Ultrasound examination of the liver: Variations in the vascular anatomy.

The hepatic vasculature is highly complex. The hepatic artery (a branch of the celiac tripod) and the portal vein (formed by the confluence of the splenic and superior mesenteric veins) provide a dual blood supply while venous drainage is guaranteed by the hepatic veins. There are also numerous anatomic variants that can involve one or more of the system's three components.Hepatic artery variants are the least common. Ten types have been identified, including several that are fairly frequent and others that are quite rare, and the variation generally involves the extrahepatic portion of the vessel. Portal vein variants are found in around 20% of the population. They can involve the main portal trunk or segmental branches. Variants of the hepatic veins are the most common. They involve the number and course (supernumerary veins) or the number, course, and openings (accessory veins).Knowledge of portal vein and hepatic vein variants, which are extremely common, is of prime importance for precise localization of lesions. Hepatic artery variants are equally important for surgical treatment of hepatic disease, especially liver transplantation, where it is essential for preoperative workup and postoperative follow-up of the recipient as well as for assessment of potential donors.

Diagnosis of liver cirrhosis by transit-time analysis at contrast-enhanced ultrasonography.

PURPOSE: The aims of this prospective study were to evaluate analysis of sulfur-hexafluoride-filled microbubble contrast agent (Sonovue) transit times as a tool for differentiating liver cirrhosis from the noncirrhotic stage of liver disease and to compare its performance with that of conventional B-mode and Doppler ultrasonography (US). MATERIALS AND METHODS: Contrast-enhanced hepatic ultrasonography with the US contrast agent Sonovue was performed on 38 patients with diagnoses of hepatic cirrhosis based on unequivocal clinical signs or liver biopsy findings (Child-Pugh classes A in 19, B in 16 and C in three), 31 patients with noncirrhotic diffuse liver disease (biopsy confirmed) and 14 controls without diffuse liver disease. Time curves of hepatic-vein signal intensity were analysed using objective criteria to determine the time of enhancement onset (hepatic-vein arrival time) and peak enhancement (hepatic-vein peak enhancement). Accuracy in diagnosing cirrhosis was compared with that based on B-mode and Doppler data. RESULTS: Hepatic-vein arrival time in cirrhotic patients was significantly shorter (p < 0.01) than in noncirrhotic (chronic liver disease and controls) patients. Peak enhancement times in these three groups were not significantly different. An arrival-time cutoff of 17 s distinguished cirrhotic from noncirrhotic patients with high accuracy (100% sensitivity, 93.3% specificity, positive and negative predictive values 92.6% and 100%, respectively) and excellent reproducibility (kappa coefficients of 1.0 and 0.93 for intraand interobserver agreement). Contrast-enhanced US showed better sensitivity than the B-mode and Doppler data. CONCLUSIONS: Analysis of the time of onset of US contrast enhancement of the hepatic vein appears to be a potentially useful noninvasive supplement to conventional sonography and Doppler in the follow-up of patients with chronic diffuse liver disease.

Contrast-enhanced ultrasound to evaluate the severity of chronic hepatitis C.

BACKGROUND: Non-invasive techniques are being developed to assess the severity of liver disease. Haemodynamic changes in the hepatic circulation during the development of liver disease can be evaluated with contrast-enhanced ultrasound. AIM: To evaluate the possible correlation between ultrasound contrast-agent transit times and different stages of chronic hepatitis C. PATIENTS: Sixteen patients with clinically evident hepatitis C virus-related cirrhosis, 22 non-cirrhotic patients with chronic hepatitis C and 14 controls with no clinical evidence of liver disease were studied. METHODS: Contrast-enhanced hepatic ultrasonography was performed with a sulphur hexafluoride-filled microbubble contrast agent, and time curves of hepatic vein signal intensity were analysed to determine the time of enhancement onset (hepatic vein arrival time) and peak enhancement (hepatic vein peak enhancement). RESULTS: Hepatic vein arrival time in cirrhotic patients was significantly shorter (p<0.001) than in non-cirrhotic patients and controls. Within the group with chronic hepatitis C, METAVIR scores of fibrosis and necro-inflammatory changes had no significant effect on hepatic vein arrival times. CONCLUSION: Analysis of the time of onset of ultrasound contrast enhancement of the hepatic vein appears to be a simple, non-invasive method for reliably excluding cirrhosis with signs of portal hypertension, but not for assessing the severity of either chronic hepatitis C or cirrhosis.

Three-dimensional sonographic study of breast nodules.

PURPOSE: We examined breast nodules with three-dimensional (3D) sonography and power-Doppler to identify new parameters that might be useful in differentiating benign and malignant lesions. MATERIALS AND METHODS: Breast nodules in 34 women were examined with a Voluson-GE 730 scanner and a 7.5 MHz linear-array dedicated 3D probe. Each nodule was examined in the B-mode, and its vascular characteristics were evaluated with power-Doppler; 3D reconstruction was used in both studies. All examinations were performed by the same operator, who was unaware of the case characteristics. The examiner classified each lesion as benign or malignant based on B-mode appearance, margin characteristics, infiltration, and blood vessel distribution on power-Doppler; lesion volume was also calculated for T staging. Results were compared with those of biopsies, which were performed on all nodules after the sonographic examination. RESULTS: Biopsy findings revealed that 29 nodules were benign and 5 malignant. Based on the 3D sonographic examination, 27 lesions were considered benign, and 7 were classified as malignant. Two of the latter diagnoses were false-positives; there were no false negatives (specificity: 93.1%, sensitivity: 100%, accuracy: 94.1%). CONCLUSIONS: 3D sonography can be used to calculate lesional mass for T1 staging of malignant breast nodules. It can also reveal wall irregularities in benign lesions that are missed on two-dimensional (2D) scans and the limits of infiltration of malignant lesions. The 3D power-Doppler examination provides a panoramic full-length view of blood vessels supplying the nodule, and the number of vessels visualized with this approach is higher than that observed on 2D studies.

Ultrasound examination of the liver: Normal vascular anatomy.

Various treatments for liver diseases, including liver transplant (particularly partial liver resection from a living donor), treatment of liver tumors, and TIPS, require detailed knowledge of the complex vascular anatomy of the liver. The hepatic artery and portal vein provide the organ with a double blood supply whereas venous drainage is furnished by the hepatic veins.Multislice computed tomography and magnetic resonance imaging provide undeniably excellent information on these structures. On ultrasound, the inferior vena cava, the openings of the hepatic veins, and the main branch of the portal vein can always be visualized, but intrasegmental vessels (portal, arterial, accessory hepatic venous branches) can be only partially depicted and in some cases not at all.In spite of its difficulty and limitations, hepatic sonography is frequently unavoidable, particularly in critically ill patients, and the results are essential for defining diagnostic and therapeutic strategies. For this reason, a thorough knowledge of the sonographic features of hepatic vascular anatomy is indispensable.

[Levofloxacin-induced bilateral rupture of the Achilles tendon: clinical and sonographic findings]. / Tendinopatia dell'achilleo da levofloxacina: dalle immagini alla diagnosi.

The fluoroquinolones are antibiotics widely used in the clinical practice. The concomitant use of corticosteroids and fluoroquinolones in elderly patients is recognised as a risk factor for developing clinically relevant tendon lesions. Fluoroquinolone-induced tendinopathy is underreported in the literature. A 67-year-old man, came to our observation complaining of 5 days history of bilateral heel pain. The patient had a medical history of sarcoidosis and was treated with a daily dose of 5 mg of prednisone. He was initially given oral levofloxacin (500 mg/die) for 10 days, because of an acute respiratory infection. Two days before the end of the antibiotic therapy, he developed bilateral heel pain. He denied any history of trauma. Physical examination revealed swelling and marked tenderness with mild palpation of the Achilles tendons at the calcaneal insertion. The ultrasound evaluation of the Achilles tendons revealed the following main abnormalities: diffuse thickening, loss of the "fibrillar" echotexture, blurred margins, and bilateral partial tendon tears. Bilateral Achilles tendon pain and rupture has been described as a rare adverse effect of fluoroquinolone treatment. Most of the fluoroquinolone-induced tendinopathies of the Achilles tendon are due to ciprofloxacin. To the best of our knowledge, this is the first description of bilateral Achilles tendon rupture due to levofloxacin. The risk/benefit ratio of the fluoroquinolones should be carefully considered and these drugs should be prescribed cautiously in elderly patients treated with corticosteroids. This case can be regarded as a representative example of the potential clinical efficacy of sonography in daily rheumatological practise.

[Late reactions to a radiologic contrast media (Iopamidol-Bracco). Prospective study]. / Reazioni tardive a un mezzo di contrasto radiologico (Iopamidolo-Bracco). Studio prospettico.

PURPOSE: This prospective, non-randomized study was aimed at evaluating the incidence of Delayed Adverse Drug Reactions (DADRs) to iodinated contrast agents and to evaluate possible risk factors to the development of these reactions. DADRs are those reactions occurring one to 48 hours after contrast medium administration. Their symptoms and frequency are not well defined, but the majority of DADRs are mild in intensity and resolve spontaneously without sequelae. In the literature, DADRs are reported to occur in 1 to 15% of patients undergoing contrast-enhanced examinations. MATERIAL AND METHODS: This prospective, non-randomized trial was carried out on 403 patients undergoing either dynamic CT or urography with iopamidol-300 (Iopamiro-300, Bracco SpA). Before the examination, data were collected regarding patients' anagraphical details, presence of risk factors, allergy, previous exposure and previous adverse reactions to iodinated contrast agent. After the examination, any adverse events occurring between 30 minutes and 48 hours post-dose were recorded, specifying time of onset and duration of symptoms. Studied variables were type of DADRs and risk factors to their development (sex, age, underlying disease, allergy, previous exposure to contrast agent, type of diagnostic examination). Two hundred and sixty-two patients were male (65%), and 141 were female (35%). Mean age was 61 years (+/- 11.8); 192 patients (48%) had underlying disease, and 115 (28%) were allergic. About half of the patients had previously undergone another contrast-enhanced examination. Two hundred and seventy-one patients underwent dynamic CT and 132 urography. RESULTS: A total of 50 patients (12.4%) reported DADRs. Factors associated with a significantly higher incidence of DADRs were found to be allergy (p = 0.001), previous exposure to contrast agent (p = 0.001), female sex (p = 0.001), underlying disease (p = 0.030). The most frequently reported DADRs were nausea and vomiting, drowsiness, rash, itching and headache. All reported reactions were mild and resolved spontaneously without sequelae. DISCUSSION AND CONCLUSIONS: In our experience, though limited and not on large numbers, DADRs to nonionic low osmolality contrast agents such as iopamidol have been few, mild, and not clinically significant. Although there are no absolute contraindications to the use of iodinated contrast agent, the risk/benefit ratio should always be evaluated, especially in patients with allergy, in those with severe renal, hepatic or cardiac insufficiency, and in diabetics.

Is CT scan monitoring useful in patients with epithelial ovarian cancer and follow-up negative CA 125 serum levels?

We retrospectively reviewed our series of ovarian cancers to assess the benefit of routine follow-up abdominal computer tomography (CT) scans in asymptomatic patients with CA 125 levels <35 U/ml. A chart review was undertaken of all patients with a diagnosis of ovarian cancers treated and followed at the Institute of Obstetrics and Gynecology, University of Ancona, from January 1986 to January 1994. In asymptomatic patients, the routine follow-up consisted of physical examination and CA 125 serum level determination every three to four months for the first two years, and every six months thereafter for a minimum of 5 years. At each visit, a history and a bimanual vaginal examination were completed. The pelvic and abdomen CT scans were performed every six months for the first year and then annually. Inclusion criteria were CA 125 levels >35 U/ml prior to surgery or initial chemotherapy, and complete routine follow-up. Fifty-two patients (75%) satisfied the inclusion criteria. After surgery, 32 of the 52 CA 125 positive patients (61%) showed a decrease in CA 125 levels; 10 other patients showed a negativity of CA 125 after cisplatinum polychemotherapy. After a median time of 49 months (range 16-117 months), 9 of the 42 patients (21%) developed a relapse. The overall CA 125 sensitivity at the time of relapse was 78%, with a specificity of 94%; the sensitivity for early detection of relapses was 70%. Two-hundred and seventy-six abdominal and pelvic CT scans were performed and 8 were positive for tumor relapse, with an overall sensitivity of 89%. The sensitivity of CT scans was 33% for early detection of relapses. The routine performance of follow-up CT scans did not significantly improve the overall detection of early relapses in ovarian carcinoma. A longitudinal monitoring of serum CA 125 is a reliable method of follow-up. Abdominal and pelvic CT scans should be performed in patients who, after a period in which they have been classified as not having evidence of disease with normal CA 125 serum levels, show elevated and rising CA 125, with the aim of finding and characterizing relapses.

[Critical analysis of the diagnostic imaging of focal hepatic lesions]. / Analisi critica della diagnostica per immagini delle lesioni epatiche focali.

The aim of this paper is to evaluate the number and type of consecutive initial diagnoses of focal hepatic lesions obtained by abdominal US and CT. The diagnoses were coded according to the Index for Radiological Diagnoses (ACR). From January 1990 through April 1991, US and CT diagnosed focal hepatic lesion in 16.4% and 9.1% of cases, respectively. A lower number of focal hepatic lesions was diagnosed by CT, which however was more accurate as to the nature of the lesion itself. This is due to the fact that CT is often used to stage hepatic neoplasms already confirmed by US-guided fine-needle biopsy (FBN). The correlation between the initial diagnosis and actual clinical status demonstrates a high rate of occasional findings, especially with US. The rate of questionable diagnoses relative to primary or secondary malignancies was very high. This could be explained by caution in making a severe diagnosis, by awareness of the limits of macroscopic diagnostic techniques and by the immediate availability of US-guided FNB. In conclusion, the coding of consecutive initial diagnoses, by US and CT, could contribute to a practical evaluation of diagnostic imaging techniques, especially when correlated with the respective anamnestic and clinical data. Further studies are necessary to confirm this hypothesis.

[Comparison of cytology and microhistology in ultrasonic_guided fine-needle biopsy of the prostate]. / Confronto tra citologia e microisotologia nel prelievo ecoguidato della prostata con aghi sottili.

The authors performed US-guided biopsy on 30 consecutive patients with prostatic masses of an undefined nature. Two samples were taken from each patient, one using an aspirating needle and another using a cutting needle. The two techniques proved to be quite complementary, even in the light of subsequent diagnostic follow-ups. Moreover, the possibility of comparing the cytological findings with the pathologic ones, with a "double blind" technique, greatly increased bioptic reliability.

[The impact of echo-guided percutaneous biopsy in the diagnosis of focal hepatic lesions]. / L'impatto della biopsia percutanea ecoguidata nella diagnosi delle lesioni epatiche focali.

In order to assess the clinical efficacy of percutaneous echo-guided biopsy (PBE), the authors evaluated its contribution to the diagnostic work-up and therapy selection in 165 cases of confirmed focal hepatic lesions. The cases were studied prospectively using a survey form. PBE yielded a significant contribution to the diagnosis in 79.4% of the cases. It was of substantial or conclusive value to therapeutic selection in 65% of the cases. Moreover, PBE allowed a high number of diagnoses which were unsuspected considering the previous standard clinical and instrumental work-ups. The clinical usefulness of PBE in focal hepatic lesion diagnoses is stressed. Its use saves time in the diagnostic management with considerable cost saving.

[Abnormalities of the female genital tract. Comparison of radiographic and echographic pictures]. / Malformazioni dell'apparato genitale femminile. Quadri radiografici ed ecografici a confronto.

An anatomical study of uterine malformations has become quite frequent in obstetrics and gynaecology because of the increasing use of corrective surgery. More than 100 cases were reviewed and the authors discuss some examples in order to present all kinds of uterine malformations which can be detected by ultrasound together with hysterosalpingography. A comparison of the diagnostic data obtained with the two methods shows US to be able to solve several cases. Hysterosalpingography is mandatory in female infertility when there is a need for examining Fallopian tube patency in addition to the morphological characteristics of the uterine cavity. The results obtained with the two methods in the study of uterine malformations allow the formulation of a diagnostic protocol concerning the study of infertile women. First of all, US must be performed, in order to exclude some causes of ovarian infertility and major uterine malformations. Hysterosalpingography should be performed when US does not prove to be totally reliable.

[Total parenteral nutrition and evaluation of nutritional status for the identification of patients at high risk]. / Nutrizione parenterale totale e valutazione dello stato nutrizionale per l'identificazione del paziente ad alto rischio.

The importance of using standardised parameters in pre-operative patient assessment is emphasised. This will identify nutritional deficiencies that are often unrecognised but play a decisive part in the patients' post-operative course. Above all such an assessment enables the clinician to administer the appropriate restorative treatment especially in the elderly patient.

[The elderly and the risk of biliary surgery]. / L'anziano ed il rischio della chirurgia biliare.

In a review of the results obtained in 5 years surgical treatment of elderly patients, the primary importance of performing elective operations on senile patients and building up such patients after careful assessment of nutritional parameters are emphasised. This reduces the risk of postoperative complications in patients who are mostly debilitated by concomitant conditions as well as presenting a reduced capacity for defence and organic recovery.

[Value of extrapolating data in tumor registries. An instrument for a deeper knowledge of epidemiology]. / Importanza della estrapolazione dei dati nei registri tumori. Uno strumento per una più approfondità conoscenza epidemiologica.

The delay in creating an Italian tumour register is pointed out with emphasis on the importance of such registers for epidemiological and clinical purposes and for both prevention and treatment. The need for more widespread information collection in this area is emphasised.

Spontaneous rupture of renal angiomyolipoma with perinephric haemorrhage: sonographic findings.

The sonographic findings observed in four patients with spontaneous rupture of a renal angiomyolipoma and perinephric haemorrhage are presented. In all cases, a hyperechoic renal mass surrounded by a large hypoechoic haematoma was identified. Furthermore, the actual site of rupture of the tumour could be seen in one case as a wedge-shaped hypoechoic structure extending from the periphery to the centre of the mass. CT has been suggested as the method of choice in the assessment of both the presence and extent of haemorrhagic complications of angiomyolipomas. However, since such lesions can be demonstrated and identified by ultrasound, which is often used as the first imaging procedure in abdominal complaints, the technique may also prove of value in planning further diagnostic tests and in choosing the appropriate therapeutic approach to these patients.

Ultrasound-computerized tomography in neonatal encephalic pathology.

The echoencephalographic examinations of 127 neonates were analysed to verify the role of US in the study of neonatal cerebral pathology, and to compare it with CT. US was of value in identifying the existence of a cerebral lesion and for follow-up. CT was more reliable for the characterization of the lesion and in establishing the surgical indications.