[Primary liver tumours in childhood]. / Primäre Lebertumoren im Kindesalter.

The reported prevalence of focal liver lesions in adult patients and children is different. The article discusses pediatric liver tumors under the criteria of histopathology and contrast enhanced ultrasound (CEUS) features. Aim of this article is also to support the already established Pediatric Registry of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) to collect data on safety and applications of ultrasound contrast agents in children (www.efsumb.org).

Contrast enhanced ultrasound in pediatric patients: a real challenge.

Ultrasound (US) imaging in the paediatric population has been a routine technique for decades, in part because of the advantages it offers over other imaging modalities. Off-label use (and its funding) is of the utmost importance in paediatrics because many drugs have not been evaluated in randomised trials in children. As a consequence such drugs are not specifically approved for use in children. This is also true for the contrast agents used in CEUS. The off-label use of CEUS in paediatric patients illustrates the need to deal with unresolved legal issues while at the same time balancing this with the need for high diagnostic performance in daily clinical routine. In addition to approved indications with a focus on the liver and Doppler enhancement, CEUS is safe and effective for the examination of many organs, as recently highlighted by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). This article provides a summary of the available literature describing the utility of CEUS in paediatric patients. Furthermore, we suggest the establishment of a registry to collect data on safety and applications of ultrasound contrast agents in children. A paediatric registry has recently been introduced by EFSUMB (www.efsumb.org).

Measurement of shear wave velocity using acoustic radiation force impulse imaging is not hampered by previous use of ultrasound contrast agents.

PURPOSE: To assess the inter-observer reproducibility of acoustic radiation force impulse imaging (ARFI) between 2 skilled physicians and to evaluate if ultrasound contrast agents (UCA) affect the measurement of shear wave velocity (SWV) using ARFI. PATIENTS AND METHODS: 53 patients (29 males, 24 females, 59 ± 15 [22-84] years) who underwent contrast enhanced ultrasound (CEUS) examination were included. ARFI was performed on liver segment V by physicians A and B before CEUS, and by physician A within 4-6 minutes and 7-10 minutes after contrast injection. In a subgroup of 31 patients (15 males, 16 females, 57 ± 18 [22-84] years), ARFI was also performed on focal liver lesions (FLL) by physician A before CEUS, and within 4-6 minutes and 7-10 minutes after contrast injection. RESULTS: The SWV values obtained by physician A and B before CEUS yielded an intra-class correlation coefficient value of 0.913 (95% CI, 0.849-0.950). No significant differences were shown between the SWV values of liver segment V in all 53 patients and of FLL in the subgroup of 31 patients obtained before CEUS and that of within 4-6 minutes and 7-10 minutes after contrast injection (all P > 0.05). CONCLUSION: ARFI showed excellent inter-observer reproducibility between 2 skilled physicians. UCA did not affect the measurement of SWV in both liver parenchyma and FLL, at least when performed 4 minutes after the contrast injection. ARFI may become an additional tool in the differential diagnosis of FLL.

Artifacts and pitfalls in contrast-enhanced ultrasound of the liver.

Ultrasound technology is always connected to possible artefacts. Since introduction of ultrasound technology the knowledge of those artefacts is eminent to avoid misinterpretations. It is important to know that with the introduction of new ultrasound technology the possibility of artefacts are rising.Whereas artefacts initially were limited to B-mode sonography, every technological step (colour Doppler sonography, contrast enhanced sonography) comes with a range of new artefacts. This article is written to explain the technological basics of ultrasound artefacts and provide the reader with examples in daily practice and how to avoid them.

Pancreas mobile.

BACKGROUND AND AIM: Up to now, little is known about the mobility of the pancreas due to changes in posture. The present study was conducted to assess the position of the pancreas in the left recumbent posture (endoscopy posture), the pancreatic mobility during changes of the posture from supine to endoscopy posture and also evaluates the possible factors associated with pancreatic mobility. METHODS: 199 patients with (68) or without chronic pancreatitis were examined using conventional gray-scale transabdominal ultrasound to image the position and mobility of the pancreatic head with reference to the vertebral spine and aorta in the supine and left recumbent position. In a subgroup of 75 consecutive healthy subjects regarding the pancreas, the exact moving distance of the central line of the pancreatic head from the supine to left recumbent position was obtained regarding the central line of the spine as the reference. Besides the 199 patients, 50 patients without pancreatic pathology were evaluated by endoscopic ultrasound with radial transducers. RESULTS: On conventional ultrasound in supine (left lateral) position the percentage of patients with right-aortal, pre-aortal, left-aortal pancreatic head were 91.0 % (49 %), 8.0 % (31 %) and 1.0 % (20 %), respectively. Significant movement of the pancreatic head in relation to the aorta was observed in 48 % of patients. The moving distance was correlated to the age, sex and the presence of chronic pancreatitis. Pancreas mobility was more pronounced in young healthy females. No association was found between the moving distance and the body mass index (BMI) and splenic size. On endoscopic ultrasound, the orientation of the pancreas with a view of more (or equal) than 180o was observed in 48 % and less than 180o in 52 % of patients. CONCLUSION: Pancreas mobile is a common phenomenon (about 50 %) which has not often been recognized in daily routine. This phenomenon is more likely in healthy young females. This knowledge might be of importance for improved interpretation of endoscopic ultrasound imaging examinations in patients with and without peripancreatic infiltration.

The pancreatic head is larger than often assumed.

Reference values for B-mode abdominal ultrasound are controversially discussed in the literature mainly due to the lack of data and non-standardized examination techniques. A cohort of 100 patients was prospectively examined. Patients with hepatobiliary diseases including gallstones, acute or chronic pancreatitis (n = 13) and non-adequate visualization (n = 10) were excluded from statistical analysis. Therefore, 77 patients were analyzed including 52 female and 25 male healthy subjects regarding the biliopancreatic system (median age ± SD: 56 ± 18 years [minimum: 22 and maximum 93 years]). The mean value of the cranio-caudal diameter of the pancreatic head was 49 ± 10 [26 - 77] mm(mean ± SD [minimum - maximum]) which is larger than usually reported except in one study. The size of the pancreatic head is often larger than assumed which is of importance to know to exclude pancreatic pathology below the level of the common bile duct.

EFSUMB guidelines 2011: comments and illustrations.

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) introduced the first guidelines on the use of contrast-enhanced ultrasound (CEUS) in 2004. This EFSUMB document focused mainly on liver applications. However, new applications extending beyond the liver were subsequently developed. Therefore, in the update of the clinical recommendations on the use of CEUS by the EFSUMB, applications in other organs were also described and published in 2008. Increased interest in recent years in the CEUS technique and in the application of CEUS in novel fields has resulted in CEUS indications and applications for nearly all organ systems. As a result, the EFSUMB initiated a new update of the guidelines in 2011 to include this additional knowledge. Some of the indications are established, whereas others are preliminary. The latter indications are categorized as emergent CEUS applications since the available evidence is insufficient for general recommendation. This article focuses on comments, illustrations and examples of the application of CEUS in the pancreas, spleen, gastrointestinal tract, kidney, adrenals, lymph nodes, perineum, and hepatobiliary system. The potential for endoscopic ultrasound to highlight the importance of CEUS in the daily routine is also addressed.

[Functional ultrasound in gastroenterology]. / Sonografische Funktionsuntersuchungen in der Gastroenterologie.

Ultrasonography has become increasingly important in the routine diagnostics of gastrointestinal diseases. It is first of all a morphological diagnostic method. As it not only assesses the wall structure of the gallbladder, the pancreatic duct and the whole gastrointestinal tract but also visualises motion sequences as a real-time-method, functional processes and their disruptions can especially be examined. The present authors give a review of the capacity of functional ultrasound in different anatomic zones and critically discuss its practical relevance.

[Perianal ultrasound]. / Perinealer (perianaler) Ultraschall (PNUS).

Perianal and perineal ultrasound is an effective but rarely applied diagnostic modality. Transmural inflammation, fistula and abscesses in patients with inflammatory bowel disease can be delineated and perirectal tumours can be staged. The method is complementary to endorectal ultrasound. Also oblique transsphincteric fistula can be displayed in detail.