Color doppler ultrasound of liver lesions: signal enhancement after intravenous injection of the ultrasound contrast agent Levovist.

Patients with focal liver lesions (hemangioma, focal nodular hyperplasia, adenoma, hepatocellular carcinoma, metastatic lesions, focal fatty lesion) received the ultrasound contrast agent Levovist (300 mg/mL and 400 mg/mL) intravenously. This ultrasound contrast agent (a suspension of micrometer-sized microparticles of galactose and microscopic gaseous bubbles) can pass through the lungs without impairment. After the administration of Levovist, increased color flow signals were detected in the liver. Five of 6 patients with metastatic liver lesions showed previously undetected blood flow in the rim of the tumor. In 4 patients with hepatocellular carcinoma, enhanced signal intensity was observed in the vessels of the rim and in 3 of those patients in the center of the tumor. One patient with adenoma and one patient with focal nodular hyperplasia showed signal enhancement in the central area of the tumor. No signal enhancement was observed in hemangiomas, a focal fatty lesion, or in a carcinoid metastatic lesion. Levovist increased the echointensity of normal and tumor vessels in liver lesions. This new ultrasound contrast agent led to the detection of tumor vessels previously not detectable by conventional color flow imaging.

[Imaging tumor vascularization of hepatocellular carcinoma with ultrasound angiography]. / Darstellung der Tumorvaskularisation von hepatozellulären Karzinomen mit Ultraschall-Angiographie.

AIM: With the introduction, in 1994, of Ultrasound Angio (UA), a technical innovation in sonographic colour coded blood-flow detection has become available using angle-independent amplitude signal plotting leading to an enhanced sensitivity in blood flow detection. METHOD: In a first application study we attempted to verify an improved blood-flow detection in hepatocellular carcinomas (HCC) compared to conventional colour coded duplex sonography. RESULTS AND CONCLUSION: In all patients with HCC we found a highly improved detection of internal vascularity. In one patient, we could even detect blood flow in the tumour which was not visible with several other conventional highly sensitive colour duplex equipment.

[Follow-up of vena cava filters with color Doppler ultrasound]. / Verlaufskontrolle von Kavaschirmen mit der Farbdopplersonographie.

In 49 patients, colour-coded Duplex sonography was performed after implantation of a Greenfield caval filter. A plain film radiograph of the abdomen was taken additionally. The examination could be assessed free of artifacts in the longitudinal and transverse section in a total of 41 patients (84%). The procedure facilitates not only a diagnosis of thrombotic changes in the vena cava but can also display the topographical position of the filter and the venous flow. Caval thrombosis was verified in 5 patients. In 7 cases there was a decentral position of the filter apex with tilting. The penetration of filter struts through the vein wall eluded sonographic diagnosis as did morphological changes to the filter (e.g. filter fracture). In combination with the plain film radiograph, colour-coded Duplex sonography can replace cavography or computed tomography in the investigation of position and venous flow.

[Acceptance of electronic data processing supported documentation of ultrasound findings in routine clinical practice. A survey]. / Akzeptanz EDV-unterstützter Dokumentation von Ultraschallbefunden im klinischen Alltag. Eine Umfrage.

We carried out a survey to determine the acceptance of the ultrasound documentation software, CUBUS, in clinical practice. Since August 1, 1988, CUBUS, versions V1.01 to V2.02 has been employed in clinical routine. By October 1991 10,850 reports had been stored in version 2.02. The software is installed on a personal computer (Siemens PCD-2, 40MB, 640 KB RAM) to which a laserprinter is connected. The work of operating the system is shared between the nursing and medical staff. In order to investigate the acceptance of the printed reports produced with this system, we carried out a poll among the physicians working at the hospital. Among the 86 physicians who receive 95% of the US reports, 58% (n = 50) responded. On the basis of the categories good, satisfactory, adequate and poor, we requested an assessment of layout, presentation, comprehension, completeness and overall impression. The overall impression was assessed as good or satisfactory in 34% and 42%, respectively. In the case of the individual criteria (see above), the categories good and satisfactory scored 62% and 34%, 58% and 32%, 68% and 18% and 72% and 24%, respectively. The terminology used was accepted by 84%. Addition of, for example, image documentation, and endosonography, will expand the advantages of the input of findings and further improve the good overall impression made by the report printout in our survey, so that the relatively long input time requirement accounting for some 30% of the total examination time, is accordingly justified.

[Diagnosis of phlebothrombosis using color-coded duplex sonography. A prospective comparison with phlebography]. / Diagnostik der Phlebothrombose durch farbkodierte Duplexsonographie. Ein prospektiver Vergleich mit der Phlebographie.

In a prospective study the reliability of colour-coded duplex-sonography (CCDS) and phlebography in the diagnosis of deep leg and pelvic vein thrombosis was compared. In 82 consecutive in- or out-patients (42 men, 40 women; mean age 53 [19-86] years) with clinically suspected leg or pelvic vein thrombosis the results of 275 phlebographies (reference method) and 275 CCDS were compared on admission and during follow-up. The two methods were performed less than 6 hours apart. In the diagnosis of thrombosis the sensitivity of CCDS was 99%, specificity 80%. In 88% of all tests, the different thrombosis levels, as diagnosed by phlebography, were also demonstrated by CCDS. These data indicate that, if the clinical picture of suspected deep leg or pelvic vein thrombosis is unclear, CCDS should be done first. Phlebography should be performed only if the results of the former are inconclusive.

[Endoscopic-sonographic control of cystogastric catheter drainage of pancreatogenic fluid collections]. / Endoskopisch-sonographisch geführte zystogastrale Katheterdrainagen pankreatogener Flüssigkeitsansammlungen.

In 1985, Hancke published a report on cystogastrostomy using a double pigtail catheter as an alternative to surgical drainage of pseudocysts. Between 1986 and 1991, with the aim of testing the technique, we carried out a prospective study in 39 patients with 40 pancreatic collections of fluid. The object of the study was to identify those collections of fluid that would be suitable for cystogastric drainage. Among the first 20 patients thus treated, permanent evacuation of the cyst was achieved in eleven. In the other nine patients, the reasons for the failure of cystogastric drainage included to immature a cyst, too small a cyst, prior cyst infection and status after a BII resection. For the patients No. 21 to 40, these conditions were adopted as exclusion criteria, with the result that we were able to increase the percentage of permanent emptying to 75%. This makes cystogastric drainage a genuine alternative to surgical and other drainage procedures. As a minimally invasive intervention, it is a first choice therapeutic procedure in suitable pancreatic pseudocysts. If cystogastric drainage is shown not to be feasible, the possibility of employing percutaneous drainage should be investigated. Surgical drainage procedures are reserved for use in such cases as cannot be treated with catheter drainage.

Localization of pancreatic endocrine tumors by endoscopic ultrasonography.

BACKGROUND: After a pancreatic endocrine tumor has been diagnosed on the basis of clinical signs and the results of laboratory tests, localization of the tumor by the usual imaging procedures fails in as many as 40 to 60 percent of patients. Endoscopic ultrasonography, a sensitive test for small carcinomas of the pancreas, might also be useful in patients with endocrine tumors of the pancreas that cannot be localized by conventional methods. METHODS: We studied 37 patients later shown to have 39 endocrine tumors of the pancreas who had negative results on transabdominal ultrasonography and CT. All the patients underwent endoscopic ultrasonography, and 22 also underwent selective angiography. All the tumors were confirmed by surgical excision and immunohistologic examination; they consisted of 31 insulinomas, 7 gastrinomas, and 1 glucagonoma, 0.5 to 2.5 cm (mean, 1.4 cm) in diameter. All but one of the patients were cured of their disease, as ascertained by at least six months of clinical and laboratory follow-up. RESULTS: Using endoscopic ultrasonography, we were able to localize 32 of the 39 tumors (sensitivity, 82 percent); no tumor was incorrectly localized. The size of the tumors was very similar (within 2 mm) to that predicted by endoscopic ultrasonography. Among the 22 patients who underwent both angiography and endoscopic ultrasonography, ultrasonography was significantly more sensitive than angiography for tumor localization (sensitivity, 82 percent vs. 27 percent). Among 19 control patients without pancreatic endocrine tumors, endoscopic ultrasonography was negative in 18 (specificity, 95 percent). CONCLUSIONS: Endoscopic ultrasonography is a highly sensitive and specific procedure for the localization of pancreatic endocrine tumors. It should be considered for the preoperative localization of such tumors once the clinical and laboratory diagnosis has been established.

[Polypoid lesions of the gallbladder--preventive cholecystectomy?]. / Polypoide Läsionen der Gallenblase--prophylaktische Cholecystektomie?

During nine years (1979-1988) there was carried out cholecystectomy in 21 patients for gallbladder polyps of unknown histology. The sex ratio female to male was 9 to 12, median age 51 (29-76) years. Most of the polyps were smaller than 5 mm, all proved to be cholesterol polyps, showing multiple localisations. Two benign adenomas had a size of 6 resp. 9 mm. Among the polyps with a diameter of more than 10 mm we found only two cholesterol polyps, but one heterotopia, one adenoma and one adenocarcinoma. Cholecystectomy is indicated for polyps with a diameter of more than 10 mm or suspicious sonographic criteria, especially sessile lesions or concomittant thickening of the gallbladder wall.

[Diagnosis of gastroenterologic diseases with sonography. Part 4: Interventional sonography, endoscopic sonography]. / Diagnostik gastroenterologischer Erkrankungen mit der Sonographie. Teil 4 (Schluss): Interventionelle Sonographie, endoskopische Sonographie.

Ultrasonography permits targeted aspiration under constant vision. The aspiration needle may be passed independently of the transducer head, may be attached laterally to the transducer, or centrally integrated within a special aspiration transducer. The complication rate, which depends upon the size of the needle, is low, so that the indication for this procedure can be "liberal". The development of every smaller probes with increasing resolution has resulted in an increase in the range of applications of endosonography, and there is already a whole spectrum of accepted indications for endosonographic inspection.

[Needle tract metastasis following sonographically guided puncture of a mesenteric lymph node metastasis in Pancoast's tumor]. / Stichkanalmetastase nach sonographisch gezielter Punktion einer mesenterialen Lymphknotenmetastase bei Pancoast-Tumor.

Peripheral bronchial carcinoma with infiltration of the right lateral thoracic wall (Pancoast tumour) was demonstrated in a 60-year-old man with breathing-related pain in the right thoracic wall of two months' duration. As part of tumour staging needle puncture of an intra-abdominal space-occupying lesion was performed, guided by ultrasonography. Histological examination confirmed it as a bronchial carcinoma metastasis. Combined radio- and chemotherapy hardly influenced tumour growth. Three months later a subcutaneous lesion became palpable in the area of the previous needle puncture which on excision proved to be a metastasis. The patient died 10 months later from the bronchial carcinoma. Percutaneous puncture of potentially malignant space-occupying lesions must be strictly indicated. The frequency of needle tract seeding is not exactly known.

[Diagnosis of gastroenterologic diseases with sonography. Part 2: Gallbladder and bile ducts]. / Diagnostik gastroenterologischer Erkrankungen mit der Sonographie. Teil 2: Gallenblase und Gallenwege.

The anatomical position of the gallbladder makes it readily accessible to ultrasonographic visualization. Gallstones, gravel and sludge present no diagnostic problems. Acute cholecystitis, empyema and perforation may be more difficult to detect. In the presence of large or numerous stones in the gallbladder, there is a danger of overlooking a carcinoma of the gallbladder. Bile duct carcinomas are difficult to detect by ultrasonography. While bile duct dilatation and the site of an occlusion are readily detected, the cause of the occlusion is usually not revealed by ultrasonography.

[Diagnosis of gastroenterologic diseases with sonography. Part 3: Pancreas and spleen]. / Diagnostik gastroenterologischer Erkrankungen mit der Sonographie. Teil 3: Pankreas und Milz.

Ultrasonic assessment of the pancreas is rendered difficult by interposed gas-containing loops of bowel and stomach. In 50% of the cases, meteorism and ileus prevent the diagnosis of acute pancreatitis. In the case of chronic pancreatitis, focal pancreatitis and carcinoma of the pancreas, too, further diagnostic procedures (CT, ERCP, fine-needle aspiration) are required. As a rule, the caliber of the pancreatic duct can readily be assessed, and may, for example, indicate a carcinoma in the head of the pancreas. Splenomegaly and focal or diffuse parenchymal lesions are detectable by ultrasonography, although an etiological differentiation is not usually possible. The most common lesions are the so-called "bland" splenic cysts. Of importance is the diagnosis of rupture of the spleen, which requires immediate treatment.

[Diagnosis of gastroenterologic diseases with sonography. Part 1: Principles--ultrasound diagnosis of diffuse and local liver damage]. / Diagnostik gastroenterologischer Erkrankungen mit der Sonographie. Teil 1: Grundlagen--sonographische Diagnostik diffuser und lokaler Leberschäden.

Ultrasonography has now become an integral part of the gastroenterological diagnostic work-up and treatment. In some clinical problems it may be employed as the sole procedure, for example in the diagnostic evaluation of gallstones, for measuring the size of the liver and spleen, or in the detection of free fluid within the peritoneal cavity. Among the diffuse lesions of the liver, macronodular cirrhosis and typical forms of fatty liver can be diagnosed ultrasonographically, while the majority of such diffuse changes are not amendable to ultrasonographic evaluation. Cystic lesions of the liver are often diagnosable with ultrasonography, while many circumscribed solid lesions, such as metastases or focal-nodular hyperplasia, pose a differential diagnostic problem.

[Imaging procedures prior to the extracorporeal shockwave lithotripsy of gallstones]. / Bildgebende Verfahren vor extrakorporaler Stosswellenlithotripsie von Gallenblasensteinen.

In order to determine whether cholecystography and computed tomography (CT) are capable of better gallstone characterization than conventional radiography alone, 91 patients (76 females, 15 males; mean age 47 +/- 12 years) with symptomatic single gallstones were studied prospectively prior to extracorporeal shock-wave lithotripsy with concomitant oral stone dissolution therapy. In addition, the value of oral cholecystography in demonstrating patency of the cystic duct was compared with ultrasound assessment of gallbladder function. Despite "negative" plain gallbladder radiographs in all patients, oral cholecystography showed significant stone calcification in 8 of the 91 patients and CT showed stone calcifications in 52 of the 91 patients. In 12 patients the maximum stone density was between 50 and 90 Hounsfield units, and in 40 patients it was more than 90 Hounsfield units. CT revealed ring-like calcification in the majority (79%) of these stones. Oral cholecystography showed satisfactory concentration of contrast medium in all patients, while ultrasonography of the gallbladder following a chemically defined test meal demonstrated contractility of more than 50% of initial volume in 69 patients and of less than 30% in 9 patients. Although oral cholecystography is a simple, readily available complication-free method, ultrasound assessment of gallbladder contraction is better for selecting patients for extracorporeal shock-wave lithotripsy. CT allows significantly better characterization of gallstones than oral cholecystography and conventional plain gallbladder radiography.

[Polypoid lesions of the gallbladder]. / Polypoide Läsionen der Gallenblase.

Ultrasound examination of the gallbladder was performed in a prospective study (from 1985 to 1988) of 14,841 consecutive patients. Polypoid changes were found in 224 (129 men, 95 women; mean age 54 [18-88] years), sonographically classified as cholesterol polyps in 212, as polypoid lesions of uncertain benignity in 12. Mean observation time of 92 patients with cholesterol polyps was 9 (3-48) months. In six the polyp diameter increased by up to 5 mm: only two of them were operated upon and the diagnosis was confirmed in both. A total of 21 patients suspected of having cholesterol polyps were operated upon, the diagnosis confirmed in 17, chronic cholecystitis in two and, in one case each, thickened wall-adherent bile or wall-adherent concrements as cause of the ultrasound changes. Six of the 12 patients with polypoid lesions of uncertain benignity were operated upon: two had an adenoma, one each had tissue heterotopy, malignant melanoma metastasis, gall-bladder carcinoma and adenomyomatosis.

Extracorporeal piezoelectric shockwave lithotripsy of multiple pancreatic duct stones under ultrasonographic control.

The first ultrasonographically controlled fragmentation of multiple pancreatic duct stones of up to 14 mm size by means of extracorporeal, piezoelectric shockwave lithotripsy is reported. On account of the ultrasound localization and continuous control during therapy a nasopancreatic tube for instillation of contrast medium and frequent x-ray checks were not necessary. The 48-year-old patient did not experience any pain during the four treatment sessions and during the follow-up period. No complications were noted.

Fragmentation of biliary calculi by means of extracorporeally generated piezoelectric shock waves.

A new extracorporeal piezoelectric lithotripter was tested for its gallstone disintegration capability. A total of 177 surgically removed gallbladder stones were submitted to piezoelectric shock-wave treatment. Prior to shock-wave application, the diameter, weight, and volume of all the stones and CT density and MR signal intensity of selected stones were determined. After shock-wave application, the chemical composition of the stones was investigated by x-ray diffractometry and/or infrared spectrometry. All the stones (maximum diameter 6-30 mm) were successfully fragmented; calculi with a maximum diameter of 17 mm, a maximum weight of 1800 mg, and a maximum volume of 2 cc were regularly disintegrated into fragments less than or equal to 4 mm. The number of shock waves required correlated most closely with volume (r = 0.82, P less than 0.001), weight (r = 0.81, P less than 0.001) and, to a somewhat lesser degree, diameter (r = 0.62, P less than 0.001). No correlation was found between the chemical composition, CT density, or MR intensity of the calculi and the number of pulses needed for fragmentation.