Echogenic Ring Research Articles

Spontaneous bilateral tubal pregnancy - case report and review of diagnostic and treatment difficulties

Introduction. Spontaneous bilateral ectopic pregnancy is a rare condition easily overlooked or misdiagnosed. We present a case of spontaneous bilateral tubal ectopic pregnancy and discuss the difficulties in diagnosing and treating such patients. Case outline. A 39-years-old patient with a history of irregular and abundant menstrual cycles complained of pelvic pain and light bleeding after 55 days of amenorrhea. Ultrasound revealed enlarged uterus with a myoma and a heterogenic formation with echogenic ring sign beside the left ovary. Free fluid with clots was present in the pelvis. As the patient was hemodynamically unstable and ectopic pregnancy was suspected, emergency laparotomy was performed. During the surgery we found that both tubes were significantly edematous, dilated, and livid in their ampullary regions. On the left tube anterior wall rupture 15 ? 8 mm was noticeable, while right tube was intact with bleeding from its abdominal ostium. Even though the patient was not informed about the possibility of bilateral salpingectomy, after thorough consideration and due to the extent of tubal damage bilateral salpingectomy was eventually performed. Histopathological analysis confirmed the presence of decidua, partially viable and partially necrotic chorionic villi, and trophoblastic tissue in both right and left tubes. Conclusions. Careful preoperative and intraoperative examination of both Fallopian tubes as well as the whole abdominal and pelvic cavity should be mandatory during every assessment of patients with ectopic pregnancy.

An Unusual Cause of Recurrent Vomiting

Question: A 28-year-old man was admitted for postprandial epigastric pain, and chronic vomiting for 6 months, associated with a 6-kg weight loss. He had no relevant medical or family history. Physical examination and laboratory workup were normal. An anechoic lesion located in the second part of the duodenum wall was revealed on abdominal ultrasound imaging, and a submucosal mass was diagnosed in the same region, using an upper endoscopy technique (Figure A). Furthermore, endoscopic ultrasound imaging (Figure B) and magnetic resonance imaging with dynamic sequences (Figure C) showed a 25 × 26-mm cystic duodenal lesion. There was no connection between the lesion and the biliary and pancreatic ducts, which seemed to be normal. What is your diagnosis? How should the patient be treated? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Endoscopic ultrasound imaging showed an anechoic duodenal lesion with an inner echogenic ring and an outer hypoechoic ring. Abdominal magnetic resonance imaging found a consistent appearance of a duodenal cyst protruding into the duodenal lumen, in the second part of the duodenum. These findings are specific to an enteric duplication cyst. We performed an endoscopic treatment of the cyst. The cyst's roof was first punctured using a needle-knife papillotome. The wall of the cyst was then incised using a polypectomy snare. Pathologic examination showed a double muscle layer with both mucosal and submucosal layers (Figure D), confirming the diagnosis of duodenal duplication cyst. The patient was discharged of hospital 24 hours later. Follow-up was uneventful. Duodenal duplication cyst is a rare congenital malformation.1Chen J.-J. Lee H.-C. Yeung C.-Y. et al.Meta-analysis: the clinical features of the duodenal duplication cyst.J Pediatr Surg. 2010; 45: 1598-1606Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 2Antaki F. Tringali A. Deprez P. et al.A case series of symptomatic intraluminal duodenal duplication cysts: presentation, endoscopic therapy, and long-term outcome (with video).Gastrointest Endosc. 2008; 67: 163-168Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Although exceptional malignant tumor developments have been described, duodenal duplication is usually associated with a good prognosis. Before the era of therapeutic endoscopy, surgical resection was performed in symptomatic patients, with significant morbidity. Various straightforward, safe, and effective endoscopic techniques have since been described, including cyst puncture, snare resection, and cyst needle aspiration/ligation, as suggested by Gjeorgjievski et al.3Gjeorgjievski M. Manickam P. Ghaith G. et al.Safety and efficacy of endoscopic therapy for nonmalignant duodenal duplication cysts.Medicine (Baltimore). 2016; 95: e3799Crossref PubMed Scopus (12) Google Scholar Long-term clinical outcomes are excellent, making therapeutic endoscopy a valid, minimally invasive alternative to surgical resection.

Double Sac Sign and Intradecidual Sign in Early Pregnancy

To assess the interobserver agreement, frequency of occurrence, and prognostic importance of the double sac sign (DSS), intradecidual sign (IDS), and other sonographic findings in early intrauterine pregnancies. We retrospectively identified all sonograms obtained between January 1, 2006, and December 31, 2011, in which: (1) the scan demonstrated an intrauterine fluid collection without a yolk sac or embryo; (2) a follow-up scan confirmed an intrauterine pregnancy; and (3) the first-trimester outcome was known. Each coinvestigator characterized the 199 study sonograms as demonstrating or not demonstrating a DSS or an IDS, based on judgment about whether the scan met published criteria defining these signs. Interobserver agreement was poor for the DSS (κ= 0.24) and IDS (κ= 0.23). Scans frequently demonstrated neither sign: 150 cases (75.4%) if we considered a sign to be present when both investigators graded it as present and 69 cases (34.7%) using the looser criterion that either graded it as present. The presence of a DSS or an IDS was unrelated to the β-human chorionic gonadotropin (β-hCG) value (P > .05, t test, all comparisons). An inner echogenic ring was present in 158 cases (79.4%), and the decidua was brighter peripherally than centrally in 102 (51.3%). The first-trimester outcome was unrelated to the presence of a DSS or an IDS, presence of an inner echogenic ring, or decidual appearance (P > .05, χ(2), all comparisons). The sonographic appearance of early gestational sacs, before visualization of a yolk sac or embryo, is highly variable. The DSS and IDS are often absent; there is poor interobserver agreement regarding these signs; and the prognosis is unrelated to their presence or absence. A round or oval intrauterine fluid collection in a woman with positive β-hCG should be treated as a gestational sac until proven otherwise, regardless of whether it demonstrates a DSS or an IDS.

Ovarian Pregnancy: Report of Two Cases

Ectopic pregnancy is the leading cause of mortality in early pregnancy. The incidence of ectopic pregnancy is estimated to be between 1 and 2 %. The majority of these pregnancies are located in the fallopian tube. However, pregnancies also occur implanted in the cervix, ovary, previous cesarean scar, and abdomen [1]. The diagnosis and treatment of these unusual implantation sites present both diagnostic and therapeutic dilemmas. Risk factors include previous pelvic inflammatory disease, IUCD usage, endometriosis, and assisted reproductive technologies [2]. Diagnosis of ovarian pregnancy is made by ultrasound appearance of a wide echogenic ring on the ovary. Laparoscopic surgery is presently considered to be the treatment of choice. Ovarian pregnancy is a rare event. Reports vary from one in 2,100 pregnancies to one in 60,000, making ovarian pregnancy 1–3 % of all ectopic pregnancies [2].

Spontaneous Unilateral Tubal Twin Ectopic Pregnancy: A Case-Based Discussion and Assessment

ABSTRACT Introduction Two percent of all 1st trimester pregnancies in the United States are ectopic. Transvaginal ultrasound is considered the mainstay in diagnosis. Color Doppler ultrasound can prove to be an added helpful modality in identifying ectopic pregnancies. Case report An 18-year-old nulliparous female presented with vaginal bleeding and lower abdominal pain. Pelvic exam revealed tenderness in the right adnexal region with elevated quantitative serum beta-hCG. A transvaginal ultrasound showed an echogenic ring adjacent to the right ovary and M-mode and color Doppler revealed two fetal heart tones. Color Doppler enabled visualization of randomly dispersed tubal arteries and heart activity of both embryos. A right salpingectomy was performed without complications and beta hCG levels returned to undetectable levels. Conclusion B mode ultrasound is a vital diagnostic tool in the detection of ectopic pregnancy. Color Doppler provides both morphologic and functional information essential for determining the optimal therapeutic strategy. Three-dimensional ultrasound with color and/or power Doppler has proven useful in both the initial diagnosis and follow-up of ectopic pregnancies especially in patients following assisted reproduction treatment.

Spatiotemporal Image Correlation Artifacts in an In Vitro Model

An experimental in vitro setting with a latex miniature balloon was designed to test the accuracy of volumetric measurements by spatiotemporal image correlation. Two-dimensional images clearly showed the round balloon as a thin echogenic ring in a translucent area. Four-dimensional reconstructed images, however, showed a severely distorted balloon. The artifacts disappeared when the surroundings of the balloons were made echogenic, mimicking the in vivo setting. We hypothesize that the artifacts were the result of gating errors. These experiments can be relevant for analysis of spatiotemporal image correlation volumes in daily practice.

Detection of enlarged yolk sac on early ultrasound is associated with adverse pregnancy outcomes

Pregnancies with mean yolk sac diameter>or=5 mm on early ultrasound require monitoring and counseling about a threefold increased risk for first-trimester loss independent of maternal risk factors such as age, body mass index, polycystic ovary syndrome, smoking, and diabetes. In addition, our study shows for the first time that enlarged yolk sac diameter may be associated with an increased risk of preterm delivery.

Catch me if you scan: ultrasound diagnosis of ectopic pregnancy

In recent years, ultrasound has become an essential tool in the assessment of women with suspected early pregnancy complications1. A large number of studies has already been published, describing the value of ultrasound in the diagnosis of ectopic pregnancy2,3. So, why write yet another review on this topic? We run a busy Early Pregnancy Unit in the area with the highest prevalence of ectopic pregnancy in the UK, which also receives many referrals from other hospitals of women with an uncertain diagnosis of ectopic pregnancy. The most interesting fact that we have learned over the years is that the majority of women referred with suspected ectopic pregnancies in fact had intrauterine ones that were either missed on ultrasound examination or misinterpreted as ectopics. This may sound surprising to many, as ultrasound diagnosis of intrauterine pregnancy is considered to be relatively simple and accurate. In many cases, ultrasound examination failed to identify a small amount of retained products of conception, due in part to inconsistencies in the sonographic diagnosis of incomplete miscarriage; this is often based on the use of arbitrary cut-off levels for endometrial thickness4. In other cases, however, sonographers were unable to decide whether a visible gestational sac represented an intrauterine or an ectopic pregnancy. In some cases with uncertain diagnosis, women had already received medical treatment with methotrexate prior to referral, leading to the loss of wanted normal intrauterine pregnancies. Another common problem is difficulty in differentiating between the various types of ectopic pregnancy. An accurate differential diagnosis is important in ectopics, as the management often differs depending on the type and exact location of the pregnancy. The purpose of this review is to summarize the sonographic criteria for the diagnosis of both intrauterine and ectopic pregnancies and to describe the principles of differential diagnosis of various types of ectopic pregnancy. We will not cover management of pregnancies of unknown location, as this issue has been covered extensively in recent publications5.

Analysis of posterior echoes using reconstructed vertical ultrasound images.

To evaluate the role of vertical images reconstructed using 3-D data in the analysis of posterior echoes. Reconstructed vertical images of US phantoms with the following artifacts were retrieved and analyzed: acoustic shadowing (clean and dirty); posterior echo enhancement (with/without lateral shadowing); and reverberation artifacts (clean and dirty). For acoustic shadowing, a stone and posterior clean acoustic shadowing were imaged as an echogenic mass or an echogenic ring containing a central echo-free area. However, the stone and dirty acoustic shadowing were imaged as an echogenic mass or an echogenic mass consisting of many fine echo spots disseminated throughout the whole mass. For posterior echo enhancement, when lateral shadowing is present, the cyst and posterior echo enhancement are imaged as a round anechoic mass or a triple circle consisting of a thin anechoic outer rim, an echogenic ring, and an anechoic center. However, when lateral shadowing is absent, they are imaged as a round anechoic mass or a double circle consisting of an echogenic outer rim and an anechoic center. For clean reverberation artifacts and dirty reverberation artifacts, vertical images of clean reverberation artifacts consist of either a homogeneous echogenic area or an absent signal. However, vertical images of dirty reverberation artifacts consist of a homogeneous echogenic area and an area consisting of fine echo spots. Our study suggests that reconstructed, previously unattainable, vertical plane images help us better understand the mode of posterior echoes.

Intracaval ultrasonography in the diagnosis of tumour involvement of the vena cava.

A retrospective study of 34 consecutive patients with possible tumour involvement of the vena cava was performed to assess the usefulness of intracaval ultrasonography. Twenty-five of the 34 patients were operated and resection carried out in 23, including seven with combined resection of the vena cava. The sonographic criterion for vena cava invasion was obliteration of the echogenic ring of the vena cava wall or intracaval tumour mass. The sensitivity, specificity and overall accuracy of intracaval endovascular ultrasonography in the diagnosis of tumour involvement of the vena cava were 100, 96 and 97 per cent respectively. The respective values were 91, 61 and 71 per cent for computed tomography and 82, 67 and 72 per cent for cavography. Ultrasonography is a useful technique that can precisely evaluate the vena cava for possible tumour invasion, especially when the presence or extent of tumour involvement is not definitely established by conventional imaging techniques.

Three-dimensional sonographic diagnosis of ovarian pregnancy

Three-dimensional sonographic diagnosis of ovarian pregnancy

The Ultrasonographic Appearance of Ovarian Ectopic Pregnancies

To evaluate the ultrasonographic findings of ovarian ectopic pregnancies. The ultrasonographic reports, videotapes, medical records, and operative summaries were reviewed for all women with a confirmed diagnosis of an ovarian ectopic pregnancy. Examinations were personally conducted by a physician who was either a radiologist-obstetrician or an obstetrician-maternal-fetal medicine specialist. Six cases were identified in the 13-year period studied. Menstrual ages ranged from 6 to 9 2/7 weeks. Most (5/6) patients had abdominal pain, with 3 demonstrating it before or at 7 weeks gestation. A wide echogenic ring with an internal echolucent area was seen in 5 of 6 patients; 1 of these also contained a yolk sac, and in another, fetal heart motion could be seen. The echogenic ring seemed to be on the surface of the ovary or within the substance of the ovary in all 5 patients. The echogenicity of the ring was greater than that of the ovary in the 5 patients in whom it was identified. At surgery, the ovarian pregnancies had the appearance of a hemorrhagic ovarian cyst in all 6 patients. In the patient in whom no echogenic ring was seen the pregnancy had ruptured. All 6 cases were biopsy proven. Ovarian pregnancies usually appeared on or within the ovary as a cyst with a wide echogenic outside ring. A yolk sac or embryo was less commonly seen. The appearance of the contents lagged in comparison with the gestational age. Early abdominal pain was common.

Echogenicity variations from porcine blood i: the “bright collapsing ring” under pulsatile flow

The temporal and radial variations of the echogenicity from porcine blood were investigated using a linear M12L transducer with a GE LOGIQ 700 Expert system. The “bright collapsing ring” (BRCR) phenomenon, a bright echogenic ring converging from the periphery to the center of the tube wall and eventually collapsing during a pulsatile cycle in cross-sectional B-mode images, was observed from porcine blood in a mock flow loop within a 0.95-cm diameter tube under certain flow conditions. The BRCR phenomenon from porcine blood was stronger as the peak speed was increased from 10 to 25 cm/s, and the mean echogenicity and the “black hole” (BLH) phenomenon, a central echo-poor zone surrounded by a bright hyperechoic zone, became weaker. As stroke rate was increased from 20 to 60 beats/min (bpm), both the BRCR and the BLH phenomena became weaker. These two phenomena were observed at three transmitting frequencies (9, 11 and 13 MHz). As hematocrit was increased from 12 to 45%, the BRCR phenomenon became more apparent. The nonlinear behavior of backscatter as a function of hematocrit reaching a maximum at hematocrit of 10 ∼ 20% was observed near the tube wall, but it changed at the center of the tube, indicating the importance of hemodynamics on the ultrasonic backscatter from flowing blood. The combined effects of shear rate and acceleration on red blood cell aggregation are suggested as a possible mechanism for these phenomena. (E-mail: paeng@cheju.ac.kr)

Ultrasonic scattering by blood: theories, experimental results and biomedical applications

In this paper, theoretical and experimental efforts that have been undertaken to better understand the phenomenon of ultrasonic scattering in blood will be reviewed. This subject is of interest in biology and medicine because the echoes generated by blood are used to extract blood velocity by ultrasonic Doppler flow and imaging devices. In the course of these investigations it became clear that ultrasonic scattering from blood is dependent upon such hematological and hemodynamic properties of blood as hematocrit, plasma protein concentration, flow rate and flow cycle duration. Several aspects of these experimental results have been successfully modeled by recent theoretical developments. An unexpected consequence of these efforts is that ultrasound appears to be a viable tool for blood flow visualization and hemodynamic measurements. Two unique hemodynamic phenomena that have never been reported in the hemodynamic literature have been observed: the black hole, a low echogenic zone in the center stream of whole blood flowing in a blood vessel under steady flow and the collapsing ring, an echogenic ring appearing near the periphery of a vessel at the beginning of a flow cycle, converging toward the center, and eventually collapsing during pulsatile flow. Similar observations have been made during clinical scanning of patients.

Cyclic and radial variation of the echogenicity from human carotid artery and porcine blood

The cyclic and radial variation of the echogenicity from human blood and porcine blood was investigated using a linear M12L transducer with a GE LOGIQ 700 Expert system. The bright collapsing ring phenomenon, a bright echogenic ring converging from the periphery to the center of the tube wall and eventually collapsing during a pulsatile cycle from the cross-sectional B mode images, was observed from porcine blood in a mock flow loop with a diameter of 0.95 cm at certain flow conditions. The bright ring phenomenon from porcine blood was stronger as the peak speed increased from 19 to 40 cm/s while the mean echogenicity decreased. As the stroke rate increased from 20 to 60 beats/minute, the phenomenon was weaker. As the hematocrit increased from 12 to 45%, the phenomenon became obvious. The black hole phenomenon was also observed at certain flow conditions. The well-known nonlinear hematocrit dependence on echogenicity was observed near the wall but the dependence pattern was changed at the center of the tube. The similar bright ring phenomenon was also observed at the harmonic images in vivo on 10 human carotid arteries. Aggregation due to the shear rate and acceleration is thought to be the explanation of the phenomena.

The ring sign: a new ultrasound sign of peripheral nerve tumours

The ultrasound ring sign is reported in two patients with benign nerve tumours. The echogenic ring lies within the mass rather than at its periphery. This appearance has not been described previously in nerve tumours.

Prenatal diagnosis of testicular torsion.

A case of the prenatal diagnosis of testicular torsion at 39 weeks' gestation is presented. The affected testicle was observed as a small rounded area of hypoechogenicity with a peripheral echogenic ring without hydrocele. The appearance was suggestive of the chronic phase of testicular torsion. The neonatal genital exploration confirmed the diagnosis.

Dopplersonographische Vitalitätskriterien bei klinisch stabiler Extrauteringravidität - eine Entscheidungshilfe für die Therapie

The differentiation between viable ectopic pregnancies with trophoblastic activity and tubal abortions could be a therapeutic aid for the determination of an operative versus a conservative management. Since the typical sonographic picture of an ectopic pregnancy - an extrauterine gestational sac surrounded by an echogenic ring - corresponds histologically to the oedematous tube in combination with the trophoblast, good vascularisation within this structure should indicate the chorionic activity of the ectopic pregnancy and thereby its viability. In 34 patients with sonographically definitely confirmed ectopic pregnancy from the 6 th to 10 th week of gestation who presented with typical but not acute symptoms of an EP (bleeding disorders, positive pregnancy test together with an empty uterus in sonography, slight ache in the lower abdomen or sonographic proof of an ectopic pregnancy in private practice) we therefore examined this echogenic ring by transvaginal colour Doppler sonography (Acuson 128 XP/10, 5 Mhz transvaginal probe EV 519) in a prospective study. Subsequently 29 patients underwent laparoscopy or laparotomy where 16 tubes had to be removed partially or completely. The histological examination of the removed tissue was performed by haematoxyline-eosine staining as well as by immune histochemical methods (factor VIII-antibody, Dako, Heidelberg, FRG) to identify and precisely localise the vessels in the area of the ectopic pregnancy seen in the Doppler sonographic examination. In accordance with the increasing experience with this technique, five patients were treated by conservative methods (single i.v. administration of methotrexate, 30mg). Whereas viable ectopic pregnancies (n=11) exhibited a ring of vessel spots at the rim of this echogenic ring, there were only three or less weak vessel spots or even no vessel spots at all in tubal abortion (n=23). The Doppler sonographic findings could also be verified on histological examination; this correlation was statistically significant also after subtracting the five ectopic pregnancies with positive heart beat (p<0.01; Fisher's exact test). The major therapeutic problem especially of the conservative approach was the slow normalisation of the pregnancy hormone. Even if this is taken into account, Doppler sonography of the echogenic ring around the extrauterine gestational sac is nevertheless an additional help for counselling the clinically stable patient concerning further therapeutic procedures, since it is a fast and simple method for determining the viability of an ectopic pregnancy. It provides a certain independence of the laboratory concerning the determination of the pregnancy hormone and it correlates with the ensuing;histological examination.

The anatomical basis of anal endosonography. A study in postmortem specimens.

Anal endosonography is an imaging modality new to the diagnostic workup of incontinence. Interpretations even of normal endosonomorphologic findings now vary considerably. The conjoined longitudinal muscle (LM), a widely ignored structure, has until recently not been fully recognized by anal endosonography. The aim of this study, therefore, was to accurately determine the normal anatomy of the anal canal and correlate it with the findings obtained by anal endosonography. Eight postmortem specimens of the anal canal were examined by endosonography. The findings were correlated with macroscopical dissection and gross sectional histology of the same specimens. The external echogenic ring is composed of two anatomical structures: the LM and the external anal sphincter (EAS). However, during anal endosonography the LM cannot always be differentiated from the EAS. Histologically, the relation of the diameters of the LM and the EAS ranged from 0.45:1 to 1.25:1. The narrow hyperechogenic ring between the inner hypoechoic layer and the external hyperechoic ring is an artificial finding that cannot be related to a distinct anatomical structure and most likely represents a sonographic interface. This study exactly outlines the relation of diameters of the conjoined longitudinal muscle and external anal sphincter for the first time. Until now, the LM has been underestimated in its dimensions. The role of such a thick muscular structure should be included in the conception of anal continence in the future. Especially in view of the fact that anal endosonography is increasingly used in the diagnostic workup of incontinence and fistula in ano, it is essential to understand the anatomical basis of endosonography. This study accurately delineates the sonomorphology of the anal muscles. When viewed in light findings reported here, endosonographic findings in diseases of the anal canal are nor based on a correct idea of the correlation between endosonomorphology and anal anatomy.

Embryonic loss in mares: Incidence and ultrasonic morphology

Pregnancy was determined by ultrasound on Days 11, 15, 20, 25, 30, 35, 40, 45, and 50 in 154 ponies and 27 horses. In ponies, the embryonic loss rate for Days 11 to 15 ( 28 154 , 18.2%) was greater (P<0.01) than for any of the subsequent five-day intervals (0% to 3.3%). There were no losses during Days 11 to 15 in horses ( 0 27 ), and the difference between ponies and horses was significant. The loss rates for the seven periods encompassing Days 15 to 50 were not significantly different among periods. Pseudopregnancy occurred more frequently (P<0.01) following embryonic loss after Day 20 (Days 11 to 15, 26%; Days 15 to 20, 33%; after Day 20, 100%). Embryonic vesicles that were lost during Days 11 to 15 were smaller on the average than control vesicles. However, most of the vesicles grew at an apparently normal rate. Two of five vesicles that were lost between Days 15 and 20 and three of four that were lost between Days 20 and 25 were undersized during preceding examinations. Undersized vesicles were found during 13 415 (3%) examinations during Days 11 to 20 in mares that maintained the embryo and in 21 106 (20%) in mares that lost the embryo. Embryonic vesicles that were lost during Days 11 to 15 usually disappeared without previous indications, except in three mares in which the vesicle was floating in a small collection of fluid. Ultrasonic indications of impending loss at later stages included failure of fixation, an echogenic ring (vesicle) or mass floating in a collection of fluid, an echogenic area in the dead embryo, absence of heart beat, and a gradual decrease in volume of placental fluids with disorganization of the placental membranes. The solid remnants and at least some of the fluids resulting from late embryonic and early fetal death were retained sometimes for weeks or months until the debris was apparently expelled through an open cervix.