Practical approach to linear endoscopic ultrasound examination of the gallbladder

The gallbladder(GB)is a susceptible organ,prone to various pathologies that can be identified using different imaging techniques.Transabdominal ultrasound(TUS)is typically the initial diagnostic method due to its numerous well-established advantages.However,in cases of uncertainty or when a definitive diagnosis cannot be established,computed tomography(CT)or magnetic resonance imaging may be employed to provide more detailed information.Nevertheless,CT scans may sometimes offer inadequate spatial resolution,which can limit the differentiation of GB lesions,particularly when smaller yet clinically relevant abnormalities are involved.Conversely,endoscopic ultrasound(EUS)provides higher frequency compared to TUS,superior spatial resolution,and the option for contrast-enhanced harmonic imaging,enabling a more comprehensive examination.Thus,EUS can serve as a supplementary tool when conventional imaging methods are insufficient.This review will describe the standard EUS examination of the GB,focusing on its endosonographic characteristics in various GB path-ologies.

Seeing beneath the surface:Harnessing point-of-care ultrasound for internal jugular vein evaluation

Point-of-care ultrasound(POCUS)of the internal jugular vein(IJV)offers a noninvasive means of estimating right atrial pressure(RAP),especially in cases where the inferior vena cava is inaccessible or unreliable due to conditions such as liver disease or abdominal surgery.While many clinicians are familiar with visually assessing jugular venous pressure through the internal jugular vein,this method lacks sensitivity.The utilization of POCUS significantly enhances the visualization of the vein,leading to a more accurate identification.It has been demonstrated that combining IJV POCUS with physical examination enhances the specificity of RAP estimation.This review aims to provide a comprehensive summary of the various sonographic techniques available for estimating RAP from the internal jugular vein,drawing upon existing data.

Use of endoscopic ultrasound-guided gallbladder drainage as a rescue approach in cases of unsuccessful biliary drainage

This narrative review provides an overview of the utilization of endoscopic ultrasound-guided gallbladder drainage(EUS-GBD)as a salvage approach in cases of unsuccessful conventional management.EUS-GBD is a minimally invasive and effective technique for drainage in patients with acute cholecystitis with high risk of surgery.The procedure has demonstrated impressive technical and clinical success rates with low rates of adverse events,making it a safe and effective option for appropriate candidates.Furthermore,EUS-GBD can also serve as a rescue option for patients who have failed endoscopic retrograde cholangiopancreatography or EUS biliary drainage for relief of jaundice in malignant biliary stricture.However,patient selection is critical for the success of EUS-GBD,and proper patient selection and risk assessment are important to ensure the safety and efficacy of the procedure.As the field continues to evolve and mature,ongoing research will further refine our understanding of the benefits and limitations of EUS-GBD,ultimately leading to improved outcomes for patients.

Evaluation of hand infections in the emergency department using point-of-care ultrasound

BACKGROUND:We aimed to evaluate the utility of point-of-care ultrasound(POCUS)in the assessment of hand infections that present to the emergency department(ED)and its impact on medical decision making and patient management.METHODS:We conducted a retrospective review of patients who presented to two urban academic EDs with clinical presentations concerning for skin and soft tissue infections(SSTI)of the hand between December 2015 and December 2021.Two trained POCUS fellowship physicians reviewed an ED POCUS database for POCUS examinations of the hand.We then reviewed patients’electronic health records(EHR)for demographic characteristics,history,physical examination findings,ED course,additional imaging studies,consultations,impact of POCUS on patient care and final disposition.RESULTS:We included a total of 50 cases(28 male,22 female)in the final analysis.The most common presenting symptoms and exam findings were pain(100%),swelling(90%),and erythema(74%).The most common sonographic findings were edema(76%),soft tissue swelling(78%),and fluid surrounding the tendon(57%).POCUS was used in medical decision making 68%of the time(n=34),with the use of POCUS leading to changes in management 38%of the time(n=19).POCUS use led to early antibiotic use(11/19),early consultation(10/19),and led to the performance of a required procedure(8/19).The POCUS diagnosis was consistent with the discharge diagnosis of flexor tenosynovitis 8/12 times,abscess 12/16 times,and cellulitis 14/20 times.CONCLUSION:POCUS is beneficial for evaluating of hand infections that present to the ED and can be used as an important part of medical decision making to expedite patient care.

Pictorial review of hepatic echinococcosis:Ultrasound imaging and differential diagnosis

Echinococcosis is a zoonotic disease caused by parasites belonging to the genus Echinococcus that primarily affect the liver.The western plateau and pastoral areas of China are high-risk regions for hepatic cystic echinococcosis and hepatic alveolar echinococcosis(HAE).The high late mortality rate associated with HAE underscores the critical need for early diagnosis to improve cure rates and mitigate the disease burden in endemic areas.Currently,the World Health Orga-nization recommends ultrasonography as the preferred initial screening method for hepatic echinococcosis.However,distinguishing between specific types of lesions,such as those of hepatic cystic echinococcosis and HAE,and other focal liver lesions is challenging.To address this issue,contrast-enhanced ultrasound is recommended as a tool to differentiate solid and cysto-solid hepatic echino-coccosis from other focal liver lesions,significantly enhancing diagnostic accuracy.In this comprehensive review,we discuss the progression of hepatic echinococcosis and detail the imaging features of various types of echinococcosis using conventional,contrast-enhanced,and intraoperative ultrasound techniques.Our objective is to provide robust imaging evidence and guidance for early diagnosis,clinical decision making,and postoperative follow-up in regions with high disease prevalence.

Is endoscopic ultrasound a promising technique in the diagnosis and treatment of liver diseases?

Percutaneous ultrasound has been a longstanding method in the diagnostics and interventional procedures of liver diseases.In some countries,its use is restricted to radiologists,limiting access for other clinicians,such as gastroenterologists.Endoscopic ultrasound,as a novel technique,plays a crucial role in diagnosis and treatment of digestive diseases.However,its use is sometimes recommended for conditions where no clear advantage over percutaneous ultrasound exists,leaving the impression that clinicians sometimes resort to an endoscopic approach due to the unavailability of percutaneous options.

Dynamic contrast enhanced ultrasound in differential diagnosis of hepatocellular carcinoma: A systematic review and meta-analysis

BACKGROUND Non-invasive differential diagnosis between hepatocellular carcinoma(HCC)and other liver cancer(i.e.cholangiocarcinoma or metastasis)is highly challenging and definitive diagnosis still relies on histological exam.The patterns of enhancement and wash-out of liver nodules can be used to stratify the risk of malignancy only in cirrhotic patients and HCC frequently shows atypical features.Dynamic contrast-enhanced ultrasound(DCEUS)with standardized software could help to overcome these obstacles,providing functional and quantitative parameters and potentially improving accuracy in the evaluation of tumor perfusion.AIM To explore clinical evidence regarding the application of DCEUS in the differential diagnosis of liver nodules.METHODS A comprehensive literature search of clinical studies was performed to identify the parameters of DCEUS that could relate to histological diagnosis.In accordance with the study protocol,a qualitative and quantitative analysis of the evidence was planned.RESULTS Rise time was significantly higher in HCC patients with a standardized mean difference(SMD)of 0.83(95%CI:0.48-1.18).Similarly,other statistically significant parameters were mean transit time local with a SMD of 0.73(95%CI:0.20-1.27),peak enhancement with a SMD of 0.37(95%CI:0.03-0.70),area wash-in area under the curve with a SMD of 0.47(95%CI:0.13-0.81),wash-out area under the curve with a SMD of 0.55(95%CI:0.21-0.89)and wash-in and wash-out area under the curve with SMD of 0.51(95%CI:0.17-0.85).SMD resulted not significant in fall time and wash-in rate,but the latter presented a trend towards greater values in HCC compared to intrahepatic cholangiocarcinoma.CONCLUSION DCEUS could improve non-invasive diagnosis of HCC,leading to less liver biopsy and early treatment.This quantitative analysis needs to be applied on larger cohorts to confirm these preliminary results.

Ultrasound unveiling:Decoding venous congestion in heart failure for precision management of fluid status

This editorial discusses the manuscript by Di Maria et al,published in the recent issue of the World Journal of Cardiology.We here focus on the still elusive pathophysiological mechanisms underlying cardio-renal syndrome(CRS),despite its high prevalence and the substantial worsening of both kidney function and heart failure.While the measure of right atrial pressure through right cardiac catheterization remains the most accurate albeit invasive and costly procedure,integrating bedside ultrasound into diagnostic protocols may substantially enhance the staging of venous congestion and guide therapeutic decisions.In particular,with the assessment of Doppler patterns across multiple venous districts,the Venous Excess Ultrasound(VExUS)score improves the management of fluid overload and provides insight into the underlying factors contributing to cardio-renal interactions.Integrating specific echocardiographic parameters,particularly those concerning the right heart,may thus improve the VExUS score sensitivity,offering perspective into the nuanced comprehension of cardio-renal dynamics.A multidisciplinary approach that consistently incorporates the use of ultrasound is emerging as a promising advance in the understanding and management of CRS.

Evaluating the efficacy of percutaneous puncture biopsy guided by contrast-enhanced ultrasound for peripheral pulmonary lesions

BACKGROUND The incidence and mortality of lung cancer have increased annually.Accurate diagnosis can help improve therapeutic efficacy of interventions and prognosis.Percutaneous lung biopsy is a reliable method for the clinical diagnosis of lung cancer.Ultrasound-guided percutaneous lung biopsy technology has been widely promoted and applied in recent years.AIM To investigate the diagnostic value of contrast-enhanced ultrasound(CEUS)-guided percutaneous biopsy in peripheral pulmonary lesions.METHODS We retrospectively collected data on 237 patients with peripheral thoracic focal lesions who underwent puncture biopsy at Wuxi People’s Hospital.The patients were randomly divided into two groups:The CEUS-guided before lesion puncture group(contrast group)and conventional ultrasound-guided group(control group).Analyze the diagnostic efficacy of the puncture biopsy,impact of tumor size,and number of puncture needles and complications were analyzed and compared between the two groups.RESULTS Accurate pathological results were obtained for 92.83%(220/237)of peripheral lung lesions during the first biopsy,with an accuracy rate of 95.8%(113/118)in the contrast group and 89.9%(107/119)in the control group.The difference in the area under the curve(AUC)between the contrast and the control groups was not statistically significant(0.952 vs 0.902,respectively;P>0.05).However,when the lesion diameter≥5 cm,the diagnostic AUC of the contrast group was higher than that of the control group(0.952 vs 0.902,respectively;P<0.05).In addition,the average number of puncture needles in the contrast group was lower than that in the control group(2.58±0.53 vs 2.90±0.56,respectively;P<0.05).CONCLUSION CEUS guidance can enhance the efficiency of puncture biopsy of peripheral pulmonary lesions,especially for lesions with a diameter≥5 cm.Therefore,CEUS guidance has high clinical diagnostic value in puncture biopsy of peripheral focal lung lesions.

Endoscopic ultrasound-guided biliary drainage using electrocauteryenhanced lumen-apposing metal stent for malignant biliary obstruction:A promising procedure

In this editorial,we comment on the article by Peng et al.Palliative drainage for biliary obstruction resulting from unresectable malignant lesions includes internal and external drainage.The procedures of biliary drainage are usually guided by fluoroscopy or transcutaneous ultrasound,endoscopic ultrasound(EUS),or both.Endoscopic retrograde cholangiopancreatography(ERCP)has been primarily recommended for the management of biliary obstruction,while EUS-guided biliary drainage and percutaneous transhepatic biliary drainage(PTBD)are alternative choices for cases where ERCP has failed or is impossible.PTBD is limited by shortcomings of a higher rate of adverse events,more reinterventions,and severe complications.EUS-guided biliary drainage has a lower rate of adverse events than PTBD.EUS-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent(ECE-LAMS)enables EUS-guided biliaryenteric anastomosis to be performed in a single step and does not require prior bile duct puncture or a guidewire.The present meta-analysis showed that ECELAMS has a high efficacy and safety in relieving biliary obstruction in general,although the results of LAMS depending on the site of biliary obstruction.This study has highlighted the latest advances with a larger sample-based comprehensive analysis.

Automatic detection of breast lesions in automated 3D breast ultrasound with cross-organ transfer learning

Background Deep convolutional neural networks have garnered considerable attention in numerous machine learning applications,particularly in visual recognition tasks such as image and video analyses.There is a growing interest in applying this technology to diverse applications in medical image analysis.Automated three dimensional Breast Ultrasound is a vital tool for detecting breast cancer,and computer-assisted diagnosis software,developed based on deep learning,can effectively assist radiologists in diagnosis.However,the network model is prone to overfitting during training,owing to challenges such as insufficient training data.This study attempts to solve the problem caused by small datasets and improve model detection performance.Methods We propose a breast cancer detection framework based on deep learning(a transfer learning method based on cross-organ cancer detection)and a contrastive learning method based on breast imaging reporting and data systems(BI-RADS).Results When using cross organ transfer learning and BIRADS based contrastive learning,the average sensitivity of the model increased by a maximum of 16.05%.Conclusion Our experiments have demonstrated that the parameters and experiences of cross-organ cancer detection can be mutually referenced,and contrastive learning method based on BI-RADS can improve the detection performance of the model.

Role of endoscopic ultrasound-guided biliary drainage for palliation of malignant biliary obstruction

Endoscopic ultrasound-guided biliary drainage(EUS-BD)directs bile flow into the digestive tract and has been mostly used in patients with malignant biliary obstruction(MBO)where endoscopic retrograde cholangiopancreatography-guided biliary drainage was unsuccessful or was not feasible.Lumen apposing metal stents(LAMS)are deployed during EUS-BD,with the newer electrocautery-enhanced LAMS reducing procedure time and complication rates due to the inbuilt cautery at the catheter tip.EUS-BD with electrocautery-enhanced LAMS has high technical and clinical success rates for palliation of MBO,with bleeding,cholangitis,and stent occlusion being the most common adverse events.Recent studies have even suggested comparable efficacy between EUS-BD and endosc-opic retrograde cholangiopancreatography as the primary approach for distal MBO.In this editorial,we commented on the article by Peng et al published in the recent issue of the World Journal of Gastrointestinal Surgery in 2024.

Multiparametric ultrasound as a new concept of assessment of liver tissue damage

Liver disease accounts for approximately 2 million deaths per year worldwide.All chronic liver diseases(CLDs),whether of toxic,genetic,autoimmune,or infectious origin,undergo typical histological changes in the structure of the tissue.These changes may include the accumulation of extracellular matrix material,fats,triglycerides,or tissue scarring.Noninvasive methods for diagnosing CLD,such as conventional B-mode ultrasound(US),play a significant role in diagnosis.Doppler US,when coupled with B-mode US,can be helpful in evaluating the hemodynamics of hepatic vessels and detecting US findings associated with hepatic decompensation.US elastography can assess liver stiffness,serving as a surrogate marker for liver fibrosis.It is important to note that interpreting these values should not rely solely on a histological classification.Contrast-enhanced US(CEUS)provides valuable information on tissue perfusion and enables excellent differentiation between benign and malignant focal liver lesions.Clinical evaluation,the etiology of liver disease,and the patient current comorbidities all influence the interpretation of liver stiffness measurements.These measurements are most clinically relevant when interpreted as a probability of compensated advanced CLD.B-mode US offers a subjective estimation of fatty infiltration and has limited sensitivity for mild steatosis.The controlled attenuation parameter requires a dedicated device,and cutoff values are not clearly defined.Quan-titative US parameters for liver fat estimation include the attenuation coefficient,backscatter coefficient,and speed of sound.These parameters offer the advantage of providing fat quantification alongside B-mode evaluation and other US parameters.Multiparametric US(MPUS)of the liver introduces a new concept for complete noninvasive diagnosis.It encourages examiners to utilize the latest features of an US machine,including conventional B-mode,liver stiffness evaluation,fat quantification,dispersion imaging,Doppler US,and CEUS for focal liver lesion characterization.This comprehensive approach allows for diagnosis in a single examination,providing clinicians worldwide with a broader perspective and becoming a cornerstone in their diagnostic arsenal.MPUS,in the hands of skilled clinicians,becomes an invaluable predictive tool for diagnosing,staging,and monitoring CLD.

Prenatal ultrasound diagnosis of fetal maxillofacial teratoma:Two case reports

BACKGROUND Facial teratoma is a rare benign tumor that accounts for about 1.6%of all teratomas and can be diagnosed by prenatal ultrasound(US).The purpose of this report was to describe our experience with the diagnosis of fetal facial teratoma by prenatal US at second trimester to provide a reference for clinical diagnosis of fetal maxillofacial teratoma.CASE SUMMARY We present two cases of patients with abnormal fetal facial findings on US at second trimester of pregnancy in our department.Case 1 was a 31-year-old G3 P1+1 female,with US revealing a heterogeneous echogenicity of 32 mm×20 mm×31 mm on the fetal face,most of it located outside the oral cavity and filling the root of the oral cavity.Case 2 was a 29-year-old G1P0 female,with fetal head and neck US revealing a cystic-solid echo mass measuring 42 mm×33 mm×44 mm,the upper edge of the lesion reaching the palate and filling the oral cavity.The contours of the lesions were visualized using three-dimensional(3D)US imaging.Both patients decided to give up treatment.Biopsies of the lesions were performed after induction of labor,and diagnosed as maxillofacial teratoma.CONCLUSION Fetal maxillofacial teratomas can be diagnosed by US in early pregnancy,allowing parents to expedite treatment decisions.

Percutaneous ultrasound-guided coaxial core needle biopsy for the diagnosis of multiple splenic lesions: A case report

BACKGROUND The overlap of imaging manifestations among distinct splenic lesions gives rise to a diagnostic dilemma.Consequently,a definitive diagnosis primarily relies on his-tological results.The ultrasound(US)-guided coaxial core needle biopsy(CNB)not only procures sufficient tissue to help clarify the diagnosis,but reduces the incidence of puncture-related complications.CASE SUMMARY A 41-year-old female,with a history of pulmonary tuberculosis,was admitted to our hospital with multiple indeterminate splenic lesions.Gray-scale ultrasono-graphy demonstrated splenomegaly with numerous well-defined hypoechoic ma-sses.Abdominal contrast-enhanced computed tomography(CT)showed an en-larged spleen with multiple irregular-shaped,peripherally enhancing,hypodense lesions.Positron emission CT revealed numerous abnormal hyperglycemia foci.These imaging findings strongly indicated the possibility of infectious disease as the primary concern,with neoplastic lesions requiring exclusion.To obtain the precise pathological diagnosis,the US-guided coaxial CNB of the spleen was ca-rried out.The patient did not express any discomfort during the procedure.CONCLUSION Percutaneous US-guided coaxial CNB is an excellent and safe option for obtaining precise splenic tissue samples,as it significantly enhances sample yield for exact pathological analysis with minimum trauma to the spleen parenchyma and sur-rounding tissue.

Point-of-care ultrasonography spotlight:Could venous excess ultrasound serve as a shared language for internists and intensivists?

Point-of-care ultrasonography(POCUS),particularly venous excess ultrasound(VExUS)is emerging as a valuable bedside tool to gain real-time hemodynamic insights.This modality,derived from hepatic vein,portal vein,and intrarenal vessel Doppler patterns,offers a scoring system for dynamic venous congestion assessment.Such an assessment can be crucial in effective management of patients with heart failure exacerbation.It facilitates diagnosis,quantification of congestion,prognostication,and monitoring the efficacy of decongestive therapy.As such,it can effectively help to manage cardiorenal syndromes in various clinical settings.Extended or eVExUS explores additional veins,potentially broadening its applications.While VExUS demonstrates promising outcomes,challenges persist,particularly in cases involving renal and liver parenchymal disease,arrhythmias,and situations of pressure and volume overload overlap.Proficiency in utilizing spectral Doppler is pivotal for clinicians to effectively employ this tool.Hence,the integration of POCUS,especially advanced applications like VExUS,into routine clinical practice necessitates enhanced training across medical specialties.

Point-of-care ultrasound in nephrology:A private practice viewpoint

Point-of-care ultrasound(POCUS)is a limited ultrasound examination performed by the clinician at the bedside,emerging as a complement to physical examination across various medical specialties.In the field of nephrology,its integration has been gradual,primarily limited to guiding procedures like temporary dialysis catheter placement or,in some cases,diagnostic kidney ultrasounds.In reality,the assessment of hemodynamic status at the bedside holds immense value for nephrologists,yet there exists limited awareness among practitioners regarding its implementation.While there is a growing trend towards incorporating multiorgan POCUS training in fellowship programs,private practice nephrologists remain relatively uninformed.This discussion explores the untapped potential of POCUS as a valuable diagnostic tool in everyday nephrology practice,demonstrating its effectiveness in diverse clinical settings,ranging from medical wards to outpatient dialysis units.Additionally,we delve into the challenges hindering its widespread adoption and consider the future trajectory of this innovative approach.

Past,present,and future perspectives of ultrasound-guided ablation of liver tumors:Where could artificial intelligence lead interventional oncology?

The first ablation procedures for small hepatocellular carcinomas were percutaneous ethanol injection under ultrasound(US)guidance.Later,radiofrequency ablation was shown to achieve larger coagulation areas than percutaneous ethanol injection and became the most used ablation technique worldwide.In the past decade,microwave ablation systems have achieved larger ablation areas than radiofrequency ablation,suggesting that the 3-cm barrier could be broken in the treatment of liver tumors.Likewise,US techniques to guide percutaneous ablation have seen important progress.Contrast-enhanced US(CEUS)can define and target the tumor better than US and can assess the size of the ablation area after the procedure,which allows immediate retreatment of the residual tumor foci.Furthermore,fusion imaging fuses real-time US images with computed tomography or magnetic resonance imaging with significant improvements in detecting and targeting lesions with low conspicuity on CEUS.Recently,software powered by artificial intelligence has been developed to allow three-dimensional segmentation and reconstruction of the anatomical structures,aiding in procedure planning,assessing ablation completeness,and targeting the residual viable foci with greater precision than CEUS.Hopefully,this could lead to the ablation of tumors up to 5-7 cm in size.

The Application Value of Ultrasound Imaging in the Differential Diagnosis of Benign and Malignant Breast Nodules of BI-RADS 3 and Above

Objective:To explore the diagnostic value of ultrasound imaging for breast nodules of breast imaging-reporting and data system(BI-RADS)category 3 and above.Methods:From June 2021 to July 2022,163 patients with breast nodules of BI-RADS 3 or above were selected as the research subjects.After pathological diagnosis,24 cases were malignant breast nodules of BI-RADS 3 or above,while 139 cases were benign breast nodules of BI-RADS 3 or above.The diagnosis rate of malignant and benign breast nodules of BI-RADS 3 or above,including 95%CI,was observed and analyzed.Results:The malignant and benign detection rates of conventional ultrasound were 88.63%and 75.00%,respectively,and the malignant and benign detection rates of ultrasound imaging were 93.18%and 87.50%,respectively,with 95%CIs greater than 0.7.Conclusion:Ultrasound imaging can help improve the diagnostic accuracy of benign and malignant breast nodules of BI-RADS 3 and above and reduce the misdiagnosis rate.

Endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction in Mexico

BACKGROUND Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)has recently emerged as an alternative treatment for gastric outlet obstruction(GOO)in selected patients.AIM To report the initial experience of EUS-GE in patients with GOO.METHODS This study was a retrospective,observational,multicenter study in which the data from 10 patients who underwent EUS-GE due to GOO between September 2021 and May 2023 were collected.We analyzed technical success,clinical success,adverse events,and survival.Technical success was defined as adequate positioning and deployment of the stent.Clinical success was defined as the patient’s ability to tolerate oral intake without vomiting 7 d after the procedure.Postprocedural adverse events were recorded.RESULTS Eleven procedures in 10 patients with GOO were included.The mean age of the patients was 67.5 years(range:56-77 years).Malignant GOO was present in 9 patients.Technical success was achieved in 9/11 procedures(82%).Among them,clinical success was achieved in 9 patients(100%).Adverse events occurred in 1 patient(9%).The median survival was 3 months(n=7;range:1-8 months).CONCLUSION EUS-GE is a feasible therapeutic option in the treatment of GOO.