Conventional Ultrasound Scanning Research Articles

Contrast-enhanced ultrasonographic findings of hepatic paragonimiasis

To investigate the features of hepatic paragonimiasis on contrast-enhanced ultrasound (CEUS) imaging. Fifteen patients with hepatic paragonimiasis who were admitted to our hospital between March 2008 and August 2012 were enrolled to this study. The conventional ultrasound and CEUS examinations were performed with a Philips IU22 scanner with a 1-5-MHz convex transducer. After conventional ultrasound scanning was completed, the CEUS study was performed. Pulse inversion harmonic imaging was used for CEUS. A bolus injection of 2.4 mL of a sulfur hexafluoride-filled microbubble contrast agent (SonoVue) was administered. CEUS features were retrospectively reviewed and correlated with pathological findings. In total, 16 lesions were detected on CEUS. The mean size of the lesions was 4.4 ± 1.6 cm (range, 1.7-6.6 cm). Subcapsular location was found in 12 lesions (75%). All the lesions were hypoechoic. Six lesions (37.5%) were of mixed content, seven (43.8%) were solid with small cystic areas, and the other three (18.8%) were completely solid. Ten lesions (62.5%) were rim enhanced with irregular tract-like nonenhanced internal areas. Transient wedge-shaped hyperenhancement of the surrounding liver parenchyma was seen in seven lesions (43.8%). Areas with hyper- or iso-enhancement in the arterial phase showed contrast wash-out and appeared hypoenhanced in the late phase. The main pathological findings included: (1) coagulative or liquefactive necrosis within the lesion, infiltration of a large number of eosinophils with the formation of chronic eosinophilic abscesses and sporadic distribution of Charcot-Leyden crystals; and (2) hyperplasia of granulomatous and fibrous tissue around the lesion. Subcapsular location, hypoechogenicity, rim enhancement and tract-like nonenhanced areas could be seen as the main CEUS features of hepatic paragonimiasis.

Comments Regarding ‘Assessment of the Accuracy of AortaScan for Detection of Abdominal Aortic Aneurysm (AAA)’

The cost of purchasing ultrasound equipment represents a significant financial burden to abdominal aortic aneurysm (AAA) screening programmes. AAA screening programmes use conventional portable ultrasound scanners equipped with colour flow and spectral Doppler modalities. These modalities are not necessary for routine aneurysm screening, adding to the cost of the equipment. Additionally, they could be potentially misleading if used without appropriate training. The introduction of a simple automated handheld device would enable AAA screening to be performed by practice nurses and General Practitioners during a routine health check. This would save a considerable amount of money, making AAA screening cheaper and more cost effective. Patients who are suspected of having an AAA can then be offered a rapid confirmation scan using conventional ultrasound in their local imaging department or vascular unit. In this context, the study by Abbas et al. (comparing the AortaScan device against computed tomography scanning 1 ) is timely and relevant. The reported sensitivity of 81% is clearly not acceptable for it to be used within a national aneurysm screening programme at the present time. However, the results should not be viewed in a completely negative light, as the device was able to detect a significant number of aneurysms. Looking from a positive perspective, the authors provide a useful waypoint for the manufacturer to develop and refine their system until sensitivity is close to 100%. It is only through the publication of unbiased studies that we get a true evaluation of emerging and innovative technologies with the potential to deliver efficiency and savings. What then should be the key performance requirements of an automated device? It should be able to measure aortic diameter to an accuracy of <5 mm, it should be capable of coping with a large burden of thrombus without misidentifying it as aortic wall and it should have the ability to identify aneurysms in the presence of marked vessel tortuousity. The authors also highlight the inability of the device to accurately display the size of aortas measuring less than 3 cm in diameter. This should be a development priority as a screening programme using an automated device could select a diameter threshold below 3 cm for patients to have a conventional ultrasound scan for additional safety. From a technological perspective, the AortaScan represents an example of disruptive innovation where complicated and expensive products are converted into simpler, affordable and more accessible ones.2 With further development, it is possible that the device will become accurate enough to be used in routine practice. This type of disruptive innovation has the potential to replace other types of diagnostic equipment that currently requires specialist operators and for the new simplified technology to be taken out of hospitals and made available in public areas such as pharmacies, supermarkets and communal places. This has the additional advantage of engaging the public with issues of healthcare and health screening in more natural environments, ultimately improving the uptake and accessibility of screening.

OC21.02: Selection of women with an ovarian tumor for surgery in specialist centers: a comparison of two triaging protocols

Objectives: To study the correlation between characteristics of contrast-enhanced ultrasound and microvessel density (MVD) of ovarian tumors. Methods: Sixty-two patients with benign and malignant ovarian tumors were examined by contrast-enhanced transvaginal ultrasound, when they were diagnosed by a conventional ultrasound scan in which the diagnosis could not be differentiated. Data were analyzed by time-intensity curves (TIC). The MVD in ovarian tumor specimens from either biopsies or surgery was examined by CD34 immunohistochemical staining. The correlation between ultrasound PI and AUC and MVD in two groups was analyzed. Results: Ovarian tumors were diagnosed as malignant in 58% (36/62) patients and benign 42% (26/62) patients by surgery, laparoscopy and ultrasound-guided biopsy. The mean tumor diameter was 1.7–9.3 cm (4.6 ± 1.8) cm. Ultrasound examination showed that: (1) in benign and malignant tumors, PI values were (13.5 ± 8.3) dB and (20.3 ± 5.2) dB, respectively; and AUCs were (8.2 ± 5.9) and (17.5 ± 5.0), respectively. PI and AUC in malignant tumors were significantly higher than those in benign tumors (P < 0.05). (2) MVD of malignant tumors (65.3 ± 22.3) was higher than that benign tumors (43.1 ± 20.4) (P < 0.01). (3) In both groups, PI value and AUC were significantly correlated with MVD (r = 0.595, r = 0.533, P = 0.002). Conclusions: Ultrasound PI value and AUC were significantly correlated with ovarian tumor MVD. Contrast-enhanced ultrasound could be helpful in the preoperative diagnosis of ovarian tumor malignancy.

Preventing deaths in Ambulatory Care from Isolated Pelvic Vein Deep Vein Thrombosis: Mortality and Mortality Meetings have a key role

Isolated Pelvic vein Deep Venous Thrombosis (DVT) is a relatively rare phenomenon, but is usually not identified by conventional lower limb duplex Ultrasound scanning. We present two cases of isolated iliac vein thrombosis; the first resulting in the patient’s death from Pulmonary Embolism (PE) after normal lower limb duplex scan. The second case was identified and successfully treated after introduction of a revised investigation algorithm following the first case. The literature supports the use of magnetic resonance imaging, CT venography, or ascending venography, to diagnose this condition.

Positron emission tomography scan for a hepatic mass

A 66-year-old male patient who is hepatitis C RNA positive, without cirrhosis, has been found to have a mass on ultrasound examination of the liver. Physical examination is unremarkable. The hemoglobin, white cell count and platelet counts are normal. The alkaline phosphatase is mildly elevated to 212 U/L(normal <115), the AST 112 U/L, and the ALT 128 U/L. The CA 19-9 is 82 U/mL (normal < 55 U/mL) and the alpha fetoprotein 12 ng /mL. A CT scan of the abdomen shows a vague mass in segment V of the liver without definite arterial enhancement. An MRI of the abdomen is carried out with contrast but the mass is still indeterminate on T1 and T2 imaging.

Unmasking pedal arteries in patients with critical ischemia using time-resolved contrast-enhanced 3D MRA

To test the diagnostic relevance of fast Gadobenate dimeglumine (Gd-BOPTA) enhanced, time-resolved, three-dimensional magnetic resonance angiography (t3D MRA) of distal calf and pedal vasculature in critical limb ischemia in a prospective comparison with conventional selective digital subtraction angiography (DSA) and high-resolution duplex ultrasound (US) scan. From April 2007 to June 2008, 34 feet of 29 consecutive patients suffering from limb-threatening ischemia underwent diagnostic US scan, DSA, and t3D MRA before treatment. The investigations took place within 3 days. A t3D MRA was performed using a 3 Tesla whole-body magnetic resonance (MR) system with an eight-element phased-array coil. Image quality and diagnostic findings were subjectively analyzed by two radiologists and one vascular surgeon. Each distal calf and foot was divided into six arterial segments for DSA and t3D MRA, and four segments were investigated by US scan. Patency or occlusion was studied with all the techniques, whereby DSA and t3D MRA were additionally evaluated in patients having greater or less than 50% stenosis. Finally, images were visually assessed by the three observers by applying a six-point grading scale. The acquired data was statistically analyzed using McNemar's test and Wilcoxon's matched-pairs signed-rank sum test. The P values of less than an alpha level of .05 were considered to be statistically significant. We achieved MRA images of diagnostic quality in all patients. Significantly more patent pedal arteries were identified by applying t3D MRA than DSA (P < .001) and US scan (P < .02). For estimating the degree of stenosis, no technique proved to be superior (P > .28). Overall image quality was rated best for t3D MRA. Additionally, potential bypass target vessels could be clearly discriminated from pedal veins due to the temporal resolution. In our prospective study, t3D MRA has been proven to be superior to DSA and US scan in pedal vasculature imaging in critical limb ischemia. This is a valuable, noninvasive method for detecting potential pedal bypass target arteries.

Proposta de sistematização do estudo elastográfico de lesões mamárias pela ultrassonografia

Proposal of systematization for the elastographic study in the ultrasound routine. Evaluation was made of 308 patients forwarded to the breast intervention service in the CTC-Genesis from May 1, 2007 to March 1, 2008 to perform percutaneous breast biopsy. Prior to the percutaneous biopsy, an ultrasound study and an elastography were performed. Lesions were primarily analyzed and classified according to the Bi-Rads lexicon criteria by the conventional ultrasound scan (B mode). The elastography was then performed and analyzed in accordance with the systematization proposed by the authors, using images obtained during compression and after decompression of the area of interest. Lesions were classified following the system developed by the authors using a four-point scale, where scores (1) and (2) were considered benign, score (3) probably benign and score (4) suspicion of malignancy. Results obtained by the two methods were compared with the histological results using the areas within the ROC (receiver operator curves) curves. The area within the curve for elastography was of 0.952 with a confidence interval between 0.910 and 0.966, error of 0.023, and of 0.867 with a confidence interval between 0.823 and 0.903, error of 0.0333 for the ultrasound. When the areas were compared, a difference between the curves of 0.026 was observed, which was statistically significant. This work shows the systematization of the elastographic study using information obtained during compression and after decompression of the ultrasound scan sample, thus showing that elastography might enhance the assessment of risk of malignancy for lesions characterized by the ultrasound.

Integrated backscatter analysis of carotid intima–media complex in patients with systemic lupus erythematosus

A number of studies based on conventional ultrasound scanning (CUS) gave contrasting results about the occurrence of early atherosclerosis in patients with systemic lupus erythematosus (SLE), while no study on early arterial sclerosis in the same patients are available. Recently, information on early arterial sclerosis can be provided by the integrated backscatter (IBS) analysis which reflects the collagen and calcium content within the vascular wall. In order to evaluate if atherosis and/or sclerosis of carotid arteries are early features of SLE, we performed carotid CUS and IBS analysis in 16 SLE patients (15 females; aged 37 +/- 10 years), free from clinically evident cardiovascular diseases and cardiovascular risk factors, with the only exception of five patients who had arterial hypertension. The same investigations were performed in 16 sex- and age-matched healthy control subjects. No statistically significant difference was observed either in carotid corrected IBS values or in carotid intima-media thickness (IMT) values between SLE patients and control subjects (-17.9 +/- 2.5 dB vs -19.0 +/- 1.7 dB, p = 0.14; 0.66 +/- 0.08 mm vs 0.62 +/- 0.13 mm, p = 0.35, respectively). The little sub-group of hypertensive SLE patients exhibited a significantly higher carotid corrected IBS mean value compared to control subjects (-16.4 +/- 3.1 dB vs -19.0 +/- 1.7 dB, p = 0.026), while it did not significantly differ in carotid IMT value from control group (0.67 +/- 0.09 mm vs 0.62 +/- 0.13 mm, respectively; p = 0.86). These findings show that neither atherosis nor sclerosis of carotid arteries are early features of SLE patients free from cardiovascular risk factors. Further studies are needed to clearly demonstrate that early carotid sclerosis affects hypertensive SLE patients.

Endosonographische Diagnostik bei Pankreastumoren

140 patients (72 men, 68 women; mean age 57 [26-83] years) with suspected pancreatic tumours were investigated by endoscopic ultrasound (EUS) and also by conventional ultrasound, computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP). The EUS scans were performed with an echo-endoscope in the descending part of the duodenum (for the head of the pancreas) or in the stomach (for the body and tail). The definitive diagnosis or exclusion of a pancreatic tumour (malignant n = 85, benign n = 4, inflammatory n = 23, no tumour n = 28) was made at operation (n = 63), by needle biopsy (n = 35), at necropsy (n = 4) or by clinical follow up (n = 38, mean 10.5 months). The sensitivity and specificity of endoscopic ultrasound (99% and 100%) were superior to the results given by conventional ultrasound scans (71% and 39%), CT (82% and 46%) and ERCP (89% and 64%). This was also true of small tumours of 3 cm or less (EUS 100%, conventional ultrasound 57%, CT 68% and ERCP 89%). However, the differential diagnosis between malignant and inflammatory masses in the pancreas was not feasible by endoscopic ultrasound, either prospectively (detection rate 69%) or by comparative analyses of echo structure. Endoscopic ultrasound appears to be a valuable aid to the diagnosis or exclusion of pancreatic tumours. When conventional ultrasound and CT give negative or doubtful results it can be used in conjunction with or instead of ERCP to confirm the diagnosis.

Unusual presentation of a woman with polycystic ovaries and complex endometrial pathology

A 28-year-old woman with polycystic ovarian syndrome (PCOS) had attempted four assisted conception treatments, all of which were complicated by lack of response of the endometrium to the hypo-oestrogenic state induced with gonadotrophin releasing hormone analogue (GnRHa). Consequently, two treatment cycles were abandoned, one prior to the ovulation induction of a fresh IVF treatment and the other prior to oestrogen replacement for a frozen–thawed embryo transfer treatment cycle. Extended down-regulation eventually resulted in endometrial thinning and allowed completion of the other two treatments, but the outcome was negative. A targeted mid-cycle ultrasound scan in a natural cycle at follow-up showed thick, non-homogenous endometrium. A repeat hysteroscopy on this occasion showed abnormal endometrium with chalk-like deposits. Histological diagnosis was chronic endometritis and endometrial hyperplasia with focal atypia. Microbiological tests, including those for Mycobacterium tuberculosis, were negative. Because of atypical endometrial hyperplasia, this patient is currently under close follow-up by the original referring team. This case highlights inherent endometrial pathology presenting as non-responding endometrium to hormonal down-regulation, the limitations of conventional ultrasound scans, and the complimentary role of concomitant hysteroscopy in the correct identification of endometrial lesions that may negatively affect the assisted conception treatments.

Hysterosalpingo-Contrast Sonography Compared with Hysterosalpingography and Laparoscopic Dye Pertubation to Evaluate Tubal Patency

Study Objective To evaluate the advantages and accuracy of hysterosalpingo-contrast sonography (HyCoSy) in assessing tubal patency compared with hysterosalpingogram (HSG) and laparoscopic dye pertubation. Design Prospective study (Canadian Task Force classification II-2). Setting Obstetrics and Gynecology Department, University of Rome Tor Vergata. Patients Twenty-three women with at least 1 year of infertility, and 15 women with a history of chronic pelvic pain, suspected endometriosis, or pelvic inflammatory disease (PID), or with sonographic markers of adhesions. Intervention HyCoSy, HSG, and laparoscopic dye pertubation. Measurements and Main Results All patients underwent HyCoSy during the proliferative phase using air with saline as contrast medium, and HSG within 1 month of HyCoSy. Laparoscopy and dye pertubation were performed only in women with chronic pelvic pain, suspected endometriosis, PID, and sonographic markers of adhesions. In women undergoing all three procedures, HSG and HyCoSy had the same high concordance as laparoscopy, 86.7% and 86.7%, respectively. Three women in the infertility group became pregnant immediately after HyCoSy and dropped out of the study. In one woman, HyCoSy could not be performed because of cervical stenosis. Considering the total number of tubes (67), concordance between HyCoSy and HSG was 89.6%. Conclusion Transvaginal HyCoSy using a combination of air and saline appears to be an inexpensive, fast, and well-tolerated method of determining tubal patency. One of the most important advantages of this technique is, in our opinion, the possibility of obtaining information on tubal status and the uterine cavity at the same time as conventional ultrasound scan is performed.

Efficacy of ultrasound scan contrast agents in the noninvasive follow-up of aortic stent grafts

Computed tomographic angiography (CTA) is currently the most commonly used technique for postoperative surveillance to detect endoleaks after endovascular stent graft repair of abdominal aortic aneurysms. We have evaluated the efficacy of duplex ultrasound scan with the addition of an ultrasound scan contrast agent in documenting endoleaks and compared these results with CTA. Conventional duplex ultrasound scan with color Doppler imaging (CDI) was first done as part of routine postoperative surveillance. After the CDI study, a 1-mL bolus of ultrasound scan contrast was given via an antecubital vein, followed by a 5-mL flush with normal saline solution. The duplex ultrasound scan evaluation of the stent graft was repeated once the contrast agent was circulating throughout the blood pool, with tissue harmonic imaging to optimize visualization of the contrast agent. Status of the stent graft, the presence or absence of any endoleak, and whether these endoleaks were graft related (group I) or arterial branch related (group II) were recorded. Findings were compared with CTA studies done within a 2-week period of the ultrasound scan examination. Twenty patients were evaluated, 18 with modular stent grafts and two with unibody bifurcated stent grafts. Patients had a mean age of 74.5 +/- 7.6 years; 19 were male, with only one female. All stent grafts remained widely patent with normal aortoiliac flow hemodynamics. Duplex ultrasound scan with contrast identified all eight of the endoleaks seen with CTA and was able to determine whether they were group I or group II leaks. In two patients, ultrasound scan with contrast detected small endoleaks at the proximal graft attachment site, with extravasation of contrast into the aneurysm sac during systole. These endoleaks were not seen with CTA but were confirmed with conventional angiography at the time of endovascular closure. Standard duplex ultrasound scan with CDI failed to identify four of the 10 endoleaks in patients with technically difficult conditions. Duplex ultrasound scan, when used with an intravenously administered ultrasound scan contrast agent in the noninvasive follow-up of patients with aortic stent grafts, appears to provide good sensitivity to the presence and type of endoleaks, even in patients with technically difficult conditions not amenable to conventional duplex ultrasound scan with CDI.

Serum alpha-glutathione S-transferase as a sensitive marker of hepatocellular damage in patients with cystic fibrosis

The aim of the study was to evaluate serum a-glutathione S-transferase (s-GSTA) levels in patients with cystic fibrosis (CF) and to compare s-GSTA with other liver function tests and with a hepatic ultrasound scan (US). The cytosolic enzyme, a-glutathione S-transferase is predominantly found in the liver and is distributed uniformly in the liver tissue. In our study s-GSTA levels were measured in 37 CF patients aged 1 to 28 years (mean age 10.4 years, 24 males). The control group consisted of 27 patients aged 2 to 17 years (mean age 8.5 years, 18 males). The presence of hepatobiliary abnormalities was assessed by clinical examination, ultrasound scan, s-GSTA, and conventional liver enzymes: alanine aminotransferase (ALT), alkaline phosphatase (ALP), aspartate aminotransferase (AST) and g-glutamyl transferase (GMT). The calculated 5-95 % range of s-GSTA for the control group was 0.098-2.54 mg/l, for the CF group 0.43-9.76 mg/l. Mean s-GSTA level in the control group was 1.55 mg/l (S.D.=1.57), and 2.05 mg/l (S.D.=2.60) in the CF group. In the group of CF patients, the serum levels were significantly higher than in the control group (P&lt;0.01). No significant correlation existed in the CF group between s-GSTA and conventional liver tests (ALT, AST, ALP and GMT). Four patients in the CF group had hepatobiliary abnormalities detectable by conventional liver tests, s-GSTA and US. Four patients had abnormal s-GSTA, while conventional liver tests and US were normal. One other patient had abnormal hepatic US, but normal standard liver tests and s-GSTA. The study has suggested that a raised s-GSTA level might be a marker of possible pathological changes of the hepatobiliar system in CF patients. Serum GSTA seems to be a more sensitive marker than transaminases for the monitoring of hepatocellular integrity and as an early predictor of hepatic damage.

Improved detection and biopsy of solid liver lesions using pulse-inversion ultrasound scanning and contrast agent infusion

The purpose of this study was to assess the ability of pulse-inversion ultrasound (US) scanning (PIUS), combined with an IV contrast agent, to detect malignant liver lesions and its impact on patient management (resectability). Additionally, to determine the feasibility of US-guided biopsy of new PIUS-findings at the same session. A total of 30 patients with known or clinically suspected cancer underwent conventional B-mode scanning and PIUS with IV-administered contrast agent. The number of liver metastases in the right and the left liver lobe, respectively, was recorded. All patients with additional findings by PIUS underwent US-guided biopsy. PIUS provided additional information in 18 patients (60%); of these, 13 (43%) had additional metastases. Of 19 patients found resectable by conventional US, 9 (47%) were considered inoperable using PIUS supported by biopsies. Biopsies of additional findings were performed in 17 of 18 patients. All biopsies of additional findings confirmed malignancy. PIUS with an IV contrast agent increased the ability to detect liver metastases compared to conventional US scanning. The technique had a high impact on patient management. The results showed that PIUS-guided biopsy was possible. PIUS with IV contrast will undoubtedly become an important diagnostic tool in the evaluation of patients with metastatic liver disease. (E-mail:bos@dadlnet.dk)

Noninvasive imaging of the biliary ducts

The noninvasive imaging techniques of conventional ultrasound and CT scanning and the new methods of MRCP and CT cholangiography have advanced rapidly during the past decade in terms of availability, speed, and accuracy. In the vast majority of patients, the presence of common duct dilatation and the presence or absence of obstructing common bile duct stones can be determined by these noninvasive imaging methods (Fig. 1). When these techniques are available, the need for invasive diagnostic endoscopy should be minimized. Endoscopic techniques with their inherent cost and risk should increasingly be reserved only to guide therapeutic maneuvers.”

Laparoscopic ultrasound for the detection of hepatic metastases during laparoscopic colorectal cancer surgery

The search for liver metastases before surgery forms an accepted part of colorectal cancer surgical practice. Intraoperative ultrasound and manual palpation of liver together form the criterion standard as far as screening for metastases is concerned. However, extracorporeal imaging, such as ultrasound and magnetic resonance imaging, are also widely used. The purpose of this study was to demonstrate the efficacy of laparoscopic ultrasound scan in detection of liver metastases during laparoscopic colorectal cancer surgery by comparison with conventional imaging modalities. A prospective, controlled study was undertaken. A total of 76 consecutive patients undergoing laparoscopic colorectal resections for malignancy were recruited. Patients underwent preoperative liver ultrasound scan and intraoperative blinded laparoscopic ultrasound scan examination performed by a single surgeon. Contrast-enhanced magnetic resonance imaging was performed within 30 days of surgery. Conventional ultrasound scan was negative in all cases. Metastases were identified during simple laparoscopic inspection of the liver in one case. Two cases shown by laparoscopic ultrasound scan to have definite metastases were confirmed by magnetic resonance imaging. In seven further instances laparoscopic ultrasound scan identified suspicious liver masses. In three cases these were confirmed to be metastases at magnetic resonance imaging; one was confirmed as a cyst, and the remaining three suspicious lesions were confirmed at serial magnetic resonance imaging scans to be benign and of no significance. Laparoscopic ultrasound scan with a flexible-tipped probe permits satisfactory hepatic examination. It is superior to conventional ultrasound scan and seems to be as effective as magnetic resonance imaging, although the latter modality is still required to delineate identified lesions.

Serum glutathione S-transferase B1 activity as an index of liver function in cystic fibrosis.

To evaluate serum glutathione S-transferase B1 (GST B1), a highly sensitive test of hepatocellular function, as a means of identifying liver disease in patients with cystic fibrosis (CF). The presence of liver disease was sought over a three year period in 60 children with CF, using a combination of clinical assessment, ultrasound examination, conventional biochemical tests of liver function (LFTs), and measurement of GST B1. Reference ranges for serum GST B1 were established in a paediatric control population. The 95% value (4.55 micrograms/l) was similar to the upper limit of normal previously derived in adults. Mean (SE) serum GST B1 activities were higher in the CF population (9.0 (1.14) micrograms/l) than in age matched controls (2.4 (0.15) micrograms/l). Ten patients with CF showed clinical signs of liver dysfunction. All but one had a serum GST B1 > 4.55 micrograms/l. Twelve other patients had elevated LFTs without clinically evident liver dysfunction, six had abnormal ultrasound scans and two showed both of these anomalies. Thirty patients with CF had neither biochemical, ultrasonographic nor clinical signs of liver disease. On review three years later, clinically important liver disease was reaffirmed in eight of the 10 index cases and had become apparent in a further eight, all of whom had elevated GST B1 activities. Five (36%) of the patients with elevated LFTs and two (33%) with isolated ultrasound changes continued to show these abnormalities. The limitations of conventional LFTs and ultrasound scans were evident from this study. The results suggest that elevated GST B1 activities may be a better predictor of hepatic dysfunction in CF than conventional LFTs.

Three-dimensional ultrasonography in prenatal diagnosis.

Within the past five years, 3D ultrasonography has developed to the degree that it offers both the patient and the examiner an entirely new visual experience in prenatal diagnosis. With the system described here (Kretz-technik, Austria), any desired plane can be displayed within the stored volume, and within seconds a high-quality 3D surface or transparent image can be calculated and displayed on the ultrasound monitor without need for an external workstation. All of this can be performed routinely in the clinical setting. Since 1989 we have routinely examined a total of 458 fetuses (242 normal and 216 with anomalies) between 16 and 38 weeks of gestation, supplementing our conventional 2D ultrasound scans with a 3D examination using an abdominal volume transducer. A comparison of the 2D and 3D techniques shows that 3D provides a diagnostic gain in a large percentage of cases (64.2%). The simplest 3D technique of the orthogonal image display provided a diagnostic gain in 46.2% (61/132) of the cases owing to the accurate topographic depiction of the desired image plane. The combined 3D display (orthogonal format plus a 3D surface or transparent view) provided a diagnostic gain in 71.5% (233/326) of the cases. This higher percentage resulted from the additional 3D surface reconstruction, the ability to view and evaluate the fetus from various angles, the ability to determine the exact size of a fetal defect, the depiction of skeletal anatomy in the transparent mode, and the improved delineation of complex malformations. Problems with 3D imaging are encountered in patients with pronounced oligohydramnios, which prevents surface reconstruction, and in the examination of moving objects, which produce motion artifacts.

INVESTIGATION OF THE IRRITABLE HIP

The respective roles of conventional radiography, ultrasound scanning, and radionuclide scintigraphy in the investigation of 62 children with the irritable hip syndrome are compared. It is recommended that conventional radiography and ultrasound scanning be routinely performed, but scintigraphy should be reserved for those with positive findings on ultrasound, as an abnormal scintigram is unusual in the presence of a normal ultrasound scan.

Investigation of the irritable hip.

The respective roles of conventional radiography, ultrasound scanning, and radionuclide scintigraphy in the investigation of 62 children with the irritable hip syndrome are compared. It is recommended that conventional radiography and ultrasound scanning be routinely performed, but scintigraphy should be reserved for those with positive findings on ultrasound, as an abnormal scintigram is unusual in the presence of a normal ultrasound scan.