[A supposed hepatocellular adenoma turns out to be intrahepatic splenosis - a case report]. / Ein vermeintliches hepatozelluläres Adenom stellt sich als intrahepatische Splenose heraus ­ ein Fallbericht.

We report the case of a 62-year-old Caucasian male patient who presented with epigastric pain to our outpatient clinic. On abdominal ultrasound we detected a 26 mm oval hypoechoic lesion in segment 2 of the left liver lobe. Performing contrast-enhanced ultrasound this lesion showed an arterial hypervascularization with centripetal filling and a spoke wheel pattern. Due to a hyperenhancement during the portal and late phase this lesion led to the diagnosis of a benign liver tumor, probably a hepatocellular adenoma (HCA). As focal nodular hyperplasia (FNH) was still another possible diagnosis, we decided to perform an MRI, which could not differentiate between HCA and hepatocellular carcinoma (HCC). Therefore, we performed liver biopsy of this lesion. Histology and immunohistochemistry led to the final diagnosis of intrahepatic splenosis. Reassessment of patient history revealed an abdominal trauma with splenic rupture 5 years ago. Intrahepatic splenosis should be considered as an important differential diagnosis in patients with unknown liver tumor and a history of splenic trauma.

Education tracking and adolescent smoking: a counterfactual and prospective cohort study.

BACKGROUND AND AIMS: Adolescent smoking is a health issue and a potential health inequality issue. Education tracking, which is the placement of students into different school types and curricula based on their learning needs or abilities, is an indicator of inequality and risk factor of adolescent smoking. We examined the effect of educational tracking, dividing students into vocational and academic high school tracks, on adolescent smoking in Taiwan. DESIGN AND SETTING: Longitudinal panel data, collected annually from 2000 over a period of 6 years as part of the Taiwan Youth project, were used. PARTICIPANTS: Adolescents (aged 13-18 years) from the first six waves of the Taiwan Youth Project were included in the project, of whom 2147 had clear information on track attendance in 10th grade, control variables in 7th/8th grades and smoking behavior in 8th grade (before track placement). Post-track smoking behavior was measured at 10th, 11th and 12th grades. MEASUREMENTS: The outcome variable was the self-reported smoking status in the 8th grade and between 10th and 12th grades. The treatment variable of interest was education tracking (vocational versus academic), which was conducted when the student was in 10th grade. Several important confounders were used for the difference-in-differences propensity score matching (e.g. parents' education and same classroom peer smoking). FINDINGS: Placement of a student in the vocational track increased the proportion of smokers by 3.3 percentage points in 10th grade (P = 0.039). The effect was even more pronounced in 11th grade (6.2 percentage points; P = 0.000) and 12th grade (5.9 percentage points; P = 0.003). CONCLUSIONS: Education tracking (placement of students into different school curricula based on learning needs or abilities) appears to be a risk factor for adolescent smoking among Taiwanese adolescents.

Large-scale integrated assessment of soil carbon and organic matter-related nitrogen fluxes in Saxony (Germany).

Changes in land-use, agricultural management and climate affect the turnover and storage of organic carbon in soils (SOC) as well as the nitrogen mobilization from soil organic matter (SOM), with potential side effects on nitrogen availability and leaching. When addressing the requests for increased carbon storage in soil as well as for the reduction of nitrogen losses, integrated approaches on regional scales are required that take into account the actual changes in agricultural management and climate. This study investigated the arable land (7345 km2) of Saxony (Germany) with regard to the following: (1) the trends of SOC storage and organic matter-related nitrogen fluxes, including their subregional and annual dynamics, (2) changes in the carbon input to arable soils and the turnover of organic matter, and (3) the contribution of different drivers (climate, crop production and fertilization, tillage system) to the simulated SOM changes for the period 1998-2014 on a 500 m grid. The model CANDY carbon balance (CCB) was specifically adapted for large-scale simulations of SOM turnover to link spatial data on soils and climate with regional statistics on agricultural management. This new 'regional mode' of CCB has been validated using data from 391 plots across different European locations. The initial SOC levels for Saxony assumed steady state conditions at the beginning of the simulation period and have been validated using data from 667 monitoring sites. The results showed an increase in the SOC stocks of the arable soils of Saxony of 785 × 103 t C (1.24‰ annually) during the simulation period. At the same time, the model simulated an average increase in organic nitrogen stored in SOM of approximately 7.5 kg N ha-1 a-1, with considerable differences between individual years and subregions. Both the increase in carbon inputs to soil (+8%) and the reduction of carbon turnover rates (-10%) had positive effects on SOC storage. While the increased use of conservation tillage was the most important driver for the overall increase in SOM storage in Saxony, climate variability and crop production and fertilization had the largest effect on its annual dynamics.

Shear wave elastography prior to transjugular intrahepatic portosystemic shunt may predict the decrease in hepatic vein pressure gradient.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to treat portal hypertension complications. Our aim was to evaluate liver and spleen stiffness measurement (LSM and SSM, respectively) changes using acoustic radiation force impulse imaging (ARFI) in comparison to Child-Pugh scores for predicting hepatic venous pressure gradient (HVPG) decreases after TIPS implantation. METHODS: This prospective study included 31 consecutive clinically significant portal hypertension patients with TIPS indication. All patients received LSM and SSM before TIPS, at baseline, 2 days (follow-up 1) and 6 weeks (follow-up 2) post-implantation. HVPG was performed during the TIPS procedure. RESULTS: The mean decrease in HVPG after TIPS was 63%. LSM and SSM decreased significantly between baseline and follow-up 2 (p < 0.001 and p < 0.001, respectively). At baseline, follow-up 1 and follow-up 2, significant correlations were detected between mean SSM and mean HVPG (p = 0.026; p = 0.018; p = 0.002, respectively). HVPG decreased to ≤ 10 mmHg in 61% of patients for which LSM, SSM, and Child-Pugh score were predictors (p = 0.033, p = 0.002 and p = 0.030, respectively). The area under the curve (AUC) for LSM, SSM, and Child-Pugh was 0.88, 0.90, and 0.84, respectively, with close sensitivity and specificity. SSM had the highest diagnostic accuracy for predicting an HVPG decrease to ≤ 10 mmHg in comparison to LSM and Child-Pugh score. CONCLUSION: Spleen stiffness is superior to liver stiffness and Child-Pugh score as a non-invasive surveillance tool for evaluating patients with clinically significant portal hypertension (HVPG ≥ 10 mmHg) prior to TIPS.

Different kinetics of liver stiffness using shear wave elastography in patients with chronic hepatitis C infection treated with interferon-free regimens.

BACKGROUND: Direct-acting antivirals (DAAs) lead to a high rate of sustained virologic response (SVR) in chronic hepatitis C infection. The aim was to evaluate liver stiffness kinetics, using acoustic radiation force impulse (ARFI) imaging elastography, during and after DAAs in patients who had reached SVR. PATIENTS AND METHODS: A total of 275 consecutive chronic hepatitis C virus-infected patients were included in this longitudinal prospective single-centre study. All patients received DAAs for 8 to 24 weeks, and liver stiffness measurements (LSMs) by ARFI at baseline, at week 4, week 12, week 24, and 24 weeks (SVR24) and 48 weeks (FU48) after the end of treatment were recorded. Transient elastography was performed at baseline and at SVR24. RESULTS: A decrease in LSM was detected at SVR24 by ARFI and transient elastography (P<0.001 and <0.001, respectively). A continuous gradual decrease in ARFI was observed in patients with cirrhosis versus a nonsignificant change in patients without cirrhosis until FU48 (P<0.001 vs. 0.877, respectively). At SVR24, higher baseline ARFI values (P=0.038) were associated with a decrease in LSM in patients with cirrhosis versus normal international normalization ratio (P=0.003), lower bilirubin (P=0.003), and higher albumin (P=0.007) in patients without cirrhosis. The incidence of liver stiffness decrease from baseline was higher in patients with cirrhosis than in those without cirrhosis (P<0.001), whereas the incidence of liver stiffness progression was more pronounced in advanced than in compensated cirrhosis (P<0.001). CONCLUSION: After DAAs in patients with SVR, liver stiffness improves in patients with cirrhosis, whereas non-cirrhotic patients show no true change in liver stiffness. Liver stiffness worsens in patients with advanced liver disease.

Clinical characteristics of patients with liver cirrhosis and spontaneous portosystemic shunts detected by ultrasound in a tertiary care and transplantation centre.

OBJECTIVES: The clinical relevance of spontaneous portosystemic shunts detected by ultrasound is insufficiently investigated. The aim of this retrospective study was to assess the frequency and clinical relevance of spontaneous portosystemic shunts in patients with liver cirrhosis. METHODS: We evaluated portosystemic shunts, liver cirrhosis and spleen size by ultrasound in 982 patients with liver cirrhosis and correlated these with laboratory results, clinical data and the incidence of clinical endpoint deaths, liver transplantation and the development of HCC during the follow-up period (mean 1.26 ± 1.53 years [range 0-7.2 years]). RESULTS: Portosystemic shunts were detected in 34% of the patients. These patients had a higher rate of alcohol-related cirrhosis (37% vs. 30%, p = .003), a higher MELD score (p < .001) and Child-Pugh grade (p < .001), as well as more frequent hepatic encephalopathy (p < .001) and oesophageal varices (p < .003). The most frequent portosystemic shunt in this cohort was an umbilical vein shunt (69%) followed by splenorenal (16%), mesenteric (7%) and combined/other shunts (8%). Patients with umbilical vein shunts had a higher rate of alcohol-related cirrhosis (p = .041) and suffered more frequently from Child B/C stages (p = .03), hepatorenal syndrome (p = .03), massive ascites (p = .001) and spontaneous bacterial peritonitis (p = .011). CONCLUSIONS: Patients with portosystemic shunts that are detected by ultrasound should be monitored carefully as these patients are associated with advanced liver disease and multiple clinical risk factors.

Long-term changes in liver elasticity in hepatitis C virus-infected patients with sustained virologic response after treatment with direct-acting antivirals.

BACKGROUND: The use of interferon-free direct-acting antiviral agents (DAAs) is associated with a rapid short-term decrease in liver stiffness in chronic hepatitis C-infected patients with sustained virologic response (SVR). OBJECTIVE: The objective of this article is to evaluate long-term changes in liver elasticity in hepatitis C patients with SVR using transient elastography (TE), FIB-4 and APRI. METHODS: A total of 143 patients were treated with DAAs and reached SVR. Patients received TE measurement (median (range)) at treatment start (baseline), follow-up week 24 (FU24) and follow-up week 96 (FU96). Laboratory data were examined at each date and FIB-4 and APRI were calculated. RESULTS: Liver elasticity showed a significant decrease from baseline to FU24 (13.1 (3.1-75) kPa to 9.3 (2.9-69.1) kPa; p < 0.0001) and declined further until FU96 (7.9 (2.4-59.3) kPa; p < 0.0001). Liver inflammation and liver function parameters normalised during long-term follow-up. Progression of liver stiffness between FU24 to FU96 despite viral clearance was observed in 24 patients (17%). Long-term liver stiffness progression was associated with aspartate aminotransferase levels and TE change from baseline to FU24. CONCLUSION: During long-term follow-up, the majority of patients with SVR had further improved liver stiffness values. Still, a significant proportion of patients may show long-term liver stiffness progression and thus continued TE follow-up is recommended.

Ethanol sclerotherapy or polidocanol sclerotherapy for symptomatic hepatic cysts.

BACKGROUND: Over the past decades, multiple approaches to aspiration sclerotherapy of large symptomatic hepatic cysts have been investigated. However, comparative data are scarce. OBJECTIVE: The objective of this article is to compare cyst reduction, symptomatic relief, and adverse events between ethanol sclerotherapy and polidocanol sclerotherapy. METHODS: This retrospective study included adults having a symptomatic hepatic cyst treated at a European tertiary referral center with ethanol sclerotherapy (Center 1) or polidocanol-sclerotherapy (Center 2). We compared cyst diameter reduction (%) and symptom improvement (yes/no) within 12 months' post-treatment between centers using multivariate regression analyses adjusted for confounding factors. Finally, we compared adverse events using Fisher's exact test. RESULTS: We included 71 patients from Center 1 and 66 patients from Center 2 (median age 57 years; 126/137 (92%) female). Cyst reduction was comparable between Centers 1 and 2: 37.5% (IQR 15.7-61.0%) versus 44.2% (IQR 24.6-60.5%), respectively (p = 0.35). Correspondingly, symptomatic relief was comparable: 30/53 (56.6%) versus 43/66 (65.2%), respectively (p = 0.88). Center 1 reported significantly more (11 versus 3; p = 0.047) adverse events than Center 2. CONCLUSION: We found comparable cyst reduction and symptomatic relief rates between ethanol- and polidocanol sclerotherapy, while adverse events occurred more often in the ethanol group. Prospective studies focused on clinical response are needed to further explore differences between approaches.

Retrograde portal vein flow and transarterial chemoembolization in patients with hepatocellular carcinoma - a case-control study.

BACKGROUND AND AIMS: Transarterial chemoembolization (TACE) is the most common treatment for hepatocellular carcinoma (HCC). In case of portal vein (PV) flow diversion, outcome may be compromised due to a decompensation of hepatic perfusion following arterial embolization. The aim of this study was to determine whether TACE in patients with retrograde PV flow results in a stronger deterioration of liver function and a poorer survival compared to patients with orthograde PV flow. METHODS: A database of 606 patients treated with TACE between 2000 and 2015 at Hannover Medical School was screened for Doppler ultrasound (US) findings on PV flow prior to TACE. A total of 407 patients were identified, among which 32 patients had retrograde PV flow. RESULTS: Patients with retrograde PV flow had significantly more often liver cirrhosis with advanced hepatic dysfunction (93.5% vs. 72.7%, p < .05). Median overall survival (OS) was 12 and 19 months in patients with retro- and orthograde PV flow, respectively (HR 1.27, p > .05). Patients with retrograde PV flow showed a trend for a shorter OS when matched for cirrhosis (12 vs. 21months, HR 1.51), Child-Pugh score/albumin-bilirubin grade (12 vs. 15 months). There was no difference in the deterioration of liver function after repeated treatments between both groups as assessed by increase of CP points and ALBI grade. CONCLUSIONS: Retrograde PV flow alone was not a significant prognostic marker, but patients with retrograde PV flow and advanced liver cirrhosis treated with TACE had a very short survival. Assessment of PV flow prior TACE may be helpful in borderline cases considered for TACE.

Liver stiffness measurements and short-term survival after left ventricular assist device implantation: A pilot study.

BACKGROUND: Hepatic dysfunction can contribute to the clinical outcome of patients with end-stage chronic heart failure (HF). This pilot study evaluated the importance of liver stiffness (LS) measurements by acoustic radiation force impulse (ARFI) imaging elastography in patients with end-stage chronic HF who underwent left ventricular assist device (LVAD) implantation. METHODS: The study enrolled 28 patients (23 men), mean age of 54 ± 11 years, with end-stage chronic HF selected for LVAD implantation. At baseline, all patients received LS measurements using ARFI elastography. Hepatic venous pressure gradient measurements and transjugular liver biopsies were performed in 16 patients. Liver stiffness was measured 21 days (Follow-up 1, n = 23) and 485 ± 136 days (Follow-up 2, n = 13) after LVAD implantation. Patients were classified according to their baseline LS into Group I (low baseline LS [no significant fibrosis = Metavir F < 2]) or Group II (high baseline LS [significant fibrosis = Metavir F ≥ 2]). RESULTS: LS at baseline was higher in Group II than in Group I (p < 0.001) and decreased significantly after LVAD implantation (Follow-up 1, p = 0.002; Follow-up 2, p = 0.002). Baseline LS correlated with liver fibrosis (p = 0.049) and central venous pressure (p = 0.001). Non-survivors showed higher LS (p = 0.019), bilirubin (p = 0.018), Model for End-Stage Liver Disease score (p = 0.001), and liver fibrosis (p = 0.004) compared with the survivors. In the univariate analysis, LS was a significant factor (p = 0.017) in predicting survival after LVAD implantation. CONCLUSIONS: ARFI elastography shows that LS is influenced by central venous congestion and histologic changes of the liver in patients with end-stage chronic HF. LS may predict the outcome in patients after LVAD implantation.

Testosterone-receptor positive hepatocellular carcinoma in a 29-year old bodybuilder with a history of anabolic androgenic steroid abuse: a case report.

BACKGROUND: Continuous use of anabolic androgenic steroid in high-doses is associated with substantial health risks, including hepatocellular adenoma. Malignant transformation from hepatocellular adenoma to hepatocellular carcinoma after anabolic androgenic steroid abuse has been rarely reported. The morphological distinction of adenoma from well-differentiated hepatocellular carcinoma is challenging and requires elaborated imaging techniques and histology. CASE PRESENTATION: We report about a 29-year old male professional bodybuilder who presented with mid-epigastric pain at the emergency unit. Ultrasound showed a severe hepatomegaly with multiple lesions. Contrast-enhanced ultrasound revealed a heterogeneous pattern with signs of hepatocellular carcinoma. CT scan of the abdomen confirmed multiple hypervascular lesions and central areas of necrosis without contrast enhancement. Subsequent diagnostics included fine needle aspiration (FNA) of suspicious lesions and mini-laparoscopy to establish the diagnosis of a ß-catenin and testosterone-receptor positive hepatocellular carcinoma embedded in multiple adenomas. The patient was subsequently treated by liver transplantation and remains tumor-free 27 month after surgery. CONCLUSION: Hepatocellular carcinoma occurring in association with anabolic androgenic steroid abuse should sensitize physicians and especially professional bodybuilders for the harmful use of high doses of steroids.

Gray scale and contrast-enhanced ultrasound imaging of malignant liver tumors of vascular origin.

OBJECTIVES: Malignant vascular tumors of the liver are rare. The aim of this study was to investigate the applicability of gray scale and contrast-enhanced ultrasonography in patients with epithelioid hemangioendothelioma (EHE) of the liver and hepatic angiosarcoma (HA) and to describe the clinical presentation. METHODS: We retrospectively analyzed all patients with epithelioid hemangioendothelioma or hemangiosarcoma of the liver from 1998 to 2011, who underwent ultrasound investigation. We describe the findings in gray scale and contrast-enhanced ultrasound and the clinical course of the disease of seven patients with EHE and five patients with HA. RESULTS: Ultrasound investigation in EHE showed mostly multiple hypoechoic irregular lesions close to the liver capsule and with a halo in some cases. Contrast enhancement revealed inhomogeneously and through all contrast phases vascularized tumors with a rim enhancement in 50%, with or without early wash out. All tumors had avascular parts. HA presented as multiple and irregular hypo-, iso- or hyperechoic lesions. After contrast enhancement, hypervascularization with individual patterns was evident in all patients. Of five, three had liquid parts. Patients with HA were significantly older (58 vs. 37 years, p = 0.014) and presented with lower thrombocyte counts (84 vs. 264, p = 0.0025) and with higher CEA levels (4.6 vs. 1.5, p = 0.03). CONCLUSION: EHE and HA are inhomogeneous tumors, explaining the high inter-individual variability and heterogeneity in ultrasound examination. The presence of multifocal lesions, heterogeneity and undefined margins may differentiate EHE or HA from hemangioma. A biopsy is essential in the diagnosis of vascular tumors.

The impact of employment transitions on health in Germany. A difference-in-differences propensity score matching approach.

This article investigates the effects of transitions between employment and unemployment on health. It also addresses the question of whether or not the widespread use of temporary employment has altered the positive health effects of employment. Drawing on data from the German Socio-Economic Panel for the period 1995-2010, we apply difference-in-differences propensity score matching to identify the direct causal effects of unemployment and reemployment on psychological and physical health. This combination of two approaches towards causal inference controls for both unobserved fixed effects and observable differences in a flexible semi-parametric specification. Our sample includes persons between the ages of 16-54 who have at least experienced one respective employment transition (treatment groups) or are continuously employed or unemployed (control groups). The results show that only psychological but not physical health is causally affected by the respective employment transitions. Specifically, the effects of unemployment and reemployment are of similar size, highlighting the importance of reemployment in compensating unemployment's negative impact on psychological health. In contrast, health selection and confounding seem to be important determinants of the cross-sectional association between unemployment and physical health. Carrying out separate analyses for permanent and temporary workers, we shed new light on the health effects of temporary employment. It has been argued that the rise of temporary employment has introduced a new inequality in the world of work, blurring the line between employment and unemployment. However, contrary to our expectations we find that both employment transitions have effects of a similar size for permanent and temporary workers. In sum, our results highlight two points. First, longitudinal research is needed to properly evaluate the health effects of unemployment, reemployment, and temporary employment. Second, compared to temporary employment, unemployment is still the greater threat to individuals' psychological health.

Changes in liver stiffness using acoustic radiation force impulse imaging in patients with obstructive cholestasis and cholangitis.

BACKGROUND: Acoustic radiation force impulse imaging is used to assess stages of liver fibrosis. The aim of our study was to evaluate liver stiffness changes in patients with biliary obstruction with or without sclerosing cholangitis after biliary drainage. METHODS: A total of 71 patients were enrolled in this prospective study (cohort N=51, control group N=20); 51 patients with obstructive cholestasis, indicated for endoscopic retrograde cholangiography, received stiffness measurement by acoustic radiation force impulse imaging before and 1-2 days after endoscopic retrograde cholangiography. Seventeen patients with obstructive cholestasis had primary or secondary sclerosing cholangitis. Forty one patients had a follow-up acoustic radiation force impulse imaging measurement after 3.0 ± 9.31 weeks. RESULTS: In all patients with obstructive cholestasis, stiffness decreased significantly after biliary drainage (p<0.001). The main decrease was observed within 2 days after endoscopic retrograde cholangiography (1.92-1.57 m/s, p<0.001) and correlated with the decrease of bilirubin and alkaline phosphatase (p=0.04 and p=0.002, respectively). In patients with sclerosing cholangitis, the initial decrease of stiffness after biliary drainage was weaker than in those without (2.1-1.85 m/s vs. 1.81-1.43 m/s, p=0.016). CONCLUSION: Acoustic radiation force impulse imaging elastography shows that liver stiffness is increased by biliary obstruction, and decreases after endoscopic retrograde cholangiography irrespective of the aetiology. In patients with sclerosing cholangitis the reduction in stiffness after biliary drainage is impaired.

Ultrasound presentation of abdominal tuberculosis in a German tertiary care center.

OBJECTIVE: Abdominal tuberculosis (TB) is a relatively rare disease in most of Europe and the typical clinical and sonographic findings in this setting have not been studied. We aimed to define sonographic findings that should alert an examiner to the possibility of abdominal TB in a low endemic region. METHODS: Case records of 17 patients with proven (n = 11) or highly likely (n = 6) abdominal TB detected in the gastrointestinal ultrasound unit at a German tertiary care center in 2003-2013 were analyzed retrospectively. Findings were compared with reported series from high-prevalence regions. RESULTS: While 76% of patients had an immigrant background, only 35% had a condition associated with immunosuppression. Lymphadenopathy was present in all cases of abdominal TB, while it was absent in 28% of patients from a control group with proven abdominal sarcoidosis. Moreover, retroperitoneal lymphadenopathy was significantly more common in TB. Other findings in patients with abdominal TB in descending order of frequency were ascites, altered hepatic texture, splenomegaly, splenic lesions, peritoneal thickening, intestinal wall lesions, hepatic lesions and hepatomegaly. 76% of abdominal TB patients had 2 or more pathological findings. CONCLUSIONS: Multiple pathological intra-abdominal findings including lymphadenopathy should alert the examiner to the possibility of abdominal TB.

Diagnostic value of ultrasound in detection of biliary tract complications after liver transplantation.

BACKGROUND: Biliary complications are significant source of morbidity after liver transplantation (LT). Cholangiography is the gold standard for diagnosis and specification of biliary complications. OBJECTIVES: Detailed analyses of ultrasound (US) as a safe imaging method in this regard are still lacking. Therefore we analyzed systematically the diagnostic value of US in these patients. PATIENTS AND METHODS: Retrospectively, 128 liver graft recipients and their clinical data were analyzed. All patients had a standardized US examination. The findings of US were compared to cholangiographic results in 42 patients. Following statistical analyses were performed: descriptive statistics, sensitivity, specificity, positive and negative predictive values (PPV, NPV). RESULTS: 42 patients had 54 different biliary complications (Anastomotic stenosis (AS) n = 33, ischemic type biliary lesions (ITBL) n = 18 and leakage n = 3). US detected n = 22/42 (52%) patients with biliary complications. The sensitivity, specificity, PPV and NPV of US were: 61%, 100%, 100%, 79% (95CI, 36-86%) for ITBL and 24%, 100, 100%, 31% (95CI, 9-46 %) for AS, respectively. CONCLUSIONS: US examination had no false positive rate. Therefore, it may be helpful as a first screening modality. But for the direct diagnosis of the biliary complication US is not sensitive enough.

Influence of different frequencies and insertion depths on the diagnostic accuracy of liver elastography by acoustic radiation force impulse imaging (ARFI).

BACKGROUND: Acoustic Radiation Force Impulse Imaging (ARFI) is an innovative elastography for staging of liver fibrosis. We evaluated the diagnostic accuracy of different probes to perform ARFI at different insertion depths. METHODS: In a prospective study, 89 chronic HCV infected patients underwent ARFI elastography using both available probes (c-ARFI: C4-1-MHz; l-ARFI: L9-4 MHz) in comparison to Fibroscan(®). Variability of ARFI elastography at different insertion depths was systematically evaluated in 39 patients (44%). According to Fibroscan(®) elastography, 32 patients (36%) presented with liver cirrhosis, 23 patients (26%) had significant fibrosis and 34 patients (38%) had no significant fibrosis. RESULTS: Mean propagation velocity with c-ARFI was 1.70±0.67m/s and 1.91±0.87m/s with l-ARFI. Results of both probes were correlated to each other (p<0.001; r=0.70) and to Fibroscan(®) (p<0.001, r=0.82 and 0.84, respectively). In patients with significant fibrosis or with cirrhosis, mean values by l-ARFI were significantly higher than by c-ARFI (p<0.001). For detection of liver cirrhosis, AUROC was 0.97 for c-ARFI (cut-off level 1.72m/s) and 0.90 for l-ARFI (cut-off 2.04m/s). Correlation coefficients of c-ARFI with Fibroscan(®) were highest at an insertion depth of 5-6cm (r=0.882 and 0.864, respectively, p<0.001) and at 3-4cm for l-ARFI (r=0.850 and 0.838, respectively, p<0.001). CONCLUSIONS: ARFI elastography with the linear and with the convex probes showed comparable validity and accuracy in the estimation of liver stiffness. The linear probe gave higher ARFI values. The most accurate insertion depth was 5-6cm for c-ARFI and 3-4cm for l-ARFI indicating that measurements should not be performed close to the liver capsule.

Fine needle sclerotherapy as a new effective therapeutic approach for nonparasitic splenic cysts: a case series.

BACKGROUND: Nonparasitic splenic cysts are rare. Until now, surgical intervention has been the standard therapy of symptomatic splenic cysts. AIMS: We herein present a retrospective analysis of an approach using percutaneous ultrasound-guided fine needle aspiration and sclerotherapy. METHODS: Out of 88,151 ultrasound reports, we identified 138 patients who presented with splenic cysts. A single splenic cyst was found in 88% (mean size 28.9 mm). Twelve patients underwent percutaneous therapy of symptomatic splenic cysts. They were younger, had larger splenic cysts and more often cyst internal echoes than the 126 untreated patients (all p < 0.0001). RESULTS: Initial sclerotherapy was performed with polidocanol 1% in 9 patients and with NaCl 10% in 2 patients. One hemorrhagic cyst was only purged. Serious adverse events were not noted. Eight patients had to undergo 1-11 further percutaneous cyst therapies. 15 of these 30 reinterventions were cyst aspiration therapies, only, and 11 of them were sclerotherapies with NaCl 10%. Four patients were readmitted to hospital for cyst retreatment. After 57 ± 43 months of follow-up, cyst size significantly decreased (p < 0.0001). Only two patients had a complicated course of cyst therapy. CONCLUSIONS: Percutaneous ultrasound-guided sclerotherapy is a new approach for symptomatic splenic cysts. In most patients, cyst size and symptoms can be significantly reduced during one hospital stay.

No evidence of substantial growth progression or complications of large focal nodular hyperplasia during pregnancy.

OBJECTIVE: Focal nodular hyperplasia (FNH) is a benign liver tumor considered to develop under the influence of estrogens. Whether women with known FNH are at higher risk of growth progression and complications during pregnancy is still controversially discussed. The authors investigated the growth pattern of FNH during pregnancy and possible related complications. MATERIALS AND METHODS: Twenty pregnant women with FNH were followed by the authors' center. Before pregnancy, diagnosis of FNH was usually established by contrast-enhanced ultrasound. During pregnancy, monitoring of FNH was performed by conventional ultrasound. Furthermore, a questionnaire was sent to all patients. RESULTS: Patient's age ranged from 24 to 36 years. Mean size of FNH before pregnancy was 58.5 ± 22.7 mm. It did not vary significantly during pregnancy (fourth month of pregnancy: 58.1 ± 23.0 mm; after pregnancy: 55.5 ± 26.8 mm; -8%; n.s.). Only in three patients, growth of FNH by 18 ± 6% was observed, while FNH size remained constant in 7 patients and even declined by -11 ± 6% in 10 patients. There were no FNH-related complications. The questionnaire was sent back by 16 patients (80%). All responding patients took oral contraceptives in the past over a mean 12.4 ± 4.4 years. Previous pregnancies were reported by 38% of patients. FNH-related fears were expressed by 63% of patients, but no FNH-related complications or symptoms during pregnancy were noted. CONCLUSIONS: This study demonstrates that women with FNH are not at risk of significant growth progression or FNH-related complications. Pregnancy should not be discouraged in these patients but careful advice and guidance are necessary.

Complications and clinical outcome of hepatic artery embolisation in patients with hereditary haemorrhagic telangiectasia.

BACKGROUND: Hepatic artery embolisation (HAE) in patients with hereditary haemorrhagic telangiectasia (HHT) is controversial because of the associated complications and unproven long-term benefit. We present our results in 20 such patients over a time span of 17 years. METHODS: Staged HAE was performed using polyvinyl alcohol (PVA) particles and coils. Complications, clinical symptoms and cardiac output were assessed before and after therapy as well as at the end of follow-up (median 92 months, range 26-208 months). RESULTS: Two patients died within 30 days following HAE (10 %). Four further deaths resulted from causes unrelated to HAE. Ischaemic cholangitis, cholecystitis and focal hepatic necrosis with biliary sepsis necessitated re-intervention in four patients. In all but one patient, clinical symptoms resolved with mean cardiac output falling from 11.84 ± 3.22 l/min pre-treatment to 8.13 ± 2.67 l/min at the end of follow-up (P < 0.001). One patient required liver transplantation for de novo symptoms of portal hypertension 4 years after primary symptoms had been cured by HAE. CONCLUSION: The 30-day mortality of HAE in patients with HHT is 10 %. The rate of complications requiring re-intervention is 20 %. Clinical response at long-term follow-up is satisfactory.