US evaluation of patients affected by IBD: how to do it, methods and findings.

Intestinal US has to be performed very accurately, to obtain an exploration of both small bowel and cholical loops that will be the most complete that is possible; so, this technique requires adequately trained operators. Convex and linear probes with frequency between 3.5 and 7.5 MHz are used: the first ones for the panoramic evaluation and to study the middle-distal sigma and rectum; the second ones to perform a detailed examination of the bowel wall. US allows to evaluate not only the thickness and structure of the bowel wall, but also the content and peristalsis of the loops, their compressibility and movability, the perivisceral spaces and the abdominal organs. In Crohn's disease, US, completed everytime by the color-power-Doppler, shows wall thickening until 20 mm and above, with multi-stratified structure that could be regular, or more and more altered until the hypoechogenic view; the bowel vascularisation could be absent or less or more increased, due to the stadium of the disease itself. Furthermore, US allows to demonstrate the presence of stenosis and various other complications (abscesses inside or outside the walls, fistulas, involvement of other organs, free fluid collections); the use of II generation US contrast media could afford information about the activity of the disease. US has a very important role in the follow-up of patients with diagnosis of Crohn's disease, to monitor the response to the medical therapy and to discover complications; US must be performed as first in subjects with abdominal pain and diarrhea, to select the ones that need more invasive examinations.

Reproducibility of bowel ultrasonography in the evaluation of Crohn's disease.

BACKGROUND: Bowel ultrasonography is increasingly used in the detection and follow-up of patients with Crohn's disease, but a limitation to its further diffusion is the lack of standardisation of ultrasonography parameters. AIMS: This study aimed to standardise the most common bowel ultrasonography parameters in order to develop an unequivocal imaging interpretation and to assess bowel ultrasonography reproducibility. PATIENTS: Twenty patients with Crohn's disease were examined. METHODS: Six ultrasonographers (mean bowel ultrasonography experience=16 years) performed the study. They chose and discussed a common assessment methodology concerning eight ultrasonography parameters: bowel wall thickness, bowel wall pattern, bowel wall blood flow, enlarged mesenteric lymph nodes, mesenteric hypertrophy, abdominal free fluid, and stenosis or fistulae at four preliminary meetings. The day of the study operators were randomised to two rooms where they independently and in turn performed ultrasonography scans. Interobserver agreement was scored by kappa statistics. RESULTS: Excellent k values were observed for bowel wall thickness (0.72-1). k Values were poor for bowel wall pattern (-0.22-0.85) and good for bowel wall blood flow (0.53-0.89). The presence of lymph nodes was reproducible (0.56-0.90) except in one case (0.25). Concordance on free fluid was excellent (0.85-1), whereas that on mesenteric hypertrophy was generally poor (0.14-0.69). Agreement was excellent for stenosis (0.81-1) whereas that for fistula was fair in room abscesses (0.31-0.48) and very good in room B (0.87-1). CONCLUSION: Bowel ultrasonography signs used in Crohn's disease can be standardised as most of them showed a fair to good reproducibility. In particular, bowel wall thickness, the most relevant parameter for Crohn's disease detection, showed an excellent reproducibility.

Automated quality control in computed radiography.

PURPOSE: The purpose of this paper is to describe the automation of quality control procedures on photo-stimulable imaging plates by means of an image-processing tool providing automatic reading of the images and automatic calculation of the quality parameters monitored. MATERIALS AND METHODS: Quality-control procedures were performed according to the main available guidelines. The quality assurance programme was applied to several Kodak and Philips devices in four radiological departments. The automatic image-processing tool was developed using public domain software (Java-based ImageJ software) and contains both reading and computation procedures. RESULTS: The quality checks and algorithms described were successfully applied, proving useful for identification of defective plates and for implementation of the quality assurance programme. The use of automation allowed significant savings in the time required for quality checks. CONCLUSIONS: Completely automated image reading allows substantial economic and human resources savings, as it eliminates much of the transfer, reproduction, processing and filing procedures.

Activity of Crohn disease: value of Color-Power-Doppler and contrast-enhanced ultrasonography.

Diagnosis and follow-up of Crohn disease (CD) often require invasive instrumental examinations, with a high risk of iatrogenic damage. Ultrasound (US) examination of bowel walls could be the first choice in managing patients with CD. We evaluated the role of tissue color power Doppler (CPD) and B-mode US with intravenous injection of contrast medium in the detection of disease activity. In our series, 52 patients with CD underwent US examination. Each study was completed with tissue CPD and US with intravenous injection of contrast medium (Sono Vue) to evaluate intestinal wall vascularization as an index of disease activity. We then compared our results with those from clinical and laboratory tests and follow-up. Data from US examination with intravenous injection of Sono Vue partly agreed with clinical and laboratory tests and CPD in disease activity evaluation but were most useful in the follow-up. Bowel US examination associated with CPD and in particular US contrast medium injection can be used to detect CD activity and modulate therapy and follow-up.

Abdominal pain and bowel dysfunction: diagnostic role of intestinal ultrasound.

BACKGROUND: Abdominal pain and irregular bowel habits are common among young people. Irritable bowel syndrome is frequent in the general population and has important economic and social costs. Inflammatory bowel diseases are chronic processes with an acute or indolent onset in young people. Differential clinical diagnosis between irritable bowel syndrome and inflammatory bowel disease can be difficult since symptoms and signs are often non-specific. OBJECTIVE: To evaluate the role of intestinal ultrasound, a non-invasive, simple and cheap diagnostic tool, in the differentiation between organic and functional bowel diseases. METHODS: Abdominal and intestinal ultrasound examinations were performed on 313 consecutive outpatients presenting with abdominal pain and irregular bowel habits lasting more than 3 months. These patients had no symptoms or signs indicative of organic disorders and no previous diagnosis of organic disease. An intestinal wall thickness of more than 7 mm was considered diagnostic for inflammatory bowel disease. Subsequently, we compared the ultrasound results with diagnoses obtained following the traditional criteria (radiological and endoscopic examinations). RESULTS: Intestinal ultrasound for the diagnosis of inflammatory bowel disease showed 74% sensitivity, 98% specificity, a positive predictive value of 92% and a negative predictive value of 92%. CONCLUSIONS: In our experience, intestinal ultrasound seems important as a first diagnostic tool in young patients without clear symptoms or signs of organic diseases, and can be used as an indication that subsequent invasive tests are required.

[Check of compliance with quality criteria for diagnostic radiographic images in quality control]. / Verifica del rispetto dei livelli diagnostici di riferimento nella radiodiagnostica nell'ambito dei controlli programmati della qualità.

PURPOSE: To devise and implement a programme of measurements to assess the entrance surface dose for a standard-sized patient and to check the compliance with diagnostic reference levels. MATERIAL AND METHODS: Dose evaluation was performed on 40 radiographic instruments. The exposure parameters were collected for the main radiographic procedures (chest, skull, spine, pelvis, abdomen) each performed with instrument on a standard-sized patient. The output of each X-ray tube at 70, 80, 90, 100, 110 and 120 kV was measured with a solid state detector during quality controls. Beam quality and geometric characteristics of the equipment were also determined. The entrance surface dose for a standard patient was assessed for each procedure carried out with the 40 instruments, thus obtaining a total of 155 radiographic techniques. Finally, the method was validated by comparing the values obtained with the solid state and an ionization chamber for X-ray beam detector. RESULTS: The comparison between the solid state detector and the ionisation chamber demonstrated a good agreement. Results show that reference diagnostic levels are respected in most examinations (147/155) even if exposure values do not always comply with those indicated by European guidelines. The measurement programme seems to be applicable in hospital practice where the large number of radiographics instruments and procedures requires the acquisition and processing of a large number of data. CONCLUSIONS: The evaluation of patient dose during quality control is feasible and allows a first check of compliance with reference levels in order to identify which procedures can be optimised by means of more specific measurements and assessments.

[Abdominal pain and bowel dysfunction: diagnostic flow-chart could be simplified?]. / Dolore addominale e alterazione dell'alvo: è possibile semplificare l'iter diagnostico?

BACKGROUND: The aim of the study was to evaluate the diagnostic role of Kruis score and intestinal ultrasound in young patients with abdominal pain and bowel dysfunction. METHODS: Prospective, double blind, case-control study in 297 consecutive patients with Crohn's disease and irritable bowel syndrome (from 1993 to 1995). INCLUSION CRITERIA: abdominal pain, bowel dysfunction without clear symptoms or signs of organic disease. The final diagnosis is obtained with usual diagnostic criteria and confirmed by at least 2 years of follow-up. Intestinal ultrasound is considered diagnostic of Crohn's disease if bowel wall thickness is = or > 7 mm; the Kruis score is diagnostic for irritable bowel syndrome if = or > 44. RESULTS: To diagnose Crohn's disease, intestinal ultrasound and Kruis score respectively showed sensitivity of 84 and 97%, specificity of 98 and 50%, positive predictive value of 91 and 33%, negative predictive value of 96 and 98%, efficacy of 95 and 60%. Both exams suggest the same diagnosis in 55% of patients with a correct diagnosis of 97%. CONCLUSIONS: The intestinal ultrasound and the Kruis score can be a good diagnostic association in young patients with abdominal pain and bowel dysfunction but without clear symptoms or signs of organic disease. If their diagnostic conclusions are the same (55%), they have a low probability of diagnostic error (3%). If they show a different diagnostic hypothesis, other markers of disease, for example ASCA, can be used.

[Abdominal pain and bowel dysfunction: the diagnostic role of ultrasonography]. / Dolore addominale e alterazione dell'alvo. Ruolo diagnostico dell'ecotomografia.

PURPOSE: To evaluate the role of intestinal ultrasound (US) in differentiating organic from functional bowel disease. MATERIAL AND METHODS: We examined with abdominal and intestinal US 313 consecutive outpatients presenting abdominal pain and bowel dysfunction, lasting more than 3 months, with no symptoms or signs of alarm and with no previous diagnosis of organic disease. Our population consisted of 191 women and 122 men, with average age at diagnosis of 36.5 years; 236 of these patients had irritable bowel syndrome, 61 Crohn's disease, and 16 ulcerative colitis. Intestinal wall thickness exceeding 7 mm was considered diagnostic for inflammatory bowel diseases. We compared US findings with the diagnosis made with the conventional diagnostic workup of radiological and endoscopic examinations. RESULTS: Sensitivity of intestinal US for diagnosis of inflammatory bowel diseases was 74% and specificity 98% (respectively 84% and 98% for the diagnosis of Crohn's disease and 38% and 98% for ulcerative colitis), and positive and negative predictive values were both 92%; efficacy was also 92%. The likelihood ratio was 35 if US was positive for inflammatory bowel diseases and 0.26 if bowel wall thickness was less than 7 mm. Diagnostic efficacy was 95% for Crohn's disease and 94% for ulcerative colitis. DISCUSSION: Intestinal US proved to be a valuable tool in diagnosing Crohn's disease. As the first step examination US can show the disease site and suggest further instrumental tests. CONCLUSIONS: In our experience intestinal US is an important diagnostic examination for the approach to young patients without symptoms or signs suggestive of organic diseases and can help avoid invasive instrumental examinations.

Current uses of diagnostic high-frequency US in dermatology.

OBJECTIVE: The diagnosis of most skin diseases, both focal and diffuse, has long relied mainly on physical examination findings. The recent introduction of technologically advanced ultrasound equipment using 20 MHz probes has permitted the specific application of ultrasound to dermatology. Accordingly, we investigated whether the findings at very high frequencies can represent a valid adjunct to clinical assessment in many skin conditions, including neoplasms, inflammatory states and diseases of unknown origin. MATERIALS AND METHODS: Skin lesions are studied using high frequency probes, which very clearly detail the three layers (epidermis, dermis and subcutaneous tissues) forming the normal skin. The choice of the probes frequency should depend mainly on the lesion diameters and site. Electronic 7.5-13 MHz linear probes depict flat and regular surfaces effectively and provide a wider field of surface vision and, therefore, a wider view than sectorial probes. Water bath sectorial mechanical probes with 10-20 MHz frequency have very superficial focusing and are excellent to study irregular surfaces. RESULTS: High frequency ultrasound can be usefully correlated with clinical tests to study focal skin lesions. The diagnosis of most benign skin cancers is usually made on clinical bases. Ultrasound examinations are performed preoperatively in questionable cases. Malignant neoplasms appear at ultrasound as hypoechoic focal lesions, generally with no specific features in relation to the histologic type; nevertheless, preoperative ultrasound may play an important role in that it measures the thickness of cutaneous melanoma, which is a very important prognostic factor. In particular, 20 MHz probes permit to assess the depth of melanoma invasion. The sonographic evaluation of melanoma thickness is usually in agreement with histologic findings. 'Satellite' neoplastic lesions growing near the main tumor can also be revealed. Color and power Doppler studies may be combined with gray-scale imaging: the identification of abnormal intra- or peritumoral low-resistance pulsatile flow signals suggests the malignant nature of the cutaneous lesion. High frequency ultrasound can also be used to study diffuse cutaneous conditions. Among them, ultrasound can provide a valid morphologic representation of psoriatic skin lesions and it is also a noninvasive and accurate method for evaluating the therapeutic efficacy of antipsoriatic drugs. In scleroderma, sonographic findings vary depending on disease activity and the patterns vary; therefore, 20 MHz probes may also prove useful over the other instrumental tools to monitor the disease course and treatment efficacy in focal scleroderma. Other potential applications include allergic dermatitis, nodular erythema, dermatomyosis, sarcoidosis, lymphedema of the limbs and allergologic conditions. Ultrasound can also be used in monitoring the response to or complications of topic drugs administration, and in the follow-up of focal burns. CONCLUSION: High frequency ultrasound can provide a reliable morphologic representation of skin lesions but it is also an accurate noninvasive tool for monitoring the therapeutic efficacy of drugs administration in focal or diffuse diseases. The application of high frequency studies to dermatology is very challenging. Indeed, the very high frequency probes up to 20 MHz currently available are particularly useful for reliable studies. Contrast-enhanced color and power doppler are very promising techniques. Advancements in technology will improve the correlation of clinical with high frequency ultrasound findings in the assessment of several skin diseases.

Long-term treatment with cabergoline, a new long-lasting ergoline derivate, in idiopathic or tumorous hyperprolactinaemia and outcome of drug-induced pregnancy.

Cabergoline (CAB), a new long-acting ergoline derivative, was shown to be very effective in reducing PRL levels in normal volunteers and in hyperprolactinemic patients. We evaluated the hormonal changes after discontinuation of long-term therapy with CAB as well as the safety of drug exposure during pregnancy both for mothers and babies. We therefore studied 48 patients (47 females and one male) with pathological hyperprolactinaemia (mean +/- SE, 117.2 +/- 15.2: median 73.2 micrograms/l), treated for 1-82 months (mean +/- SE, 28.3 +/- 3; median 18). After long-term treatment, CAB was withdrawn in 11 patients and PRL levels were persistently normal for almost 15 days and significantly lower (p < 0.05) than basal at 30, 45, 60, 90, 120 days. Three patients had normal PRL levels still at 45 days after treatment discontinuation. Nine patients became pregnant after 1-37 months (mean 12.4) of therapy. In two patients the pregnancy was interrupted spontaneously in one case and voluntarily in the other. In all but one patients after delivery or three-month breast feeding, PRL levels trended towards reduction. In two cases (one with microadenoma and one with idiopathic hyperprolactinaemia) PRL remained in the normal levels for 1-3 years after delivery. In conclusion CAB is able to inhibit plasma PRL levels for long time (up to 120 days) after withdrawal in patients with pathological hyperprolactinaemia treated with long-term therapy.

[Echographic diagnosis of a large, asymptomatic, perirenal hematoma caused by a bleeding angiomyolipoma in tuberous sclerosis]. / Diagnosi ecografica di voluminoso ematoma perirenale asintomatico da sanguinamento di angiomiolipoma in sclerosi tuberosa.

The authors describe a case of 21-year-old man suffering from tuberous sclerosis, more than once operated for subependymal astrocytomas, presenting multiple bilateral renal angiomyolipomas of 1.5 cm as greatest diameter. Last abdominal ultrasonographic exam, done a few years after the former, revealed an angiomyolipoma measuring 10 cm in diameter at the upper pole of the right kidney. This angiomyolipoma projected into a large haematoma of 15 cm in diameter, absolutely asymptomatic. After CT control bone lesions were removed. This case shows the progressive increase in number and size of renal angiomyolipomas, with subsequent haemorrhagic complications, suggesting as opportune periodic ultrasonographic controls.

Ultrasonography in the detection of Crohn's disease and in the differential diagnosis of inflammatory bowel disease.

The diagnostic accuracy of abdominal ultrasonography in inflammatory bowel disease (IBD) has been evaluated in a prospective, randomized, blind study. A total of 181 patients (89 with Crohn's disease, 57 ulcerative colitis and 35 controls) were examined. Sensitivity and specificity of diagnosis in Crohn's disease, corrected for prevalence, were 80.8 and 79.2%, respectively, and a very similar accuracy was found in the differential diagnosis of IBD. In conclusion, ultrasonography can play a role in detecting Crohn's disease and in the differential diagnosis of chronic IBD.

[First experiences with trans-rectal echotomography in perianal abscess pathology]. / Prime esperienze di ecotomografia trans-rettale nella patologia ascessuale perianale.

Trans-rectal ultrasound with a 5 MHz probe was used to examine 16 patients who had perianal fistulas and 5 of them underwent one or more surgical explorations. In 11 cases, all surgically checked, sonography was able to demonstrate a pararectal abscess and accurately image the site, size, extension and--in some cases--the fistula itself. It can be advised that, using high frequency probes (7 or 10 MHz), transrectal ultrasound could provide even more exact diagnostic information in anorectal pathology.