[Ultrasound-guided biopsy of the pancreas: a multicenter study]. / Punción pancreática ecodirigida: estudio multicéntrico.

OBJECTIVE: Members of "Asociación de Ecografía Digestiva" decided to carry out a multicenter retrospective study on fine-needle aspiration biopsy for pancreatic space-occupying lesions under ultrasonographic guidance and via the percutaneous route in order to assess this technique s performance versus endoscopic ultrasound-guided biopsy. SUBJECTS: 10 hospitals for a total of 222 patients with suspiciously malignant, 8-120-mm pancreatic lesions were included in the study. RESULTS: The analysis of results shows a sensitivity of 89%, a specificity of 98%, a positive predictive value of 99%, and a negative predictive value of 74%, for an overall diagnostic accuracy of 91%. No major complications occurred. CONCLUSION: Percutaneous fine-needle aspiration for pancreatic lesions is highly cost-effective and has few and mild complications.

Punción pancreática ecodirigida: estudio multicéntrico / Ultrasound-guided biopsy of the páncreas: a multicenter study

Objetivo: en el seno de la Asociación de Ecografía Digestivase decidió realizar un estudio retrospectivo multicéntrico sobre lapunción-aspiración con aguja fina (PAAF) de lesiones ocupantesde espacio pancreáticas, mediante control ecográfico y por víapercutánea, con el objetivo de valorar el rendimiento de dicha técnicay poder compararla con la punción mediante ultrasonografíaendoscópica.Participantes: en el estudio han participado 10 hospitalescon 222 pacientes con lesiones pancreáticas entre 8 y 120 mm,sospechosas de malignidad.Resultados: el análisis de los resultados muestra una sensibilidaddel 89%, especificidad 98%, valor predictivo positivo 99% ynegativo 74%, con precisión diagnóstica global 91%. No encontramosninguna complicación significativa.Conclusión: la PAAF de lesiones pancreáticas por vía percutáneaes de alta rentabilidad diagnóstica y con pocas y leves complicaciones

Objective: members of “Asociación de Ecografía Digestiva”decided to carry out a multicenter retrospective study on fine-needleaspiration biopsy for pancreatic space-occupying lesions underultrasonographic guidance and via the percutaneous route in orderto assess this technique’s performance versus endoscopic ultrasound-guided biopsy.Subjects: 10 hospitals for a total of 222 patients with suspiciouslymalignant, 8-120-mm pancreatic lesions were included inthe study.Results: the analysis of results shows a sensitivity of 89%, aspecificity of 98%, a positive predictive value of 99%, and a negativepredictive value of 74%, for an overall diagnostic accuracy of91%. No major complications occurred.Conclusion: percutaneous fine-needle aspiration for pancreaticlesions is highly cost-effective and has few and mild complications

Tumor mucinoso papilar intraductal pancreático / Pancreatic intraductal papillary mucinous tumor

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Ultrasonography in patients with chronic liver disease: its usefulness in the diagnosis of cirrhosis.

OBJECTIVE: To prospectively assess the usefulness of ultrasonography in predicting the presence of cirrhosis in patients with asymptomatic chronic liver disease in unknown stage. EXPERIMENTAL DESIGN: Eighteen doppler and ultrasonographic features were prospectively assessed immediately before performing laparoscopy and/or liver biopsy. Usefulness of predictive variables selected by multiple regression analysis and included in a scoring scale was determined by ROC curves. PATIENTS: One hundred and thirteen consecutive patients with neither clinical nor biochemical signs of advanced liver disease submitted for study. RESULTS: Liver enlargement, liver surface nodularity, liver parenchyma distortion, flattening of flow wave in hepatic veins, portal and splenic veins dilatation, decreased variability in splenic vein caliber with breathing. Collateral vessels, and splenomegaly were associated to cirrhosis. Multivariate analysis showed the joint assessment of hepatic echostructure, portal vein caliber and spleen area to be the best approach to ultrasonographic staging, with sensitivity of 80%, specificity of 92% and accuracy of 89% in the diagnosis of cirrhosis. CONCLUSIONS: Ultrasonography enabled the presence or absence of cirrhosis to be correctly determined even in patients with asymptomatic disease. Combined assessment of hepatic echostructure, portal vein diameter and spleen size provides the highest accuracy.

Utilidad de la ecografía en el diagnóstico de cirrosis en pacientes con hepatopatía crónica / Ultrasonography in patients with chronic liver disease: its usefulness in the diagnosis of cirrhosis

Objetivo: establecer la utilidad de la ecografía en la predicción de la existencia de una cirrosis hepática en pacientes con enfermedad hepática crónica clínicamente silente. Diseño experimental: estudio prospectivo y ciego. Inmediatamente antes de la realización de laparoscopia y/o biopsia hepática se practicó una ecografía abdominal, con estudio Doppler. Mediante regresión logística múltiple se determinó el valor predictivo para la presencia de cirrosis de 18 variables analizadas. Mediante curvas ROC se estableció la precisión de las variables predictoras para determinar la presencia o ausencia de cirrosis. Pacientes: ciento trece pacientes consecutivos sin indicios clínicos ni bioquímicos de enfermedad hepática avanzada ingresados para filiación de una hepatopatía crónica. Resultados: el tamaño hepático, la irregularidad de la superficie hepática, la alteración en su ecoestructura, el aplanamiento de la onda de flujo de la vena suprahepática, la dilatación de las venas porta y esplénica, la disminución de las modificiaciones del calibre de la vena esplénica con la respiración, la presencia de circulación colateral y la evidencia de esplenomegalia se asociaron a la presencia de cirrosis. La valoración conjunta de la ecoestructura hepática, el calibre de la vena porta y el tamaño del bazo permitió establecer el diagnóstico de cirrosis con una sensibilidad del 80 por ciento, especificidad del 92 por ciento y precisión del 89 por ciento. Conclusiones: la ecografía permite analizar correctamente la presencia o ausencia de cirrosis aún en pacientes sin indicios clínicos de insuficiencia hepatocelular ni hipertensión portal. La mayor precisión diagnóstica se obtiene mediante la valoración conjunta de la alteración en la ecoestructura hepática, el calibre de la vena porta y el tamaño del bazo (AU)

[Renal Doppler ultrasonography and its relationship with the renal function in patients with liver cirrhosis]. / Ecografía Doppler renal y su relación con la función renal en pacientes con cirrosis hepática.

BACKGROUND: To relate the renal hemodynamic changes, as assessed by Doppler ultrasonography,with the development of ascites, renal function, and endogenous vasoactive systems in patients with liver cirrhosis. PATIENTS AND METHODS: 60 cirrhotic patients were studied prospectively, 31 of these compensated and 29 with ascites. The renal resistive index, renal function and plasmatic levels of renin, aldosterone, noradrenaline and ADH activity were determined. RESULTS: The renal resistive index was significantly higher in the cirrhotic patients with ascites (0.68) than in the compensated cirrhotics (0.63) and was significantly correlated with the serum levels of creatinine,urinary excretion of sodium, plasmatic renin activity and plasmatic concentration of aldosterone. CONCLUSIONS: The renal resistive index, study by means of Doppler ultrasonography, shows progressively increased levels with the evolution of the disease, with the deterioration of the renal function and with the activation of the endogenous vasoactive systems.

Ecografía Doppler en la valoración de la hemodinámica renal en pacientes con hepatopatía crónica / Doppler ultrasonography in the assessment of renal hemodynamics in patients with choric liver disease

OBJETIVO: valorar los cambios hemodinámicos renales mediante determinación con ecografía Doppler del índice de resistencia (IR) renal en pacientes con hepatopatía crónica en diferentes estadios evolutivos. En pacientes con cirrosis, analizar el IR renal en función de la presencia o no de ascitis y la respuesta al tratamiento diurético. PACIENTES Y MÉTODOS: se estudió de forma prospectiva 24 sujetos con hepatitis crónica, 39 pacientes cirróticos compensados y 34 con ascitis. Los cirróticos con ascitis se dividieron en grupo 1: con respuesta a medidas dietéticas y bajas dosis de diuréticos, y grupo 2: ascitis refractaria o que precisan dosis superiores de diuréticos. RESULTADOS: El IR renal fue significativamente superior en los pacientes cirróticos con ascitis (0,68 ñ 0,06) que en los cirróticos compensados (0,63 ñ 0,03; p < 0,01), y en éstos que en los sujetos con hepatitis crónica (0,61 ñ 0,04; p < 0,05). Los cirróticos con ascitis del grupo 1 presentaron un IR renal inferior a los del grupo 2 (0,65 ñ 0,05 vs 0,72 ñ 0,06; p < 0,01). CONCLUSIONES: el IR renal se incrementa conforme avanza la hepatopatía crónica. Los pacientes cirróticos con elevación del IR renal son no respondedores o requieren mayor dosis de diuréticos. Se requieren estudios para valorar la utilidad del IR renal en la predicción de la respuesta al tratamiento diurético en pacientes con ascitis (AU)

Risk factors for hepatocellular carcinoma in patients with liver cirrhosis.

OBJECTIVE: Although cirrhosis is known to predispose toward hepatocellular carcinoma (HCC), there is no agreement on the factors that can influence the risk for HCC in patients with cirrhosis. This study was designed to identify differences in cirrhosis-related risk factors for developing HCC in relation to epidemiological characteristics, stage of the disease and etiology. METHODS: 512 patients from southwestern Spain with Child-Pugh stage A or B cirrhosis were examined periodically by ultrasonography, and alpha-fetoprotein (AFP) concentration was measured. RESULTS: The average length of follow-up was 37 months. A total of 52 cases of HCC were detected, which represented a risk of 17% after 5 years of follow-up. The Cox model showed that the risk of HCC increased by 8% per year of increasing age. Male sex (relative risk: 3.4), hepatitis C virus infection (relative risk: 4.6), hepatitis B virus infection (relative risk: 2.9) and AFP levels higher than 15 ng/ml (relative risk: 2.5) were also shown to be risk factors. Among alcoholic patients, only age (risk increased by 15% per year), and hepatitis C virus infection (relative risk: 5.4) were risk factors for HCC. However, in patients infected by hepatitis C virus, the main risk factors were age (relative risk increased by 8% per year), male sex (relative risk: 3.9), co-infection with hepatitis B virus (relative risk: 4.9), and increased AFP (relative risk: 2.8). Of the patients with HCC, 71% were infected with hepatitis C virus. Alcoholism, Child-Pugh stage and duration of cirrhosis did not increase the risk of the appearance of HCC. CONCLUSIONS: The risk of HCC increased to 17% after 5 years of follow-up in patients with Child-Pugh stage A or B cirrhosis. Hepatitis C virus infection was the main risk factor in patients with cirrhosis. Other risk factors were age, male sex, hepatitis B virus infection and altered AFP level.

Factores de riesgo de aparición del carcinoma hepatocelular en pacientes con cirrosis hepática / Risk Factors for hepatocellular carcinoma in patients with liver cirrhosis

OBJETIVO: determinar la existencia de diferencias en el riesgo de presentar un carinoma hepatocelular (CHC) en pacientes con cirrosis en función de sus características epidemiológicas, evolución de la hepatopatía y su etiología. PACIENTES Y MÉTODOS: 512 pacientes cirróticos en grado A/13 de Child-Pugh menores de 70 años fueron valorados periódicamente mediante ecografía y determinaciones de alfa-fetoproteína (AFP). RESULTADOS: tras un seguimiento medio de 37 meses se detectaron 52 CHC (riesgo acumulado del 17 por ciento a los 5 años). El modelo de Cox demostró que por cada año de edad el riesgo de CHC se incrementó un 8 por ciento. El sexo varón (RR: 3,4), la infección por virus C (RR: 4,6), la infección por el virus B (RR: 2,9) y la alteración de la AFP (RR: 2,5) también se mostraron como factores de riesgo. Entre los pacientes etílicos, sólo la edad (incremento del 15 por ciento por cada año transcurrido) y la infección por el virus C (RR: 5,4) fueron factores de riesgo. En los pacientes infectados por el virus C supusieron un mayor riesgo: la edad (S por ciento por cada año), el sexo varón (RR: 3,9), la coinfección por el virus B (RR: 4,9) y la elevación de la AFP (RR: 2,8). El 71 por ciento de los pacientes con CHC tenían infección por el virus C. El etilismo y la duración de la cirrosis no incrementaron el riesgo de aparición del tumor, CONCLUSIONES: el riesgo de aparición del CHC asciende al 17 por ciento tras 5 años de seguimiento en pacientes con cirrosis en grado A/B de Child-Pugh. El virus C es el principal factor de riesgo en nuestro medio. Otros factores demostrados son la edad, el sexo varón, la infección por el virus B y la alteración de la AFP. El etilismo y la duración de la hepatopatía no influye en el riesgo de aparición del tumor (AU)

[Hepatic abscesses: is simple aspiration puncture with echography control an alternative to catheter drainage?]. / Abscesos hepáticos: es la punción-aspiración simple con control ecográfico una alternativa al drenaje con catéter?

UNLABELLED: Percutaneous drainage is currently the treatment of choice in liver abscess. The most commonly used technique is catheter placement but this procedure is not free of complications. OBJECTIVE: To analyze the safety and efficacy of needle aspiration in the treatment of liver abscesses. PATIENTS AND METHODS: Non-random, prospective study of nine patients with pyogenic liver abscess who underwent simple needle aspiration with sonographic guidance. RESULTS: In all patients, aspiration identified the etiologic agent. In eight patients (88.9%) the procedure was effective and in the remaining patients, the abscess was finally drained by sonographically guided catheter placement. In five patients, aspiration was successful at the first attempt and only one abscess required more than two attempts. No complications were observed. CONCLUSIONS: In our experience, needle aspiration with sonographic guidance is safe and effective in the treatment of pyogenic liver abscesses. Use of catheters is reserved for cases of rapid reaccumulation of exudate without general improvement in the patient.

Doppler ultrasonography in the assessment of renal hemodynamics in patients with chronic liver disease.

AIM: To assess renal hemodynamics by Doppler analysis of resistive index (RI) in small intrarenal arteries in patients with chronic liver diseases at different stages, and to analyze renal RI in patients with cirrhosis as a function of the absence or presence of ascites and the response to diuretic therapy. METHODS: Prospective cross-sectional study of 24 patients with chronic hepatitis, 39 with compensated cirrhosis, and 34 with ascites. The last group was divided into two subgroups: 1) responders to sodium restriction and a low dose of diuretics, and 2) patients with refractory ascites or those requiring high-dose therapy. RESULTS: Renal RI was increased in patients with cirrhosis and ascites (0.68 +/- 0.06) in comparison with patients with compensated cirrhosis (0.63 +/- 0.03, p < 0.01). Renal RI in the latter group was higher than in patients without cirrhosis (0.61 +/- 0.04, p < 0.05). Renal RI in patients with ascites was lower in subgroup 1 than in subgroup 2 (0.65 +/- 0.05 vs 0.72 +/- 0.06, p < 0.01). CONCLUSIONS: Renal RI increases as liver disease progresses. Patients with cirrhosis and ascites and increased RI require high-dose treatment or do not respond. Further studies are needed to demonstrate the predictive value of renal RI in assessing the effectiveness of diuretic therapy.

Prognostic usefulness of ultrasonographic signs of portal hypertension in patients with child-pugh stage A liver cirrhosis.

OBJECTIVE: The aim of this study was to identify factors related with mortality in patients with cirrhosis in the absence of habitual biochemical markers of liver dysfunction. METHODS: Seventy-five cirrhotic patients in Child-Pugh stage A, without hepatocellular carcinoma, were followed until death or the end of the study period. We analyzed the association between cumulative survival and 15 variables determined at the moment of inclusion: age, sex, time from diagnosis of cirrhosis, alcohol abuse, history of variceal bleeding, hepatitis B and C virus infection, Child-Pugh score, plasma albumin and bilirubin levels, prothrombin activity, and four sonographic parameters (size of liver, portal vein diameter, size of spleen, and presence of collateral circulation). RESULTS: Mean follow-up was 38.7+/-10 months. Eighteen patients died. Four-year cumulative survival was 77.4+/-5%. Only five variables had a significant influence on survival according to log-rank test: sex, previous variceal bleeding, hepatitis B virus infection, portal vein diameter, and size of the spleen. Multivariate Cox's model showed male sex (relative risk 4.6; 95% confidence interval 1.2-16.8) and diameter of the portal vein > 13 mm, splenomegaly > 145 mm, or both together (relative risk 6.0; 95% confidence interval 1.3-27.2) as independent predictors of the risk of death. CONCLUSIONS: Child-Pugh stage A cirrhotic patients have substantial variability in mid-term survival. Ultrasonography is a useful aid in establishing their prognosis. Men with dilation of the portal vein, splenomegaly, or both, form a group with a significantly higher risk of death.

Abdominal tuberculous abscesses in AIDS patients: percutaneous treatment.

OBJECTIVE: to analyze certain epidemiological and ultrasonographic features, and the response to percutaneous treatment, of abdominal tuberculous abscesses in patients with human acquired immunodeficiency syndrome. METHODS: we reviewed the clinical records and ultrasonographic findings in 7 patients with abdominal tuberculous abscesses who were treated in our service by ultrasonography-guided percutaneous drainage. RESULTS: in 5 patients there was a previous diagnosis of AIDS. The abscesses (two in one patient) were located mainly in the retroperitoneum and appeared mottled at ultrasonography. Seven of the abscesses were drained via catheter, whereas in the remaining case aspiration puncture was used. Mycobacterium tuberculosis was found in the drained material in 6 patients, and 1 case presented superinfection by Enterococcus faecalis. Percutaneous drainage was effective in 6 patients, and in the remaining case it was only palliative. CONCLUSIONS: the incidence of abdominal tuberculous abscesses is increasing in patients with AIDS, and in some patients it is the first symptom. Abscesses are located primarily in the retroperitoneum. They can be dealt with satisfactorily by percutaneous drainage guided by ultrasonography.

Focal splenic lesions in patients with AIDS: sonographic findings.

BACKGROUND: The purpose of this study was to describe the sonographic features of the focal splenic lesions in patients with AIDS and to know the frequency and etiology of these features. METHODS: Sonographic exams of 278 AIDS patients were reviewed retrospectively. We recorded the clinical indications for sonograms and sonographic findings of those patients with focal splenic lesions. In addition, patients' histories were reviewed to determine the etiology of such lesions. Ultrasound exams were performed with a 3.5-MHz transducer. RESULTS: Sonography demonstrated focal splenic lesions in 22 patients (7.9%). Eighteen patients (81.8%) showed small, multiple, hypoechoic, rounded splenic lesions; one patient had a solitary defect with similar features. In these 19 patients (86.3%), splenic lesions were due to disseminated Mycobacterium tuberculosis infection. One case showed two large hypoechoic wedge-shaped lesions that were splenic infarctions secondary to acute bacterial endocarditis. In two patients (9%) with solitary and multiple small hypoechoic lesions, the cause of the lesions remained unknown. All patients had splenomegaly. Hepatomegaly with focal lesions, retroperitoneal lymphadenopathy, or ascites were also seen. CONCLUSION: In our area, the finding of splenomegaly with small, multiple, hypoechoic lesions in AIDS patients should make clinicians suspect splenic tuberculosis as a first possibility.

[Usefulness of ultrasonography in the early diagnosis of hepatocarcinoma in patients with liver cirrhosis]. / Utilidad de la ecografía en el diagnóstico precoz del hepatocarcinoma en pacientes con cirrosis hepática.

OBJECTIVE: To assess the efficacy of a screening program of ultrasonography (U.S.) every six months in the early diagnosis of HCC in liver cirrhosis patients. PATIENTS AND METHODS: We review retrospectively the 99 HCC detected by U.S. in our service from January 1991 to July 1994. We compared patients in the ultrasonography screening program (Group I) with patients who did not (Group II) and, also with, patients with a previous diagnosis of cirrhosis (Group IIa) and patients with simultaneous HCC diagnosis of and cirrhosis (Group IIb). Liver function, the tumor size and extension, and the chance of treatment at the time of diagnosis were analyzed in each group. RESULTS: Twenty (58%) HCC out of 34 from group I single nodules < 5 cm in diameter vs seven (11%) out of 65 from group II (p < 0.001) were detected and this difference persisted between group I and groups IIa and IIb (p = 0.002 and p < 0.001). Most patients with grade C Child-Pugh's score (24 from 27) in each group showed a > 5 cm or multinodular HCC. Ten patients from group I were treated vs 4 from group II (p = 0.001). CONCLUSIONS: Ultrasonography screening program is useful in the early diagnosis of HCC in liver cirrhosis patients and increases the chances of treatment.

[The usefulness of abdominal echography in the diagnosis of portal hypertension in cirrhotic patients]. / Utilidad de la ecografía abdominal en el diagnóstico de hipertensión portal en pacientes cirróticos.

The differences in sonographic measurements of the splanchnic vessels, their modifications during respiration, the spleen size and the presence of collaterals of the portal system among 110 cirrhotic patients with portal hypertension and 30 control subjects are analyzed to verify the usefulness of conventional sonography in the diagnosis of portal hypertension. We achieved a sensitivity above 70% and a specificity of at least 90% with the following signs: 1) dilation of portal, splenic and superior mesenteric veins, 2) limited variations of the latter two during respiration, and 3) splenomegaly. A higher sensitivity was achieved considering variations in splenic caliber during respiration under 33% (91%) or superior mesenteric vein during forced expiration above or equal than 7 mm (88%). These measurements could be found in 71.8% and 57.2% respectively. On the other hand, values of portal vein and spleen size were easily obtained. The usefulness of all measurements persists if we take into account only patients with Child-Pugh score < 7. Collateral circulation was demonstrated in 18%. Portal vein above 14 mm, variations in splenic caliber under 13% or superior mesenteric vein during forced expiration above or equal than 9 mm were obtained in any of control subjects but respectively in 33%, 46% and 69% of patients in portal hypertension group. We conclude that ultrasonography is a reliable and noninvasive tool in the diagnosis of portal hypertension in cirrhotic patients.

[Ultrasonography-guided percutaneous drainage of hepatic abscess. Results and complications]. / Drenaje percutáneo guiado por ecografía de los abscesos hepáticos. Resultados y complicaciones.

Interventional echography has been proposed as an effective method for the drainage of pyogenic hepatic abscesses. We present the technique and the results with this therapeutic alternative in 23 patients suffering from this serious disease. The procedure was effective in 19 patients (82.6%), being palliative in 3 cases (a carcinoma of the gallbladder, a biliary-bowel fistula and a gastric perforation). The drainage failed in 4 patients (17.4%) (in an infected hematoma were and in 3 cases due to technical problems). There were 4 complications, one of them severe (pleural empyema). We consider that percutaneous drainage guided by echography should by a first choice in the treatment of hepatic abscesses. To achieve good results and to avoid complications it is necessary to have good knowledge of the technique.