Sonography of the small bowel after oral administration of fluid: an assessment of the diagnostic value of the technique

PURPOSE

This study was performed to assess the feasibility and possible advantages of bowel sonography after fluid filling of intestinal loops compared with conventional sonography.

MATERIALS AND METHODS

Forty-five consecutive patients with known or suspected coeliac disease (35 females, ten males; age range 11-65 years) prospectively underwent sonography before and after ingestion of 750 ml of an aqueous solution of polyethylene glycol. Results before and after fluid distension were compared to assess whether luminal filling improved small-bowel visualisation.

RESULTS

Luminal filling improved visualisation of intestinal features (luminal diameter, mucosal folds, parietal layers) in 77.6% of cases (marked, moderate or mild improvement in 2, 16 and 17 patients; 4.4%, 35.5% and 37.7%), respectively, and showed no change or worsening in 20% and 2.2% nine and one patient), respectively. Baseline examination showed abnormal features in 13/25 celiac patients (dilated fluid-filled loops, increased peristalsis, transient intussusception, mesenteric lymph nodes, intraperitoneal fluid). Reexamination after luminal filling showed additional abnormalities in six of the previous 13 and in three further coeliac patients. There were no false positive signs due to fluid administration.

CONCLUSIONS

Luminal filling can improve visualisation of bowel walls and fold pattern and may be helpful in selected cases.

An unusual case of adrenal metastasis from colorectal cancer: computed tomography and fluorine 18-fluoro-deoxy-glucose positron emission tomography-computed tomography features and literature review

Incidentally discovered adrenal masses are a common diagnostic problem. While computed tomography (CT) and magnetic resonance (MR) imaging can adequately characterize most benign or malignant adrenal masses, in some cases the results are indeterminate. We report and discuss a case of an adrenal metastasis with misleading clinical and CT features, in which an abnormal metabolic uptake detected through fluorine 18-fluoro-deoxy-glucose positron emission tomography (¹⁸F-FDG PET)-CT raised the suspicion of adrenal metastasis relatively early compared with apparently normal results on repeated follow-up CT examinations.

CT enterography with polyethylene glycol solution vs CT enteroclysis in small bowel disease

OBJECTIVE

The aim of the study is to compare CT enterography with polyethylene glycol solution (PEG-CT) with CT enteroclysis (CT-E) in patients with suspected small bowel disease.

METHODS

145 patients underwent abdominal contrast-enhanced 16-row multidetector CT after administration of 2000 ml of PEG by mouth (n = 75) or after administration of 2000 ml of methylcellulose by nasojejunal tube (n = 70). Small bowel distension, luminal and extraluminal findings were evaluated and compared with small bowel follow-through examination in 60 patients, double contrast enema in 50, surgery in 25 and endoscopy in 35. Statistical evaluation was carried out by χ² testing. For both techniques we have also calculated the effective dose and the equivalent dose in a standard patient.

RESULTS

Crohn's disease was diagnosed in 64 patients, neoplasms in 16, adhesions in 6. Distension of the jejunum was better with CT-E than PEG-CT (p<0.05: statistically significant difference). No significant difference was present for others sites (p>0.05). Evaluation of pathological ileal loops was good with both techniques. The values of sensitivity, specificity and diagnostic accuracy were respectively 94%, 100% and 96% with CT-E, and 93%, 94% and 93% with PEG-CT. The effective dose for PEG-CT was less than the dose for the CT-E (34.7 mSv vs 39.91 mSv).

CONCLUSION

PEG-CT shows findings of Crohn's disease as well as CT-E does, although CT-E gives better bowel distension, especially in the jejunum, and has higher specificity than PEG-CT.

Work stress in radiologists. A pilot study

PURPOSE

We studied occupational stress and its psychosocial effects in a sample of Italian radiologists and radiotherapists:

MATERIALS AND METHODS

Radiologists and radiotherapists attending two medical conferences were invited to complete a questionnaire comprising four sections investigating the risk of occupational stress (organisational discomfort, Karasek's Job Content Questionnaire, Siegrist's Effort-Reward Imbalance, Warr's Job Satisfaction) and four sections investigating the health effects of such stress (Goldberg's Anxiety and Depression Scales, General Health Questionnaire, Lifestyles Questionnaire).

RESULTS

Radiologists and radiotherapists generally expressed high levels of control, reward and satisfaction. However, 38.5% complained of severe organisational discomfort, 24% reported job strain, 28% reported effort/reward imbalance and 25% were dissatisfied. Female radiologists and radiotherapists showed higher levels of organisational discomfort than their male colleagues. Younger and less experienced radiologists and radiotherapists had higher strain scores than their older and more experienced colleagues. A significant correlation was observed between stress predictors and the effects of stress on health, including depression and anxiety, psychological distress and unhealthy lifestyles.

CONCLUSIONS

Radiologists and radiotherapists are exposed to major occupational stress factors, and a significant percentage of them suffer from workplace stress. A special effort is required to prevent this condition.

Multidetector CT in small-bowel neoplasms

PURPOSE

The aim of this study was to assess the diagnostic potential of multidetector computed tomography (MDCT) in the evaluation of small-bowel neoplasms.

MATERIALS AND METHODS

We studied 120 patients with suspected small-bowel disease by 16-slice MDCT after oral administration of a polyethylene glycol solution (n=56) or methylcellulose via a nasojejunal tube (n=64). Unenhanced and contrast-enhanced CT was performed. Contrast-enhanced CT images were acquired 40 s after IV injection of 130 ml of iodinated contrast agent at a rate of 3 ml/s. Multiplanar reconstructions were performed at the end of the examinations.

RESULTS

Fifteen patients were found to be affected by small-bowel neoplasm (six had non-Hodgkin's lymphoma, three had carcinoid tumour, two had Peutz-Jeghers syndrome, two had adenocarcinoma, two had melanoma metastases, one had lipoma). In the remaining patients, 58 cases of Crohn's disease and seven miscellaneous diseases were detected. All findings were confirmed by barium studies, surgery or endoscopy.

CONCLUSIONS

MDCT performed after bowel-loop distension with low-density contrast material and IV administration of iodinated contrast agent is a reliable method for diagnosing and staging small-bowel neoplasms.

Hypercreatininemia and hyperglycemia: diabetic nephropathy or "inverted peritoneal auto-dialysis"?

We describe a case of 51-year-old male with fever, abdominal pain and inguino-scrotal hernia. Laboratory examination revealed hypercreatininemia and hyperglycemia, firstly interpreted as diabetic nephropathy. US and CT scan showed a hernia of the bladder into the scrotum. Surgery revealed multiple bladder perforations with peritoneal diffusion of urine. So, hypercreatininemia was caused by peritoneal reabsorption of urea and creatinine, a condition that may be described as "inverted peritoneal auto-dialysis". Surgical reposition and repairment of the bladder led to rapid normalization of serum urea and creatinine. Discharged diagnosis was intraperitoneal rupture of inguino-scrotal hernia of the bladder in patient with recent onset of diabetes mellitus.

Amebic abscess of urachal remnants

We report a rare case of amebic abscess of the urachus, mimicking an urachal neoplasm: no previous reports of amebic infection of the urachus were found in the literature. The challenges of the differential diagnosis between urachal abscess and carcinomas based both on clinical and radiological data are discussed.

Sonographic diagnosis of distal biceps tendon rupture: a prospective study of 25 cases

OBJECTIVE

To describe the sonographic findings of distal biceps tendon ruptures and to assess the accuracy of the technique.

METHODS

Twenty-five patients with clinically indicated distal biceps tendon ruptures were prospectively studied by sonography. Five patients also underwent magnetic resonance imaging. Surgical confirmation was obtained in 14 patients.

RESULTS

Seventeen complete tendon ruptures and 3 partial tears were correctly shown by sonography; 1 complete rupture was incorrectly shown as a partial tear by sonography. Sonographic features of complete rupture were absence of tendon in the expected location, fluid collection in a typical tendon gap, and a mass in the antecubital fossa. Sonographic features of incomplete rupture were intratendinous hypoechogenicity and tendon thinning. Peritendinous fluid was found in complete and incomplete ruptures.

CONCLUSIONS

In distal biceps tendon ruptures, sonography is a cost-effective method that can confirm the clinical indications with good accuracy and can show tendon lesions when the clinical indications are low.

[Role of Doppler color ultrasonography in the diagnosis of thyroid carcinoma]

The aim of this study is to assess the efficacy and accuracy of color flow-Doppler sonography (CFDS) in predicting the malignancy of thyroid nodules. Seventy eight consecutive patients (52 females and 26 males), with 78 thyroid nodules (29 single nodules and 49 in a nodular goiter) have been examined by CFDS, before surgery, evaluating the hypoechogenicity of the nodule, the presence of microcalcifications and the halo sign absent and the vascular pattern, which has been classified as follows: absence of blood flow (type I), perinodular blood flow (type II), intranodular, with or without perinodular blood flow (type III), which is considered the most typical pattern of malignancy. On histology 22 nodules as carcinoma (CA) and 56 as benign nodules (BN) have been diagnosed. The most predictive for malignancy, sonographic pattern, "microcalcifications", has been found in 13/22 CA and in 4/56 BN (P < 0.0001, specificity 93%, sensitivity 59%); "hypoechogenicity" in 16/22 CA and in 8/56 BN (P < 0.0001, specificity 86%, sensitivity 73%), "absent halo sign" in 18/22 CA and in 16/56 BN (P < 0.0001, specificity 71%, sensitivity 82%.) have been found. On CFD type III pattern has been detected in 17/22 CA and in 24/56 BN (P < 0.15, specificity 57%, sensitivity 77%); type IIIa pattern (intranodular without perinodular blood flow) has been the most predictive for malignancy (P < 0.0001, specificity 100%, sensitivity 36%). The combination of type III pattern with "hypoechogenicity" in 13/22 CA and in 2/56 BN (p < 0.0001, specificity 93%, sensitivity 59%) has been found, with "absent halo sign" in 15/22 CA and in 3/56 BN (P < 0.0001, specificity 94.6%, sensitivity 68%), has been found, with "microcalcification" in 10/22 CA and in 0/56 BN (P < 0.0001, specificity 100%, sensitivity 45%) has been found. The combination of "microcalcifications" and absent halo sign" with type III pattern has been the most specific for malignancy, being detected in 11/22 Ca and 2/56 BN (P < 0.0001, specificity 96%, sensitivity 50%). In conclusion our results suggest that CFDS has an useful role in the assessment of thyroid nodules and it may provide information highly predictive for malignancy, above all when multiple, sonographic and vascular patterns are contemporaneously present in a thyroid nodule.

Role of color Doppler sonography in the assessment of musculoskeletal soft tissue masses

Fifty-six patients with soft tissue masses of the limbs (36 benign, 20 malignant) prospectively underwent sonography (color Doppler and pulsed Doppler examinations) to assess the role of Doppler interrogation in differentiating benign from malignant lesions. Sonography showed 60% sensitivity, 55% specificity, 71% negative predictive value, 42% positive predictive value, and 57% accuracy. Color Doppler evaluation showed 85% sensitivity, 88% specificity, 91% negative predictive value, 80% positive predictive value, and 87% accuracy. Diastolic and venous velocities and pulsatility index values were not statistically significant. Mean systolic velocity was 0.27 m/s in benign lesions and 0.55 m/s in malignant lesions. By combining sonographic and Doppler data, a correct diagnosis was obtained in 51 of 56 patients (90% sensitivity, 91% specificity, 85% positive predictive value, 94% negative predictive value, 91% accuracy). Color Doppler and pulsed Doppler evaluations represent a useful adjunct to sonography and should be routinely included in the evaluation of musculoskeletal soft tissue masses by ultrasonography.

Diagnostic imaging of differentiated thyroid carcinoma

The role of diagnostic imaging in differentiated thyroid carcinoma is analyzed. 99mTc-pertechnetate 123I and 131I scintigraphy allows the evaluation of nodules with their differentiation in cold (hypofunctioning) and hot (functionally autonomous) nodules; thyroid carcinomas are cold nodules even if most of them are benign. On sonography thyroid nodules are well visualized with the definition of their site, number, size (not very useful parameters for the diagnosis of malignancy), echoic structure, and vascularization on color Doppler. The sonographic findings suggestive of differentiated thyroid carcinoma are: solid and hypoechoic structure, irregular ill-defined margins, absent or discontinuous peripheral ring, microcalcification, intranodular vascularization, local lymphadenopathies. These findings are characteristic but not pathognomonic, mostly for papillary carcinoma, while in the frequently isoechoic follicular carcinoma microcalcification and lymph node metastases are rare. Only the finding, although rather infrequent, of the dissemination to adjacent structures (muscles and vessels) is a definite indication for malignancy of a thyroid nodule. Color Doppler sonography plays a major role in the postoperative staging and follow-up, in combination with thyroglobulin determination and 131I whole body scintigraphy and it allows the detection of local and/or laterocervical lymph node recurrence. The most typical sonographic findings of metastatic lymphadenopathy are the roundish shape (length/anteroposterior diameter ratio-L/A < 1.5), not visible or displaced nodal hilum, thickened cortical layer with echoic structure similar to that of thyroid parenchyma, at times with microcalcification, cortical vascularization and dismantled angioarchitecture. CT and MRI are occasionally more useful to evaluate the substernal or retrosternal extension of voluminous thyroid masses and to identify local or distant metastases.

Work-related musculoskeletal complaints in sonologists

The prevalence of musculoskeletal complaints of the hand and wrist, and the neck and back, in physicians who operate sonography equipment was evaluated, and associations between these complaints and various work-related and personal variables were studied. A questionnaire survey was distributed among physician sonographers (sonologists) in Italy. The relationship between work habits and musculoskeletal complaints was analyzed by logistic regression models adjusted for gender, age, and duration of work with ultrasound. A total of 2041 physician sonographers completed the questionnaire. It was found that a large proportion of the subjects regularly had work-related complaints, such as neck and back pain (NBP) (18.5%) or hand and wrist cumulative trauma disorder (HWD) (5.3%). Roughly 80% of the sonographers were currently affected, or had been affected in the past, by one or more work-related symptoms. Various work-related factors appeared to be related to musculoskeletal syndromes. The average time spent for each examination was related both to NBP and HWD. Discomfort for transducer design was the best predictor of HWD, whereas a comfortable chair and correct position of the body protected from the onset of NBP. These results support the role of ergonomic factors in the pathogenesis of both NBP and HWD in sonographers.

[Frequency of musculoskeletal symptoms in diagnostic medical sonographers. Results of a pilot survey]

INTRODUCTION

We report the results of a pilot survey in diagnostic medical sonographers. Aim of the study was to evaluate the frequency of musculoskeletal disorders in sonologists and the relationship of these symptoms to ergonomic factors.

MATERIALS AND METHODS

340 sonographers (258 male, 82 female doctors; mean age 41.5 +/- 7.2 years) were given a questionnaire to fill out. The questionnaire asked questions about the sonologist's age, gender, technique of ultrasound procedure, physical activity, and work-related musculoskeletal complaints. Two symptom lists regarded carpal tunnel syndrome (CTS) symptoms (8 items) and other work-related musculoskeletal symptoms (13 items). The categorized response variables "have now" or "in the past" were provided. The symptoms experienced were categorized into three levels as no symptoms, few symptoms (1-4 symptoms), and many symptoms (> 5 symptoms).

RESULTS

One third of the respondents reported having at least one or more work-related symptoms in the upper extremities. The most frequent symptoms were tingling (17.6%), numbness or finger pain (13.5%). Carpal tunnel syndrome had been diagnosed in 5 cases (1.5%). More than 60% of all respondents have experienced one or more musculoskeletal symptoms in the cervical or lumbar spine. The commonest symptom was neck and low back pain (67%). The pain was generally intermittent and occurred at the end of the workday. Motion impairment in the neck and/or back was present in 23.5% of cases. Twenty-five percent of respondents had received treatments for their symptoms and 10% reported having stopped work because of their symptoms. Data analysis showed that muscular efforts such as gripping the transducer, applying sustained pressure, and scanning with a correlated flexed or hyperextended wrist were significantly correlated with increasing severity of symptoms in the hand, wrist, and forearm area. On the other hand, low back pain appeared to be negatively correlated with correct position of the body.

CONCLUSIONS

Several physical risk factors (e.g., repetitive work and force exertion, twisting of the body and poorly-adjustable chairs) have been identified for work-related upper extremity and spine disorders. Ergonomic redesign of the workstation configuration as well as allowing sufficient recovery time to body and arm muscles appear to be the main goals to achieve prevention of musculoskeletal disorders in sonographers.

Doppler sonography of hemodynamic changes of the inferior mesenteric artery in inflammatory bowel disease: preliminary data

OBJECTIVE

To our knowledge, Doppler data for the inferior mesenteric artery are currently restricted to healthy patients. The present study was conducted to evaluate changes in inferior mesenteric artery flow in patients with inflammatory bowel disease.

SUBJECTS AND METHODS

Doppler sonography of the inferior mesenteric artery was prospectively performed in 24 patients with Crohn's disease (active, n = 15; inactive, n = 9), in 22 patients with ulcerative colitis (active, n = 14; inactive, n = 8), and in 40 healthy controls. Disease activity was determined with clinical and laboratory indicators (medical history, physical examination, laboratory data, and endoscopy with histology). Flow velocity, pulsatility index, and estimated flow volume were measured in all patients and compared with the corresponding values for control subjects. Hemodynamic parameters were then correlated with location of disease (small bowel and right and proximal transverse colon versus distal transverse and left colon) and disease activity or inactivity.

RESULTS

Among patients with active disease, inferior mesenteric artery flow was significantly greater in those with left colon involvement (group 1, 20 patients) than in patients with involvement of the small bowel or right colon (group 2, nine patients) and in control subjects. Median flow values for group 1 were peak systolic velocity, 1.96+/-0.57 m/sec; mean velocity, 0.63+/-0.25 m/sec; minimum velocity, 0.17+/-0.20 m/sec; pulsatility index, 3.07+/-1.24; and estimated flow volume, 0.40+/-0.17 l/min. Median flow values for group 2 were peak systolic velocity, 1.27+/-0.56 m/sec; mean velocity, 0.29+/-0.14 m/sec; minimum velocity, 0.06+/-0.10 m/sec; pulsatility index, 4.71+/-0.98; and estimated flow volume, 0.14+/-0.11 l/min. Median flow values for control subjects were peak systolic velocity, 1.41+/-0.48 m/sec; mean velocity, 0.43+/-0.19 m/sec; minimum velocity, 0.10+/-0.16 m/sec; pulsatility index, 3.49+/-0.49; and estimated flow volume, 0.13+/-0.06 l/min. Compared with control subjects, patients with acute disease involving the left colon (group 1) presented increases in flow velocity (systolic velocity, p < .001; minimum velocity, p = .01; mean velocity, p < .001) and estimated flow volume (p < .001) and a decreased pulsatility index (p = .01). A significant increase in inferior mesenteric artery flow was also found when group 1 patients were compared with those of group 2 (active disease affecting the small bowel and right colon) and group 3 (13 patients with quiescent disease of the left colon).

CONCLUSION

In this preliminary study, active inflammation of the left colon in patients with Crohn's disease or with ulcerative colitis was associated with a substantial increase in inferior mesenteric artery flow that could be seen on Doppler sonography.

Diagnostic imaging in thyrotoxicosis

In thyrotoxicosis, imaging mainly scintigraphy, color Doppler sonography and radioiodine uptake test are used in the differential diagnosis as well as in the morphofunctional evaluation of the thyroid before and after therapy (mainly pharmacological or with radioiodine). Radioiodine uptake test differentiates high uptake thyrotoxicosis (Graves'disease, toxic nodular goiter) and low uptake thyrotoxycosis (subacute or silent thyroiditis, ectopic thyrotoxicosis, iodine-induced hyperthyroidism). In Graves'disease scintigraphy shows thyroid enlargement with intense homogeneous tracer uptake; rarely nodules with no uptake are present. On color Doppler sonography, a part from enlargement, typical findings are: diffuse structural hypoechogenicity (at times with echoic nodules), parenchymal hypervascularization ("thyroid inferno"), high systolic velocities (PSV > 70-100 cm/sec) in inferior thyroid arteries. Scintigraphy is the only method able to evidence an autonomously functioning thyroid nodule and stage it (in association to clinical findings and TSH, FT3, FT4 determination) as: toxic, non toxic (or pretoxic) and compensated, depending on whether there is inhibition of extranodular tissue. A scintigraphically "hot" nodule appears hypervascularized on color Doppler sonography (especially in the toxic or pre-toxic phase) with high PSV (> 50-70 cm/sec) in the ipsilateral inferior thyroid artery. The most reliable parameters in the evaluation of the therapeutic efficacy are: decreases in thyroid (Graves'disease) or nodular (autonomously functioning nodule) volume; decreased radioiodine uptake (Graves'disease); functional recovery of suppressed parenchyma (autonomously functioning nodule); decreased PSV in the inferior thyroid arteries.

Diagnostic imaging of the thyroid: methodology and normal patterns

The diagnostic imaging of the thyroid is based on sonography and scintigraphy, which to-date play a unique role in the morphofunctional study of the thyroid gland. The high spatial resolution of sonography allows an accurate evaluation of the thyroid morphology, size and parenchymal structure. Color Doppler sonography allows a qualitative assessment associated with quantitative parameters of glandular vascularization. Furthermore, sonography is the simplest procedure to achieve an accurate, reproducible measurement of thyroid volume. Scintigraphy provides information unavailable by other methods on the regional thyroid function. The most common tracer for thyroid scintigraphy is 99mTc pertechnetate. 123I and 131I are essential for radioiodine uptake test. CT and MRI, while invaluable for other organs and apparatus, play a limited role in the diagnosis of thyroid disease.

Diagnostic imaging of euthyroid goiter

In diffuse or nodular euthyroid goiter, diagnostic imaging is indicated to define, by sonography, the morphology, size and structure of the goiter and to evaluate, by scintigraphy, the regional thyroid function. The instrumental diagnosis of thyroid nodule is essentially based on sonography, scintigraphy and (US-guided) needle aspiration cytology. The evaluation of some sonographic findings (echogenicity, calcification, lesion margins and presence of peripheral ring) may direct to the differentiation of a benign or malignant lesion. The role of color Doppler in the characterization of thyroid nodules is still controversial. Scintigraphy provides information on nodular function, being also the only exam able to show the presence of autonomously functioning thyroid tissue ("hot" nodule), whose diagnosis allows to rule out the presence of thyroid carcinoma with a very strong probability. In intrathoracic goiter, CT and MRI and indicated to show the continuity with the cervical thyroid and to define the relationships with adjacent structures. Radioiodine scintigraphy shows with high (> 90%) diagnostic accuracy the thyroid nature of a mediastinal mass (plunging goiter).

Uterine intracavitary disorders: role of sonography and combination with other radiologic techniques

Since it serves as the site for the implantation of the fertilized ovum, it is evident that significant disorders in the uterine cavity and endometrial mucosa represent potential factors of sterility/infertility. Among the acquired pathological conditions, a possible cause of sterility, there are inflammatory (endometritis) or post-traumatic (synechiae) disorders and proliferative mucosal (endometrial hyperplasia, polyps) and muscular (fibroma) disorders. Sonography (by transabdominal or preferably endovaginal route, and sonohysterography) is the first choice procedure being in most cases adequate for clinical assessment. According to the specific disease, the diagnostic combination with hysteroscopy, hysterosalpingography, Magnetic Resonance Imaging can be suitable.

Uterine adenomyosis and tubal endometriosis: diagnostic imaging

Endovaginal sonography plays a major role in the study of pelvic endometriosis and uterine adenomyosis. Other procedures as CT or MRI are reserved for particular cases. Diagnostic problems and main radiologic findings are analyzed.

Ovarian factor infertility

The diseases of the ovary which most frequently cause infertility are: anovulation from follicular atresia, the empty follicle syndrome, the luteinized unruptured follicle syndrome; chronic anovulation syndromes, within which polycystic ovarian syndrome plays a major role; ovarian endometriosis. Sonography and Color Doppler US are the first choice procedures in the monitoring of ovarian cycles, which combined with serum hormone values, are able to identify possible changes in the physiologic sequence of the cycle. In follicular atresia, ovaries with minute follicles (3mm or less) and early disappearance of primary follicle are observed on sonography. The empty follicle syndrome characterized by the lack of oocytes within the primary follicle, is of difficult sonographic diagnosis, a possible sign being the missed visualization of cumulus oophorus. The luteinized unruptured follicle syndrome consists in the absence of oocyte expulsion from primary follicle persisting more than 48 hours after LH blood peak. Doppler spectra of blood flow in perifollicular ovarian arteries maintain the features of the follicular phase, i.e. low diastolic velocities and high resistances. Among chronic anovulation syndromes, hyper-and hypogonadotropism cause ovarian amenorrhea where ovaries are similar to those of women in menopause: small size, very few or absent follicles. The polycystic ovarian syndrome is characterized by an abnormal pulsatile GnRH release which causes LH hypersecretion and FSH hyposecretion. The latter is not able to stimulate the growth and maturation of follicles, while the former causes hyperandrogenism with hirsutism and obesity and is responsible for hypertrophy and stromal hyperechogenicity. The sonographic diagnosis of polycystic ovarian syndrome is based on standardized morphostructural signs as increased volume of the ovaries (> 10 cm3), the presence of numerous (> or = 10) peripheral microfollicles (< or = 5 mm) with hyperechoic stroma. The endometrial cyst, usually present in ovarian endometriosis is visualized with sonography as a round neoformation with ill-defined walls, filled with a uniformly hypoechoic, corpuscular, partly hemorrhagic fluid; less frequently the appearance is that of a more complex structure posing differential diagnostic problems, mainly with the hemorrhagic corpus luteum; both pathological conditions appear poorly vascularized at Color Doppler, with tracings of high resistance arterial flow. Among the procedures of second choice, CT can show the high blood density common to the two conditions while on MRI the signal is mostly hyperintense in T1-weighted sequences with areas of lower signal intensity in T2-weighted sequences.

Sonographic and Doppler assessment of the inferior mesenteric artery: normal morphologic and hemodynamic features

BACKGROUND

We wanted to evaluate prospectively the feasibility of sonographic and Doppler assessment of the inferior mesenteric artery (IMA) and to provide data on its normal morphological and hemodynamic characteristics.

METHODS

Sonography and Doppler study of the IMA were performed on 116 patients without splanchnic vessel pathology. Vessel diameter, systolic, diastolic, and time-averaged mean flow velocities, pulsatility index values, and flow volumes were correlated with patient age (< 50 years vs. > or = 50 years) using the Wilcoxon rank-sum test. Findings were verified by splanchnic angiography in 11 cases.

RESULTS

Technically valid studies were obtained in 103/116 cases (88.8%). Flowmetric data showed high peripheral resistance (mean +/- SD: systolic flow velocity, 1.41 m/s +/- 0.48; minimal diastolic flow velocity, 0.10 m/s +/- 0.16; pulsatility index, 3.49 +/- 0.49). Mean flow volume calculated in 80 cases was 0.13 L/min +/- 0.06. Older subjects presented significantly higher time-averaged mean flow velocities and lower resistance than those younger than 50 years.

CONCLUSIONS

The success rate for sonographic and Doppler study of the IMA is similar to that observed with larger splanchnic vessels. Knowledge of its normal characteristics is necessary for recognition of pathological conditions and for studies of its physiological behavior.

A new method for evaluating small intestinal motility using duplex Doppler sonography

OBJECTIVE

Many techniques currently used to study motility of the small intestine are too complex for large-scale use; other techniques provide information that is nonspecific and nonquantitative. The aim of the present study was to verify whether intestinal peristalsis can be seen and quantitatively assessed by means of duplex Doppler sonography.

SUBJECTS AND METHODS

We prospectively studied 152 normal fasting subjects using sonography, duplex Doppler sonography, and stethoscopic auscultation or phonocardiographic registration of bowel sounds in three abdominal sites. In each subject, we positioned the sample volume near the intestinal wall and then recorded Doppler signals of different amplitude and duration that related to bowel motility. Studies were repeated after ingestion of water (n = 55) and after a standard test meal (n = 73). The number of peristaltic waves and the number of bowel sounds revealed by the different imaging techniques were compared and statistically evaluated by Student's t test.

RESULTS

Intestinal movements were classified as peristaltic or nonperistaltic (mixing movements) based on amplitude and duration of Doppler signals. The mean number of peristaltic waves revealed by Doppler sonography was three per minute in fasting subjects, with no significant increase after ingestion of water (3.78 per min) or the test meal (3.92 per min). The mean number of bowel sounds obtained with auscultation and phonocardiographic recordings was significantly higher in fasting subjects (8.7 per min) and after ingestion of water (9.55 per min) or the test meal (12 per min).

CONCLUSION

Intestinal contractions produce Doppler signals of different amplitudes and duration, thus potentially allowing differentiation between peristaltic and nonperistaltic movements. This differentiation is not possible with auscultation or phonocardiographic registration because similar bowel sounds are produced by nonprogressive, mixing movements as well as by true peristaltic movements. Duplex Doppler sonography allows graphic visualization of intestinal movements that can be subjected to qualitative and quantitative analysis and may be suitable for the noninvasive study of small-bowel motility.

[Clinico-ultrasonographic assessment of the thyroid volume and function in chronic enteritis and colitis: preliminary data]

Inflammatory bowel diseases (IBD) such as Crohn's disease (CD) and ulcerative colitis (UC) have frequent extraintestinal (hepatobiliary, cutaneous, ocular, articular, urinary) complications. On the contrary, no data are available about possible thyroid involvement. We studied thyroid morphology and function in 39 patients affected with active IBD (13 UC; 26 CD) before (all) and 45 and 90 days after onset of therapy (21/39), and in 55 normal control subjects. Every time, the following exams were performed: thyroid US (parenchymal assessment, thyroid volume calculation), hormone and immunologic assays (T3, T4, FT3, FT4, TSH; antithyroglobulin and antithyroid microsomal/peroxidase antibodies). A statistically significant increase in thyroid volume was found in IBD (mean: 22.1 ml) compared to control subjects (mean: 15.6 ml), more frequently in CD (18/26 patients; 69.2%) than in UC (2/13 patients; 15.4%). Parenchymal structure was inhomogeneous in the two groups of patients (88.4% CD; 15.4% UC) more frequently than in control subjects (12.7%). Hormone assays demonstrated increased FT4 values in UC (9/13 patients; 69.2%) and decreased T4 values in CD (14/26 patients; 53.8%). IBD patients increased frequency of antithyroglobulin and antithyroid microsomal/peroxidase antibodies. Such abnormalities subsided only partially after therapy. Our data suggest that in IBD there is a frequent thyroid involvement with morphological, hormone, and immunologic abnormalities.

Abdominal lymphadenopathy in benign diseases: sonographic detection and clinical significance

We prospectively evaluated the frequency of lymphadenopathy in the right upper abdominal quadrant as detected by sonography in 650 consecutive unselected patients, after excluding patients with a known lymphoma or abdominal carcinoma and patients with acquired immunodeficiency disease. Evidence of enlarged lymph nodes (few in number, with an elongated shape and isoechoic to the liver, 8 to 22 mm in size), found primarily in the gastrohepatic ligament and porta hepatis, was seen on sonographic scans in 106 patients (16.3%). Associated conditions in 69 of 106 patients (65%) were hepatobiliary or pancreatic diseases and, less frequently, other benign entities (12 patients; 11.3%); in 25 cases (23.5%) no significant abdominal or systemic disease was present. Comparison with CT or surgical findings, or both, was available in 36 cases. We conclude that lymphadenopathy in the right upper abdominal quadrant may be found in relation to different non-neoplastic conditions as well as in the absence of any significant intra-abdominal disease. The frequency of this finding on sonographic scans must be recognized to prevent misdiagnosis of lymphoma or metastatic disease as well as to avoid overstaging of local (hepatobiliary, pancreatic, gastric) neoplasms.

Sonographic estimation of fetal liver weight: an additional biometric parameter for assessment of fetal growth

A single fetal ultrasonogram was obtained between the 20th and 40th weeks of gestation in 327 pregnancies. Fetal body weight was calculated with standard methods and fetuses were classified as appropriate for gestational age (303 fetuses), large for gestational age (four fetuses), or small for gestational age (20 fetuses). Fetal liver weight was estimated on the basis of longitudinal, anteroposterior, and cephalocaudal liver dimensions multiplied by a constant (k) of 0.42 determined experimentally in a previous study of adult livers. Estimated liver weights in appropriate for gestational age fetuses were not statistically different from published standards based on autopsy findings (P < 0.005). Similar findings were obtained in two other normal pregnancies examined serially until delivery. Estimation of fetal liver weight appears to be an accurate and reproducible method and may enhance sonographic assessment of fetal growth abnormalities and conditions with fetal liver involvement.

Duplex-Doppler evaluation of intestinal peristalsis in patients with bowel obstruction

Duplex-Doppler was used to visualize intestinal peristalsis in 30 patients with intestinal distension. The series included 12 patients with acute mechanical obstruction, 13 with long-standing mechanical obstruction, and five with paralytic ileus. The Duplex-Doppler recordings showed several patterns characterized by different degrees of intensity and frequency of the signals according to the type of obstruction, its duration, and the site of Doppler sampling relative to the obstructed segment. Duplex-Doppler evaluation provided both qualitative and quantitative data about intestinal peristalsis, allowing differentiation between mechanical and paralytic ileus. The visualization of intestinal segments having different degrees of peristaltic activity proved useful in localizing the site of mechanical obstruction.

Color Doppler ultrasonography in the differential diagnosis of focal hepatic lesions. The SH U 508 A (Levovist) experience

The differential diagnosis of focal hepatic lesions is a current problem even though many study methods are available. Color Doppler US has been recently suggested as a diagnostic technique capable of depicting lesion vascularization patterns to better understand lesion nature. However, this examination is often difficult and long. In this study, we investigated the role of a US contrast agent SH U 508 A (Levovist) enhancing the color Doppler signals for easier and better depiction of lesion vascularization. Seventy-four patients with one or more focal hepatic lesions (mean diameter: 5.6 cm) were examined. The lesions were 38 HCCs, 4 cholangiocarcinomas, 1 intrahepatic biliary duct carcinoma, 1 case of multiple adenomas, 2 regenerations nodules in cirrhosis, 2 cases of FNH, 18 metastases and 8 hemangiomas. In 54 cases the US contrast agent allowed the visualization of some vessels inside the lesions which had been missed at baseline examinations. Moreover, the vessels which had been depicted on baseline images were better demonstrated. In all but one patient with severe hepatic steatosis, normal parenchymal vessels were markedly enhanced. Our results in the different kinds of tumors are here reported.

[Doppler ultrasonography assessment of the inferior mesenteric artery. Feasibility study and definition of morphologic and flowmetric characteristics]

The conventional and Doppler US assessment of the inferior mesenteric artery has not been reported in the literature to date. In the present study, the feasibility of Doppler US of the inferior mesenteric artery was prospectively investigated in 112 consecutive nonselected patients; the corresponding morphological features (size and vessel course) and Doppler flowmetry (peak systolic, peak diastolic and mean velocities; pulsatility index) were defined. In 32 patients (29%) neither conventional nor color-Doppler nor duplex imaging was possible. Of the extant 80 patients, in 65 (81%) all the three methods allowed the correct assessment of the inferior mesenteric artery; in 15 patients (19%) the results were suboptimal (poor US visualization, or inadequate Doppler flowmetry). In 33/80 patients, arterial blood flow was quantitatively assessed in 1/min. As for the patients who underwent further diagnostic procedures--e.g., CT and angiography--a close correlation was demonstrated between the morphological and functional data obtained by Doppler US and the corresponding CT and angiographic features. The possibility of analyzing the inferior mesenteric artery with conventional and Doppler US, besides the celiac trunk and the superior mesenteric artery, should allow splanchnic circulation to be more completely assessed, thanks to information about normal hemodynamics (after a meal or in response to pharmacological treatments) as well as about the diseases known to affect intestinal perfusion--e.g., mesenteric ischemia.

[The role of ultrasonography in thyroid disease]

Ultrasound examination of the thyroid gland is widely used in the diagnosis of thyroid disease. This test is easy and rapid to perform, widely available and the results are readily interpreted. Using ultrasound the image of foci of disease within the gland are easily identified, especially using high frequency probes which enable solid nodules up to approx 3 mm to be revealed with 10 MHz probes. In non-nodular thyroid disease the ultrasonic structure guides the diagnosis (thyroiditis, Graves' disease). During the follow-up of thyroidectomised patients ultrasound can easily reveal postoperative anatomic variations and an early diagnosis can be obtained of any signs of local recurrence of the primary disease. Only hemiagenesia and hypoplasia can be accurately evaluated in congenital disease, whereas in the event of the persistence of the thyroglossal duct the latter can only be diagnosed if it presents a cystic evolution. Thyroid ectopia cannot be identified and must be studied using thyroscintigraphy, preferably performed using 131I as the isotope. The acquired pathology is classified into phlogistic processes, diffuse or nodular hyperplasia, benign and malignant neoplasia. This classification is widely accepted by virtually all authors. In thyroiditis, ultrasound may facilitate the diagnosis of De Quervain's non-suppurative sub-acute thyroiditis (TANS) and Hashimoto's chronic thyroiditis, although always in association with clinical and laboratory tests. The most frequent thyroid pathology is without doubt goitre. This disorder may occur in a non-nodular (widespread goitre with an endemic or sporadic pattern) or nodular form which may be single or multiple. The term goitre is used to indicate the increased volume of the thyroid gland independently of the causes which have provoked it. Common goitre is defined as being endemic when in some geographic area 10% of the general population or 20% of the school-aged population suffers from thyroid hyperplasia (areas of goitrogenic endemic disease). Graves' disease may be included in the group of thyroid hyperplasia diseases, although it is distinguished from the simple versions by the marked glandular hyperactivity which creates manifest hyperthyroidism. In this pathology ultrasonography must be supplemented by colour-Doppler wherever possible. Thyroid nodules are subdivided in terms of their echostructure into 5 types: liquid, mixed (prevalently solid or prevalently liquid), hyperechogenic solid, isoechogenic solid and hypoechogenic solid. The characteristics of benign nodules are: hypoechogenic structure, regular edges, complete and uniform hypoechogenic peripheral halo.(ABSTRACT TRUNCATED AT 400 WORDS)

[Biliodigestive anastomoses on echography. The normal and pathological aspects]

The normal and pathological US features of different types of bilioenterostomy (hepaticojejunostomy, choledochoduodenostomy, polyductal bilioenteric anastomosis) are described, as observed in a prospective study of 27 patients, for a total number of 35 (18 normal and 17 abnormal) examinations. For 20 patients with hepaticojejunostomy, the bilioenteric anastomosis was identified on 13/13 normal examinations and 10/12 pathological examinations. For 2 patients with choledochoduodenostomy, the bilioenteric anastomosis was identified on 2/2 examinations. For 5 patients with polyductal bilioenteric anastomosis (each patient having 2 or 3 anastomoses), all surgical anastomoses were separately identified on 6/8 examinations; as for the remaining 2 patients, 2/3 and 1/3 anastomoses were seen. An abnormal condition was correctly recognized in all the 11 patients with local disease (lithiasis and benign biliary stricture, 2 patients; benign biliary stricture, 5 patients; primary cholangiocarcinoma, 1 patient; recurrent malignancy, 3 patients); in 1 patient, parenchymal and biliary abnormalities due to vascular obstruction were misinterpreted as a result of benign stricture. US can demonstrate the surgical anastomoses between the resected common bile duct or second order intrahepatic ducts and the jejunal loop, with typical features according to the type of surgery performed. Knowledge of such normal appearances after bilioenteric surgery is mandatory in order to detect and correctly evaluate such possible abnormalities at this site as lithiasis and benign or malignant strictures.

[Ultrasonography in the monitoring of internal biliary drainage using an endoscopically inserted prosthesis]

Endoscopic retrograde biliary drainage by means of transtumoral endoprostheses is an effective technique for palliative decompression of malignant biliary obstruction. However, serial follow-up is required for an early detection of eventual long-term complications. In the present study 37 patients with malignant biliary obstruction, treated by endoscopic insertion of one or more biliary stents, were prospectively evaluated by sonography, with serial clinical and US examinations up to 10 months. In our experience, sonography could correctly identify both the endoprostheses and their location in the biliary tract. Most important, sonography has proved to be a sensitive method to detect possible stent dysfunctions, besides providing with information about the progression of the underlying malignancy.

The thyroid gland with low uptake lesions: evaluation by ultrasound

An ultrasound examination was performed in 401 patients who had isotopically cold, solitary lesions of the thyroid gland. Of the parameters studied, the level of echoes was the most useful in making the sonographic diagnosis: the rate of malignancy was extremely low both in hyperechoic and echo-free lesions. The presence of a peripheral, complete "halo" appeared to be helpful in differentiating benign lesions from malignant lesions. Approximately 20-25% of the lesions thought to be solitary on the radionuclide study were found to be multinodular on US. When fine-needle aspiration biopsy was used with US the need for surgical exploration of the thyroid gland was obviated in selected cases.

Sonographic patterns of the gallbladder in acute viral hepatitis

Ultrasound was used for a serial evaluation of gallbladder modifications in 61 patients with acute viral hepatitis during both the acute phase of the illness and recovery. Most of the patients studied within 7 days from the onset of symptoms and/or jaundice showed sonographic abnormalities of the gallbladder (increased wall thickness, reduced volume, abnormal bile content). A normal ultrasound pattern of the gallbladder was progressively restored during the clinical recovery in most of the patients. A statistical correlation was found between the gallbladder wall thickness and the alanine transferase index.

[Echography in the study of renal pathology in childhood]

Results of US study in 30 children with various renal lesions are reported, and compared with clinical and surgical features. Different ultrasonographic aspects are discussed with special interest on cogenital abnormalities. US is proposed as first choice investigation in newborns with antenatal ultrasonographic demonstration of renal lesions and in all patients where a mass of renal origin is suspected. Renal function, nevertheless, must be investigated with radiologic and/or radioisotopic techniques. US have still a large indication in short term follow-up of renal lesions where surgical treatment is not indicated.

Ultrasonographic patterns in hepatic hemangiomas

Twenty-one cases of hepatic hemangioma were examined by ultrasound, and three main sonographic patterns were identified. In 14 cases hyperechoic focal areas were observed, in five cases larger hemangiomas exhibited a complex pattern, and in two cases hemangiomas appeared as rounded sonolucent areas with distal enhancement mimicking cysts. Hemangiomas may have significantly variable ultrasonographic features. According to the authors' experience, only in cases of hyperechoic well-defined lesions in asymptomatic patients can a definite diagnosis of hemangioma be made.

Pancreatic cystadenocarcinoma: diagnostic problems

Eleven cases of pancreatic cystadenocarcinoma were studied with respect to the differential diagnosis from that of pancreatic pseudocysts, using diagnostic ultrasound as the initial investigative technique. Most of the cases presented an ultrasonic picture that correlated well with the gross pathology, but this correlation was not reliable enough to be considered characteristic in differentiating such masses from pseudocysts. The authors divide the cystadenocarcinomas of the pancreas into four echographic classes. In all but one of the classes, diagnostic ultrasound was insufficient by itself to render an accurate diagnosis. In such cases other techniques, i.e. CT, tissue biopsy, and especially angiography, were required for a reliable diagnosis.

[Echography inthe study of the gallbladder wall]

In 511 patients with clinical symptoms of chronic or acute biliary disease, gallbladder area was studied by automatic equipments. In 39 patients different features of the gallbladder wall lesions were demonstrated, in some cases associated with gall stones or bile modifications. Gallbladder wall lesions were divided in three different groups, diffuse, localized or both, according to their appearance and extension. Correlations between the echographic patterns and the clinical and pathological pictures were established. The authors concluding stress the diagnostic value of cholecystosonography in detecting wall lesions such as chronic or acute cholecystitis, cholecystosis and gallbladder tumours. The indications of cholecystosonography are in such a way extended well beyond the demonstration of gallstones and bile modifications to the diagnosis of chronic and acute cholecystitis.

Bilateral pseudocystic pheochromocytoma

A case of bilateral pheochromocytoma presenting as primarily cystic suprarenal masses is reported. The computed tomographic manifestations, possible etiology, and differential diagnosis of these cystic suprarenal lesions are discussed.