present article differentiates the diagnostic capability of ultrasonic diagnosis depending on technical equipment and sonographer's educational level. These facts are important to stabilize the position of ultrasound in the ensemble of other imaging methods. The use of mobile ultrasound machines and an improved training (e.g. by computer assisted sonosimulator systems) will lead to an increasing importance of ultrasound.

Increasing sensitivity of morphological diagnosis in hepatocellular carcinoma (HCC) by combination of cytological and fine-needle histological examination after ultrasound guided fine needle biopsy.

UNLABELLED: Increasing sensitivity of morphological diagnosis by combination of cytological and fine-needle histological examination after ultrasound guided fine needle biopsy in hepatocellular carcinoma (HCC). AIM: We investigated the factors which may affect the sensitivity of morphological diagnostics (cytology and fine-needle histology) in HCC after ultrasound guided biopsy. METHOD: In 62 patients, an ultrasound guided cytological (n = 62) and fine-needle histological (n = 45) biopsy was performed. In addition, the smears were investigated by cytophotometry (n = 62). RESULTS: Considering each method separately, the sensitivity of both cytological and histological diagnostics was about 80%. The sensitivity could be raised to 89% by combining the two methods. In seven patients, the HCC could not be primarily confirmed morphologically. In nine patients, the result of histological and cytological investigation was not congruent. With regard to the size of the biopsied lesion, tumor stage, cytophotometric finding and survival these 16 patients (group A) were compared with the 46 patients in whom the HCC could be primarily confirmed morphologically (group B). The statistical analysis did reveal a significantly lower percentage of tumors with diploid or tetraploid (euploid) cells in group B. Euploid tumors were significantly more highly differentiated. In patients with euploid tumors, the sensitivity of the cytological investigation was 67% and respectively 75% of the histological investigation. The sensitivity could be raised to 82% in this population by combining the two investigations. On the other hand in aneuploid tumors, the sensitivity could only be increased from 93% and 88% respectively to 97% by combining cytology and fine-needle histology. SUMMARY: Our investigations show that the sensitivity of morphological diagnostics can be raised especially in the highly differentiated HCC with a physiological DNA content by combination of cytological and fine-needle histological investigations.

Acute CMV-colitis in a patient with a history of ulcerative colitis.

A symptomatic cytomegalovirus (CMV) infection usually occurs in patients with debilitating diseases, immunosuppression, transplantations and acquired immunodeficiency syndrome (AIDS). Gastrointestinal infections with CMV, especially colitis, are usually found in immunocompromised patients and rarely affect immunocompetent subjects. Here we report the case of a young female patient with a history of ulcerative colitis (UC) who presented with an acute attack of colitis caused by CMV infection. This was documented by the presence of CMV early antigen, antibodies and evidence of CMV in the colonic mucosa. After combined anti-inflammatory and antiviral treatment the patient recovered completely. As most attention is given to CMV-pathogeneity in immunocompromised patients, here we discuss the relationship to inflammatory bowel diseases.

Acute CMV-Colitis in a Patient with a History of Ulcerative Colitis.

A symptomatic cytomegalovirus (CMV) infection usually occurs in patients with debilitating diseases, immunosuppression, transplantations and acquired immunodeficiency syndrome (AIDS). Gastrointestinal infections with CMV, especially colitis, are usually found in immunocompromised patients and rarely affect immunocompetent subjects. Here we report the case of a young female patient with a history of ulcerative colitis (UC) who presented with an acute attack of colitis caused by CMV infection. This was documented by the presence of CMV early antigen, antibodies and evidence of CMV in the colonic mucosa. After combined anti-inflammatory and antiviral treatment the patient recovered completely. As most attention is given to CMV-pathogeneity in immunocompromised patients, here we discuss the relationship to inflammatory bowel diseases.

[New ultrasound techniques]. / Neue Technologien in der Sonographie.

Modern ultrasound technologies can be divided into methods of visual image improvement/presentation, image quantification, and echo contrast agent applications. Image improvement can be realized by options such as Photopic, tissue harmonic imaging, and panorama methods. Parametric ultrasound quantifies observer-independent image textures. Echo contrast agents offer a better detection of tumor lesions and vascular kinetic investigations.

[Intestinal tuberculosis: Easier overlooked than diagnosed]. / Darmtuberkulose: leichter zu übersehen als zu sichern.

Intestinal tuberculosis: Easier overlooked than diagnosed. The medical history of two Asian immigrants suffering from intestinal tuberculosis demonstrates the difficulties in finding the correct diagnosis. Intestinal tuberculosis resembles Crohn's disease with regard to clinical symptoms, macroscopic and microscopic intestinal findings. Sonographic, radiologic, endoscopic, and histological examinations facilitate distinguishing both entities. Diagnosis of intestinal tuberculosis is made by identification of the causative microorganism in tissue specimens. As this may be difficult and time-consuming, a therapeutic trial with anti-tuberculous agents may be warranted.

[Fulminant course of leptospirosis complicated by multiple organ failure]. / Fulminanter Verlauf einer Leptospirose mit multiplen Organmanifestationen.

We describe a case of a 39-year-old male, who initially presented with severe muscle pain, fever, shortness of breath and tachycardia. He was admitted to hospital with suspected myocarditis. The next days he developed a generalized icterus and acute renal failure. Suspecting leptospirosis an intravenous therapy with penicillin was started. Due to pulmonary and circulatory insufficiency intensive care was necessary. In course the patient developed all known manifestations of leptospirosis including, cardiac arrhythmia and asystolia due to AV-block III degrees, recurrent atelectases of the lungs, hyperbilirubinemia, thrombocytopenia, hepatitis, pancreatitis, very severe rhabdomyolysis and polyradiculitis with areflexia and tetraplegia. Additionally, the patient had a transient hyperthyreosis, which has not been described in the literature so far. After 33 days the patient left the intensive care unit and was discharged out of hospital a fortnight later. 4 weeks later he was able to return to work. The only residuum of this illness is a partial paresis of his right quadriceps muscle.

Surgical removal of a distinct subcutaneous metastasis of multilocular hepatocellular carcinoma 2 months after initial percutaneous ethanol injection therapy.

Subcutaneous tumor seeding after percutaneous ethanol injection therapy (PEI) for hepatocellular carcinoma is a rarely seen complication. It is reported due to needle track seeding during PEI after a distance of 6-46 months. Metastatic tumor spread is described subcutaneously, to the chest wall, abdominal wall and diaphragm. We report the case of a 76-year-old patient with chronic hepatitis B infection and cirrhosis which let to a multilocular hepatocellular carcinoma who underwent PEI. This patient developed 2 months after primary PEI a subcutaneous tumor formation confined to the right lower chest wall. Surgical tumor resection was performed. The histopathological evaluation confirmed subcutaneous seeding of the preknown hepatocellular carcinoma with a maximum of 30 mm in diameter. As a risk of PEI subcutaneous metastasis of the primary tumor should be considered even in early stage of therapy and close follow-up of the patient during treatment is required. Surgical tumor resection to ensure the curative intention of PEI is advisable.

Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis.

BACKGROUND: Prospectively identifying patients whose renal function or blood pressure will improve after the correction of renal-artery stenosis has not been possible. We evaluated whether a high level of resistance to flow in the segmental arteries of both kidneys (indicated by resistance-index values of at least 80) can be used prospectively to select appropriate patients for treatment. METHODS: We evaluated 5950 patients with hypertension for renal-artery stenosis using color Doppler ultrasonography, and we measured the resistance index ([1 - end-diastolic velocity divided by maximal systolic velocity] x 100). Among 138 patients who had unilateral or bilateral renal-artery stenosis of more than 50 percent of the luminal diameter and who underwent renal angioplasty or surgery, the procedure was technically successful in 131 (95 percent). Creatinine clearance and 24-hour ambulatory blood pressure were measured before renal-artery stenosis was corrected; 3, 6, and 12 months after the procedure; and yearly thereafter. The mean (+/-SD) duration of follow-up was 32+/-21 months. RESULTS: Among the 35 patients (27 percent) who had resistance-index values of at least 80 before revascularization, the mean arterial pressure did not decrease by 10 mm Hg or more after revascularization in 34 (97 percent). Renal function declined (defined by a decrease in the creatinine clearance; of at least 10 percent) in 28 (80 percent); 16 (46 percent) became dependent on dialysis and 10 (29 percent) died during follow-up. Among the 96 patients (73 percent) with a resistance-index value of less than 80, the mean arterial pressure decreased by at least 10 percent in all but 6 patients (6 percent) after revascularization; renal function worsened in only 3 (3 percent), all of whom became dependent on dialysis; and 3 (3 percent) died (P<0.001 for the comparison with patients with a resistance-index value of at least 80). CONCLUSIONS: A renal resistance-index value of at least 80 reliably identifies patients with renal-artery stenosis in whom angioplasty or surgery will not improve renal function, blood pressure, or kidney survival.

Comparison of portal venous flow in cirrhotic patients with and without paraumbilical vein patency using duplex-sonography.

AIM: In a prospective study we examined the effect of paraumbilical vein patency on the portal venous blood flow in patients with liver cirrhosis by Duplex-sonography. In this context we investigated the influence of the aetiology and the severity of cirrhosis on the development of venous paraumbilical shunts. METHOD: In 70 patients (Child A: 16; Child B: 27; Child C: 27) with cirrhosis of different aetiologies the portal venous flow velocity, the blood flow volume, and the diameter of the portal vein were examined by Duplex sonography after an overnight fast. RESULTS: 16 patients had a patent paraumbilical vein. The mean portal venous flow velocity (19.2 +/- 7.8 cm/s) and the flow volume (1.29 +/- 0.50 l/min) were significantly higher in patients with paraumbilical vein patency than in patients without paraumbilical shunts (14.4 +/- 4.6 cm/s; p = 0.029 and 0.88 +/- 0.34 l/min; p = 0.007 respectively). The prevalence of shunts of the paraumbilical vein in cirrhotics was significantly lower in category Child A (6.3%) than in Child B (25.9%; p = 0.011) and Child C (33.3%; p = 0.006). CONCLUSION: The occurrence of relatively high portal blood flow velocities in cirrhotics must remind the examiner of the potential existence of spontaneous portosystemic shunts. Those shunts must be carefully looked for with colour-Doppler ultrasound. In order to assess the true parenchymal blood flow we suggest to perform additional measurements of the right portal trunk and the left portal vein distal to the shunt. With an increase in the severity of liver cirrhosis the incidence of paraumbilical vein patency rises.

[Sonographic diagnosis of an unusual recurrence of Chilaiditi syndrome after hemicolectomy]. / Sonographische Diagnose eines ungewöhnlichen Rezidivs des Chilaiditi-Syndroms nach Hemikolektomie.

A 71-year old patient presented with acute abdominal pain, nausea and emesis 3 months after right hemicolectomy for Chilaiditi's syndrome. The initial ultrasound examination revealed a loop of thick walled small intestine between the anterior surface of the right liver lobe and the diaphragm. In addition, small amounts of perihepatic fluid were found. The chest x-ray confirmed a recurrence of Chilaiditi's syndrome with intestinal gas under the right diaphragm. Elongation and flaccid of intestinal and hepatic suspensory ligaments are thought to be the principal predisposing factors. However, in our patient, a wedge-shaped enlarged lobus caudatus served as a guide rail for the bowel and facilitated access to the space under the right diaphragm. Although the patient recovered completely after 3 days of conservative therapy a high risk of recurrence remains. In summary, ultrasound examination can reliably diagnose Chilaiditi's syndrome and should also be used, as the method of choice in the follow-up of this rare syndrome, thus avoiding unnecessary x-ray exposure.