Spigelian hernia: diagnosis by high-resolution real-time sonography.

The purpose of this study was to demonstrate the role of high-resolution real-time sonography in the diagnosis of spigelian hernias. The sonographic findings in three patients, two of whom had surgical confirmation, are presented. We also discuss and demonstrate the anatomic and pathologic factors that predispose to these hernias. In all three cases, real-time high-resolution sonography was very helpful in providing detailed images of the abdominal wall defect, the hernial sac and contents, and the relationship of the contents to the spigelian fascia and the rectus, external oblique, and internal oblique muscles. The role of the Valsalva and other provocative maneuvers in demonstrating the "in and out" sliding movement of the contents of the hernia also is discussed. Although the number of cases in our study is small, we think that this modality may be the most effective means for establishing this diagnosis, especially in cases with equivocal clinical findings.

Pulsatile lower limb venous Doppler flow: prevalence and value in cardiac disease diagnosis.

The purpose of this study was to assess the frequency and significance of pulsatile Doppler waveforms in lower limb veins. We used Doppler sonographic data from the common femoral vein. In the first of two groups, the findings in 250 patients were correlated with the presence of cardiac decompensation on concurrent chest radiographs. In the second group, the findings in 81 patients were correlated with the presence of tricuspid regurgitation on Doppler echocardiograms. A venous Doppler sonographic examination was considered normal if spontaneous anterograde phasic flow was present and pulsatile if flow had a cyclic retrograde component. In group 1, 21% had pulsatile waveforms whereas 24% had cardiac decompensation. In group 2, 36% had pulsatile waveforms and 43% had tricuspid regurgitation. A statistically significant correlation was found between the presence of these abnormal waveforms and cardiac decompensation or tricuspid regurgitation, with sensitivities of 57% and 54%, specificities of 91% and 78%, positive predictive values of 66% and 66%, negative predictive values of 87% and 69%, and accuracies of 82% and 68%, respectively. In a subgroup of 55 patients who had both tests for correlation and in whom both were in agreement, the sensitivity of venous Doppler sonographic examination for detecting pathologic cardiac conditions was 79%, specificity was 87%, positive predictive value was 83%, negative predictive value was 84%, and accuracy was 84%. In 77 patients with pulsatile waveforms, including 24 without concurrent chest radiographs or echocardiograms, 63 (82%) had no prior history of cardiac disease. When correlated separately with chest radiograph or Doppler echocardiography, the test is not very sensitive in the diagnosis of cardiac disease; however, when both correlating tests are performed and are in agreement, all diagnostic parameters of the venous Doppler sonographic test, including sensitivity, become fairly high. The presence of pulsatile lower limb venous Doppler flow should alert the sonologist that a pathologic cardiac condition may be the culprit, especially in patients who have no such prior diagnosis.

Pulsatile venous Doppler flow in lower limbs: highly indicative of elevated right atrium pressure.

OBJECTIVE: The purpose of this study was to determine if pulsatile flow in lower limbs as seen on venous Doppler waveforms correlates with increased right atrium pressure. MATERIALS AND METHODS: Of 429 patients who, over a 14-month period, underwent venous Doppler imaging of the lower limb to exclude deep venous thrombosis, 343 records were available for review at the time of the study. Of these, 74 had right atrium pressure measurements available for correlation. Seventeen patients were excluded because of thrombosis in the common femoral vein. Six other patients were also excluded because the time difference between the Doppler and the correlative studies was more than 4 weeks. The remaining 51 patients constituted the study subjects. In 18 of these, the right atrium pressure was measured within 1 week, 31 within 2 weeks, 42 within 3 weeks, and 51 within 4 weeks. In the study, we evaluated the three major veins of the lower limb (the common femoral, superficial femoral, and popliteal) by venous Doppler imaging. Data from only the common femoral vein were included in our analysis because this vessel was the least involved with thrombosis. The findings were correlated with the presence or absence of right-sided heart failure as determined by right atrium pressure measurement. A Doppler waveform was considered pulsatile when it had a cyclic retrograde component. A right atrium pressure of more than 8 mm Hg was considered elevated. RESULTS: Of 51 patients, 17 (33%) had pulsatile lower limb venous Doppler flow waveforms and 33 (65%) had elevated right atrium pressure. We found a statistically significant correlation between the presence of these abnormal waveforms and elevated right atrium pressure. The sensitivity of lower limb venous Doppler imaging for detecting right-sided heart failure as determined by right atrium pressure measurement was 46%, specificity was 94%, positive predictive value was 94%, negative predictive value was 50%, and accuracy was 65%. CONCLUSION: Pulsatile lower limb venous Doppler waveform correlates well with right-sided heart failure, as indicated by a right atrium pressure measurement of more than 8 mm Hg. However, because of its low sensitivity, lower limb venous Doppler imaging cannot be used to screen for right-sided heart failure.