Ultrasound in the examination of the gallbladder - a holistic approach: grey scale, Doppler, CEUS, elastography, and 3D

Optimization of diagnostic ultrasonography of the gallbladder based on own experience and literature

Although transabdominal imaging of the gallbladder has become a gold standard, new light should be shed on some aspects, which will prove useful in everyday practice. Therefore, based on our own experience and the available literature, we would like to draw attention to those elements of gallbladder ultrasound imaging which may increase its diagnostic efficacy. The paper draws attention to the difficulty in assessing certain anatomical structures, such as the inferior wall, the bottom and the region of the neck of the gallbladder, and offers ways to improve their imaging. We also emphasized the negative effects of duodenal and transverse colon (along with their contents) adhesion to the bottom of the gallbladder on the correct diagnosis. Due to the importance of size in the management strategy for detected gallbladder polyps, we suggest their measurement on an image enlarged with the zoom function. This technique also allows for an accurate assessment of the shape and echostructure of these lesions. An enlarged image of a polyp makes it possible to trace its behavior in time. We also remind that the hepatic wall of the gallbladder is the only site allowing for a reliable wall thickness measurement. We also pointed to the importance of changing patient's position when assessing the mobility and the nature of lesions. Altering patient's position during examination may help detect anomalies in the form of a floating gallbladder, which may promote its torsion. Finally, pathologies whose diagnosis may be facilitated by color-coded blood flow imaging are also presented. The issues discussed in this paper are only a fraction of problems faced by an ultrasound operator in the field of gallbladder diagnostic imaging. However, the proposed ultrasound approaches should help solve some of these problems in everyday practice.

Although transabdominal imaging of the gallbladder has become a gold standard, new light should be shed on some aspects, which will prove useful in everyday practice. Therefore, based on our own experience and the available literature, we would like to draw attention to those elements of gallbladder ultrasound imaging which may increase its diagnostic efficacy. The paper draws attention to the difficulty in assessing certain anatomical structures, such as the inferior wall, the bottom and the region of the neck of the gallbladder, and offers ways to improve their imaging. We also emphasized the negative effects of duodenal and transverse colon (along with their contents) adhesion to the bottom of the gallbladder on the correct diagnosis. Due to the importance of size in the management strategy for detected gallbladder polyps, we suggest their measurement on an image enlarged with the zoom function. This technique also allows for an accurate assessment of the shape and echostructure of these lesions. An enlarged image of a polyp makes it possible to trace its behavior in time. We also remind that the hepatic wall of the gallbladder is the only site allowing for a reliable wall thickness measurement. We also pointed to the importance of changing patient’s position when assessing the mobility and the nature of lesions. Altering patient’s position during examination may help detect anomalies in the form of a floating gallbladder, which may promote its torsion. Finally, pathologies whose diagnosis may be facilitated by color-coded blood flow imaging are also presented. The issues discussed in this paper are only a fraction of problems faced by an ultrasound operator in the field of gallbladder diagnostic imaging. However, the proposed ultrasound approaches should help solve some of these problems in everyday practice.

Quantitative contrast-enhanced US helps differentiating neoplastic vs non-neoplastic gallbladder polyps

OBJECTIVES

To differentiate between large (≥ 1 cm in diameter) gallbladder (GB) non-neoplastic and neoplastic polyps using quantitative analysis of contrast-enhanced ultrasound (CEUS) findings.

METHODS

From September 2017 to May 2018, 29 patients (10 males; median age, 63 years) with GB polyps of ≥ 1 cm in diameter who were undergoing cholecystectomy were consecutively enrolled. All patients underwent preoperative conventional US and CEUS examinations. Quantitative analysis of CEUS findings using time-intensity curves between the two groups was independently performed by two radiologists. The interobserver agreement for the quantitative analysis of the CEUS results was measured using the intraclass correlation coefficient. Receiver operating characteristic analysis was performed to evaluate the diagnostic performance of CEUS examination.

RESULTS

After the cholecystectomy, the patients were classified into the non-neoplastic polyp group (n = 12) and the neoplastic polyp group (n = 17) according to the pathological results. The interobserver agreement for quantitative assessment between the two radiologists was near perfect to substantial. Quantitative assessment of the CEUS findings revealed that the rise time, mean transit time, time to peak, and fall time of non-neoplastic GB polyps were significantly shorter than those of neoplastic polyps (p < 0.001, p = 0.008, p = 0.013, and p = 0.002, respectively). The sensitivity and specificity of the quantitative CEUS parameters for the differentiation between the two groups were 76.5-100% and 75%, respectively, with an area under the curve of 0.765-0.887.

CONCLUSIONS

Quantitative analysis of CEUS findings could be valuable in differentiating GB neoplastic polyps from non-neoplastic polyps.

KEY POINTS

• Quantitative analysis of CEUS findings could be valuable in differentiating gallbladder neoplastic polyps from non-neoplastic polyps. • Quantitative analysis of CEUS findings in gallbladder polyps provides cut-off values for differentiation between neoplastic polyps and non-neoplastic polyps with near-perfect to substantial interobserver agreement.

[Radiologic diagnosis of the gallbladder and bile ducts - part 2 : Acute and chronic cholecystitis, primary sclerosing cholangitis (PSC), benign and malignant masses of the biliary system]

Upper abdominal pain, icterus and cholestasis are the symptoms leading to evaluation of the biliary tract. Together with its complications biliary stone disease is the main reason for inflammation of the biliary system. A distinction is made between acute and chronic variants. In chronic bile duct inflammation primary sclerosing cholangitis (PSC), primary biliary cirrhosis (PBC) and more recently IgG4-associated sclerosing cholangitis are of particular importance. Besides benign and tumor-like-lesions, malignant entities as gallbladder carcinoma and cholangiocarcinoma (CCC) in its three locations have to be mentioned. Despite all recent improvements, specificity of bile-tract imaging still remains limited, especially regarding malignant masses. Therefore the final diagnosis is made in many cases by histological analysis.

[Radiologic diagnostics of the gall bladder and bile ducts-part 1 : Imaging techniques-normal variants and congenital disorders-cholelithiasis]

Upper abdominal pain, icterus and cholestasis are the main symptoms leading to evaluation of the biliary tract. Since the advent of contrast-enhanced ultrasound techniques the accuracy of bile duct imaging has significantly improved. This is also true for computed tomography using isotropic secondary reconstructions as well as magnetic resonance imaging (MRI) including MR cholangiography (MRC), classically and after iv injection of hepatobiliary contrast agent. Diffusion-weighted imaging sequences have a recently proven ability for improving biliary tract imaging. These technical improvements provide the depiction of the non-dilated biliary tract system in diagnostic quality. Therefore, normal variants and congenital disorders of biliary tract anatomy are delineated as well as insights into the postoperative situs and complications related to surgery. Cholelithiasis is the most frequent disease of the gall bladder and biliary tract. Together with related complications, in the majority of cases it is also the reason for bile duct inflammation. Due to the immediate need for treatment special care has to be taken for hydrops of the gall bladder.

CEUS in the differential diagnosis between biliary sludge, benign lesions and malignant lesions

PURPOSE

Conventional grayscale ultrasound (US) is accurate in the diagnosis of gallbladder disease (GD), but in some cases, it is not decisive. Contrast-enhanced ultrasound (CEUS) improves the diagnostic accuracy of US. The primary objective of this study is to assess the reliability of CEUS in the diagnosis of sludge; the secondary objective is to assess the ability of CEUS to diagnose cancer.

METHODS

We retrospectively reviewed the US of 4137 patients positive for GD. In 43/4137 (1.04%), the use of could not discriminate between sludge and neoplasms. Then, we evaluated CEUS in only 39 of these patients, and in 4/43 (9%) cases it was not performable. After CEUS, the absence of enhancement was considered diagnostic for sludge, while contrast washout within 60 s diagnosed malignant lesions.

RESULTS

Among the 39 patients, 16 had biliary sludge and 23 had lesions of the gallbladder wall; 9 of these were carcinomas and 14 were benign tumors. The absence of enhancement was present in 16/16 patients with sludge and in 0/23 patients with lesions of the gallbladder (sensitivity and specificity 100%). Washout was within 60 s in 9/9 gallbladder carcinomas and 2/14 benign lesions (sensitivity 100%; specificity 85%).

CONCLUSIONS

US is confirmed to be accurate in the diagnosis of GD. In doubtful cases, CEUS is very accurate in biliary sludge diagnosis. An intralesional washout at 60 s is a pattern of malignancy that can orient towards a correct diagnosis, but it is limited by the presence of false positive results, especially for smaller lesions.

Contrast-enhanced ultrasonography improves the diagnostic specificity for gallbladder-confined focal tumors

PURPOSE

To investigate the value of contrast-enhanced ultrasonography (CEUS) in the differential diagnosis of malignant and benign focal gallbladder diseases confined to the gallbladder wall.

METHODS

From July 2006 to May 2016, 88 patients (mean age 48.8 years; age range 18-77 years) were enrolled. All patients had focal gallbladder lesions confined to the gallbladder wall according to CEUS examination. The conventional ultrasound and CEUS characteristics of the lesions were evaluated, and diagnostic performance was evaluated via receiver-operating characteristic (ROC) analysis.

RESULTS

Multiple logistic regression analysis showed that three characteristics, an irregular shape, branched intralesional vessels and hypo-enhancement in the late phase, were features indicating a malignant gallbladder disease (all P < 0.05). When combining any two of these three features, diagnostic specificity improved from 51.5%-77.3% to 92.4% (P < 0.05 for all), and the area under the ROC (AUROC) curve improved from 0.735-0.874 to 0.917, without a significant loss of sensitivity.

CONCLUSIONS

CEUS features have greater specificity than those from conventional US for the differentiation of benign and malignant gallbladder diseases confined to the gallbladder wall, without a loss of sensitivity.

Value of contrast-enhanced ultrasound in the differential diagnosis of gallbladder lesion

AIM

To describe contrast-enhanced ultrasound (CEUS) features and evaluate differential diagnosis value of CEUS and conventional ultrasound for patients with benign and malignant gallbladder lesions.

METHODS

This study included 105 gallbladder lesions. Before surgical resection and pathological examination, conventional ultrasound and CEUS were performed to examine for lesions. Then, all the lesions were diagnosed as (1) benign, (2) probably benign, (3) probably malignant or (4) malignant using both conventional ultrasound and CEUS. The CEUS features of these gallbladder lesions were analyzed and diagnostic efficiency between conventional ultrasound and CEUS was compared.

RESULTS

There were total 17 cases of gallbladder cancer and 88 cases of benign lesion. Some gallbladder lesions had typical characteristics on CEUS (e.g., gallbladder adenomyomatosis had typical characteristics of small nonenhanced areas on CEUS). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of CEUS were 94.1%, 95.5%, 80.0%, 98.8% and 95.2%, respectively. These were significantly higher than conventional ultrasound (82.4%, 89.8%, 60.9%, 96.3% and 88.6%, respectively). CEUS had an accuracy of 100% for gallbladder sludge and CEUS helped in differential diagnosis among gallbladder polyps, gallbladder adenoma and gallbladder cancer.

CONCLUSION

CEUS may provide more useful information and improve the diagnosis efficiency for the diagnosis of gallbladder lesions than conventional ultrasound.

A sculpture masterpiece for the teaching of anatomy

Background and aim

The study of anatomy remains the backbone of medical education in the first years. There is a constant need for educational materials that enable the assimilation of knowledge by students. The casts after human bodies have not lost the value, even in the era of virtual education. We present in this paper a museal item destined to improve the anatomy teaching.

Methods

Given the existence in the department of anatomy from Cluj –Napoca of an item of exceptional artistic and scientific value, we intensively searched Pubmed and Scopus, as well as by manual search of printed only documents, for all papers related to the muscle man by Brancusi created for educational purposes of anatomy students.

Results

This paper presents summary data from the biography of the creators of this item, the world famous sculptor Constantin Brancusi and the professor of anatomy and surgery from Bucharest Dimitrie Gerota. We also describe this item and the conditions which generated it

Conclusion

Teaching anatomy relies on the quality of the didactic support. The muscle man by Brancusi is a very realistic reproduction of a man, very useful for anatomical training and teaching.

Role of contrast-enhanced ultrasound (CEUS) in the diagnosis of endometrial pathology

Ultrasound is the reference imaging procedure used for the exploration of endometrial pathology. As medical procedures improve and the requirements of modern medicine become more demanding, gray-scale ultrasound is insufficient in establishing gynecological diagnosis. Thus, more complex examination techniques are required: Doppler ultrasound, contrast-enhanced ultrasound (CEUS), 3D ultrasound, etc. Contrast-enhanced ultrasound is a special examination technique that gains more and more ground. This allows a detailed real-time evaluation of microcirculation in a certain territory, which is impossible to perform by Doppler ultrasound. The aim of this review is to synthesize current knowledge regarding CEUS applications in endometrial pathology, to detail the technical aspects of endometrial CEUS and the physical properties of the equipment and contrast agents used, as well as to identify the limitations of the method.