Exposure to heavy metals and the risk of osteopenia or osteoporosis: a systematic review and meta-analysis.

The relationship between heavy metal exposure and risk of osteopenia or osteoporosis has biological plausibility, yet it remains inconclusive; therefore, we conducted a systematic review and meta-analysis to evaluate the associations between exposure to heavy metals (i.e., cadmium, lead, and mercury) and the risk of osteopenia or osteoporosis. Databases of MEDLINE, Embase, Scopus, and Web of Science were searched through November 2019, to identify studies that evaluated the relationship between exposure to cadmium, lead, and mercury and risk of osteopenia or osteoporosis in adults. Fourteen eligible studies were included. Effect sizes expressed as pooled odds ratios (OR) and 95% confidence intervals (CI) were estimated using weighted random-effect models. Exposure to cadmium (OR = 1.35; 95% CI: 1.17 to 1.56; P ≤ 0.001) and lead (OR = 1.15; 95% CI: 1.00 to 1.32; P = 0.05) was associated with an increased risk of osteopenia or osteoporosis, unlike mercury. Subgroup analyses showed cadmium exposure increased the risk of osteopenia or osteoporosis in older (> 65 yrs.; OR = 1.43; 95%CI: 1.08 to 1.88, P = 0.01) compared with younger (18-65 yrs.; OR = 1.24; 95% CI: 1.02 to 1.52, P = 0.03) adults. Also, lead exposure increased the risk in men (OR = 1.55; 95% CI: 1.15 to 2.09, P = 0.007) unlike in women. By contrast to urinary levels, blood (OR = 1.26; 95% CI: 1.08 to 1.47, P = 0.003) and dietary (OR = 1.46; 95% CI: 1.28 to 1.67, P < 0.001) levels of cadmium were associated with an increased risk of osteopenia or osteoporosis. Exposure to cadmium and lead may be associated with an increased risk of osteopenia or osteoporosis, although high heterogeneity was detected.

[Primary perivascular epitheloid cell tumour (PEComa) of the liver - is a new entity of the liver tumors?]. / Das PECom der Leber - eine neue Entität der Lebertumoren?

Perivascular epitheloid cell tumor (PEComa) is a rare tumor, characterized by dual Expression of smooth muscle and melanocytic markers. Due to the development of diagnostic procedures, we now diagnose PEComa more often. We report about a case of PEComa of the liver as an accidental finding. We analyze the clinical and morphological characteristics of this tumor and compare it with the data of the literature. Management of patients with PEComa is not yet standardized; therefore biopsy with immunhistochemical staining is necessary for the diagnosis. In case of liver tumors which cannot be classified by their morphology on imaging modalities, it is important to think about this rare entity.

[Guideline compliant diagnostics of hepatocellular carcinoma]. / Leitliniengerechte Diagnostik des hepatozellulären Karzinoms.

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the third most common cause of cancer death worldwide. The incidence continues to rise and only a detailed surveillance of patients with chronic liver disease can allow an early assessment. Diagnosis is made by imaging techniques, such as contrast-enhanced ultrasound (CEUS), computed tomography (CT), magnetic resonance imaging (MRI) and also histopathological examination of biopsy material. The determination of the tumor marker alpha fetoprotein (AFP) is no longer established for early detection but can be used as a supplement in addition in HCC history progressio.

Contrast-enhanced ultrasound (CEUS) in the diagnostic algorithm of hepatocellular and cholangiocellular carcinoma, comments on the AASLD guidelines.

Contrast-enhanced ultrasound (CEUS) has long been present in important guidelines and recommendations for the diagnostic work-up of focal liver lesions in patients with cirrhosis. These guidelines have included the guidelines of the American Association for the Study of Liver Diseases (AASLD) 2005, the Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma, the recommendations of the Japanese Society of Hepatology, and the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) guidelines 2004, 2008 and 2012 (in preparation). Recently, the AASLD removed CEUS from their guidelines in part because of the perceived possibility of false-positive hepatocellular carcinoma (HCC) diagnosis in patients with intrahepatic cholangiocarcinoma (ICC), and in part because CEUS is not available in the USA. This latter factor means that published results are not entirely applicable to a North American population. The present manuscript discusses the diagnostic algorithm of hepatocellular carcinoma and provides information on the differential diagnosis between HCC and ICC.

Peripapillary duodenal varices as a rare cause of severe bleeding in a patient with no other signs of portal hypertension--successful endoscopic treatment with cyanoacrylate injection.

Duodenal varices (DVs) are a rare cause of upper gastrointestinal bleeding and rather suspected in patients with portal hypertension. Bleeding DVs are difficult to manage and often fatal due to delayed diagnosis. We report on a 71-year-old patient with massive upper gastrointestinal haemorrhage, who did not show any clinical signs of portal hypertension; however, he had a history of duodenal segmental resection 8 years before. The source of bleeding could not be detected with different imaging methods such as angiography and computed tomography. Upper gastrointestinal endoscopy finally revealed DVs, which were located just adjacent to the papilla. After endoscopic injection therapy with n-butyl 2-cyanoacrylate the bleeding stopped immediately and the patient soon stabilised. Despite the peripapillar localisation no signs of pancreatitis or cholestasis occurred; during 10-month follow-up a marked regression of the varices without further signs of variceal bleeding was observed.

[Differentiated therapy of liver tumors]. / Differenzialtherapie von Lebertumoren.

Focal nodular hyperplasia is a polyclonal hyperplasia of liver cells as a result of locally enhanced blood flow because of vessel malformations. Only symptomatic FNH is an indication for resection or enucleation. In contrast to FNH growth of adenoma is dependent on sexual hormones. Solitary HNFalpha-inactivated and inflammatory adenomas larger than 5 cm should be removed because of risk of tumor rupture or bleeding, while beta-catenin mutated adenomas should be surgically removed at any stage because of risk of malignant transformation. The prognosis of patients with HCC is dependent on the tumor stage, but also on the liver function. Resection is the treatment of choice for HCC in patients without liver cirrhosis. Patients with liver cirrhosis and early HCC without extrahepatic metastasis can be successfully treated by liver transplantation. If transplantation is not possible these tumors should be removed by local percutaneous ablation. Transarterial chemoembolization is an effective treatment for more advanced HCC in patients with good liver function. Studies showed that the multikinase inhibitor sorafenib significantly improves survival of patients with advanced or metastatic HCC in child A cirrhosis. The only curative option for patients with intrahepatic cholangiocarcinomas is surgical resection. Patients with unresectable cholangiocarcinomas should be treated with a chemotherapy consisting of Gemcitabine-Cisplatin-combination.

The type of arterial anastomosis influences hepatic hemodynamics and overall survival in liver graft recipients.

AIM: Evaluation of the influence of arterial anastomoses on hepatic hemodynamics and overall survival in liver graft recipients using color Doppler ultrasound. METHOD: 224 patients recruited retrospectively were divided into five groups according to arterial anastomoses: (1) common hepatic (CHA)/gastro duodenal, (2) CHA/CHA, (3) aorta/celiac trunc, (4) aorta/aorta, (5) more than one anastomosis. We compared maximum portal [(P)Vmax], systolic [(A)Vmax] and end diastolic [(A)Vmin] arterial velocities, resistance indexes(RI), spleen and liver size between the groups. We analyzed further in a multivariate analysis the influence of time elapsed since orthotopic liver transplantation, age of recipient and donor on significant parameters as well as the overall survival of the patients between the groups. RESULTS: Significant differences were found for: (A) Vmax between groups 2/4 (p<0.007) and 2/5 (p<0.010), (A) Vmin between groups 1/3 (p<0.029) and 2/3 (p<0.015) and RI between the groups 1/3 (p<0.018) and 3/4 (p<0.006). (A)Vmax and RI were only dependent on the type of arterial anastomosis (p<0.008 and p<0.014). The overall survival of the patients between the groups was significantly different (p<0.047). CONCLUSION: In this study we report the natural course of the mean values of portal and arterial velocities in different arterial reconstructions for the first time. (A) Vmax of the hepatic artery is identified as the most promising candidate prognostic parameter for the assessment of hemodynamic alterations after liver transplantation originating in the type of arterial anastomosis performed. The group of patients with more than one anastomosis had the lowest arterial (A) Vmax and simultaneously the lowest overall survival.

[Diagnostic imaging of liver tumours. Current status]. / Bildgebende Diagnostik von Lebertumoren: Aktueller Stand.

Nowadays, contrast enhanced ultrasound (CEUS) is an imaging technique equivalent to multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) for the detection and characterization of focal liver lesions. These methods have comparable sensitivity and specificity in differentiating a liver lesion as "benign" or "malignant". For benign lesions, CEUS is the recommended method of the choice. In unclear cases, or if CEUS is not available, MRI or CT are the methods of the second choice. If a benign tumor remains unclear, then a needle biopsy is recommended. In the case of a malignant tumor, it is necessary to use a second imaging technique besides CEUS. In addition to the detection and characterization of a liver tumor, CT and MRI provide information on the extrahepatic spread of a tumor, particularly into the lung or retroperitoneum. The rapid development of surgical and interventional approaches requires accurate information on the character and number of malignant liver lesions. Therefore, the combined use of CEUS and MDCT or MRI currently represents the most modern and optimal standard of imaging. The standardization of CT and MRI protocols has increased the general diagnostic level of these images. Adequate training and a certificate for the use of CEUS is recommended in order to maintain the high diagnostic level of this method (EFSUMB guide lines). An optimal interdisciplinary imaging strategy for focal liver lesions minimises unnecessary invasive or potentially harmful imaging and reduces health costs.

[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.

[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.

Diagnosis of Chilaiditi's syndrome with abdominal ultrasound.

Chilaiditi's sign is a radiographic term used when the hepatic flexure of the colon is seen interposed between the liver and right hemidiaphragm. When symptomatic, this is Chilaiditi's syndrome. We report a case of a 70-year-old man who presented with abdominal pain, vomiting, singultus and constipation. Ultrasound was initially performed which showed an intestinal loop between the anterior surface of the right liver lobe and the diaphragm. The chest X-ray revealed colon gas under the right diaphragma and the abdominal CT-scan confirmed the hepatodiaphragmatic interposition of the colon. Colonic elongation and laxity of colonic and hepatic suspensory ligaments are the principal predisposing factors. The advantages of the abdominal ultrasound in the diagnosis and follow-up as well as possible complications and forms of therapy with this syndrome are discussed.

[Atypical gallstone ileus: radiologic and sonographic findings]. / Atypischer Gallensteinileus: radiologische und sonographische Befunde.

We report on a case of an atypically located gallstone ileus as a rare complication of cholecystolithiasis. A 61-year old lady with a history of diabetes type II and nephrolitiasis presented with abdominal pain lasting for 8 days and with vomiting and diarrhoea. Physical examination revealed a palpable tumour and pain in the left lower abdomen. An extensive elevation of blood sugar, CRP and leukocytosis was found. Initially X-ray of the abdomen and sonography showed signs of a subileus. Additionally a 5 x 2 cm mass with dorsal shadowing was detected by ultrasound. Gallbladder and the biliary system were normal. The sonographic suspicion of a gallstone ileus was confirmed by a subsequent CT scan. Under operation the gallstone was found in the distal Jejunum. A gallstone ileus must be included in the differential diagnosis of a tumour in the left lower abdomen. A tumour with dorsal shadowing and signs of a subileus may be the only sonographic findings of a gallstone ileus.

3D-ultrasound in imaging, diagnosis and follow-up of an atypical hydatid cyst.

Abdominal ultrasonography is the procedure of choice to diagnose hydatid cysts caused by Echinococcus granulosus. Recently three-dimensional ultrasonography has become available for clinical application. We report a case of an atypical seronegative hydatid disease, in which the additional use of 3D-sonography improved the sonographic diagnosis, which was confirmed by a fine needle biopsie complicated by an anaphylactic reaction. In addition the potential advantage of 3D-ultrasonography in diagnosis and follow-up hydatid disease will be discussed, especially in the context of new alternative therapeutic options like chemotherapy with benzimidazoles or the percutaneous drainage by the PAIR procedure (puncture-aspiration-injection-re-aspiration).

Percutaneous sonographic gastrostomy: method, indications, and problems.

OBJECTIVES: This study evaluated the application of ultrasound (US) guidance in the percutaneous placement of gastric feeding tubes in patients in whom endoscopic placement of a nutrition tube is not possible. METHODS: Thirty-eight patients with upper gastrointestinal obstruction were entered in a prospective study with US-guided nutrition tube application. Feasibility of placement, side effects, and nutritional states were monitored for a mean follow-up of 4 months. RESULTS: Ultrasound allowed rapid puncture after filling of the stomach with water through a nasal tube in 34/38 cases. In four cases a total upper gastrointestinal obstruction required an initial stomach insufflation through a direct puncture. Puncture-related major complications were not observed. Minor complications during the observation time were one late dislocation, five cases with broken material after about 6 months (four could be changed by using the Seldinger technique), and two minor local infections. The nutrition through feeding tubes stabilized body weight and body composition parameters. CONCLUSION: The percutaneous sonographic gastrostomy (PSG) is a safe and minimally invasive procedure for enteral nutrition in all cases with upper gastrointestinal obstruction when endoscopic placement of a feeding tube is not possible. Percutaneous sonographic gastrostomy may help to stabilize the nutritional parameters and general condition in patients with malignant diseases.

Sonography under Daylight Conditions.

PURPOSE: Gray scale image assessment in clinical ultrasound requires working in dim light or a dark room. Daylight conditions offer the advantage of shorter visual reaction time and enhanced visual perception. Look-up table manipulations could improve image brightness. MATERIALS AND METHODS: We investigated the possibility of brightness and contrast enhancement of coloured adaptive linear look-up tables (CALUT's) and their artifact resistance. Therefore under real-time conditions red/brown, green and blue CALUT's were calculated using the gray scale distribution (mean and standard deviation) of the actual image. The changes in contrast of several structural features (echo-poor and echogenic lesions, artifacts) were assessed by clinical investigators (n = 7). RESULTS: The CALUT's produced, independent of the original, images with constant brightness and contrast. Even under daylight conditions no artifacts appeared. Under scotopic conditions the red/brown CALUT's showed the best results compared to the unchanged image and the gray, green, and blue CALUT's. Hyper and hypoechoic differences with small contrast to the surrounding tissue are enhanced and can be detected more easily. CONCLUSION: Daylight sonography allows examination even in non-darkened rooms without loss of information. Eye adaptation to changing light conditions is no longer necessary; the offered image information is more suitable for the eye.

[3D and color Doppler ultrasound evaluation of cystic space-occupying lesion near the head of the pancreas]. / 3D- und Farbdopplersonographische Evaluation einer am Pankreaskopf gelegenen zystischen Raumforderung.

AIM: Differential diagnosis of cystic lesions in the abdomen may be very difficult. We present the clinical manifestation and the diagnostic steps of a rare case of an aneurysm of the gastroduodenal artery mimicking a cystic lesion. We also discuss the imaging methods we used to verify the diagnosis such as colour Doppler sonography and 3D-sonography. METHOD AND PATIENT: A 42-year old woman with chronic pancreatitis was admitted to our hospital after an extended diagnostic program (sonography, computed tomography and laparoscopy) with the diagnosis of a pancreatic pseudocyst with vascular erosion. Using conventional sonography we found a cystic lesion of 5 x 5 cm diameter with parietal deposits between pancreas and coeliac trunk. After colour Doppler sonography we found an arterial jet in the cystic tumor; initially the source of the jet seemed to be the hepatic artery. We referred the patient to our department of radiology with the diagnosis of hepatic artery aneurysm. The aneurysm was confirmed by the angiography and was embolised with coils in the same session. However, the source of the aneurysm was not the hepatic, but the gastroduodenal artery. By postangiographical 3D-sonography we could clearly reconstruct the relation of the aneurysm to the gastroduodenal artery. CONCLUSION: Colour Doppler sonography should be the first imaging tool for clarifying cystic lesions in the abdomen. 3D-sonography is a reliable and useful method to identify visceral vessels of the abdomen. Nowadays the "gold standard" angiography should preferably be used as a therapeutic procedure.