Small intestine contrast ultrasonography vs computed tomography enteroclysis for assessing ileal Crohn's disease

AIM:To compare computed tomography enteroclysis(CTE) vs small intestine contrast ultrasonography(SICUS) for assessing small bowel lesions in Crohn's disease(CD),when using surgical pathology as gold standard.METHODS:From January 2007 to July 2008,15 eligible patients undergoing elective resection of the distal ileum and coecum(or right colon) were prospectively enrolled.All patients were under follow-up.The study population included 6 males and 9 females,with a median age of 44 years(range:18-80 years).Inclusion criteria:(1) certain diagnosis of small bowel requiring elective ileo-colonic resection;(2) age between 18-80 years;(3) elective surgery in our Surgical Unit;and(4) written informed consent.SICUS and CTE were performed ≤ 3 mo before surgery,followed by surgical pathology.The following small bowel lesions were blindly reported by one sonologist,radiologist,surgeon and histolopathologist:disease site,extent,strictures,abscesses,fistulae,small bowel dilation.Comparison between findings at SICUS,CTE,surgical specimens and histological examination was made by assessing the specificity,sensitivity and accuracy of each technique,when using surgical findings as gold standard.RESULTS:Among the 15 patients enrolled,CTE was not feasible in 2 patients,due to urgent surgery in one patients and to low compliance in the second patient,refusing to perform CTE due to the discomfort related to the naso-jejunal tube.The analysis for comparing CTE vs SICUS findings was therefore performed in 13 out of the 15 CD patients enrolled.Differently from CTE,SICUS was feasible in all the 15 patients enrolled.No complications were observed when using SICUS or CTE.Surgical pathology findings in the tested population included:small bowel stricture in 13 patients,small bowel dilation above ileal stricture in 10 patients,abdominal abscesses in 2 patients,enteric fistulae in 5 patients,lymphnodes enlargement(> 1 cm) in 7 patients and mesenteric enlargement in 9 patients.In order to compare findings by using SICUS,CTE,histology and surgery,characteristics of the small bowel lesions observed in CD each patient were blindly reported in the same form by one gastroenterologistsonologist,radiologist,surgeon and anatomopathologist.At surgery,lesions related to CD were detected in the distal ileum in all 13 patients,also visualized by both SICUS and CTE in all 13 patients.Ileal lesions > 10 cm length were detected at surgery in all the 13 CD patients,confirmed by SICUS and CTE in the same 12 out of the 13 patients.When using surgical findings as a gold standard,SICUS and CTE showed the exactly same sensitivity,specificity and accuracy for detecting the presence of small bowel fistulae(accuracy 77% for both) and abscesses(accuracy 85% for both).In the tested CD population,SICUS and CTE were also quite comparable in terms of accuracy for detecting the presence of small bowel strictures(92% vs 100%),small bowel fistulae(77% for both) and small bowel dilation(85% vs 82%).CONCLUSION:In our study population,CTE and the non-invasive and radiation-free SICUS showed a comparable high accuracy for assessing small bowel lesions in CD.

High mechanical index post-contrast ultrasonography improves tissue structural display of hepatocellular carcinoma

Background The advent of second generation agent-SonoVue and low mechanical index real-time contrast enhanced ultrasonography （CEUS） imaging have been shown to improve the diagnostic performance of uhrasonography in hepatocellular carcinoma （HCC）. But no report has described the effect of high mechanical index （MI） post-CEUS. This study aimed to investigate the value of post-CEUS in displaying tissue structures of HCC. Methods Seventy-six HCCs in 65 patients were included in the study. Each patient underwent three scans, high-MI （ MI ： 0. 15 - 1.6 ） pre-contrast ultrasound, low-MI （ MI ： 0. 04 - 0. 08 ） CEUS with contrast agent SonoVue, and high-MI post-contrast ultrasound, which was performed within 3 minutes after CEUS. The size, boundary, echogenicity, internal echotexture and posterior acoustic enhancement of the HCCs in the conventional scans before and after CEUS were evaluated. According to pathological evidence, diagnosis rates of pre-contrast, CEUS and post-contrast scans were determined and compared. The potential mechanism of post-contrast ultrasound imaging was also discussed. Results Compared with pre-contrast, post-contrast ultrasound showed improvement in image quality in most HCCs： twenty-six （34. 2% ） more lesions showed well defined margins and fourteen （18.4%） more nodules showed halo sign; twenty-three （30. 3% ） lesions demonstrated enlarged in sizes; changes in echogenicity were seen in 30 lesions （39.5%） ; eighteen （23.7%） more lesions showed heterogenecity and 20 （26. 3% ） more lesions showed “mosaic”or “nodule-in-nodule” sign; twelve （15.8%） more lesions showed posterior acoustic enhancement. Post-contrast ultrasound showed increased diagnostic accuracy of 93.4% （71/76）, compare with 88.2% （67/76） of CEUS alone. Conclusions High-MI post-contrast ultrasound utilizes harmonic signals during the rupture of microbubbles, and significantly improves the display of echo-characteristics of HCCs in ultrasound images, which adds diagnostic values for CEUS. Post-contrast ultrasound could play an important role in tissue characterization, and may be included in CEUS protocols.

Characters of normal prostate and prostate cancer lesions by transrectal contrast enhanced ultrasonography

Objective:The aim of the study was to observe the characters and differences of the inner and outer parts of prostate gland, the prostatic cancer lesions in inner and outer parts of prostate glands by transrectal contrast enhanced ultrasonography (TRCEUS) in order to provide valuable information for diagnosing of prostatic cancers. Methods: The ultrasound contrast agent was SonoVue (from Bracco Company, Italian). Instrument adopted Esaote Company Technos DU8 (transrectal ultrasonography). We observed the starting and ending times of transrectal contrast enhancement in the normal prostate inner gland group (16 cases), normal prostate outer gland group (16 cases), and the prostatic cancer lesions in inner gland group (8 cases) as well as in outer gland group (11 cases), respectively. Results: There was no significant difference in the starting time of the normal prostate glands between the inner gland and outer gland groups (P>0.05), likewise no significant difference between the cancer lesions in the inner gland and outer gland groups (P>0.05), but starting times of the cancer lesions in both groups were earlier than those of the normal prostate inner and outer glands groups (P<0.01). The ending time of enhancement was no significant difference among all groups (P>0.05). Conclusion: The earlier starting time of contrast enhancement in prostatic cancer lesions by TRCEUS has important value of distinguishing the cancer lesions from normal prostate glands. It is helpful to diagnose the prostatic cancer lesions.

Value of contrast-enhanced ultrasound in diagnosis of focal liver lesions

Objective： By observing the pattern of the focal liver lesions （FLL） in different phases by real time contrast-enhanced ultrasound （CEUS）, compared to enhanced CT, investigate the value of CEUS in diagnosing focal liver lesions. Meth. ods： 35 patients with unconfirmed focal liver lesions were studied by contrast agent SonoVue and Technos DU 8 produced by Esaote company. Results： Among the 14 cases of hepatocellular carcinoma （HCC）, 10 were typical, presented with early artery enhancement and immediate wash-out. The enhancement patterns of 6 livers metastasis were diverse, including peripheral or entire degree enhancement. The wash-out time in malignant tumors was eadier than other focal liver lesions （P 〈 0.05）, appeared as hypoechoic in the portal phase or parenchyma phase. The 6 cases of hemangioma were enhanced centripetally nodular in artery phase and washed out after several minutes. The patterns of different lesions were similar compared to contrast-enhanced CT, without significant statistic differences. Conclusion： The contrast enhanced ultrasound technique can significantly improved the value of diagnosing focal liver lesions.

Tuberous sclerosis complex-lymphangioleiomyomatosis involving several visceral organs:A case report

BACKGROUND Lymphangioleiomyomatosis(LAM)is a rare cystic lung disease characterized by the proliferation,metastasis,and infiltration of smooth muscle cells in the lung and other tissues,which can be associated with tuberous sclerosis complex(TSC).The disorder of TSC has a variable expression,and there is great phenotypic variability.CASE SUMMARY A 32-year-old Chinese woman with a history of multiple renal angioleiomyolipoma presented with a productive cough persisting for over 2 wk.Highresolution chest computed tomography revealed interstitial changes,multiple pulmonary bullae,bilateral pulmonary nodules,and multiple fat density areas of the inferior mediastinum.Conventional and contrast ultrasonography revealed multiple high echogenic masses of the liver,kidneys,retroperitoneum,and inferior mediastinum.These masses were diagnosed as angiomyolipomas.Pathology through thoracoscopic lung biopsy confirmed LAM.Furthermore,high-throughput genome sequencing of peripheral blood DNA confirmed the presence of a heterozygous mutation,c.1831C>T(p.Arg611Trp),of the TSC2 gene.The patient was diagnosed with TSC-LAM.CONCLUSION We highlight a rare case of TSC-LAM and the first report of a mediastinum lymphangioleiomyoma associated with TSC-LAM.

Decreased phagocytic activity of Kupffer cells in a rat nonalcoholic steatohepatitis model

AIM: To investigate Kupffer cell dynamics and phagocytic activity,using a rat nonalcoholic steatohepatitis (NASH) model. METHODS: Male F344 rats were fed either a control diet or a choline-deficient L-amino acid-defined (CDAA) diet,followed by contrast enhanced ultrasonography (CEUS) using Levovist. The uptake of latex beads by the Kupffer cells was determined by fluorescent microscopy. The status of the Kupffer cells was compared between the two groups,using the immunohistochemical staining technique. RESULTS: After 4 or more wk of the CDAA diet,CEUS examination revealed a decrease in the signal intensity,20 min after intravenous Levovist. Fluorescent microscopic examination showed that the uptake of latex beads by the Kupffer cells was reduced at week 1 and 2 in the study group,compared with the controls,with no further reduction after 3 wk. Immunohistochemical staining revealed no significant difference in the Kupffer cell counts between the control group and the CDAA group. CONCLUSION: CEUS examination using Levovist demonstrated reduced contrast effect and phagocytic activity in the liver parenchymal phase,although the Kupffer cell numbers were unchanged,indicating reduced phagocytic function of the Kupffer cells in the rat NASH model. We believe that CEUS examination using Levovist is a useful screening modality,which can detect NASH in fatty liver patients.

Small invasive ductal carcinoma of the pancreas distinct from branch duct intraductal papillary mucinous neoplasm

Endoscopic ultrasonography （EUS） is a highly sensitive diagnostic method for the detection of small pancreatic carcinomas. Recently, there have been some reports describing the utility of contrast-enhanced harmonic EUS （CEH-EUS） which uses sonographic contrast agent for differentiation of a pancreatic mass. This report describes a case of small adenocarcinoma of the pancreas distinct from branch duct intraductal papillary mucinous neoplasm （IPMN） in which investigation by EUS took place every 6 mo and diagnosis was made accurately by additional CEH-EUS during the follow-up of the branch duct IPMN. A 68-year-old female was admitted to our hospital because of a branch duct IPMN in the pancreatic body. She had been followed-up by EUS every 6 too. However, after 2 years EUS demonstrated a low echoic area distinct from the branch duct IPMN which was vaguely discernible by EUS, and accurate sizing and differential diagnosis were considered difficult on the EUS imaging. CHEUS with Sonazoid revealed a hypovascular tumor and we suspected small pancreatic carcinoma. The histopathological diagnosis was adenocarcinoma （10 mm） in the pancreatic tail, distinct from the branch duct IPMN of the pancreatic body. EUS and CEH-EUS may play an important role in the correct diagnosis of small pancreatic tumors, including synchronous and metachronous occurrence of IPMN and ductal adenocarcinoma of the pancreas.

Posterior choroidal leiomyoma: new findings from a case and literature review

·Posterior choroidal leiomyoma is a sporadic, rare benign tumor that is always confused with anaplastic melanoma. Here we report a case and provide a review. Most of the preoperative findings in our case were suggestive of malignant choroidal melanoma. However, the contrast enhanced ultrasound(CEUS) suggested a benign hemangioma. In summary, the posterior choroidal leiomyomas were yellowish-white in color and most commonly located in the temporal quadrant of the fundus(11/15). They were more frequent in Asians(13/16), the prevalence was almost equal in males and females(9:7), with a mean age of 35y. Microscopically, the tumor typically showed spindle cell bundles and nonmitotic ovoid nuclei arranged in intersecting fascicles. Vitrectomy is now a popular treatment option and definitive diagnosis can be made after immunohistochemistry. Finally, some summarized features of this tumor differ from those previously described. These may help in the diagnosis of posterior choroidal leiomyoma and differentiation from malignant melanoma.