Contrast-enhanced ultrasonography could be a non-invasive method for differentiating none or mild from severe fibrosis in patients with biopsy proven non-alcoholic fatty liver disease.

OBJECTIVE: The gold standard for diagnosing fibrosis stage in non-alcoholic fatty liver disease (NAFLD) is liver biopsy. The aim of this study was to determine whether contrast-enhanced ultrasonography (CEUS) with transit time measurements could be a non-invasive alternative for differentiating none or mild from severe fibrosis in NAFLD patients. Various serum markers and clinical variables were also evaluated. MATERIALS AND METHODS: Fifty-eight patients with NAFLD underwent CEUS prior to liver biopsy. All patients were also evaluated according to the Göteborg University Cirrhosis Index (GUCI), the AST-Platelet Ratio Index (APRI), the NAFLD fibrosis score, and the FIB-4 and BARD score. RESULTS: The hepatic vein arrival time (HV) was shorter in patients with severe fibrosis (25.9 ± 4.8 vs 29.5 ± 4.7 s, p = 0.023), and the difference between the hepatic and portal vein (ΔHV-PV) was shorter (2.3 ± 2.8 vs 6.4 ± 2.8 s, p < 0.0001) while the difference in arrival time between the portal vein and hepatic artery (ΔPV-HA) arrival time was significantly longer (6.0 ± 2.2 vs 3.6 ± 1.6 s, p < 0.0001). The area under receiver operating characteristics curve values for HV, ΔHV-PV and ΔPV-HA to separate none or mild from severe fibrosis was 0.71, 0.83 and 0.84, respectively. The corresponding figures for GUCI, APRI, NAFLD fibrosis score, FIB-4 and BARD score were 0.93, 0.92, 0.86, 0.90 and 0.77, respectively. CONCLUSIONS: CEUS and non-invasive scoring systems could exclude severe fibrosis in NAFLD patients.

Do radiologists agree on findings in radiographer-acquired sonographic examinations?

OBJECTIVES: Sonographic examinations are usually regarded as observer dependent, but a recently introduced method using documentation with cine loops acquired in a standardized way attempts to address this problem. The aim of this study was to evaluate the intraobserver and interobserver agreement of sonographic liver examinations using strictly standardized examination protocols with cine loop documentation. METHODS: Ninety-eight outpatients were examined by a radiographer using the standardized method. Three radiologists, each with 10 to 20 years of experience in sonography, reviewed the cine loops retrospectively. After 4 weeks, the review was repeated; the 3 radiologists were blinded to the initial reading. The κ coefficient was used to analyze intraobserver and interobserver agreement, and agreement in percent was also calculated. RESULTS: The intraobserver agreement was highest for concrements in the gallbladder (κ= 0.91-0.96) and lowest when assessing the need for further examination (κ = 0.38-0.64). For increased liver echogenicity, κ varied between 0.73 and 0.92 and for skip areas between 0.73 and 0.90. The interobserver agreement was also highest for concrements in the gallbladder (κ = 0.84-1.00) and lowest for the need for further examination (κ = -0.12-0.46). For most other findings, substantial intraobserver agreement was found. CONCLUSIONS: For sonographic examinations performed according to a standardized examination protocol by a radiographer and viewed by an experienced radiologist, good interobserver agreement was found, except for judgments of the need for further examinations.

Ultrasonographic findings in patients with peristomal bulging.

AIM: The aim of this study was to obtain a classification of peristomal bulging based on findings at ultrasonography in patients with a sigmoid colostomy. METHODS: The patient material comprised 30 men and 33 women. The median age was 69 years (28-90) and the median time between stoma creation and investigation was 68 months (3-426). Any bulging was measured, and the abdominal opening for the stoma bowel was evaluated at the clinical examination. At the ultrasonographic investigation, the patients were first investigated in the supine position to measure the transverse and vertical diameter of the abdominal opening and the thickness of the abdominal muscles. RESULTS: Three types of ultrasonographic findings were identified. In ultra-I, the stoma bowel was completely fixed or showed telescoping-like movement through the abdominal opening. In ultra-II, fatty tissue was prolapsed together with the stoma bowel forming a bend in the subcutaneous tissue. In ultra-III, another bowel segment or fatty tissue passed beside the stoma bowel through the abdominal opening into the abdominal wall. A normal finding without any bulging at the clinical examination was associated with a smaller area and a smaller diameter of the abdominal opening than the area and diameter in patients with a visible peristomal bulging. There was no difference in the thickness of the muscle layer of the abdominal wall between patients with and without bulging. CONCLUSIONS: Ultrasonography can make a dynamic diagnosis of parastomal hernia. In patients with visible peristomal bulging, the area of the abdominal opening is increased but there is no decrease in the thickness of the muscles of the abdominal wall.

Radiographer-acquired and radiologist-reviewed ultrasound examination--agreement with radiologist's bedside evaluation.

BACKGROUND: Growing demand for ultrasound examinations and higher quality requirements motivate searching for routines combining the diagnostic accuracy of radiologist-performed examinations with the economical advantages of sonographer-performed examinations. One possible approach is to use strictly standardized acquisition and documentation schemes that give the radiologist access to all relevant information after the examination. PURPOSE: To compare a recently introduced routine, combining acquisition by a radiographer, documentation as standardized cine-loops, and review by a radiologist ('standardized method'), with the formerly used routine where the diagnosis is made bedside by the radiologist ('traditional method'). MATERIAL AND METHODS: In 64 policlinic patients, the kidneys (n=27) or the gallbladder (n=37) were examined with both the standardized and the traditional method. The radiologists' findings of hydronephrosis, tumors, cysts, echogenicity changes, and cortical thickness (in the kidneys), and wall thickness, concrements, and polyps (in the gallbladder) were compared between the methods with respect to agreement (proportion of agreement and kappa coefficient) as well as systematic differences (McNemar's test). RESULTS: The findings at the gallbladder examination showed a median agreement of 97% (86-100%; kappa=0.64-1.00), and those at the kidney examination, an agreement of 90% (78-100%; kappa=0.69-1.00). There were no significant systematic differences between the methods. CONCLUSION: The satisfactory agreement in this preliminary study indicates that the new workflow with ultrasound examinations performed by a radiographer and analyzed off-line by a radiologist is promising, and motivates further studies.

Contrast-enhanced ultrasound for extrahepatic lesions: preliminary experience.

Ultrasound imaging (US) is a convenient, inexpensive and non-invasive investigation. Its use is limited by low sensitivity in the detection of a number of parenchymal lesions, especially those produced by trauma, such as infarctions. Contrast enhancement with SonoVue improves the sensitivity of ultrasound in the detection and characterization of focal liver lesions to such an extent, that it may replace computed tomography (CT) and magnetic resonance imaging (MRI). Preliminary experience suggests that SonoVue-enhanced sonography may be useful in the detection of lesions in which blood flow is severely reduced as compared to surrounding parenchyma, such as infarctions, lacerations, hematomas, necrotic tissue and non-vascular cysts, especially in the spleen, kidney and pancreas. This technique can also rule out occlusion of the superior mesenteric, splenic and portal veins, and dilation of the biliary tree. Clinical trials comparing contrast-enhanced sonography with contrast-enhanced computed tomography are warranted to establish the role of this inexpensive and non-invasive technique in the routine work-up of patients with abdominal trauma or presenting with sudden flank pain.

[Adenomatoid tumour of the adrenal gland]. / Adenomatoid tumor i binyre.

An adenomatoid tumour in the right suprarenal gland was discovered during clinical cancer staging of a 73-year-old woman. Adenomatoid tumours in the suprarenal glands are rare and are most often found incidentally. A definitive diagnosis is made on the basis of histology since imaging methods are non-specific. Differential diagnoses comprise malignant vascular neoplasm or adenocarcinoma. Immunohistochemistry or electron microscopy allows uncomplicated distinction between these tumours. In general, it is recommended to obtain biopsies from suprarenal processes.

Emergency real-time contrast-enhanced ultrasonography for detection of solid organ injuries.

BACKGROUND: There is no controversy about the use of CT for detection of internal injuries in patients with high-energy multitrauma. However, in most patients isolated blunt abdominal trauma is mild or moderate and the risk of injury to organs other than the liver, spleen or kidneys is minimal. CT scanning exposes patients to radiation, and may often be avoided if significant damage to these three organs can be visualized by contrast-enhanced ultrasonography (CEUS). MATERIALS AND METHODS: In our series SonoVue (Bracco, Milan) and Siemens Acuson Sequoia ultrasound machines were used. Initially patients with injuries detected by CT were examined using CEUS. Subsequently CEUS was used as the first and only modality in patients with mild or moderate blunt abdominal trauma to one flank, provided that they were able to cooperate and were otherwise suitable for US examination. RESULTS: CEUS was able to sensitively detect lacerations and haematomas in the liver, spleen and kidneys in cooperative patients. CEUS also demonstrated very thin lacerations of the parenchyma of these organs. These results were also found in children. CONCLUSION: In our experience CEUS is an accurate and valuable tool for the detection or exclusion of parenchymal damage to the liver, spleen and kidneys. With the proper organization, standardized dynamic documentation and well-trained sonographers, CEUS may replace CT in many patients with mild to moderate blunt abdominal trauma, thus avoiding unnecessary exposure to radiation in this often young and healthy population.

Long-term follow-up of patients with NAFLD and elevated liver enzymes.

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of elevated liver enzymes in patients of developed countries. We determined the long-term clinical and histological courses of such patients. In a cohort study, 129 consecutively enrolled patients diagnosed with biopsy-proven NAFLD were reevaluated. Survival and causes of death were compared with a matched reference population. Living NAFLD patients were offered repeat liver biopsy and clinical and biochemical investigation. Mean follow-up (SD) was 13.7 (1.3) years. Mortality was not increased in patients with steatosis. Survival of patients with nonalcoholic steatohepatitis (NASH) was reduced (P = .01). These subjects more often died from cardiovascular (P = .04) and liver-related (P = .04) causes. Seven patients (5.4%) developed end-stage liver disease, including 3 patients with hepatocellular carcinoma. The absence of periportal fibrosis at baseline had a negative predictive value of 100% in predicting liver-related complications. At follow-up, 69 of 88 patients had diabetes or impaired glucose tolerance. Progression of liver fibrosis occurred in 41%. These subjects more often had a weight gain exceeding 5 kg (P = .02), they were more insulin resistant (P = .04), and they exhibited more pronounced hepatic fatty infiltration (P = .03) at follow-up. In conclusion, NAFLD with elevated liver enzymes is associated with a clinically significant risk of developing end-stage liver disease. Survival is lower in patients with NASH. Most NAFLD patients will develop diabetes or impaired glucose tolerance in the long term. Progression of liver fibrosis is associated with more pronounced insulin resistance and significant weight gain.

Contrast-enhanced ultrasound in trauma.

When attempting a literature review on contrast-enhanced ultrasound (CEUS) in trauma, very few articles are found. There are a large number of papers dealing with FAST (focused assessment with sonography in trauma) which, in practice, is the definition for detection of free fluid in the abdomen, but there are papers covering assessment of parenchymal damage with non-enhanced ultrasound. This review focuses on direct assessment of parenchymal damage in blunt abdominal trauma, and includes papers on non-enhanced ultrasound to give a historical background to scientific approaches to ultrasound diagnosis of parenchymal injury. A report on our local experience of CEUS in trauma has also been included.