Doppler sonography of hemodynamic changes of the inferior mesenteric artery in inflammatory bowel disease: preliminary data.

OBJECTIVE: To our knowledge, Doppler data for the inferior mesenteric artery are currently restricted to healthy patients. The present study was conducted to evaluate changes in inferior mesenteric artery flow in patients with inflammatory bowel disease. SUBJECTS AND METHODS: Doppler sonography of the inferior mesenteric artery was prospectively performed in 24 patients with Crohn's disease (active, n = 15; inactive, n = 9), in 22 patients with ulcerative colitis (active, n = 14; inactive, n = 8), and in 40 healthy controls. Disease activity was determined with clinical and laboratory indicators (medical history, physical examination, laboratory data, and endoscopy with histology). Flow velocity, pulsatility index, and estimated flow volume were measured in all patients and compared with the corresponding values for control subjects. Hemodynamic parameters were then correlated with location of disease (small bowel and right and proximal transverse colon versus distal transverse and left colon) and disease activity or inactivity. RESULTS: Among patients with active disease, inferior mesenteric artery flow was significantly greater in those with left colon involvement (group 1, 20 patients) than in patients with involvement of the small bowel or right colon (group 2, nine patients) and in control subjects. Median flow values for group 1 were peak systolic velocity, 1.96+/-0.57 m/sec; mean velocity, 0.63+/-0.25 m/sec; minimum velocity, 0.17+/-0.20 m/sec; pulsatility index, 3.07+/-1.24; and estimated flow volume, 0.40+/-0.17 l/min. Median flow values for group 2 were peak systolic velocity, 1.27+/-0.56 m/sec; mean velocity, 0.29+/-0.14 m/sec; minimum velocity, 0.06+/-0.10 m/sec; pulsatility index, 4.71+/-0.98; and estimated flow volume, 0.14+/-0.11 l/min. Median flow values for control subjects were peak systolic velocity, 1.41+/-0.48 m/sec; mean velocity, 0.43+/-0.19 m/sec; minimum velocity, 0.10+/-0.16 m/sec; pulsatility index, 3.49+/-0.49; and estimated flow volume, 0.13+/-0.06 l/min. Compared with control subjects, patients with acute disease involving the left colon (group 1) presented increases in flow velocity (systolic velocity, p < .001; minimum velocity, p = .01; mean velocity, p < .001) and estimated flow volume (p < .001) and a decreased pulsatility index (p = .01). A significant increase in inferior mesenteric artery flow was also found when group 1 patients were compared with those of group 2 (active disease affecting the small bowel and right colon) and group 3 (13 patients with quiescent disease of the left colon). CONCLUSION: In this preliminary study, active inflammation of the left colon in patients with Crohn's disease or with ulcerative colitis was associated with a substantial increase in inferior mesenteric artery flow that could be seen on Doppler sonography.

[Ultrasonography, with Doppler color, and cytologic correlations in Plummer's disease]. / Correlazioni ecografiche, con color-Doppler e citologiche della malattia di Plummer.

PURPOSE: We carried out a retrospective study to assess the different B-mode and color Doppler features of Plummer's disease and to compare them with cytologic findings. MATERIAL AND METHODS: One hundred and eighty autonomous nodules were studied with B-mode US. Mean patient age was 55 years for women and 56 years for men. Twenty-seven patients were also submitted to color Doppler US. Forty-nine autonomous nodules were also submitted to cytologic examination by fine needle aspiration (FNA). RESULTS: The most frequent US pattern was a hypoechoic solid nodular lesion (59.8%), while 45.6% of the nodules exhibited a mixed US pattern. No mixed areas were found in 100% of the nodules in the patients under 20 and over 60. In contrast, various degrees of mixed areas were found in the patients 20-59 years old, with the highest rate (24.9%) in the 40-49 age range and the lowest rate (6.2%) in the 20-29 age range. The mixed areas were most frequently correlated with bigger nodules and the toxic phase. Calcifications were found in 4.3% of the partially autonomous nodules in 4.1% of the pretoxic nodules and in 8.6% of the toxic nodules. Color Doppler US showed rich internal and peripheral vascularization (pattern A) in 74.1% of the nodules and a mostly perilesional flow (pattern B) in 25.9% of the cases. Pattern A prevailed in the toxic phase (75%), while pattern B in the partially autonomous nodules (85.7%). Simple hyperplasia was the most frequent (63.3%) cytologic feature in the solid nodular lesions, while bleeding (10.2%) was typical of the mixed anechoic nodular lesions. Cytologically undifferentiated lesions were found in the toxic phase of Plummer's disease (50%). DISCUSSION: Solid lesions in Plummer's disease are characterized by hyperplasia, while the diagnosis of hemorrhagic pseudocyst is typical of mixed lesions. CONCLUSIONS: Color Doppler US provides data on the functional phase of Plummer's disease and is a very useful tool to monitor medical treatment results; moreover, it permits to characterize the lesions with the richest vascularization, avoiding inadequate cytologic sampling.

A new method for evaluating small intestinal motility using duplex Doppler sonography.

OBJECTIVE: Many techniques currently used to study motility of the small intestine are too complex for large-scale use; other techniques provide information that is nonspecific and nonquantitative. The aim of the present study was to verify whether intestinal peristalsis can be seen and quantitatively assessed by means of duplex Doppler sonography. SUBJECTS AND METHODS: We prospectively studied 152 normal fasting subjects using sonography, duplex Doppler sonography, and stethoscopic auscultation or phonocardiographic registration of bowel sounds in three abdominal sites. In each subject, we positioned the sample volume near the intestinal wall and then recorded Doppler signals of different amplitude and duration that related to bowel motility. Studies were repeated after ingestion of water (n = 55) and after a standard test meal (n = 73). The number of peristaltic waves and the number of bowel sounds revealed by the different imaging techniques were compared and statistically evaluated by Student's t test. RESULTS: Intestinal movements were classified as peristaltic or nonperistaltic (mixing movements) based on amplitude and duration of Doppler signals. The mean number of peristaltic waves revealed by Doppler sonography was three per minute in fasting subjects, with no significant increase after ingestion of water (3.78 per min) or the test meal (3.92 per min). The mean number of bowel sounds obtained with auscultation and phonocardiographic recordings was significantly higher in fasting subjects (8.7 per min) and after ingestion of water (9.55 per min) or the test meal (12 per min). CONCLUSION: Intestinal contractions produce Doppler signals of different amplitudes and duration, thus potentially allowing differentiation between peristaltic and nonperistaltic movements. This differentiation is not possible with auscultation or phonocardiographic registration because similar bowel sounds are produced by nonprogressive, mixing movements as well as by true peristaltic movements. Duplex Doppler sonography allows graphic visualization of intestinal movements that can be subjected to qualitative and quantitative analysis and may be suitable for the noninvasive study of small-bowel motility.

[Unusual case of acute suppurative thyroiditis]. / Raro caso di tiroidite acuta suppurativa.

Acute suppurative thyroiditis is an acute disease of the thyroid gland. In this paper the authors report a case of acute suppurative thyroiditis complicated by abscessual evolution in an addict patient study with ultra-sonography and treated with fine needle aspiration and antibiotic therapy. The patient reached our observation for a swelling of the neck. Ultrasonography showed diffuse hypoechogenicity in both thyroid lobes and mixed nodule with hyperechoic trabeculas inside. This nodule underwent fine needle aspiration (FNA) for cytologic and cultural evaluation. Diagnosis was acute suppurative thyroiditis. Ultrasonography presented features similar to other thyroid pathology (sub-acute thyroiditis, haemorrhagic cyst, thyroid lymphoma and anaplastic carcinoma). In our case none of the ultrasonographic features were diagnostic except hyperechoic trabeculas inside. Ultrasonographic features of acute suppurative thyroiditis are very rare in the literature. Ultrasonography and fine needle aspiration are the only methods that confirm this diagnosis.

[Early and systematic use of ultrasonography in emergency patients with renal colic: analysis of the actual diagnostic efficacy]. / Impiego precoce e sistematico dell'ecografia nei pazienti ricoverati d'urgenza per colica renale: analisi della reale efficacia diagnostica.

In this study, the diagnostic yield of ultrasonography (US) in the early phase of acute urinary obstruction was retrospectively assessed and compared with that of clinical examination. 351 patients were admitted to our emergency department because of suspected renal colic over an 11 months' period: urinary obstruction was subsequently confirmed with other examinations in 76 of them, who were all submitted to renal US within 2 hours of the onset of symptoms. Emergency US results were then retrospectively compared with clinical and laboratory data and the cost of each US exam was calculated. Thirty-nine of 76 patients had negative US findings (51.3%). In the extant 37 patients, US showed hydronephrosis (which was mild in 13 patients and moderate in 6) and renal stones (in 18 patients). Hydronephrosis was associated with renal stones or increased parenchymal echogenicity in 5 and 6 patients, respectively. Pain, which was always severe, was not a useful sign for diagnostic purposes. In contrast, all the 37 patients with abnormal US findings (hydronephrosis, renal stones and increased parenchymal echogenicity) exhibited specific clinical and laboratory abnormalities such as hematuria, ketonuria and marked blood pressure increase (diastolic pressure > 100 mmHg). The same abnormalities, although less severe (mild hematuria and ketonuria and increased diastolic pressure not exceeding 100 mmHg) were nevertheless present in all the 39 patients with negative US findings and yet having a renal colic. The cost of each emergency US exam (calculated on the basis of literature tables and reference cost) was approximately It. L. 104,000. The corresponding total cost for submitting to US all the 76 patients with renal colic was approximately It. L. 7,900,000. In the early phase of urinary obstruction, the association of hematuria, ketonuria and increased blood pressure was more reliable than US findings-the latter method yielding a 51.3% false-negative rate. The presence and severity of the above clinical and laboratory abnormalities might thus represent a criterion to select the patients who are less likely to have positive US findings. This should allow the cost of medical and non-medical staff, equipment and materials to be reduced. As for our personal series, It. L. 28,000,000 was the estimated additional cost of performing US routinely in all the remaining (275) patients with suspected renal colic.

[Clinico-ultrasonographic assessment of the thyroid volume and function in chronic enteritis and colitis: preliminary data]. / Valutazione clinico-ecografica del volume e della funzione tiroidea nelle enteriti e coliti croniche: dati preliminari.

Inflammatory bowel diseases (IBD) such as Crohn's disease (CD) and ulcerative colitis (UC) have frequent extraintestinal (hepatobiliary, cutaneous, ocular, articular, urinary) complications. On the contrary, no data are available about possible thyroid involvement. We studied thyroid morphology and function in 39 patients affected with active IBD (13 UC; 26 CD) before (all) and 45 and 90 days after onset of therapy (21/39), and in 55 normal control subjects. Every time, the following exams were performed: thyroid US (parenchymal assessment, thyroid volume calculation), hormone and immunologic assays (T3, T4, FT3, FT4, TSH; antithyroglobulin and antithyroid microsomal/peroxidase antibodies). A statistically significant increase in thyroid volume was found in IBD (mean: 22.1 ml) compared to control subjects (mean: 15.6 ml), more frequently in CD (18/26 patients; 69.2%) than in UC (2/13 patients; 15.4%). Parenchymal structure was inhomogeneous in the two groups of patients (88.4% CD; 15.4% UC) more frequently than in control subjects (12.7%). Hormone assays demonstrated increased FT4 values in UC (9/13 patients; 69.2%) and decreased T4 values in CD (14/26 patients; 53.8%). IBD patients increased frequency of antithyroglobulin and antithyroid microsomal/peroxidase antibodies. Such abnormalities subsided only partially after therapy. Our data suggest that in IBD there is a frequent thyroid involvement with morphological, hormone, and immunologic abnormalities.

Abdominal lymphadenopathy in benign diseases: sonographic detection and clinical significance.

We prospectively evaluated the frequency of lymphadenopathy in the right upper abdominal quadrant as detected by sonography in 650 consecutive unselected patients, after excluding patients with a known lymphoma or abdominal carcinoma and patients with acquired immunodeficiency disease. Evidence of enlarged lymph nodes (few in number, with an elongated shape and isoechoic to the liver, 8 to 22 mm in size), found primarily in the gastrohepatic ligament and porta hepatis, was seen on sonographic scans in 106 patients (16.3%). Associated conditions in 69 of 106 patients (65%) were hepatobiliary or pancreatic diseases and, less frequently, other benign entities (12 patients; 11.3%); in 25 cases (23.5%) no significant abdominal or systemic disease was present. Comparison with CT or surgical findings, or both, was available in 36 cases. We conclude that lymphadenopathy in the right upper abdominal quadrant may be found in relation to different non-neoplastic conditions as well as in the absence of any significant intra-abdominal disease. The frequency of this finding on sonographic scans must be recognized to prevent misdiagnosis of lymphoma or metastatic disease as well as to avoid overstaging of local (hepatobiliary, pancreatic, gastric) neoplasms.

Sonographic estimation of fetal liver weight: an additional biometric parameter for assessment of fetal growth.

A single fetal ultrasonogram was obtained between the 20th and 40th weeks of gestation in 327 pregnancies. Fetal body weight was calculated with standard methods and fetuses were classified as appropriate for gestational age (303 fetuses), large for gestational age (four fetuses), or small for gestational age (20 fetuses). Fetal liver weight was estimated on the basis of longitudinal, anteroposterior, and cephalocaudal liver dimensions multiplied by a constant (k) of 0.42 determined experimentally in a previous study of adult livers. Estimated liver weights in appropriate for gestational age fetuses were not statistically different from published standards based on autopsy findings (P < 0.005). Similar findings were obtained in two other normal pregnancies examined serially until delivery. Estimation of fetal liver weight appears to be an accurate and reproducible method and may enhance sonographic assessment of fetal growth abnormalities and conditions with fetal liver involvement.

[Experimental use of duplex Doppler ultrasonography in the evaluation of intestinal motility in occlusive syndromes]. / Impiego sperimentale del duplex Doppler nella valutazione della motilità intestinale nelle sindromi occlusive.

Intestinal motility is currently evaluated by means of clinical, radiologic and electromanometric methods. Of late, US has allowed to visualize the intestinal loops and their movements directly assessing wall patterns and endoluminal contents, as well as the degree of distension of the ileal loops; its diagnostic value is in fact well established in the study of such specific diseases of the GI tract as inflammatory conditions and neoplasms. On the contrary, the use of duplex-Doppler US to investigate bowel motility is quite new. We used duplex-Doppler US to evaluate intestinal peristalsis in 37 patients presenting with acute abdominal pain (15 patients with early mechanical obstruction; 13 patients with long-standing mechanical obstruction; 9 patients with paralytic ileus). In 29 patients the diagnosis was surgically confirmed; in 8 patients the diagnosis was established by means of other diagnostic techniques. The duplex-Doppler recordings showed typical patterns characterized by different degrees of signal intensity and frequency according to the type of obstruction (mechanical or paralytic ileus), to its duration (acute or long-standing), and to the site of Doppler sampling (proximal to or in the obstacle). As regards the correct identification of the cause of the obstruction, duplex-Doppler sensitivity and specificity were 85% and 100%, respectively. The positive predictive value was high (100%) whereas the negative predictive value was low (37.5%). Duplex-Doppler evaluation provides both qualitative and quantitative data about intestinal peristalsis, allowing true peristaltic movements to be discriminated from simple mixing movements of the bowel. The possibility to identify intestinal segments with different degrees of peristaltic activity seems very useful to detect the site of the obstacle in mechanical obstruction.

Duplex-Doppler evaluation of intestinal peristalsis in patients with bowel obstruction.

Duplex-Doppler was used to visualize intestinal peristalsis in 30 patients with intestinal distension. The series included 12 patients with acute mechanical obstruction, 13 with long-standing mechanical obstruction, and five with paralytic ileus. The Duplex-Doppler recordings showed several patterns characterized by different degrees of intensity and frequency of the signals according to the type of obstruction, its duration, and the site of Doppler sampling relative to the obstructed segment. Duplex-Doppler evaluation provided both qualitative and quantitative data about intestinal peristalsis, allowing differentiation between mechanical and paralytic ileus. The visualization of intestinal segments having different degrees of peristaltic activity proved useful in localizing the site of mechanical obstruction.

[Role of ultrasonography-guided fine-needle biopsy in the selection for surgical treatment in thyroid diseases. Multicenter retrospective study of 5,109 patients]. / Analisi del ruolo della citologia agoaspirativa ecoguidata quale criterio di selezione nella terapia chirurgica delle malattie tiroidee. Studio retrospettivo multicentrico su 5109 pazienti.

FNAB cytology is a very specific diagnostic tool for distinguishing benign from malignant lesions. It allows the histologic type to be diagnosed too. FNAB findings also help select the type of surgery. The value of FNAB cytology was investigated in 5,109 patients examined from 1987 through March 1993. 607 patients has surgical confirmation. 444 patients underwent cytology before surgery, while 163 patients were not submitted to FNAB. Histology diagnosed 116 malignant tumors (19.2%): 83 of them were papillary carcinomas (71.5%), 26 follicular carcinomas (2.6%), 1 primary thyroid lymphoma (0.9%) and 3 medullary carcinoma (2.6%). Seventy-nine of 116 cases had been diagnosed by FNAB cytology, while 37 of 116 were diagnosed at surgery. Aspiration biopsy under US guidance reduced the rate of thyroidectomies from 19.2% to 8.5% because true-positive cases were assessed before surgery. FNAB cytology should be used as a preliminary diagnostic tool, thanks to its high accuracy and to its capabilities of distinguishing benign from malignant lesions for proper medical or surgical treatment. Moreover, FNAB cytology allows potentially malignant lesions to be surgically explored.

[The role of ultrasonography in thyroid disease]. / Il ruolo dell'ecografia nella patologia tiroidea.

Ultrasound examination of the thyroid gland is widely used in the diagnosis of thyroid disease. This test is easy and rapid to perform, widely available and the results are readily interpreted. Using ultrasound the image of foci of disease within the gland are easily identified, especially using high frequency probes which enable solid nodules up to approx 3 mm to be revealed with 10 MHz probes. In non-nodular thyroid disease the ultrasonic structure guides the diagnosis (thyroiditis, Graves' disease). During the follow-up of thyroidectomised patients ultrasound can easily reveal postoperative anatomic variations and an early diagnosis can be obtained of any signs of local recurrence of the primary disease. Only hemiagenesia and hypoplasia can be accurately evaluated in congenital disease, whereas in the event of the persistence of the thyroglossal duct the latter can only be diagnosed if it presents a cystic evolution. Thyroid ectopia cannot be identified and must be studied using thyroscintigraphy, preferably performed using 131I as the isotope. The acquired pathology is classified into phlogistic processes, diffuse or nodular hyperplasia, benign and malignant neoplasia. This classification is widely accepted by virtually all authors. In thyroiditis, ultrasound may facilitate the diagnosis of De Quervain's non-suppurative sub-acute thyroiditis (TANS) and Hashimoto's chronic thyroiditis, although always in association with clinical and laboratory tests. The most frequent thyroid pathology is without doubt goitre. This disorder may occur in a non-nodular (widespread goitre with an endemic or sporadic pattern) or nodular form which may be single or multiple. The term goitre is used to indicate the increased volume of the thyroid gland independently of the causes which have provoked it. Common goitre is defined as being endemic when in some geographic area 10% of the general population or 20% of the school-aged population suffers from thyroid hyperplasia (areas of goitrogenic endemic disease). Graves' disease may be included in the group of thyroid hyperplasia diseases, although it is distinguished from the simple versions by the marked glandular hyperactivity which creates manifest hyperthyroidism. In this pathology ultrasonography must be supplemented by colour-Doppler wherever possible. Thyroid nodules are subdivided in terms of their echostructure into 5 types: liquid, mixed (prevalently solid or prevalently liquid), hyperechogenic solid, isoechogenic solid and hypoechogenic solid. The characteristics of benign nodules are: hypoechogenic structure, regular edges, complete and uniform hypoechogenic peripheral halo.(ABSTRACT TRUNCATED AT 400 WORDS)

Eco-Doppler evaluation of intestinal peristalsis in normal and in some pathological conditions: preliminary data.

Duplex-Doppler sonography could be employed in the quantitative investigation of intestinal motility. Preliminary data indicate reproductivity of the method in normal subjects and possible clinical applications in some pathological conditions affecting intestinal transit. Particularly, the possibility to discriminate between segments at different peristaltic activity seems to be very useful in intestinal obstruction. Further studies are necessary to validate this method.

Extracorporeal shock-wave lithotripsy of biliary stones.

Extracorporeal shock-wave lithotripsy (ESWL) is the newest, the most rapid and most promising nonsurgical treatment for symptomatic patients with radiolucent (cholesterol) gallstones in a well opacified (functioning) gallbladder. About 10% of patients with gallstones fulfill the requirements to be selected for ESWL. Results indicate 78% of stone free patients at 12 months and 93% at 24 months, regardless of the size and number of treated stones. The cost-benefit trade-offs of ESWL versus conventional surgical treatment is still a matter of debate.