[Doppler and color Doppler ultrasound diagnosis in differentiation of focal liver lesions]. / Doppler- und Color-Doppler-Ultraschalldiagnostik zur Differenzierung fokaler Leberläsionen.

The frequent detection of benign liver lesions during ultrasound routine examination and a possible curative therapy of early detected malignant tumors require a reliable method of differentiation. Conventional gray-scale ultrasound, according to this problem, has been extended by the Duplex technique and color Doppler ultrasound. Measurement of blood flow velocity by Doppler in the center and at the periphery of liver lesions is not reliable enough to distinguish between benign and malignant lesions. Color Doppler ultrasound possesses some reliable criteria for differentiation. A central spot could be detected in 2 out of 12 hemangiomas, a giant spot in 1 out of 3 giant cavernous hemangiomas. The halo sign without detectable blood flow is considered to be specific for malignancy. We found this sign in 26 out of 81 malignant liver lesions and only in one benign lesion (sensitivity 32%, specificity 97%). The vascularization of focal liver lesions is excellently demonstrated with color Doppler ultrasound. This is very helpful for the diagnosis (e.g. "chaotic blood vessel architecture' in malignant tumors) and for the therapy of focal liver lesions (e.g. follow-up examinations after chemotherapy or chemoembolization). Therefore, application of Duplex and color Doppler ultrasound is highly recommended as a noninvasive diagnostic method of first choice for unknown liver lesions.

Concanavalin-A-extractable non-mucous glycoprotein concentrations in gallbladder bile of cholesterol gallstone patients.

BACKGROUND: The relationship between protein concentrations and the nucleation activity of bile in cholesterol gallstone patients has already been investigated. Nucleation promoters are mucins and concanavalin A (Con-A)-extractable glycoproteins. Nucleation inhibitors are apolipoproteins. We wanted to investigate whether a change in concentration of apolipoprotein A-I (Apo A-I) or Con-A in the bile of cholesterol stone carriers is dependent on the nucleation time. METHODS: Total protein was measured by fluorescence photometry, and Con-A-extractable glycoproteins were separated by their affinity to lectins and measured by photometry. Apolipoproteins were measured by radioactive competitive protein binding assay. RESULTS: The protein concentrations in our bile samples were 2.41 +/- 1.08 mg/ml for the whole group, 2.73 +/- 1.07 mg/ml for a nucleation time less than 3 days, and 2.04 +/- 1.00 for a longer nucleation time. The concentration of the Con-A fraction accounted for 0.289 +/- 0.096 mg/ml, 0.306 +/- 0.081 mg/ml, and 0.274 +/- 0.109, respectively. The Apo A-I concentration was 52 +/- 64 micrograms/ml; 50 +/- 56 micrograms/ml for a nucleation time less than 3 days and 85 +/- 133 micrograms/ml for a longer nucleation time. CONCLUSIONS: Obviously, individual protein fractions have an effect on the nucleation behaviour of gallbladder bile in cholesterol gallstone patients.

Transhepatic topical dissolution of gallbladder stones with MTBE and EDTA. Results, side effects, and correlation with CT imaging.

Forty-two patients with symptomatic gallstones (28 women, 14 men, mean age 49.8 +/- 13.2 years) were recruited for contact dissolution therapy. Pretreatment CT scans of the gallbladder were obtained in every patient under standard conditions. For contact dissolution treatment of heterogeneous gallstones or gallstones with attenuation values of more than 50 Hounsfield units, methyl tert-butyl ether and bile acid ethylene diaminetetraacetic acid were used in alternating administration at time intervals and durations adapted to the individual tolerance of the patients. In the case of gallstones with mean attenuation values under 50 Hounsfield units, the dissolution therapy was performed with methyl tert-butyl ether alone. In 12 (28.6%) patients a complete dissolution of gallbladder stones could be achieved; 11 patients (26.2%) revealed gallbladder sludge but no radiologically or sonographically visualized residual stone debris. The remaining 19 (45.2%) patients had residual gallstone debris. Shell fragments in three of five rimmed gallstones, seven of eight laminated gallstones, and all densely calcified stones were refractory to contact dissolution therapy. Dissolution rates correlated well with mean attenuation values, whereas no significant correlation was found between stone number and dissolution rates or between stone diameter and dissolution rates respectively. The mean instillation time required for stones with a mean density of more than 50 HU was 17.7 +/- 11.5 hr of bile acid ethylene diaminetetraacetic acid and 5.8 +/- 3.2 hr of methyl tert-butyl ether. In the case of isodense stones, the average instillation time of methyl tert-butyl ether was 12.3 +/- 4.7 hr.(ABSTRACT TRUNCATED AT 250 WORDS)

[Does drug-induced litholysis still have a place in treatment of gallstones?]. / Hat die medikamentöse Litholyse noch einen Platz in der Behandlung von Gallensteinen?

In past years, laparoscopic cholecystectomy has largely taken the place of conservative therapy. However, analysis of our data shows, that conventional litholytic therapy of cholesterol stones using bile acids: a) achieves a success rate of over 80%, as long as the patients are well selected prior to therapy (stones < 1 cm diameter, stone size < one fourth of gallbladder contraction of more than 50% as compared when fasting, isodensity of stones in CT) b) has a mortality rate of 0% c) has high patient compliance, because typical episodes of biliary colics and general dyspeptic complaints due to stones are reduced. Therefore, combination bile acid therapy for lysis of selected cholesterol gallbladder stones is still justified today. Particularly young women with small, suspended concrements or patients with recurrent cholesterol stones benefit by this treatment. Extracorporeal lithotripsy can be justified today only in combination with bile acid therapy. However, the number of treatable persons with gall stones is quite small (< 20% of all patients with stones), duration of therapy is three years and the recurrence rate 2-5 years after successful lysis is 25-50% (solitary stones recur less often than multiple ones). Considering a prevalence of 20% of persons with gall stones in the European Economic Community, there are 12 million patients potentially eligible for litholysis.

Structured reporting of medical findings: evaluation of a system in gastroenterology.

A system using structured reporting of findings was developed for the preparation of medical reports and for clinical documentation purposes in upper abdominal sonography, and evaluated in the course of routine use. The evaluation focussed on the following parameters: completeness and correctness of the entered data, the proportion of free text, the validity and objectivity of the documentation, user acceptance, and time required. The completeness in the case of two clinically relevant parameters could be compared with an already existing database containing freely dictated reports. The results confirmed the hypothesis that, for the description of results of a technical examination, structured data reporting is a viable alternative to free-text dictation. For the application evaluated, there is even evidence of the superiority of a structured approach. The system can be put to use in related areas of application.

Extracorporeal shock wave lithotripsy in symptomatic cholesterol gallbladder stone patients with a second generation electrohydraulic lithotripter (MPL-9000): experiences with 106 patients over 15 months.

One hundred and six patients were treated with a second generation underwater spark discharge lithotripter (Dornier MPL-9000). During the 15-month study period, Kaplan-Meier analysis predicted a stone clearance rate of 16.5% after 4 months, 37% (7 months), 71% (10 months), and 81% (15 months), respectively. Patients with multiple stones had a 5% probability to be free of stones after 13 months of treatment, when compared to 100% in patients with solitary stones smaller than 2 cm (p less than 0.001). Stones with densities below 100 Hounsfield units (HU) on computed tomography disappeared in 75% of the cases within 13 months. Rim calcified stones were cleared in 100% after 10 months of treatment. Fragmentation efficacy proved to be an essential predictive parameter for stone clearance: a fragment size below 5 mm after extracorporeal shock wave lithotripsy resulted in a 100% stone clearance within 13 months regardless of the initial stone number, size, and density. None of the stones fragmented to pieces of more than 10 mm in diameter could be dissolved within the observation period. Obviously, modern generation electrohydraulic lithotripters are effective in stone fragmentation, thus providing the basis for successful bile acid therapy provided the patients are properly selected.

The relationship between serum lipids, nucleation time, and biliary lipids in patients with gallstones.

The relationship between biliary lipids, cholesterol saturation index, nucleation time, and serum lipids was studied in a group of 45 gallstone patients (10 male, 35 female; age 50.1 +/- 14.5 years). Bile was obtained by direct fine-needle puncture of the gallbladder under local anesthesia and sonographic monitoring. No significant correlation between the serum lipids and either the cholesterol saturation index or total biliary cholesterol levels was observed. We found a positive correlation between the nucleation time and serum triglycerides content (r = 0.45, p = 0.0018) and a negative correlation between nucleation time and biliary cholesterol level (r = -0.38, p = 0.009). The fatty acids derived from the triglycerides are primarily resynthesized to phospholipids in the liver. When the supply of free fatty acids exhausts the metabolic capacity of the liver as, for example, in fat-rich diets, triglycerides accumulate in the liver cells and may possibly by excreted in the bile. Free fatty acids stimulate mucin hypersecretion in the gallbladder. This mucosal hypersecretion has been assigned a significant role in the formation of gallbladder stones. We also found a positive correlation between the total biliary bile acids and serum high density lipoprotein (HDL)-cholesterol in patients with a rapid nucleation time (r = 0.50, p = 0.0128). This supports the findings of other researchers, which suggests that HDL-cholesterol is devoted primarily to bile acid synthesis. In patients with a short nucleation time, the cholesterol saturation index, total lipid concentration, biliary cholesterol, mean age, and biliary bile acids were statistically different in comparison with patients with a prolonged nucleation time.

[Electronic documentation of findings, performance statistics and image analysis in endoscopy]. / Elektronische Befunddokumentation, Leistungsstatistik und Bildanalysen in der Endoskopie.

Endoscopic data processing in endoscopy departments can hardly be performed without electronic data management nowadays. Written report and endoscopic image storage have to be performed in parallel applying modern sophisticated electronic systems. Sufficient storage capacity has to be taken care for. In the near future image processing of electronically storage endoscopic images will become available.

[The chemical composition of gallstones and their suitability for litholysis and lithotripsy]. / Chemische Zusammensetzung von Gallenblasensteinen und Eignung zu Litholyse und Lithotripsie.

The chemical composition of gallstones removed at surgery from 107 patients (81 women, 26 men; mean age 59 [18-85] years) was examined. In 64 women (79%) and 21 men (81%) microchemical analysis demonstrated concrements with a more than 50% cholesterol content (500 mg/g). Using as definition of cholesterol stones a 75% cholesterol content, only 35 women (43%) and 10 men (39%) would be classified as cholesterol stone carriers. Grossly visible layer formation was present in 18 stones; in eight stones calcium content was higher in the outer layer than in the core. There was no demonstrable relationship between gallstone composition and age.

Pain in extracorporeal shock-wave lithotripsy: a comparison of different lithotripters in volunteers.

The aim of the present study was to investigate pain sensations experienced during extracorporeal shock-wave application, comparing an electrohydraulic (MPL 9000; Dornier Medizintechnik, Germering, Germany), an electromagnetic (Lithostar Plus; Siemens, Erlangen, Germany), and a piezoelectric (Piezolith 2300; Wolf, Knittlingen, Germany) shock-wave system. In nine healty volunteers, three therapeutically used intensities were applied in a randomized order with each lithotripter (MPL 9000: 16, 20, and 24 kV; Lithostar Plus: settings 5, 7, and 9; and Piezolith 2300: settings 2, 3, and 4). The subjects received nine series of 20 shock waves amounting to a total of 180 shock waves per session. The treatment was performed under clinical conditions, and no premedication was given. A visual analog scale and the McGill Pain Questionnaire were used for assessment of pain. In addition, somatosensory evoked potentials caused by shock-wave stimulation were recorded. Some of the volunteers were unable to bear the pain caused by the highest shock-wave intensity of the electrohydraulic (n = 3) and the electromagnetic system (n = 4). Estimates using the visual analogue scale showed increased pain sensations with increasing energy settings for each lithotripter. The amplitudes of the somatosensory evoked potentials became larger, and latencies shortened with increasing stimulus intensities (P less than 0.05). Subjective estimates by means of the visual analogue scale (P less than 0.01) as well as the McGill Pain Questionnaire (NS) and the somatosensory evoked potentials (P less than 0.05) showed that stimulation by the piezoelectric lithotripter was less painful than stimulation by the two other generators.

Computed tomography after ESWL of gallbladder calculi.

Computed tomography (CT) was performed on 88 patients before and after extracorporeal shock wave lithotripsy (ESWL) of gallstones to find the effects of ESWL on the gallbladder and surrounding liver tissue. Post-ESWL scans demonstrated a thickening of the gallbladder wall in 25 (28.4%) cases. In one patient an intrahepatic bilioma beside the gallbladder was seen 3 days after ESWL treatment. Hematoma of the gallbladder wall or the adjacent liver tissue was not seen, and neither a hydrops nor biliary-induced pancreatitis was observed. The authors conclude that while some patients undergoing ESWL will show some posttreatment abnormality on CT scans, the procedure is associated with a low frequency of serious gallbladder and liver trauma.

The quality of gastroenterological reports based on free text dictation: an evaluation in endoscopy and ultrasonography.

The majority of physicians consider the use of free dictation for medical reports to be essential in many domains. One of the main criticisms of structured data entry is the possible lack of flexibility and completeness. Electronic documentation systems exist for endoscopy and ultrasonography examinations which are based on structured input as well as on free dictation. Endoscopy and ultrasonography reports based on free dictation were evaluated for omissive errors. The data evaluated was drawn from a database of 18,239 gastroscopy and 3,340 colonoscopy reports dictated by 28 physicians over 74 months, and 18,834 ultrasonography reports dictated by 37 physicians over 42 months. The error rates varied from 0% to 41.8% depending upon the particular feature and the particular examination, but were usually below 15%. The results were independent of the experience of the examiner. This study provides baseline measurements of omissive error rates for selected findings in gastrointestinal endoscopy and abdominal ultrasonography which can be used as standards for the development and evaluation of systems for collection of clinical data.

In vitro fragmentation of gallstones: comparison of electrohydraulic, electromagnetic and piezoelectric shockwave lithotripters.

To compare the fragmentation efficiency of three different shockwave systems, 63 human gallstone triplets were disintegrated in vitro using an electrohydraulic (MPL 9000, Dornier), an electromagnetic (Lithostar Plus, Siemens) and a piezoelectric (Piezolith 2300, R. Wolf) lithotripter. Since each stone triplet was obtained from the same gallbladder, the concrements of one such set were identical in physicochemical parameters. According to the maximal diameter, the calculi were divided into group A (6 to 15 mm) and group B (16 to 30 mm). Shockwave application was terminated when residual fragments measured 4 mm or less. Forty-five triplets were fragmented at energy settings mainly used in clinical treatment of patients with gallbladder stones (MPL 9000: 20 kV; Lithostar Plus: setting 9 (maximal); Piezolith 2300: setting 3). The fragmentation endpoint was achieved in group A (n = 3 x 36) with the Piezolith 2300 after median 150 (range = 50 to 500) pulses and with the Lithostar Plus after 150 (50 to 750) pulses compared with 500 (50 to 1,500) pulses using the MPL 9000 (p less than 0.01). In group B (n = 3 x 9) the Lithostar Plus (median = 750, range = 250 to 1,250 pluses) required fewer discharges than the Piezolith 2300 (1,250, 250 to 2,500 pulses; p less than 0.05) and the MPL (1,500, 500 to 1,600 [upper limit] pulses; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)