The changing place of liver biopsy in clinical practice: an audit of an Australian tertiary hospital.

Liver biopsy is an important tool in hepatology, with a role now generally limited to cases of diagnostic uncertainty. A retrospective audit performed at the Royal Melbourne Hospital aimed to identify the indications for liver biopsy and its impact on management. Ten per cent (20/195) of biopsies lacked a strong clinical indication, with hepatology involvement in only 8/20. We recommend prior hepatologist assessment to minimise unnecessary biopsies.

Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) in the liver--update 2012: a WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS.

Initially, a set of guidelines for the use of ultrasound contrast agents was published in 2004 dealing only with liver applications. A second edition of the guidelines in 2008 reflected changes in the available contrast agents and updated the guidelines for the liver, as well as implementing some non-liver applications. Time has moved on, and the need for international guidelines on the use of CEUS in the liver has become apparent. The present document describes the third iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS) using contrast specific imaging techniques. This joint WFUMB-EFSUMB initiative has implicated experts from major leading ultrasound societies worldwide. These liver CEUS guidelines are simultaneously published in the official journals of both organizing federations (i.e., Ultrasound in Medicine and Biology for WFUMB and Ultraschall in der Medizin/European Journal of Ultrasound for EFSUMB). These guidelines and recommendations provide general advice on the use of all currently clinically available ultrasound contrast agents (UCA). They are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis and improve the management of patients worldwide.

Contrast-enhanced ultrasound in gallbladder disease: a pictorial review.

With its excellent contrast and spatial resolution, and the ability to image in real-time, ultrasound is the main imaging modality for assessing the gallbladder (GB). The application of contrast-enhanced ultrasound (CEUS) of the GB is now increasingly recognized as a useful addition to ultrasound and other cross-sectional imaging in the assessment of neoplastic and non-neoplastic GB disease. With the ability to image microcirculation and optimal contrast resolution, CEUS allows high-quality delineation in real-time, allowing for increased diagnostic confidence. In addition, ultrasound contrast agents have a favorable safety profile and can be used if CT or MR contrast agents are contraindicated or undesired. In this review, the CEUS appearances of a range of GB diseases encountered are presented, including adenomyomatosis, polyps, carcinoma, sludge, and cholecystitis with mural ulceration or perforation.

Liver atrophy complicating benign bile duct strictures. Surgical and interventional radiologic approaches.

The hepatic atrophy and hypertrophy complex has been described in a selected group of nine patients with benign bile duct stricture. The clinical features common to this group were a high biliary stricture and a long-standing history of cholangitis and intermittent jaundice. A history of multiple surgical procedures and associated vascular damage or portal hypertension is strongly suggestive of the atrophy and hypertrophy complex. The radiologic criteria for the diagnosis of this condition are presented. Computerized tomography and HIDA scintigraphy were valuable as noninvasive means to diagnose lobar liver atrophy. The atrophy and hypertrophy complex described herein poses significant therapeutic problems and demands approaches other than those normally applicable for high biliary strictures. A combined surgical and radiologic approach with additional interventional radiologic procedures may be appropriate in patients in whom hilar anastomosis is difficult or impossible.

Percutaneous transhepatic endoprostheses for hilar cholangiocarcinoma.

In patients with unresectable hilar cholangiocarcinoma, percutaneous transhepatic endoprosthesis insertion is one of the available methods of palliation. We reviewed our experience with it in 35 consecutive patients with hilar cholangiocarcinoma who were judged on clinical or radiologic evidence to be unsuitable for resective or palliative surgery. The 30-day mortality rate was 14 percent (5 of 35 patients). Of the remaining 30 patients, endoprosthesis placement was successful in 28, with 2 patients discharged with a permanent external drainage catheter. Twenty-four patients survived a median of 3 months (range 1 to 17 months), and 2 were lost to follow-up. Good or fair palliation of symptoms was achieved in 50 percent of the discharged patients and in 66 percent of those living longer than 3 months. We believe that percutaneous transhepatic endoprostheses can provide useful palliation in patients with hilar cholangiocarcinoma, even in the presence of advanced disease.

Real-time ultrasound measurement of bladder volume: a comparative study of three methods.

The accuracy of different ultrasound methods for determining the volume of urine in the bladder was compared using three methods in current use. Each method was applied to the same ultrasound images from 16 patients with prostatic hypertrophy. The calculated volumes were compared with the true volumes derived by measurement of voided and catheter-drained urine. All methods showed similar degrees of accuracy in quantifying bladder volumes. The range of errors of the best method tested was +/- 35% of true volume and this suggests that ultrasound measurement of bladder volume is not sufficiently accurate for many clinical and research applications.

The ultrasonographic appearances of hilar cholangiocarcinoma (Klatskin tumours).

The findings on ultrasound of 40 patients presenting between 1984 and 1987 who were subsequently proven pathologically to have hilar cholangiocarcinoma were reviewed. The sonograms of 17 other patients in whom pathological confirmation was not obtained but who were also presumed to have Klatskin tumours on clinical and radiological grounds, were also reviewed. All patients demonstrated intrahepatic bile duct dilatation with no evidence of free communication between the right and left hepatic ducts. A hilar mass was observed in 74% of the patients. Seventy-nine per cent of the hilar masses were of increased echogenicity relative to surrounding liver, 19% were of reduced echogenicity and 2% of mixed echogenicity. An intraluminal mass was seen in 21% of the patients and bile duct wall thickening was observed in 4%. The mass detection rate of different ultrasound equipment was also compared. In 15 patients the ability of ultrasound to predict the order of intrahepatic bile duct involvement was compared with cholangiography.

Carotid artery stenosis--reassessment of the Doppler criteria.

Few previous studies of the accuracy of duplex Doppler in the assessment of carotid artery stenosis have looked at the accuracy in excluding disease in populations with a significant number of normal arteries. In addition, few studies have compared different criteria for stenosis. Duplex Doppler was used to evaluate the carotid arteries in 80 patients. Two well-described methods for analysing Doppler traces were used and the results were compared with those obtained from non-selective digital subtraction angiography. On the basis of these findings, the Doppler criteria used for carotid stenosis were redefined in terms of changes in peak velocity rather than Doppler frequency shift. Using these criteria, the sensitivity of Doppler in identifying carotid stenosis was 97% (98% sensitivity for greater than 50% stenosis) and specificity was increased from 84% to 93%.

Ultrasound in chronic liver disease.

BACKGROUND: With the high prevalence of diffuse liver disease there is a strong clinical need for noninvasive detection and grading of fibrosis and steatosis as well as detection of complications. METHODS: B-mode ultrasound supplemented by portal system Doppler and contrast-enhanced ultrasound are the principal techniques in the assessment of liver parenchyma and portal venous hypertension and in hepatocellular carcinoma surveillance. RESULTS: Fibrosis can be detected and staged with reasonable accuracy using Transient Elastography and Acoustic Radiation Force Imaging. Newer elastography techniques are emerging that are undergoing validation and may further improve accuracy. Ultrasound grading of hepatic steatosis currently is predominantly qualitative. CONCLUSION: A summary of methods including B-mode, Doppler, contrast-enhanced ultrasound and various elastography techniques, and their current performance in assessing the liver, is provided. TEACHING POINTS: • Diffuse liver disease is becoming more prevalent and there is a strong clinical need for noninvasive detection. • Portal hypertension can be best diagnosed by demonstrating portosystemic collateral venous flow. • B-mode US is the principal US technique supplemented by portal system Doppler. • B-mode US is relied upon in HCC surveillance, and CEUS is useful in the evaluation of possible HCC. • Fibrosis can be detected and staged with reasonable accuracy using TE and ARFI. • US detection of steatosis is currently reasonably accurate but grading of severity is of limited accuracy.

Radiology teaching: essentials of a quality teaching programme.

Medical student teaching is an important component of radiology education. Despite the practice of radiology undergoing significant changes during the last two or three decades, the importance of radiology has not translated fully into medical school curricula in Australia and New Zealand. This article reviews the essential components of a quality medical student teaching programme.

Spiral computed tomography-intravenous cholangiography with three-dimensional reconstructions for imaging the biliary tree.

This study aimed to assess the ability of CT-i.v. cholangiography to show the perihilar biliary and cystic duct anatomy and to assess the relative performance of axial, maximum intensity projection and surface rendered displays. We also assessed the correlation between serum bilirubin levels and adequacy of biliary opacification. Spiral CT was carried out following infusion of 100 mL of Biliscopin in 181 patients with suspected biliary disease. The display of biliary anatomy was of high quality, with 91% of patients having good opacification of at least first-order bile ducts and 84% having good opacification of at least third-order right and left hepatic ducts. The quality of biliary opacification correlated inversely to serum bilirubin levels, with levels above two to three times the normal value being associated with lower rates of good opacification. Maximum intensity projection and surface rendered reformats aided anatomical interpretation to a similar degree. The relative frequency of types of perihilar branching patterns and cystic duct junctional anatomy correlated closely to those reported from previous anatomical studies.

Bile duct varices presenting as a porta hepatis mass.

Bile duct varices are a rare manifestation of portal vein cavernous transformation. They can present as an apparent enhancing, vascular mass in the porta hepatis and are readily diagnosed using ultrasound and CT modalities. Diagnosis is important to avoid unnecessary intervention and concomitant risk of haemobilia.

Lower limb deep venous thrombosis: a critical view of ultrasound.

The replacement of venography with ultrasound in investigation of lower limb deep venous thrombosis (DVT) is a trend that generally has been appropriate. However, there is substantial variation in reported accuracies related to different clinical contexts, operator experience and sophistication of equipment. The best and most consistent results are for suspected acute femoropopliteal thrombosis, while there is variation in accuracy and diagnostic approach for below knee thrombosis. Potential exists for substantial diagnostic inaccuracy for suspected recurrent DVT, in surveillance of high-risk patients and in patients with possible pulmonary embolism. The choice of ultrasound over contrast venography should take account of local expertise and accuracy, availability of resources, clinical indication for investigation and cost-effectiveness.

Interventional radiology in the biliary tract.

Interventional radiology in the biliary tract comprises an increasing range of techniques, most of which involve the percutaneous placement and manipulation of some type of catheter system in the bile ducts or gallbladder under imaging control. These techniques have become well established in the management of a number of benign and malignant biliary disorders.

A home-made phantom for learning ultrasound-guided invasive techniques.

An ultrasound phantom is described which allows practice of ultrasound-guidance of needle placement over variable depths and into targets of variable size. The phantom mimics a solid organ in its echogenicity and can be cheaply and easily made from resources of the domestic kitchen.

Magnetic resonance cholangiopancreatography.

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive imaging method for examining the biliary and pancreatic ducts. The technique uses heavily T2-weighted imaging, which produces high signal from bile and other static fluids by virtue of their long T2 time, while suppressing background signal. Fast scanning techniques, particularly half-Fourier fast spin-echo techniques, are continuing to improve image resolution and allow scans within short breath-holds, reducing the effects of respiratory movement. The MRCP method has reached a level of resolution and reliability where it may well largely replace diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in the near future. A review of MRCP techniques and imaging findings is presented with emphasis on half-Fourier imaging, with reference to potential clinical indications and limitations. Use of MRCP shows a high sensitivity and specificity for detection of biliary dilatation, calculi, strictures and anatomical variants. Experience with MR imaging of the pancreatic duct is less extensively described in the literature, but pancreatic duct dilatation, calculi and anatomy can now be reliably detected. However, as experience with MRCP increases, some sources of errors and limitations are becoming apparent, with image artefacts, and gas, blood or sludge within ducts potentially mimicking stones or strictures.