An ultrasound scoring system for the diagnosis of liver disease in cystic fibrosis.

Advances in the management of the pulmonary complications of cystic fibrosis may result in an increasing prevalence of patients with chronic liver disease which may, therefore, become more important in the long-term management of cystic fibrosis patients. However, no simple and reliable test is available for the diagnosis of liver disease in cystic fibrosis. In particular percutaneous liver biopsy is highly inaccurate and potentially dangerous. Imaging techniques, including real-time ultrasound scanning, have been used to evaluate the hepato-biliary system in cystic fibrosis and may represent the best available techniques for documenting hepatic involvement. The purposes of this study were to construct an ultrasound scoring system using three cardinal features of hepatic ultrasound in cystic fibrosis: coarseness of the parenchyma, nodularity of the liver edge and increased periportal echogenicity, to enable the accurate, early diagnosis of liver involvement in cystic fibrosis. The scoring system was validated by correlating the results against ultrasound markers of portal hypertension, clinical and haematological data. The scoring system proved to be reproducible and to correlate well with the markers of hepatic disease detailed above. The results also suggest that the scoring system may allow the identification of patients with pre-cirrhotic chronic liver disease and so may prove of value in selecting a sub-group of patients more likely to respond to therapy.

Excursion-volume relation of the right hemidiaphragm measured by ultrasonography and respiratory airflow measurements.

BACKGROUND: Although real time ultrasonography has been used in the last decade to record diaphragmatic motion, the relation between diaphragmatic excursion and different inspired volumes (VT) has not been assessed by ultrasound. METHODS: Ten normal subjects were studied in the supine posture. Diaphragmatic excursion and VT were assessed simultaneously by M mode ultrasonography and respiratory airflow measurements at different inspired volumes. Ultrasound recordings of the movement of the right hemidiaphragm were carried out in the longitudinal plane subcostally. The transducer was held in a fixed position by a frame, built especially to eliminate any artefactual movement caused by outward motion of the anterior abdominal wall on inspiration. RESULTS: Mean (SD) maximal diaphragmatic excursion recorded was 6.0 (0.7) cm. Inspired volumes ranged from 15(5%) to 87(10%) of the subjects' inspiratory capacity. A linear relation between diaphragmatic excursion and VT was found in all subjects (r = 0.976-0.995). The regression line had a slope of 1.66 (0.24) cm/l. This slope had no correlation with either the height (r = 0.007) or weight (r = 0.143) of the subjects. In five subjects in whom diaphragmatic excursion could be recorded at volumes near total lung capacity, the relation between diaphragmatic excursion and VT became alinear at very high lung volumes. CONCLUSIONS: The relation between diaphragmatic excursion and VT was linear between 15(5%) and 87(10%) of inspiratory capacity. Ultrasonography of the diaphragm is a simple technique that could be applied in the clinical investigation of patients with suspected abnormalities of diaphragmatic movement.

Diaphragmatic movement in hemiplegic patients measured by ultrasonography.

BACKGROUND: It is known that automatic breathing is controlled by centres in the lower brain stem, whereas volitional breathing is controlled by the cerebral cortical centres. In hemiplegia, lesions above the brain stem result in paralysis of limb muscles. This study was performed to determine whether the diaphragm might also be affected in patients with hemiplegia. METHODS: Studies were performed in six normal control subjects and in eight patients with complete hemiplegia caused by a lesion above the brain stem, all with no known chest disease. Full lung function tests were performed. Diaphragmatic excursion and inspired volume (VT) were measured simultaneously by M mode ultrasonography and respiratory airflow measurements. Recordings of diaphragmatic excursion were performed on each side separately during volitional and automatic breathing at a similar range of VT. RESULTS: Lung function tests lay within the normal range in all the control subjects. In the hemiplegic patients mean (SD) vital capacity was 79 (18)% and residual volume was 123(30)% of predicted. Total lung capacity and functional residual capacity were in the normal range. In the control subjects no significant difference in diaphragmatic excursion was found between volitional and automatic breathing for the same range of inspired volume. By contrast, there was a significant decrease in diaphragmatic excursion during volitional breathing compared with automatic breathing on the affected side in four of the eight hemiplegic patients. CONCLUSIONS: In four of eight hemiplegic patients reduced diaphragmatic movement was present on the paralysed side during volitional inspiration when compared with automatic inspiration. The hemidiaphragm may be involved on the affected side in patients with hemiplegia.

Case report: the transabdominal ultrasound appearances of a colovesical fistula.

When the clinical manifestations of colovesical fistulae lack diagnostic features, significant diagnostic delay may result. The literature contains conflicting recommendations regarding the optimal method of imaging such fistulae. We describe the transabdominal ultrasound appearances of a colovesical fistula and review the relevant literature. The identification of the ureteric orifices with their associated urinary jets and the use of abdominal compression are essential components of the technique.

Interpretation of duplex Doppler ultrasound in renal transplants in the early postoperative period.

A prospective study of duplex Doppler ultrasound in 29 renal transplants was undertaken to determine how to interpret Doppler findings in the immediate postoperative period. The study included intraoperative pulsed Doppler recordings from grafts immediately following release of vessel clamps. Subsequent follow-up studies were performed in the immediate postoperative period. Intraoperative Doppler appearances in the group as a whole were normal; there was a significant deterioration in Doppler appearances in the first 24-48 h of the postoperative period. In the absence of rejection subsequent Doppler appearances returned to normal. An abnormal Doppler appearance immediately following transplantation should be an expected result. If the Doppler fails to improve, or deteriorates having started to improve, rejection should be strongly suspected.

Doppler assessment of the uterine circulation and the clinical behaviour of gestational trophoblastic tumours requiring chemotherapy.

The haemodynamics of the uterine arteries and myometrium were assessed using Doppler ultrasound in forty consecutive patients requiring treatment for invasive mole and choriocarcinoma. The investigations were performed prior to the commencement of chemotherapy and the subjects followed prospectively. The Doppler waveforms from the uterine arteries were analysed using the pulsatility index. It was found that patients with a pulsatility index of 1.1 or less were significantly more likely to develop drug resistance than those with a higher value (P < 0.04). There was no significant association between the pulsatility index and metastatic disease or uterine bleeding. Five out of eight patients who developed drug resistance could have avoided initial inadequate treatment if the Doppler findings were included in the scoring system for selecting chemotherapy for these tumours. It can be concluded that assessment of the uterine arteries using the pulsatility index prior to the treatment of patients with invasive mole and choriocarcinoma is of help in predicting those who will develop drug resistance.

Ultrasonic morphology of the uterus and ovaries after treatment of invasive mole and gestational choriocarcinoma.

Ultrasound imaging of the uterus and ovaries was performed on 41 patients after completion of apparently successful cytotoxic chemotherapy for invasive mole and choriocarcinoma. Uterine volume was calculated and the echopattern of the uterus and ovaries assessed. Forty-nine per cent of subjects had an abnormal uterine appearance and 20% had ovarian theca-lutein cysts. Two patients relapsed on follow-up but no predictive ultrasonic features could be established on uterine or ovarian morphology after chemotherapy.

Preliminary Doppler studies on the uterine artery and myometrium in trophoblastic tumours requiring chemotherapy.

The uterine circulation in 38 patients with invasive mole or choriocarcinoma were investigated using Doppler ultrasound. Twenty-six non-pregnant and 23 pregnant volunteers were assessed in a similar fashion to act as control groups. The pulsatility indices were significantly lower in the patients with trophoblastic disease when compared with the non-pregnant and pregnant groups (Student's t-test; P less than 0.001 and P less than 0.02 respectively). The uterine circulation in persistent trophoblastic diseases shows a characteristic Doppler profile suggesting the presence of large low resistance blood vessels. This may be useful in the initial assessment of these tumours before cytotoxic chemotherapy.

Noninvasive monitoring of renal blood flow characteristics during acute renal failure in man.

Duplex Doppler ultrasound (DDU) was used to study the blood flow characteristics of the renal interlobar artery in 20 subjects with acute renal failure (ARF), 14 subjects with transient impairment of renal function and 23 control subjects with normal function. Renovascular resistance was assessed by pulsatility index (PI) and change in flow velocity by change in mean frequency shift (delta f). The 99% confidence intervals for PI in the three groups were 3.32-5.46, 1.58-2.34 and 0.99-1.33 respectively. Values for delta f were 0.2-0.38, 0.5-0.62 and 0.7-1.02 kHz respectively. Ten ARF patients recovered function, 99% confidence intervals for PI just prior to recovery were 0.9-1.48 and for delta f 0.52-1.02 kHz. There was increased renovascular resistance and reduced intrarenal blood flow velocity at the onset of ARF. These changes persisted during ARF; recovery of function occurred after they returned to normal. Similar, but less marked, changes were found in patients with a transient impairment of function.

Doppler time velocity waveform studies of the uterine artery and uterus.

This study describes a reliable and reproducible method of obtaining Doppler frequency shift waveforms from the uterine artery based on observations in 26 non-pregnant women. The waveforms were detected easily but direct display of the vessel was inconsistent. The values of the pulsatility index calculated from the waveforms had a mean of 3.25 (SD 0.83). The standard error of the mean was 0.16 and based on this, the 95% reference range was 1.21 to 5.29. The stage of the menstrual cycle did not affect the pulsatility index nor was there any significant difference between subjects who were nulliparous and those who had had previous pregnancies. These results show that Doppler ultrasound can be applied to the non-pregnant uterus and the data presented may be used as a baseline for the study of uterine pathology.

Practical use of duplex Doppler analysis of the renal vasculature in critically ill patients.

Duplex doppler examination of blood flow in renal interlobar arteries was analysed in twelve critically ill patients before and during low-dose dopamine infusion (2 micrograms/kg/min). Renal vasodilatation and increased blood flow were observed with dopamine, confirming results with indirect or invasive techniques. The doppler ultrasound technique is entirely non-invasive, is simple and quick to carry out, provides instant results, and will allow tailoring of inotropic support in critically ill patients to provide optimum renal blood flow.

Experiences with ultrasonic parasagittal sector B-mode scanning in pericardial effusion.

During parasagittal B-mode scanning of the liver, pulsatile cardiac interfaces are demonstrable by increasing the swept gain. In a normal patient the interface of hemidiaphragm and pericardium is combined. In a patient with a pericardial effusion there is a transsonic semilunar space which separates the combined diaphragmatic and pericardial interface from that of a pulsatile epicardium. A review of 30 cases of proven pericardial effusions revealed that the diagnostic accuracy of this method is virtually the same as that of M-mode scanning and, furthermore, that by using both methods some of the pitfalls of M-mode scanning can be avoided.

Experiences with grey scale ultrasonography in hepatic amoebiasis.

Ultrasound examination was conducted in 151 proven cases of amoebic liver abscess. In the majority of patients the lesion was solitary but 25% of patients had multiple lesions; 17% of all the abscesses were in the left lobe of the liver. Most abscesses had no, or very few internal echoes and these were either of the same density as the normal liver (15%) or less dense (84%). In all cases there were relatively fewer echoes in the lesion. Abscesses in critical areas were accurately located especially in relation to the pericardium. Other liver lesions such as hepatoma which may enter into the clinical diagnosis can be recognised. Ultrasound has particular value in accurate localisation of the lesion for aspiration, demonstration of unsuspected multiple abscesses and size estimation in serial studies of the patient under treatment. The diagnostic errors were mainly due to initial inexperience and demonstrated some of the diagnostic pitfalls. It is concluded that the introduction of this technique has proved to be of considerable value in the diagnosis and management of amoebic liver abscess in our area, where the disease is still a major clinical entity. If diagnosed early and treated adequately the condition has an excellent prognosis.

Grey scale ultrasound appearances in hepatocellular carcinoma.

Thirty patients with histologically proven hepatocellular carcinoma were examined ultrasonically. All except two of these cases were reported ultrasonically as having a solid mass. Forty-three per cent of these lesions appeared multiple and 90% had irregular walls or boundaries. Stretching or distortion of the inferior margin of the liver is considered significant and 53% of cases demonstrated this feature. Just over two-thirds (67%) of the lesions were echogenic and under one-third (27%) were mixed lesions with echogenic and transonic areas. These transonic areas are considered to be due to the necrosis within the tumour. Most patients presented late and died within three months. Ninety per cent had clinical hepatomegaly or an epigastric mass. So far the main benefits of ultrasonography have been the recognition or exclusion of treatable disease such as liver abscess, cysts and congestive conditions of the liver, which may also present with unexplained hepatomegaly or epigastric masses. The possibility of a recognisable echo pattern for hepatocellular carcinoma emerged from this study. By conducting selective ultrasonic surveys in endemic areas and by employing the ultrasonic criteria described early diagnosis may be possible. Aspects of management and research may be assisted.

Polyhydramnios associated with congenital pancreatic cysts and asphyxiating thoracic dysplasia. A case report.

The antenatal ultrasonic detection of congenital pancreatic cysts is described in a case of polyhydramnios associated with fetal asphyxiating thoracic dysplasia. The formation of polyhydramnios is discussed.