EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Diagnostic Ultrasound-Guided Interventional Procedures (Short Version).

This is the second part of the series on interventional ultrasound guidelines of the Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). It deals with the diagnostic interventional procedure. General points are discussed which are pertinent to all patients, followed by organ-specific imaging that will allow the correct pathway and planning for the interventional procedure. This will allow for the appropriate imaging workup for each individual interventional procedure (Long version/ short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Diagnostic Ultrasound-Guided Interventional Procedures (Long Version).

This is the second part of the series on interventional ultrasound guidelines of the Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). It deals with the diagnostic interventional procedure. General points are discussed which are pertinent to all patients, followed by organ-specific imaging that will allow the correct pathway and planning for the interventional procedure. This will allow for the appropriate imaging workup for each individual interventional procedure (Long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (Short Version).

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (long Version).

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (long version).

Guideline for Technical Quality Assurance (TQA) of ultrasound devices (B-Mode)--version 1.0 (July 2012): EFSUMB Technical Quality Assurance Group--US-TQA/B.

The Technical Quality Assurance group was initiated by the EFSUMB Board in 2007 and met firstly in 2008 to discuss and evaluate methods and procedures published for performing technical quality assurance for diagnostic ultrasound devices. It is the aim of this group of experts to advise the EFSUMB Board of effective and efficacious methods for routine use and to make recommendations regarding the technical aspects of EFSUMB by-law 9, parts 11.6. & 11.7. The group's work focused on new developments and related European projects to establish a common guideline. There is a great need of a well established protocol and dedicated processing software for the performance testing of medical ultrasound equipment. The measurements should be user independent as much as physically possible. Only if these goals are achieved in an international (firstly European) context, the optimal quality of ultrasound imaging can be offered and maintained to the medical community. This guideline aims to offer and summarize suitable procedures and evaluation processes to lend support for an optimal Technical Quality Assurance (TQA) scheme. The content of this guideline was presented to the EFSUMB Board of Directors (delegates) and approved by the EFSUMB Executive Board (ExB) at the regular meeting during EUROSON 2012 in Madrid April 2012.

[Ultrasound of the salivary glands]. / Ultraschall der Speicheldrüsen.

In acute inflammatory diseases sonography can differentiate between obstructive or non-obstructive sialoadenitis. Abscess formations may be detected and the maturation of the colliquation may be controlled. Abscesses may be punctured under US guidance. In Sjögren's syndrome the sonographic changes correlate with the histological destruction, in acute forms hypervascularisation is found in color Doppler. In fibrotic cases the stimulation-induced hyperemia is impaired. In sialoadenosis inflammatory and tumorous lesions can be ruled out by sonography. Tumors of the salivary glands can be visualized with high sensitivity. Like other imaging methods the specificity in assessment of the histology of a tumor is low. Multilocular lesions as sarcoidosis, lymphoma, metastases or cystadenolymphoma are discussed. In deep located, malignant tumors or when the tumor cannot be delineated completely, MR or CT are obligatory to delineate the tumor. Sonography enables the diagnosis of cysts or ranulae. The accuracy of sonography in assessment of sialolithiasis is about 90 %. Non-opaque stones can be visualized, too. However, small stones of less than 2 mm are difficult to detect since the posterior shadow may be missing. The concrements can be differentiated into intraductal or intraglandular stones. Indirect signs like ductal dilatations or inflammatory changes may be found. Pseudotumorous lesions as hypertrophy of the masseter muscle, tuberculosis, sarcoidosis or lymphoepithelial lesions in AIDS are discussed. In children the main differential diagnosis of salivary gland pathologies are addressed. In many diseases sonography is the first line imaging modality in assessment of salivary glands.

[Tumours of the large bowel and rectum: possibilities and limitations of sonographic evaluation]. / Tumoren des Kolon und Rektum:Möglichkeiten und Grenzen der Sonografie.

PURPOSE: Sonographic detection rate of colorectal tumours in comparison with endoscopy. MATERIALS AND METHODS: Within a period of 32 months all sonographically detected colorectal tumours were registered and the results compared with endoscopic findings within the same period. The patients had no peroral preparation for the sonographic examination which was always performed before coloscopy. RESULTS: The study encloses 521 tumours in 417 patients. The tumours can be subdivided into 181 cancers, 122 polyps > or = 1 cm, 207 polyps < 1 cm and 11 other tumours. 62 % (112/181) of cancers could be detected by sonography, 30 % of stage pTis, pT1 or pT2, 82 % of stage pT3 or pT4. The detection rate was 20 % for polyps > or = 1 cm, but only 2 % for polyps < 1 cm. The majority of larger tumours not detected on sonography (15/18) was located in the rectum and lower sigmoid colon. CONCLUSION: Colorectal cancers of stage T3 and T4 can be detected sonographically in a high percentage of cases. Sonography provides insufficient results in detecting polyps and small cancers, and even larger tumours may be missed especially in the lower sigmoid colon and rectum.

[Sonography of acute appencitis and the main differential diagnoses]. / Sonographie bei Appendizitis und deren Differentialdiagnosen.

Today sonography is the first line imaging method for diagnosing acute appendicitis. Experienced investigators will have an accuracy of more than 90%. Sonography can diagnose many conservatively managed diseases. The most important differential diagnoses are infectious ileocoecitis, right sided diverticulitis, appendagitis, adnexitis, ruptured or torque ovarian cysts, ectopic pregnancies. Ureterolithiasis, cholecystitis, haematomas in the psoas muscle or in the rectus muscle are rarer causes of right lower quadrant pain. Sonography can reduce the high rate of false positive clinical examinations concerning acute appendicitis. It has to be stated that an exclusion of appendicitis can only be made sonographically if the normal appendix can be seen in its full length and/or an other differential diagnosis can be depicted that explains the clinical symptoms. Mucoceles are rare cystoid lesions of the appendix. They exhibit a typical onion skin sign structure caused by different mucus viscosities. In large mucoceles a tumor causes this lesion.

[Sonography in acute diverticulitis of the sigmoid colon]. / Sonographie bei akuter Sigma-divertikulitis.

Sonography is the primary diagnostic method in the painful left lower quadrant. Experienced investigators can diagnose an acute diverticulitis in more than 90%. In unclear cases or when complications are suspected, CT should be performed. Sonography can diagnose most differential diagnosis of the painful left lower quadrant as colitis, appenagitis or haematomas.

Axillary sentinel lymph-node biopsy: gamma probe assisted sonographic localisation.

AIM: To evaluate axillary sentinel lymph-node (SLN) identification and localisation with gamma probe-assisted sonography. PATIENTS AND METHODS: The study comprises 42 patients. Sonographically guided peri-lesional injection of the radiopharmacon was performed on 40 breasts. Two patients with melanoma of the upper extremity underwent intracutaneous injection. After the acquisition of images with the gamma camera, the delineated lymph nodes were marked on the skin. A high-frequency transducer with an adapted gamma probe was then used to identify the SLN. Before surgery, the SLN was localised with a hook-wire. Node activity was controlled intraoperatively. RESULTS: In two out of 42 cases, lymphatic mapping did not reveal SLNs. Multiple SLNs at different sites, all with similar activity, were demonstrated in one patient, while in another patient the sonographically visible lymph nodes were too small for exact correlation. Hook-wire localisation of the SLN was performed in the remaining 38 axillary spaces. Gamma probe-assisted sonography allowed for correct localisation of SLNs in 35/38 patients (92 %). Localisation was not correct in 3 patients (8 %), but in all cases the hook-wire was located next to the SLN. CONCLUSION: Preoperative identification and correct localisation of the SLN is possible in a high percentage of cases. This method allows rapid intraoperative detection of the SLN and could be used for exact correlation of sonographic appearance and histopathological results.

Sonography of the neck: current potentials and limitations.

For many clinical conditions, sonography is the first line imaging modality in the evaluation of cervical soft tissue lesions. Cervical cysts, lipomas, paragangliomas, neurogenic tumours, haemangiomas or lymphangiomas usually display a typical sonographic morphology. Sonography can be used for evaluation of soft tissue lesions and cervical lymph node assessment. Most of the afflictions of the salivary glands can be diagnosed sonographically. Sonography is also used for guided biopsy of lymph nodes, cervical soft tissue tumours or salivary gland lesions. The relationship of tumours or lymph nodes to the great cervical vessels can be evaluated. Colour Doppler can visualise the vascularisation of cervical soft tissue lesions, often narrowing down the differential diagnosis.

Small hepatocellular carcinomas in patients with liver cirrhosis: potentials and limitations of contrast-enhanced power Doppler sonography.

Detection and characterization of focal liver lesions are critical for patients with liver cirrhosis. The potential of contrast-enhanced sonography in the characterization of focal liver lesions is well established in the literature. However, prospective studies in the assessment of patients with suspected hepatocellular carcinoma (HCC) in liver cirrhosis are rare. B-mode imaging often cannot differentiate small focal lesions in cirrhotic livers. Also, power Doppler is not capable of characterizing small focal lesions in cirrhosis. Contrast-enhanced sonography with a first-generation enhancer seems to improve the accuracy of diagnosis of small HCC. The differentiation of HCC and dysplastic nodules is notoriously difficult. In addition, other arterial hypervascularized liver lesions should be considered, depending on the clinical background. The limitations and drawbacks of contrast-enhanced sonography should be considered. All imaging methods are of limited value in the detection of solid liver lesions smaller than 1 cm.

[Lipoma in the parotid gland: typical US and CT morphology]. / Ein Lipom in der Ohrspeicheldrüse: Typische US- und CT-Morphologie.

Up to 3% of all parotid tumours are lipomas. Parotid lipomas can be diagnosed almost specifically by imaging as US, CT, MRI. On ultrasound parotid lipomas are ovoid, hypoechogenic lesions with typical feathered structure. Colour Doppler sonography did not detect any signals in the tumour. CT enables the definite diagnosis by measurement of density values equivalent to fat.

Sonography of the salivary glands.

Due to their superficial position, the parotid, the submandibular, and the sublingual glands can be imaged with high-resolution transducers. In acute inflammatory diseases sonography can differentiate between obstructive or non-obstructive sialoadenitis. Abscess formations may be detected and the maturation of the colliquation may be controlled. Abscesses may be punctured under US guidance. In Sjögren's syndrome the sonographic changes correlate with the histological destruction, and in acute forms hypervascularization is found in color Doppler. In fibrotic cases the stimulation-induced hyperemia is impaired. In sialoadenosis inflammatory and tumorous lesions can be ruled out by sonography. Tumors of the salivary glands can be visualized with high sensitivity. Like other imaging methods the specificity in assessment of the histology of a tumor is low. Multilocular lesions, such as sarcoidosis, lymphoma, metastases, or cystadenolymphoma, are discussed. In deep located, malignant tumors or when the tumor cannot be delineated completely, MR or CT are obligatory to delineate the tumor. Sonography enables the diagnosis of cysts or ranulae. The accuracy of sonography in assessment of sialolithiasis is approximately 90%. Non-opaque stones can be visualized, too; however, small stones of less than 2 mm are difficult to detect since the posterior shadow may be missing. The concrements can be differentiated into intraductal or intraglandular stones. Indirect signs, such as ductal dilatations or inflammatory changes, may be found. Pseudotumorous lesions, such as hypertrophy of the masseter muscle, tuberculosis, sarcoidosis, or lymphoepithelial lesions in AIDS, are discussed. In children the main differential diagnosis of salivary gland pathologies are addressed. In many diseases sonography is the first-line imaging modality in assessment of salivary glands.

[Acute left lower quadrant abdominal pain: ultrasonographic differential diagnosis]. / Akute linksseitige Unterbauchschmerzen: Sonographische Differenzialdiagnose.

Acute left lower quadrant pain is frequently caused by diverticulitis, especially in elderly patients. The most common differential diagnoses include renal colic, urinary tract infection, gynaecologic disorders, epiploic appendicitis, perforated carcinoma, other inflammatory diseases of the colon and diseases of the abdominal wall. Because the clinical impression may lead to a false diagnosis, further evaluation is necessary. Imaging methods are used to establish a correct diagnosis and to differentiate between benign self-limited disorders and those which require immediate intervention. Sonography and CT are the imaging methods of choice for the examination of patients with left lower quadrant pain. Both methods have shown to be accurate in verifying diverticulitis as well as in establishing alternative diagnoses. This review reports the sonographic appearance of the different entities and refers to other imaging methods if necessary.

[Epiploic appendagitis: sonographic findings in 28 cases]. / Spontane Nekrose einer Appendix epiploica: Sonographische Zeichen in 28 Fällen.

AIM: To investigate the sonographic signs of epiploic appendagitis in a larger number of patients and to add new details. PATIENTS AND METHODS: Over a period of approximately 8 years 28 patients were sonographically diagnosed to have epiploic appendagitis. The following sonographic signs were investigated: echogenicity of the lesion; compressibility; shape of the lesion; adherence to the anterior abdominal wall; peripheral rim; central hypoechoic line; thickening of the colonic wall. In 11 of these patients colour Doppler sonography was performed. In addition all 28 patients underwent CT. RESULTS: In 28/28 cases (100 %) a moderately hyperechoic, ovoid, non-compressible mass adjacent to the colon was demonstrated. The mass was surrounded by a hypoechoic rim in 20 cases (71 %) and was fixed to the abdominal wall in 26/28 cases (93 %). Five cases (18 %) revealed a central hypoechoic line, and slight thickening of the colonic wall was visible in 2 cases (7 %). In those cases where colour Doppler sonography was performed, colour flow was absent in the central part of the lesion. In the peripheral zone slightly increased colour flow was demonstrable in 9/11 cases. CONCLUSION: Epiploic appendagitis has a characteristic sonographic appearance with a moderately hyperechoic, ovoid, non-compressible lesion adjacent to the colon and adherent to the abdominal wall. The mass is frequently surrounded by a hypoechoic rim. Colour Doppler sonography shows a central avascular area and slightly increased colour flow in the peripheral zone.

[Colonic diverticulosis: A comparison between sonography and endoscopy]. / Kolondivertikulose: Sonographie und Endoskopie: ein Vergleich.

AIM: To investigate the ability of sonography to diagnose diverticulosis and to demonstrate the typical appearance of normal diverticula. PATIENTS AND METHODS: Sixty consecutive patients underwent sonography for prospective evaluation of the presence of diverticulosis of the left hemicolon. Diverticula were assessed for number, diameter, echogenicity, and wall thickness. Sonographic results were compared with those of endoscopy. RESULTS: Sonography yielded positive results in 28/33 patients (85 %) with endoscopically proven diverticulosis. Sonography on average could demonstrate less diverticula per patient than endoscopy. Two sonographic results were false positive. Diverticula had a maximum average diameter of 8.7 mm and the diverticular wall measured 1 mm at most. In many cases the diverticular wall could not be demonstrated by sonography. All diverticula except for one were hyperechoic. In 39 % of patients with diverticulosis one or more diverticula showed clear acoustic shadowing indicative of a faecalith. The maximum diameter of the colonic wall was 3.3 mm on average. Sonography could demonstrate the descending colon in all cases. The sigmoid colon was not visible in 3 cases and could rarely be evaluated in its entire length. CONCLUSION: Sonography can diagnose diverticulosis of the left hemicolon in most cases. Normal diverticula present as hyperechoic protuberances of the colonic wall with acoustic shadowing of varying intensity. The diverticular wall is thin and often not demonstrable at sonography.

Colonic diverticulitis: diagnostic value and appearance of inflamed diverticula-sonographic evaluation.

Acute bowel inflammation frequently originates from thin-walled diverticula of the colon. Not the presence of diverticula, but the demonstration of an inflamed diverticulum, is diagnostic of diverticulitis in cases of bowel wall thickening and pericolic inflammation. The aim of this study was to investigate the sonographic appearance and detectability of inflamed diverticula. One hundred seventy-five consecutive patients with clinically suspected diverticulitis underwent sonographic examination. Outpouchings from the colonic wall centred in the pericolic inflammation were considered inflamed diverticula. Depending on the sonographic appearance they were divided into four groups: hypoechoic; predominantly hyperechoic; hyperechoic with surrounding hypoechoic rim; and hyperechoic with acoustic shadowing. Sonography showed inflamed diverticula in 79 (77%) of 102 patients with diverticulitis. Inflamed diverticula were hypoechoic in 37%, predominantly hyperechoic in 4%, hyperechoic with surrounding hypoechoic rim in 41% and hyperechoic with acoustic shadowing in 18% of patients. In 23 (23%) of 102 patients no inflamed diverticulum was demonstrable. This group included 17 patients with complicated diverticulitis and 6 false-negative cases. An inflamed diverticulum as a sign of diverticulitis yielded an overall sensitivity of 77% and a specificity of 99%. Sensitivity in uncomplicated disease was 96%. In patients with uncomplicated diverticulitis an inflamed diverticulum is a sign of diverticulitis with excellent sensitivity and specificity, usually with solitary and less frequently with more than one inflamed diverticulum being demonstrable. In patients with complicated diverticulitis an inflamed diverticulum is often not detectable.

Abdominal wall hernias: cross-sectional imaging signs of incarceration determined with sonography.

OBJECTIVE: The aim of this study was to determine with sonography whether distinct cross-sectional imaging signs exist that may differentiate between incarcerated and nonincarcerated abdominal wall hernias. SUBJECTS AND METHODS: The sonographic appearance of 149 consecutive abdominal wall hernias was prospectively investigated and correlated with subsequent surgical results. Commercially available 4- to 10-MHz linear transducers and 2- to 5-MHz curved transducers were used to evaluate the hernias. RESULTS: Surgery revealed 126 nonincarcerated and 23 incarcerated hernias. The sonographic signs suggestive of incarceration that we identified included free fluid in the hernia sac, which was observed in 91% of the incarcerated hernias and in 3% of the nonincarcerated hernias; bowel wall thickening in the hernia, which was detected in 88% of the incarcerated hernias and in none of the nonincarcerated hernias; fluid in the herniated bowel loop, which was detected in 82% of the incarcerated hernias and in 3% of the nonincarcerated hernias; and dilated bowel loops in the abdomen, which occurred in 65% of the incarcerated hernias and in none of the nonincarcerated hernias. These imaging findings allowed the identification of incarceration in all 23 cases and led to a false-positive result in two of 126 nonincarcerated hernias. CONCLUSION: Cross-sectional imaging signs indicating hernial incarceration included free fluid in the hernial sac, bowel wall thickening in the hernia, fluid in the herniated bowel loop, and dilated bowel loops in the abdomen. Sonography is an appropriate cross-sectional imaging modality for detecting these signs that are helpful in diagnosing patients with atypical clinical presentations.