Comments and illustrations of the WFUMB CEUS liver guidelines: Rare benign focal liver lesion, part I.

Improved detection and characterization of common focal liver lesions (FLL) are the main topics of the World Federation for Ultrasound in Medicine and Biology (WFUMB) guidelines on the use of contrast-enhanced ultrasound (CEUS). On stateof-the-art CEUS imaging, to create a library of rare FLL, especially concerning their atypical imaging characteristics, might be helpful for improving clinical diagnostic efficiency. In this review, we aim to summarize the ultrasound and CEUS features of rare benign FLL. Currently there are limited reports and images published.

Comments and illustrations of the WFUMB CEUS liver guidelines: Rare benign focal liver lesion, part II.

It is important to be familiar with the typical imaging features of the uncommon or even extremely rare focal liver lesions (FLL). Current guidelines of the World Federation for Ultrasound in Medicine and Biology (WFUMB) is aimed at assessing the usefulness of contrast enhanced ultrasound (CEUS) in the management of various FLL. In this review, we aim to summarize the ultrasound and CEUS characteristics with literature review of some extremely rare benign FLL, which might be helpful for improving diagnostic efficiency clinically.

Comments and illustrations of the WFUMB CEUS liver guidelines: Rare focal liver lesions - non-infectious, non-neoplastic.

In this series of papers on comments and illustrations of the World Federation for Medicine and Biology (WFUMB) guidelines on contrast enhanced ultrasound (CEUS) the topics of non-infectious and non-neoplastic focal liver lesions (FLL) are discussed. Improved detection and characterization of common FLL are the main topics of these guidelines but detailed and illustrating information is missing. The focus in this paper is on non-infectious and non-neoplastic FLL and their appearance on B-mode, Doppler ultrasound and CEUS features. Knowledge of these data should help to raise awareness of these rarer findings, to think of these clinical pictures in the corresponding clinical situation, to interpret the ultrasound images correctly and thus to initiate the appropriate diagnostic and therapeutic steps in time.

Comments and illustrations of the WFUMB CEUS liver guidelines: Rare focal liver lesion - infectious parasitic, fungus.

In this series of papers on comments and illustrations of the World Federation for Medicine and Biology (WFUMB) guidelines on contrast enhanced ultrasound (CEUS) the topics of parasitic and fungus infections are discussed. Improved detection and characterization of common focal liver lesions (FLL) are the main topics of these guidelines but detailed and illustrating information is missing. The focus in this paper on infectious (parasitic and fungus) focal liver lesions is on their appearance on B-mode and Doppler ultrasound and CEUS features. Knowledge of these data should help to raise awareness of these rarer findings, to think of these clinical pictures in the corresponding clinical situation, to interpret the ultrasound images correctly and thus to initiate the appropriate diagnostic and therapeutic steps in time.

Normative values of the internal genital organs of the female pelvis in transvaginal and transabdominal ultrasound.

AIM: To conduct a systemic review of published data on reference values for both transabdominal and transvaginal ultrasound in gynecology. MATERIALS AND METHODS: Literature from 1970 to 2020 of reference values for the female pelvis in healthy subjects was reviewed. According to the determination of reference intervals for laboratory values reference values are generally determined using 95%-reference intervals and their associated 90%-confidence intervals. The list of articles was supplemented with extensive crosschecking of the reference lists of all retrieved articles. RESULTS: A total of 33 studies were included and analyzed. The diagnostic performance of transvaginal ultrasound (TVUS) has a higher sensitivity and specificity than transabdominal ultrasound (TAUS) for high quality imaging of the uterus and the bilateral adnexa. The length of normal uterus is about 50-80 mm in fertile age. There is no consensus about the cut off value of the thickness of the endometrium in asymptomatic postmenopausal women, while a measurement of >5 mm and postmenopausal bleeding is suspect and requires further examination. The distribution of normal ovarian volumes is narrow with small volumes in postmenopausal women. CONCLUSION: Normal values are helpful in delimiting the pathological changes in the female pelvis. While sonomorphologic criteria are more important than the ovarian size for the assessment of ovarian masses and reference values of the uterus in adults have little impact on routine practice, normative values in pediatric patients are important for the detection of pathologies. Normative values of the internal genital organs in females are sufficiently validated; still further research is required to assess the role of normative values in routine clinical practice and in sonographic screening for endometrial and ovarian cancer.

Classification of acute appendicitis (CAA): treatment directed new classification based on imaging (ultrasound, computed tomography) and pathology.

PURPOSE: Acute appendicitis (AA) is amongst the most common causes of acute abdominal pain. In spite of progress based on risk stratifications, "negative" appendectomies are performed in up to 30% of patients whilst the appendix perforates in others. Preoperative classification of AA based on imaging is therefore recommended. The aim was to classify AA based on imaging (ultrasound/US, computed tomography/CT), surgical pathology, and/or histopathology in order to differentiate between complicated and uncomplicated AA. A new classification of acute appendicitis (CAA) shall be illustrated by typical US and CT images and be employed in a diagnostic and therapeutic algorithm. METHODS: Medline, Embase, and the Cochrane Library were searched. Any study after 1970, which investigated clinical scores, pathology, US, CT, magnetic resonance imaging, and treatment of AA, was included. Typical images were taken from the author's image database. RESULTS: Five main types of AA are defined, normal appendix (type 0), nonvisualised appendix (type X), uncomplicated AA (type 1), complicated AA without perforation (type 2), and complicated AA with perforation (type 3). The imaging modality is indicated by an additional letter, e.g., type p3b for free perforation on pathology. Standardised reporting of the appendix evaluation by US and CT is presented, as well as algorithms for AA management. Imaging features indicating imminent perforation, as well as likely recurrence, were both classified as complicated AA. CONCLUSION: Imaging is mandatory in suspected AA. The CAA clearly separates uncomplicated from complicated forms of AA allowing nonoperative management in selected patients with uncomplicated forms of AA.

Does lymph node morphology using ultrasound reflect aetiology? A pictorial essay, part I.

The evaluation of lymph nodes (LNs) using ultrasound requires a high level of clinical and sonographic competence. This "pictorial essay" is intended to illustrate eye-catching examples of relevant "clinical-sonographic visual diagnoses" of LNs. We provide typical images and take-home messages of eye-catching features to illustrate the featured publications.The first part includes "important differential diagnoses of eye-catching features of suspected lymphadenopathy" and "benign lymphadenopathy". The second part will include "Eye-catching features of malignant lymphadenopathy, both carcinoma and lymphoma".

Does lymph node morphology using ultrasound reflect aetiology? A pictorial essay, part II, malignant lymphadenopathy.

The evaluation of lymph nodes (LN) using ultrasound requires a high level of clinical and sonographic competence. This "pictorial essay" is intended to illustrate eye-catching examples of relevant "clinical-sonographic visual diagnoses" of LNs. We provide typical images and take home messages of eye-catching features to illustrate the featured publications.The first part included the introduction into the subject, indications for US examination and the widely accepted recognized features for LN characterization. The key features for the differential diagnosis of suspected lymphadenopathy and benign lymphadenopathy are illustrated. In the second part eye-catching features of malignant lymphadenopathy and the differential diagnosis of carcinoma and lymphoma are shown.

Gastrointestinal Ultrasound (GIUS) in Intestinal Emergencies - An EFSUMB Position Paper.

An interdisciplinary group of European experts summarizes the value of gastrointestinal ultrasound (GIUS) in the management of three time-critical causes of acute abdomen: bowel obstruction, gastrointestinal perforation and acute ischemic bowel disease. Based on an extensive literature review, statements for a targeted diagnostic strategy in these intestinal emergencies are presented. GIUS is best established in case of small bowel obstruction. Metanalyses and prospective studies showed a sensitivity and specificity comparable to that of computed tomography (CT) and superior to plain X-ray. GIUS may save time and radiation exposure and has the advantage of displaying bowel function directly. Gastrointestinal perforation is more challenging for less experienced investigators. Although GIUS in experienced hands has a relatively high sensitivity to establish a correct diagnosis, CT is the most sensitive method in this situation. The spectrum of intestinal ischemia ranges from self-limited ischemic colitis to fatal intestinal infarction. In acute arterial mesenteric ischemia, GIUS may provide information, but prompt CT angiography is the gold standard. On the other end of the spectrum, ischemic colitis shows typical ultrasound features that allow correct diagnosis. GIUS here has a diagnostic performance similar to CT and helps to differentiate mild from severe ischemic colitis.

EFSUMB Gastrointestinal Ultrasound (GIUS) Task Force Group: Celiac sprue and other rare gastrointestinal diseases ultrasound features.

Transabdominal gastrointestinal ultrasound (GIUS) is unique in its capacity to examine the bowel non-invasively and in its physiological condition, including extra-intestinal features such as the splanchnic vessels, mesentery, omentum and lymph nodes- even at the bedside. Despite this, and its extensive documentation for its usefulness, it has only been fully implemented in a few European countries and expert centres. Therefore, the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) established a GIUS Task Force Group in 2014 consisting of international experts from 9 European countries with the objectives to standardize and promote the use of GIUS in a clinical setting. This is achieved by publishing clinical guidelines and recommendations on indications and use of GIUS and so far,4 guidelines have been published: first on "examination techniques and normal findings", second on "inflammatory bowel disease", third on "acute appendicitis and diverticulitis" and fourth on "transrectal and perineal ultrasound".This paper describes the ultrasound features of miscellaneous disorders such as celiac disease, cystic fibrosis, omental infarction, Meckel's diverticle, endometriosis, intestinal neoplasia, mucocele, amyloidosis, GVHD, foreign bodies, vasculitis, and pneumatosis cystoides intestinalis. Bowel ultrasound can be indicated in most of these conditions to investigate intestinal symptoms but in other cases the alterations of the bowel can be also an incidental finding that suggest other examinations which finally help to discover an unknown pathological condition.

EFSUMB Position Paper: Recommendations for Gastrointestinal Ultrasound (GIUS) in Acute Appendicitis and Diverticulitis.

An interdisciplinary task force of European experts summarizes the value of gastrointestinal ultrasound (GIUS) in the management of acute appendicitis and diverticulitis. Based on an extensive literature review, clinical recommendations for these highly common diseases in visceral medicine are presented.In patients with acute appendicitis, preoperative sonography has been established as a routine procedure in most European countries for medical and legal reasons. Routine sonography in these patients may reduce the rate of unnecessary surgery by half. The sensitivity, specificity, and accuracy of ultrasound reach values above 90 % and are equivalent to CT and MRI. However, the high operator dependence may be a problem, for example in point-of-care ultrasound in emergency departments. Structured training programs, quality controls and standardized ultrasound reporting should be increasingly implemented.In the case of suspected acute diverticulitis, "ultrasound first" should also be a basic element in the approach to all patients. Sonography can confirm the diagnosis and allows early risk stratification. As treatment strategies have become less aggressive and more tailored to the stage of diverticulitis, accurate staging has become increasingly important. GIUS and CT have proven to have similar sensitivity and specificity. Especially in cases of uncomplicated diverticulitis, GIUS will be the one and only imaging procedure. CT may work as a backup and has particular advantages for diverticulitis located in the distal sigmoid, inflammation deep in the small pelvis and insufficient ultrasound scanning conditions. This step-up approach (ultrasound first and CT only in case of a negative or inconclusive ultrasound result) has proven to yield the best accuracy.

EFSUMB Recommendations and Clinical Guidelines for Intestinal Ultrasound (GIUS) in Inflammatory Bowel Diseases.

The accuracy and usefulness of gastrointestinal ultrasound (GIUS) for detecting activity and complications of inflammatory bowel diseases (IBD), has been reported in studies, promoting this technique as an important tool for the management of IBD patients. Whilst well recognised by international guidelines, standardization and general agreement in the definition of the luminal and extra-intestinal features, still need to be well defined.A task force group of 17 experts in GIUS faced this issue, by developing recommendations and clinical guidelines for the use of GIUS in IBD, under the auspices of EFSUMB. This article presents the consensus on the current data on sonographic features of IBD and summarises the accuracy of different sonographic modalities for the management of IBD patients.

EFSUMB Recommendations and Guidelines for Gastrointestinal Ultrasound.

In October 2014 the European Federation of Societies for Ultrasound in Medicine and Biology formed a Gastrointestinal Ultrasound (GIUS) task force group to promote the use of GIUS in a clinical setting. One of the main objectives of the task force group was to develop clinical recommendations and guidelines for the use of GIUS under the auspices of EFSUMB. The first part, gives an overview of the examination techniques for GIUS recommended by experts in the field. It also presents the current evidence for the interpretation of normal sonoanatomical and physiological features as examined with different ultrasound modalities.

EFSUMB Recommendations and Guidelines for Gastrointestinal Ultrasound.

In October 2014 the European Federation of Societies for Ultrasound in Medicine and Biology formed a Gastrointestinal Ultrasound (GIUS) task force group to promote the use of GIUS in a clinical setting. One of the main objectives of the task force group was to develop clinical recommendations and guidelines for the use of GIUS under the auspices of EFSUMB. The first part, gives an overview of the examination techniques for GIUS recommended by experts in the field. It also presents the current evidence for the interpretation of normal sonoanatomical and physiological features as examined with different ultrasound modalities.

Colonic diseases: the value of US examination.

The colon is affected by a number of diseases, mainly inflammatory, ischemic, and neoplastic conditions. Depending upon clinical indications endoscopy, US, CT, or other radiological methods are used for evaluation. The fact that US is frequently used as the initial imaging method in patients with non-specific clinical symptoms allows for greater influence in further diagnostic evaluation and with treatment, provided the investigator is familiar with the features of different intestinal diseases. This article will describe the anatomical characteristics of the colon, the US technique for examination of the colon, and the typical US features of the more common diagnoses of the colon.

CT in the differentiation of pancreatic neoplasms--progress report.

Today, computed tomography (CT) is the most commonly used imaging method in the assessment of pancreatic tumors. The sensitivity of CT in detection of pancreatic tumors is more than 90% when direct and indirect signs are used for diagnosis. However, the potential to differentiate exocrine (non-endocrine) tumors of the pancreas is limited. CT is used in these lesions to perform an adequate staging, especially for surgical purposes. The operative resectability, primarily in regard to vessels, lymph node metastasis and hepatic metastasis, has to be assessed. Keeping in mind the limitations of this macromorphological imaging procedure, CT has the best reproducibility and overall accuracy of all imaging methods. Using multislice CT it is possible to perform non-axial reconstructions with high resolution. In functional endocrine tumors, multislice spiral CT will enhance the diagnostic capabilities, since the whole organ can be examined in thin slices, with high resolution during the rather short arterial phase of the contrast medium. Since some endocrine tumors are hypovascular, a scan during the portovenous phase is recommended too. The diagnosis of benign pancreatic tumors, like serous cystadenoma and pancreatic lipomas, is addressed. The most important pseudotumors of the pancreas are discussed.

Suspicion of microscopic colitis raised by sonographic examination.

This report describes the case of a 57-year-old woman who was incidentally identified as having lymphocytic colitis after she underwent routine transabdominal sonographic examination. She initially reported having no irregularities in her bowel movements. Sonography revealed the following nonspecific findings: watery stool in the entire colon, slight thickening of the hypoechoic mucosal layer and moderate thickening of the hyperechoic submucosal layer of the colon, and no pathologic findings in the small intestine. On additional questioning, the patient said that she had had watery diarrhea for the last 10 years, with as many as 10 bowel movements daily. Endoscopic examination and biopsy were performed. Histopathologic examination of biopsy specimens showed lymphocytic infiltration of the mucosa and some collagen deposits, consistent with a diagnosis of lymphocytic colitis. Treatment was begun with loperamide, sulfasalazine, and budesonide. Within 3 weeks of the start of treatment, the number of bowel movements decreased to 1-2 daily. Follow-up sonography at that time revealed normalization of the bowel contents and disappearance of the thickened submucosal layer of the colon. Nonspecific sonographic findings like those in this case lead to the need to rule out various diseases through further appropriate evaluations to identify the correct diagnosis.

Ovoid shape of the vermiform appendix: a criterion to exclude acute appendicitis--evaluation with US.

PURPOSE: To investigate whether the shape of the appendix in transverse section may be considered an ultrasonographic (US) criterion to exclude or confirm acute appendicitis. MATERIALS AND METHODS: The shapes of appendices of 100 control subjects, of 174 patients with clinical suspicion of acute appendicitis but without acute appendicitis, and of 108 patients with acute appendicitis were prospectively evaluated with US. Definite diagnoses in patients with clinical suspicion of acute appendicitis were established and confirmed either with surgery and histologic examination in 161 patients or with clinical follow-up in 121 patients. Statistical measures such as sensitivity, specificity, positive and negative predictive values, and accuracy were assessed for the appendiceal shape as a diagnostic US criterion for acute appendicitis. RESULTS: An at least partly round appendix indicated acute appendicitis with a sensitivity of 100%; specificity of 37%; positive and negative predictive values of 50% and 100%, respectively; and accuracy of 61%. In 67 of 174 patients with clinical suspicion of acute appendicitis but without acute appendicitis, the partly ovoid appendiceal shape aided in the exclusion of acute appendicitis, since it indicated a normal appendix with a probability of 86%. In 65 of 174 patients with clinical suspicion of acute appendicitis but without acute appendicitis, the ovoid shape over the entire appendiceal length excluded acute appendicitis with confidence. CONCLUSION: The shape of the appendix in transverse section is a useful US criterion, since an ovoid shape over the entire appendiceal length reliably rules out acute appendicitis.