Expectant treatment of ectopic pregnancies: clinical and sonographic predictors.

OBJECTIVE: We identified the potential clinical and sonographic predictors of the spontaneous resolution of ectopic pregnancies. SUBJECTS AND METHODS: We performed a prospective study of 78 consecutive patients with a transvaginal sonographic diagnosis of ectopic pregnancy who had either two consecutive quantitative measurements of their beta subunit of human chorionic gonadotropin (beta-hCG) more than 24 hrs apart or an embryo with a heart beat. We evaluated the patient's age, time from the last menstrual period, beta-hCG level, size of ectopic pregnancy, presence of a gestational sac or embryonic elements, vascularity on color Doppler sonography, peak systolic velocity, and resistive index of ectopic pregnancy at the time of presentation as potential independent predictors of the final outcome. Logistic regression was performed to identify the independent predictors. RESULTS: Forty-six patients had declining beta-hCG levels, and 32 ectopic pregnancies showed an embryo with a heart beat or had steady or rising beta-hCG levels. Univariate analysis indicated that a longer time from the last menstrual period (older ectopic pregnancies), lower beta-hCG levels, and the absence of gestational sac are statistically more significantly seen in ectopic pregnancies with declining beta-hCG levels (p < 0.05). Resistive index of ectopic pregnancy reached borderline significance (p = 0.05). In a multiple logistic model, the same variables were independent predictors of outcome (p < 0.05). Resistive index was also a predictor (p = 0.09). CONCLUSION: Longer times from the last menstrual period, lower beta-hCG levels, absence of gestational sacs, and higher resistive indexes of ectopic pregnancy at the time of presentation appear to be independent predictors of the spontaneous resolution of ectopic pregnancy.

Acquired cystic kidney disease: rapid progression from small to enlarged kidneys simulating adult polycystic kidney disease.

A 57-year-old man on chronic hemodialysis presented marked bilateral renal enlargement due to acquired cystic kidney disease (ACKD). He had been on hemodialysis for less than 3 years only (14 months prior to receiving a functional renal transplant which lasted 8 years, followed by 18 additional months of dialysis), before the diagnosis of ACKD was made following an episode of flank pain with gross hematuria. The marked changes in kidney appearance during this 11-year period were documented by serial ultrasound examination showing the kidneys to be of near-normal size before the start of dialysis (> or =10 cm in 1986), then shrunken and contracted 5 years later while having a functioning renal transplant (<5 cm in 1991), and markedly enlarged reaching the size of adult polycystic kidney disease after returning to dialysis (>13 cm in 1997). Since the risk of ACKD increases with duration of dialysis, we sought additional predisposing factors in this unusual case and found that 2 years after renal transplantation, the patient was diagnosed with breast cancer for which he was treated with surgical excision and tamoxifen. Based on ultrasound evidence that the tamoxifen treatment preceeded the appearance of the renal cystic changes, we wonder whether this drug may have played a role in the rapid development of ACKD.

Sonographic appearance of benign and malignant conditions of the colon.

OBJECTIVE: The objective of this study was to compare the sonographic appearance of different abnormalities of the colon to evaluate the role of sonography in their differential diagnosis. MATERIALS AND METHODS: We retrospectively reviewed videotaped sonographic examinations of 99 patients with proven diagnoses that included diverticulitis (n = 35), malignancy (n = 20), Crohn's disease (n = 16), pseudomembranous colitis (n = 14), ischemic colitis (n = 9), and ulcerative colitis (n = 5). Data were collected with regard to gut features, including the site of colonic involvement, associated small-bowel involvement, length of diseased segment, stratification, luminal contents, pneumatosis, and diverticula. Perigut features evaluated included abnormal fat, abscess, fistula, and ascites. RESULTS: On sonography, the following features were statistically significant (p < .05). Involvement of the small bowel was more common in patients with Crohn's disease than in the remainder of the study population (44% versus 1%). Left-sided colonic disease (91% versus 38%), diverticula (91% versus 3%), and perigut findings (91% versus 57%), including abnormal fat (83% versus 39%) and abscess (34% versus 8%), were features that indicated diverticulitis. Malignant conditions were more common in patients with a greater wall thickness (mean, 26.2 mm versus 10.2 mm), asymmetric involvement (85% versus 39%), loss of stratification (85% versus 20%), absence of perigut findings (65% versus 22%), and involvement of a short diseased segment (70% versus 16%). Involvement of the entire colon (50% versus 2%), luminal contents (64% versus 28%), and ascites (64% versus 26%) were features suggesting pseudomembranous colitis. CONCLUSION: Although the sonographic appearances of abnormalities of the colon overlap, some sonographic features are helpful in the differential diagnosis of colonic abnormalities.

Role of endovaginal sonography in the diagnosis and management of ectopic pregnancy.

Although diagnostic laparoscopy is still considered the standard reference in the diagnosis of ectopic pregnancy (EP), use of high-resolution endovaginal sonography, in conjunction with qualitative serum assays of the beta subunit of human chorionic gonadotropin (beta-hCG), allows detection of earlier and smaller EPs. The most common endovaginal sonographic finding of EP (89%-100% of cases) is an extraovarian, round or elongated, solid tubal mass. A tubal ring (an extrauterine saclike structure) is the second most common finding (40%-68% of cases). Pelvic fluid may be present, but it is a nonspecific finding. An EP may have a pseudosac, which can be distinguished sonographically from the true gestational sac of an intrauterine pregnancy. Color Doppler techniques can complement endovaginal sonographic findings, but they should be performed only after a thorough real-time evaluation of the adnexal region. Current therapeutic options for EP include expectant management (ie, close follow-up), medical treatment (usually injections of methotrexate), and surgery. Accurate diagnosis with endovaginal sonography is the prerequisite to nonsurgical management, since surgery is the logical treatment if laparoscopy is used for diagnosis.

Endovaginal sonographic appearance of benign ovarian masses.

This article illustrates the different appearances of benign ovarian and paraovarian masses at endovaginal sonography. A retrospective study was performed of the records for 118 patients with 140 surgically proved benign adnexal masses, including dermoid cysts (n = 27), endometriomas (n = 40), epithelial inclusion cysts (n = 14), serous cystadenomas (n = 11), mucinous cystadenomas (n = 14), fibromas (n = 11), cystadenofibromas (n = 12), paratubal cysts (n = 5), hydrosalpinges (n = 3), and tubo-ovarian abscesses (n = 3). Preoperative diagnosis was made in 96% of the dermoid cysts on the basis of a hyperechoic attenuating component or multiple small horizontal interfaces and in 100% of uncomplicated fibromas on the basis of a hypoechoic attenuating mass. There was an overlap among the endovaginal sonographic appearances of the other condition.

Accuracy of endovaginal sonography for the detection of fallopian tube blockage.

The patency of 814 fallopian tubes in 414 patients was evaluated by endovaginal sonography immediately prior to hysterosalpingography. In the 659 fallopian tubes that were normal with free spillage, endovaginal sonography did not reveal any tubal or peritubal abnormality (specificity 100%). Of the 64 fallopian tubes with definite hydrosalpinx on hysterosalpingography, only 22 were detected on endovaginal sonography (sensitivity 34%). Four of 57 (7%) fallopian tubes with definite proximal blockage on the hysterosalpingogram showed hydrosalpinx on the same side on endovaginal sonography, indicating the association of proximal and distal tubal blockages in a small group of patients with blocked fallopian tubes. This combination can only be detected by the addition of endovaginal sonography to hysterosalpingography. Ten of 11 (91%) hydrosalpinges in seven patients who underwent endovaginal sonography immediately after hysterosalpingography were detected by ultrasonography. Only two of these had been visible on pre-hysterosalpingography endovaginal sonograms. This would indicate that the poor sensitivity of endovaginal sonography for diagnosing hydrosalpinx is at least partly due to its lack of distention. We conclude that an abnormal endovaginal sonogram is highly predictive of the presence of a blocked tube, but endovaginal sonography has a poor sensitivity for the diagnosis of a hydrosalpinx detectable by hysterosalpingography. Endovaginal sonography would be useful to detect a combination of proximal and distal blockage in a subgroup of patients with tubal blockage.

Transvaginal US appearance of endometrial abnormalities.

A retrospective study was performed on a series of 44 patients who had undergone transvaginal ultrasound (US) before hysterectomy. The surgically proved endometrial abnormalities included cystic atrophy, cystic and adenomatous hyperplasia, polyps, and malignancy. The following endometrial findings were evaluated: endometrial thickness, echogenicity, smoothness or irregularity of the contour, definition of the contour, and the presence of cystic areas. Some overlapping features were present between the benign and malignant conditions. Although cystic changes were seen in 76% of benign conditions manifesting with endometrial thickening, cystic changes were also present in 24% of endometrial malignancies. In the majority of endometrial malignancies, the endometrial contour was poorly defined, but 40% of the cases manifested as well-defined endometrial thickening. Most endometrial carcinomas (88%) were either diffusely or partially echogenic, 12% were isoechoic, and there was no endometrial carcinoma that was purely hypoechoic. Although the presence of cystic changes favors a benign condition, malignancy cannot be reliably excluded. Malignancy should be considered in the presence of a poorly defined, irregular endometrium. Transvaginal US has a significant role in the assessment of the endometrium, and although it can help in the differentiation between some benign and malignant conditions, there remain some overlapping features.

Replaced or right accessory hepatic artery: can ultrasound replace angiography?

The accuracy of ultrasonography in detecting the right hepatic artery was prospectively assessed in 128 patients undergoing abdominal angiography. Twenty-five (19%) of the ultrasound studies were technically inadequate mainly because of gas superimposition. Of the remaining 103 cases, 14 had a replaced hepatic artery, which was diagnosed in 10 cases with ultrasound (sensitivity 71%). Eighty-nine did not have a replaced hepatic artery and the ultrasound assessment was falsely positive in four of them (specificity 96%). Two of the four false negative results could be explained by a stenosis of the superior mesenteric artery in front of the origin of the replaced hepatic artery. Two of the four false positive results could be explained by the presence of a stenosis of the celiac trunk with hypertrophy of the pancreaticoduodenal arteries, one of them being misdiagnosed as a replaced hepatic artery.