Abdominal Sonogram Research Articles

Sonographic fatty liver and hepatitis B virus carrier status: Synergistic effect on liver damage in Taiwanese adults

To examine the epidemiology of hepatitis B virus carrier status (HBVC) and sonographic fatty liver (SFL) in Taiwanese adults, and to evaluate their possible interaction in inducing liver damage (LD). >From an epidemiological viewpoint, we analyzed previous studies which indicated that fatty liver sensitizes host immune response to HBV infection and enhances liver damage. A cross-sectional retrospective analysis of health records including medical history, physical examination, abdominal sonogram, blood biochemistry and hepatic virological tests. We utilized the Student's t-test, chi-square, multivariate logistic regression and synergy index to assess risks for LD. Among a total of 5406 Taiwanese adults (mean age 46.2 years, 51.5% males), the prevalence of LD, HBVC and SFL were 12.3%, 15.1% and 33.4%, respectively; 5.1% of participants had SFL plus HBVC. Multivariate logistic regression analysis demonstrated that male gender (odds ratio (OR) = 2.8, 95% confidence interval (CI): 2.3-3.5), overweight state (OR = 1.6, 95% CI: 1.3-2.0), HBVC (OR = 2.5, 95% CI: 2.0-3.1) and SFL (OR = 4.2, 95% CI: 2.2-5.3) were independently associated with LD. Synergism analysis showed that the adjusted OR for LD in adults with HBVC-alone was 3.3 (95% CI: 2.4-4.6), SFL-alone, 4.7 (95% CI: 3.7-6.1) and combined HBVC and SFL, 9.5 (95% CI: 6.8-13.3); the synergy index was 1.4 (95% CI: 1.001-2.0). In Taiwanese adults, SFL plus HBVC have a significant synergistic association with LD.

Intussusception in Childhood Acute T Cell Lymphoblastic Leukemia: An Unusual Complication - Report of 2 Cases.

Clinically significant gastrointestinal complications in children with acute lymphoblastic leukemia (ALL) have been reported. However, intussusception is a very rare complication. In one study of 286 children with ALL gastrointestinal complications occurred in 5.6% of patients with intussusception seen in only 0.3% of patients. We describe two cases of intussusception during chemotherapy for T-cell leukemia. Patient #1 was an 8 year old girl on chemotherapy for T-cell ALL. Around week 9 following POG 9404 protocol of consolidation chemotherapy, patient presented with severe abdominal pain and vomiting, and had marked, diffuse tenderness of the abdomen with guarding and hypo-active bowel sounds. Abdominal radiograph showed thickening of the descending colon; abdominal sonogram was normal; abdominal computed tomography (CT) scan however, revealed a soft tissue and fluid-filled mass extending from the cecum to the descending colon. These findings were consistent with a large bowel intussusception, which was successfully reduced with a barium enema. Patient #2 was a 15 year old male receiving chemotherapy for T-cell ALL following POG 9404 protocol. At week 14 of consolidation chemotherapy, patient presented with a 2 day history of nausea and colicky peri-umbilical and right lower quadrant abdominal pain. An abdominal CT scan revealed an ileocolic intussusception without bowel obstruction and mild wall thickening of the cecum. Barium enema resulted in successful reduction of the intussusception. Interestingly, both our patients were treated with high dose methotrexate 5gm/m2 during this time period and both experienced delayed excretion of methotrexate. To our knowledge, there is no known reported association between high dose methotrexate and intussusception. We speculate that the two could be related. The increased use of high dose methotrexate therapy in T-cell ALL may result in a higher incidence of intussusception in this population. Although, intussusception in ALL is a very rare complication, awareness of this entity and early recognition with radiological intervention may prevent unnecessary surgery and the associated morbidity and mortality in these patients.

Hepatic Epithelioid Hemangioendothelioma 15 Years Later

Purpose: Epithelioid hemangioendothelioma (EHE) is an uncommon cause of increased alkaline phosphatase. Few cases have been described; none of them in Latin Americans or with a 15 year retrospective follow up. This vignette presents a 34 y/o Hispanic male who presented in 1991 with a one-month history of lightheadedness and weight loss. Physical exam was remarkable for coarse, non-tender hepatomegaly. Initial laboratory data revealed microcytic anemia, and an elevated alkaline phosphatase. Abdominal sonogram showed hepatomegaly with multiple calcifications. A liver biopsy demonstrated minute areas of fibrosis and microcalcifications. Endoscopy, colonoscopy and small bowel series were normal. Tumor markers including; AFP, CEA and HCG were normal. Repeat liver biopsy was positive for Factor VIII immunoperoxidase stains consistent with EHE. Chest CT showed evidence of bilateral lung metastasis. As of 2006 the patient shows no evidence of disease progression and is being followed with periodical CT scans. EHE is a vascular tumor of endothelial origin that preferentially arises in soft tissues of the extremities and in the lung. Liver involvement occurs as metastasis or as a primary tumor. Common presenting symptoms are upper abdominal pain, anorexia and weight loss. Jaundice, fever, and variceal bleeding are rarely seen. Liver function tests are usually normal, except for alkaline phosphatase. Imaging usually reveals peripheral multifocal hypovascular lesions, multiple calcifications, and fibrotic indentations of the liver capsule. Diagnosis is established by histology with a multifocal pattern of liver involvement, evidence of vascular differentiation, fibrotic centers, and involvement of adjacent sinusoids. This tumor is relatively avascular. Weibel-Palade bodies (cytoplasmic inclusions) may be seen. Immunochemistry, CD31, CD34, Factor VIII and anticytokeratins have been used for identification of this tumor. EHE has a low propensity to metastasize. Therapeutic options include observation, chemotherapy, radiotherapy or orthotopic liver transplantation (OLT). Surgical resection of amenable lesions should be considered. OLT has been shown to prolong survival even in the presence of metastatic disease. Prognosis is unpredictable. Most patients experience long survival. Important prognostic features include: younger age, disparity between the presence of multiple lesions and patients overall well-being, and presence of intramural calcifications.

2088: Portal venous gas: Sonographic appearance and clinical significance

Objectives: This study was to investigate the data of patients with sonographic finding of portal venous gas(PVG), to explain its sonographic appearance, incidence and clinical significance. Methods: During four years (from January 2001 through December 2004) at our institution, 67,235 abdominal sonograms were obtained. Sonography evaluated five patients with PVG. All of the examinations were retrospectively analyzed. Results: The incidence of PVG was 0.007 = (5/67,235). PVG was easily confirmed by sonography and its sonographic signs included echogenic, moving foci within the lumen of the portal vein and/or poorly defined, echogenic patches within the hepatic parenchyma. From literature, bowel ischemic diseases were most etiologies for PVG. In our group, the underlying diseases included abdominal abscess (n = 1), necrotizing enterocolitis (n = 1), hepatic transplantation (n = 1) and blunt abdominal trauma (n = 2). In three patients, PVG was thought to be a severe sign of disease and the patients underwent surgery. For the others, PVG had no influence on disease and the patients kept conservative treatments. All five patients recovered quickly. Conclusions: PVG is a rare but easily identified sonographic sign, which can be caused by multiple diseases. Sonographic findings of PVG were very helpful to make further diagnosis and proper treatment of those underlying diseases.

Splenic Abscess: An Easily Overlooked Disease?

Splenic abscess is an uncommon but potentially life-threatening disease. Recent advances in radiology have affected the diagnosis and management of this disease entity. The purpose of this study was to review our experience in managing these patients. We retrospectively reviewed the medical records of 51 patients with splenic abscess as seen in a tertiary medical center between 1998 and 2003. We analyzed the demographics, clinical manifestations, etiology, predisposing factors, diagnostic modalities, bacteriologic profile, treatment, and outcome of these patients. The mean age was 59.9 +/- 14.2 years (ranging from 21-89 years). The male:female ratio was 29:22. Common symptoms included fever (82%), abdominal pain (71%), and nausea and vomiting (46%). The majority of these patients (83%) had leukocytosis. Thirty-six patients had associated parenchymal liver diseases and 26 patients had diabetes mellitus. Abdominal sonogram or computed tomography was performed to establish the diagnosis. Most cultures from the abscess cavities grew gram-negative enteric bacilli. Patients were treated with antimicrobial therapy only (n = 33), additional percutaneous drainage with a pigtail catheter (n = 11), or splenectomy (n = 7), and the survival rates were 48 per cent, 45 per cent, and 100 per cent, respectively. Splenic abscess should be considered in a patient with fever, left upper abdominal pain, and leukocytosis. Splenectomy appears to have better treatment outcome than percutaneous drainage or intravenous antibiotics alone.

Short- and Long-term Effects of Emergency Medicine Sonography on Formal Sonography Use

It has been reported that use of formal sonographic studies by departments of radiology initially increases after inception of an emergency medicine (EM) sonography training program, but there are no data on whether this trend continues as the training program matures. The purpose of this study was to evaluate the effect of an ongoing EM sonography program on formal sonography use after more than a decade of experience. This retrospective, computer-assisted review compared emergency department (ED) abdominal sonographic studies ordered in the 3 years before inception of an EM sonography program (1992-1994) with those ordered in the 8 years after its inception (1995-2002). To determine the relative change, all abdominal sonograms ordered by ED physicians were compared with equivalent outpatient formal sonograms by all other physicians in the hospital. The study site is a community teaching hospital with a current ED census of 50,000. In the initial 4 years (1995-1998), the number of formal studies increased significantly in both absolute numbers (annual mean, 95 versus 162; P < .002) and as a percentage of all outpatient sonograms ordered at the institution (5.1% versus 8.5%; P < .0001). However, in the following 4 years (1999-2002), the absolute number of formal studies remained constant but decreased when adjusted for an increased ED census. Emergency department-ordered formal studies also decreased as a percentage of all sonograms ordered (5.1% versus 4.1%; P = .002). Emergency department use of formal sonography services increases with the introduction of ED sonography but decreases markedly as the program matures.

Pediatric Penetrating Renal Artery Trauma:Stent-Graft Treatment With 2-Year Follow-up

To report the 2-year follow-up of a pediatric patient who underwent stent-graft repair for penetrating renal artery trauma. An 11-year-old boy presented with a single anterior abdominal stab wound. He was normotensive (110/70 mmHg) but tachycardic (120 bpm). A focused abdominal sonogram for trauma revealed significant free intraperitoneal fluid. He underwent an urgent laparotomy, during which a minor liver injury was repaired. A large, nonpulsatile, non-expanding, left-sided retroperitoneal hematoma was identified but not explored. The boy remained hemodynamically unstable, so diagnostic angiography was performed. A single left proximal renal artery perforation was found. The lesion was treated with a 6x17-mm balloon-expandable stent-graft. Completion angiography demonstrated an excellent proximal and distal seal, without evidence of extravasation. The patient's condition stabilized, and he recovered completely. Serial renal duplex scans up to 2 years have documented normal renal artery blood flow and no migration of the stent-graft; the kidneys are equal in size. The serum creatinine level remains normal. In appropriately selected patients, transcatheter stent-graft placement is a promising new kidney salvage modality to treat renal artery injury in children. Serious concern remains regarding the placement of covered stents in the pediatric population, as the long-term durability and the adaptability of growing arteries to renal stents are not known.

Jejunojejunal Intussusception Following Jejunostomy

Jejunojejunal intussusception is a rare complication of jejunostomy, and its preoperative diagnosis and surgical treatment have not been reported. A 78-year-old man suffered from vomiting off and on after emergency exploratory laparotomy with omentoplasty for perforated duodenal ulcer. He also received Witzel jejunostomy for early feeding. Ileus developed postoperatively and plain X-ray of the abdomen showed distended small bowel loop with scanty colon gas. Small bowel series performed with water-soluble contrast medium revealed substantial fluid retention in the stomach, duodenum and proximal jejunum. Infusion of contrast medium into the feeding tube revealed normal caliber of the distal small bowel. Abdominal sonogram revealed target sign as well as the feeding tube in a dilated jejunum. Abdominal computed tomography confirmed the sonographic impression of jejunojejunal intussusception. Reduction of intussusception was done during exploratory laparotomy. The jejunostomy feeding was continued and the postoperative course was uneventful.

Hepatic Infarction and Hepatic Artery Pseudoaneurysm With Peritoneal Bleeding After Radiofrequency Ablation for Hepatoma

A 75-year-old man with liver cirrhosis, Child-Pugh grade A, received percutaneous radiofrequency ablation (RFA) for a 2.5-cm hepatoma in right lobe of the liver (Figure A). The procedure went smoothly, and the patient was discharged 2 days later. On the 7th day post-RFA, he developed progressive right abdominal pain. On arrival, he was hemodynamically stable and had right abdominal tenderness. An abdominal sonogram disclosed massive echogenic materials and fluid accumulation under the liver capsule and within the peritoneum.

Flow Pattern of the Fluid During Embryo Transfer Determined With Transabdominal Ultrasound is a Predictive Factor in the Pregnancy Rate in IVF-ET Cycle

Optimization of the embryo transfer technique to improve implantation rate is still a challenging subject in IVF cycle. Several approaches have been developed such as using ultrasound guidance during ET, performing a mock embryo transfer prior to the actual procedure, removing the cervical mucus and flushing the cervical canal with medium and using soft catheter. Although, ultrasound guidance offered some advantages such as visualization of the catheter tip and air bubble, and the measurement of the tip from the fundus. There is still debate about the role of the appaerance of the flow pattern and the appearance of the air bubble in IVF-ET cycle. Our aim was to evaluate the effect of the flow pattern of the fluid on the outcome of IVF cycle. Observational study A total of 246 embryo transfer procedures were evaluated. Only cycles with 3 good quality embryos transferred on day 3 were included. Tip of the catheter was located 2 cm below the uterine fundus. Abdominal sonogram was performed with the full bladder. The total amount of fluid loaded with the embryos was 40 μl. Air tight syringe was used to transfer the embryos. Fundal splash was observed in 214 embryo transfers (Group I) whereas in 32 transfers embryo associated air bubble moved backwards (Group II) following injection. Average age, duration of infertility, number of oocytes obtained were similar between two groups. Pregnancy rates were 52.3% (112/214) and 25% (8/32) (p<0.05) for Group I and Group II, respectively. Flow pattern of the medium during embryo transfer observed with abdominal sonogram is an important parameter on the success rate of embryo transfer. Clinical pregnancy rate is worse following embryo transfers in which fluid moved backwards in the endometrial cavity.

Non-Occlusive Mesenteric Ischemia in Chronically Dialyzed Patients: A Disease with Multiple Risk Factors

Background: Non-occlusive mesenteric ischemia (NOMI) can be a fatal complication in dialysis patients. Intradialytic hypotension is usually the precipitating factor. The occurrence of 16 cases in 5 years (1998–2002), compared with only 4 in previous years, led us to investigate other risk factors contributing to NOMI. A control group of stable hemodialysis patients was used for comparison. Results: 20 patients were studied: 17 diagnosed surgically, and 3 clinically. The mean age was 70.8 ± 1.8 years, and the male:female ratio 7:13. Nineteen patients were on hemodialysis. Clinically overt atherosclerosis was present in 17 patients. Preceding dialysis-associated hypotension was identified in all patients studied and access thrombosis in 6 patients. In all patients, abdominal pain was the presenting symptom. Initial abdominal examination was unimpressive in 16 patients. The hemoconcentration, leukocytosis and metabolic acidosis were the most prominent laboratory findings. 5/11 abdominal sonograms showed intestinal pathology. 2/3 angiographies were diagnostic. Three patients responded to early fluid challenge and did not require surgery. Pathology was related to the area of the superior mesenteric artery in all 15 patients operated. Twelve (60%) patients died from the event. The 1-year mortality rate was 17/20 patients (85%). Possible contributing factors, other than dialysis-associated hypotension, included: high-dose recombinant human erythropoietin (rhEPO) therapy (179 ± 35 vs. 116 ± 10 U/kg/week in the control group, p < 0.05); metastatic calcifications (abdominal aorta 14/14, aortic valve 11/18; medial calcification of mesenteric arteries in 2/11 pathology specimens); digoxin, and hypoalbuminemia. Conclusions: The increased incidence of NOMI in dialysis patients may be related to overly aggressive rhEPO therapy and the unsuspected presence of mesenteric arterial medial calcifications. Identification of patients at risk, prevention of intradialytic hypotension and a controlled increase in dry weight may help to reduce the incidence of NOMI in chronically dialyzed patients.

Long-Term Follow-up after Robotic Cholecystectomy

Most surgeons gain their first clinical experience with surgical robots when performing cholecystectomies. Although this procedure is rather easily applicable for the da Vinci surgical system, the long-term outcome after this operation has not yet been clarified. This study follows up our institutional first series of robotic cholecystectomies (June to November 2001). Patients were assessed on the basis of standardized management including a quality-of-life questionnaire, clinical examination, blood tests, and abdominal sonogram. The follow-up rate for 23 patients after robotic cholecystectomy was 100 per cent and the median follow-up time 33 (30-35) months. There was one (4%) recurrence of gallstone disease in a patient who suffered from solitary choledocholithiasis 29 months after robotic cholecystectomy. Abdominal sonogram, clinical examinations, and blood tests revealed no post-cholecystectomy-specific pathological findings. The main long-term symptoms were bloating (57%), heartburn (43%) and nausea (30%). Of the patients, 96 per cent (22 patients) felt that the operation had cured or significantly improved their specific preoperative symptoms. Long-term results after robotic laparoscopic cholecystectomy are excellent and comparable to those for the conventional laparoscopic procedure. The advanced vision control and instrument maneuverability of robotic surgery might open minimally invasive surgery also for complicated gallstone disease and bile duct surgery.

Ceftriaxone-associated biliary pseudolithiasis in paediatric surgical patients

It is well known that ceftriaxone leads to pseudolithiasis in some patients. Clinical and experimental studies also suggest that situations causing gallbladder dysfunction, such as fasting, may have a role for the development of pseudolithiasis. In this study, we prospectively evaluated the incidence and clinical importance of pseudolithiasis in paediatric surgical patients receiving ceftriaxone treatment, who often had to fast in the post-operative period. Fifty children who were given ceftriaxone were evaluated by serial abdominal sonograms. Of those, 13 (26%) developed biliary pathology. Comparison of the patients with or without pseudolithiasis revealed no significant difference with respect to age, sex, duration of the treatment and starvation variables. After cessation of the treatment, pseudolithiasis resolved spontaneously within a short period. The incidence of pseudolithiasis is not affected by fasting.

Diagnostic Pathways and Delays on Route to Operative Intervention in Acute Appendicitis

The purpose of this study was to determine the elements associated with delay in the evaluation of acute appendicitis at a community teaching hospital. We performed a retrospective chart review of patients undergoing operative exploration for presumed appendicitis in a 12-month period. Cases were categorized by the presence or absence of advanced radiographic imaging. Demographic information and time intervals from triage to operative incision were compared. One hundred twenty-four patients underwent operative exploration for presumed appendicitis. Forty-one patients had no advanced imaging, 67 had a CT scan, 8 had a sonogram, and 8 had both CT/sonogram. Patients using advanced radiographic imaging prior to operative exploration were no less likely to have a normal appendix at surgery. Diagnostic imaging significantly increased the preoperative emergency department length of stay. Two-thirds of patients with presumed acute appendicitis were imaged before operative exploration. The use of abdominal CT and sonogram resulted in significantly increased preoperative emergency department length of stay with no apparent improvement in diagnostic accuracy.

Focused abdominal ultrasound for blunt trauma in an emergency department without advanced imaging or on-site surgical capability

To determine whether focused abdominal sonogram for trauma (FAST) in a rural hospital provides information that prompts immediate transfer to a tertiary care facility for patients with blunt abdominal trauma who would otherwise be discharged or held for observation. Prior to the study, participating emergency physicians underwent a minimum of 30 hours of ultrasound training. All patients who presented with blunt abdominal trauma to our rural hospital between Mar. 1, 2002, and Apr. 30, 2003, were eligible for study. Following a history and physical examination, the emergency physician documented his or her disposition decision. A FAST was then performed, and the disposition reconsidered in light of the FAST results. Sixty-seven FAST exams were performed on 65 patients. Three examinations (4.5%) were true-positive (95% confidence interval [CI] 0.9%-12.5%); 60 (89.6%) were true-negative (95% CI 79.7%-95.7%), 4 (6%) were false-negative (95% CI 1.7%-14.6%) and none (0%) were false-positive (95% CI 0%-5.4%). These values reflect sensitivity, specificity, negative predictive value and positive predictive values of 43%, 100%, 94% and 100% respectively. FAST results did not alter the decision to transfer any patient (0%: 95% CI 0.0%-5.4%), although one positive FAST may have led to an expedited transfer. One of 38 patients who was discharged after a negative FAST study returned 24 hours later because of worsening symptoms, and was ultimately found to have splenic and pancreatic injuries. This study failed to demonstrate that FAST improves disposition decisions for patients with blunt abdominal trauma who are evaluated in a hospital without advanced imaging or on-site surgical capability. However, the study is not sufficiently powered to rule out a role for FAST in these circumstances, and our data suggest that up to 5.4% of transfer decisions could be influenced by FAST. Rural emergency physicians should not allow a negative FAST study to override a clinical indication for transfer to a trauma centre; however, positive FAST studies can be used to accelerate transfer for definitive treatment.

False-Negative Rate of Abdominal Sonography for Detecting Hepatocellular Carcinoma in Patients with Hepatitis B and Elevated Serum α-Fetoprotein Levels

Routine screening for hepatocellular carcinoma among chronic carriers of hepatitis B virus using a combination of abdominal sonography and serum alpha-fetoprotein levels is widely practiced. Negative results on an abdominal sonogram generally indicate the absence of hepatocellular carcinoma despite the elevation of alpha-fetoprotein levels, but the false-negative rate of abdominal sonography has not been established prospectively. In our screening program, we routinely investigated patients with Lipiodol (iodized oil) CT when they presented with alpha-fetoprotein levels above 20 ng/mL or a focal lesion as depicted on abdominal sonography. Lipiodol CT comprised a hepatic angiogram with injection of Lipiodol selectively in the hepatic arteries, followed by an unenhanced CT scan 10 days later. Positive findings on Lipiodol CT were confirmed histologically by biopsy or surgical resection. We defined false-negative as histologic diagnosis of hepatocellular carcinoma within 3 months of normal findings on screening abdominal sonography. One hundred three patients with elevated alpha-fetoprotein levels were investigated with Lipiodol CT within 2 months of abdominal sonography. Of these, three of 70 patients with negative abdominal sonography had histologically confirmed hepatocellular carcinoma. Thus, abdominal sonography has a false-negative rate of 4.3%. Lipiodol CT is associated with a significant false-positive rate of 43.7%. The sensitivity, specificity, and positive predictive value of abdominal sonography for early detection of hepatocellular carcinoma among hepatitis B virus carriers with elevated alpha-fetoprotein levels was 85.7%, 81.7%, and 54.5%, respectively. Negative results on a screening abdominal sonogram among hepatitis B virus carriers with elevated alpha-fetoprotein levels does not rule out the presence of small hepatocellular carcinoma. Routine use of Lipiodol CT as a supplementary screening tool is not recommended.

Polycystic Liver Disease

As sonographic resolution capabilities improve and more abdominal sonograms are requested, diagnosis of polycystic liver disease (PLD) is on the increase. At first glance, the numerous liver cysts caused by PLD can be alarming. However, the disease is usually asymptomatic, and lab tests are generally within normal ranges. Prudent sonographers are advised to recognize and document the cysts for future reference in the event that symptoms progress. Appropriate reactions by the clinician, along with an understanding of the disease and its ramifications, are important to keep the patient informed.

The course of neurofibromatosis type 1 on immunosuppression after lung transplantation: report of 2 cases

We describe 2 patients with neurofibromatosis type 1 (NF1) who underwent lung transplantation. Case 1 reports a patient with NF1 with no complications 5 years after bilateral lung transplantation. Case 2 details a patient with NF1 diagnosed with both post-transplant lymphoproliferative disorder (PTLD) and massive intra-abdominal sarcoma consistent with a malignant nerve sheath tumor 9 months after lung transplantation. There was no clinical evidence of sarcoma preceding or immediately following lung transplant as demonstrated by a normal abdominal sonogram 3 months post-transplantation. Although an increased risk for cancer has been documented in NF1, the rapid malignant degeneration of a neurofibroma following transplantation raises concern about immunosuppression and transplantation candidacy among individuals with NF1.

Advanced Trauma Life Support System (ATLS) in a Peripheral Hospital.

Dear Editor, It was Dr James Stynor, an American Orthopaedic Surgeon who introduced a structural trauma management training programme, following the death of his wife and serious injury to his 3 children in an air crash in 1970s. This approach is now regarded as gold standard in early trauma, initial assessment and resuscitation. The basic philosophy of the ATLS is to treat lethal injury first, then reassess and treat again. Component steps of ATLS are:- Elements of primary survey are: Airway with cervical spine control Breathing and ventilation Circulation with control of haemorrhage Dysfunction of the central nervous system Exposure in a controlled environment Secondary survey: Head to toe examination of the undressed stable patient The ATLS approach focuses on the second or early death group where death is preventable [1]. At least one in five and possibly as many as one in three, trauma deaths in hospital are preventable [2]. We have adopted ATLS with modification as required for our hospital setting (Table 1). Pre-hospital trauma life support (PHTLS) is essential component of ATLS in which Regimental Medical Officers (RMOs), Nursing Assistants (NAs) and Battlefield Nursing Assistants (BFNAs) are trained in Combat Survival Skills. We have done away with the system of receiving the casualties in Ml Room and shifting them to the ward. We receive our casualties directly in the acute ward, where Nursing officer/NA on duty does the primary survey and sends information quickly to Duty Medical Officer (DMO) and surgical team. In primary survey they carryout ABCD of the ATLS. Doctors do the re-primary survey and secondary survey. In documentation, investigations and required X-rays are carried out in the acute ward itself. Focused abdominal sonogram for trauma (FAST) is done in the ward with portable ultrasound by the surgeon [3]. Triage of mass casualties is carried out by the surgeon. In this small peripheral 49 bedded hospital with limited staff and equipment we have managed 372 battle casualties successfully with no mortality in 2 years. Table 1 Advanced Trauma life Support System (ATLS) Protocol 169 MH Our experience with ATLS is wonderful. It is recommended that all large hospitals should have a trauma wing to handle polytrauma cases and follow ATLS to prevent early deaths. It is also recommended that the concept of PHTLS be taught to all officers of other Arms and Services during their training to enable them to ensure better Combat Survival Skills of their troops.

The use of colour-coded duplex sonography increases diagnostic accuracy of abdominal ultrasound

Colour Doppler sonography (CDS) avoids misinterpretation of abdominal ultrasonography. Differential diagnosis of pathological structures found by grey-scale sonography can be difficult in many cases. The present study aimed to determine how often additional colour Doppler sonography could be of benefit to avoid misinterpretation of grey-scale ultrasound images. 1350 abdominal sonograms were examined. The sonographic examination was performed using a Toshiba SSA-140 A-ultrasound machine (3.75 MHz and 2.5 MHz-transducer). Findings which could be misinterpreted in grey-scale images, e. g. structures suspicious of lymph nodes, small areas of ascites, hydronephrosis, cysts or cholestasis, were examined by additional colour Doppler sonography. 327 findings (= 24 % of the cases) were classified as requiring additional examination by colour Doppler sonography. In 73 of these cases (= 22 % of cases having additional CDS), CDS identified blood flow in the pathological structure, which avoided misinterpretation of the grey-scale imaging. Additional CDS avoids misinterpretation of grey-scale sonography especially in patients with portal hypertension.