Specific Sonographic Findings Research Articles

Ultrasound imaging in crystal arthropathies: a pictorial review.

The prevalence of crystal arthropathies in the general population is rising. The purpose of this pictorial study is to describe the sonographic elements of the most prevalent crystal arthropathies by emphasizing particular sonographic findings using illustrative images and cases while considering technical details and common pitfalls. Using established recommendations, specialists in the fields of sonography and crystal arthropathies agreed by consensus on the unique ultrasound signs associated with each of the conditions. Gout, calcium pyrophosphate deposition arthropathy, and hydroxyapatite arthropathy are the three most prevalent crystal arthropathies. Today's high-resolution sonography enables reliable evaluation of the underlying crystal deposits, post-inflammatory changes, and a precise description of joint inflammation. High-prevalence crystal arthropathies are reliably detectable by ultrasound with current ultrasound equipment. It is necessary to have extensive ultrasound training, know specific sonographic findings, and understand all possible differential diagnoses for disorders affecting the musculoskeletal system.

Sonographic Predictors of Ovarian Torsion in Premenarchal Girls

To identify preoperative transabdominal sonographic predictors of surgically confirmed ovarian torsion (OT) in premenarchal girls METHODS: We conducted a retrospective case-control study of 32 premenarchal girls aged 0-12 undergoing surgery for OT (cases) or a non-torsed ovarian mass (controls) from 2006 to 2017 at a single academic center. Cases had ICD-9/10 codes for torsion of the ovary, adnexa, ovarian pedicle, or fallopian tube and surgically confirmed OT; controls had codes for ovarian mass or cyst and surgically confirmed absence of OT. Preoperative transabdominal ultrasounds were analyzed by 3 radiologists blinded to final diagnosis. We used χ2, Fisher[s exact, and Student's t tests for statistical comparisons. From 2016 to 2017, 32 patients presented with acute abdominal pain or symptoms concerning for ovarian mass requiring ultrasound imaging and subsequent diagnostic laparoscopy; 24 (75.0%) had confirmed OT by laparoscopy, and 8 (25.0%) did not. The mean age in both groups was similar (7.3±2.9 years). Preoperative sonographic variables significantly associated with OT included presence of a simple cyst (20.8% vs 12.5%), ovarian heterogeneity (100% vs 12.5%), presence of peripheralized follicles (70.8% vs 0%), and asymmetry of color Doppler (75.0% vs 37.5%; all P < .05). Presence of free fluid, arterial color Doppler, and a whirlpool sign were not predictive of OT. In premenarchal patients, although certain variables on transabdominal sonography predicted surgically confirmed OT, only the presence of peripheralized follicles was unique to girls with OT. The decision to proceed with diagnostic laparoscopy for suspected OT can be aided by these specific sonographic findings but should ultimately be based on high clinical suspicion.

The Prognostic Value of Ultrasound Findings in Preoperatively Distinguishing between Uncomplicated and Complicated Types of Pediatric Acute Appendicitis Based on Correlation with Intraoperative and Histopathological Findings.

Objective: This study compares the preoperative ultrasound findings of all children with a clinical picture of acute appendicitis on the basis of intraoperative and histopathological findings to assess the feasibility of this approach in preoperatively distinguishing between uncomplicated and complicated cases. Methods: This retrospective study includes 224 pediatric patients who underwent ultrasound prior to appendectomy at our institution between January 2016 and February 2022. Logistic regression analysis was used to investigate the association between sonographic and intraoperative histopathological findings. Results: Of the 224 participants, 61.1% were intraoperatively diagnosed with uncomplicated appendicitis (59.8% male). Multivariate logistic regression analysis revealed that patients with a higher appendiceal diameter, presence of appendicolith, and peritonitis were more likely to suffer from complicated appendicitis. Finally, the common anatomical position of the appendix and an appendiceal diameter greater than 6 mm had the highest sensitivity (94.6% and 94.5%, respectively) for predicting complicated appendicitis, with the most specific (99.3%) sonographic finding being the existence of an abscess. Conclusions: Preoperative abdominal ultrasound in children with a clinical diagnosis of acute appendicitis can distinguish between uncomplicated and complicated appendicitis in most cases of pediatric appendicitis. A higher appendiceal diameter, the presence of appendicolith, and peritonitis are parameters noted by ultrasound that strongly predict complicated appendicitis.

309 Sonograhic Appearances of Hobnail Thyroid Carcinoma: A Rare Tumour

Abstract Background Hobnail papillary thyroid carcinoma is a rare, recently described papillary thyroid carcinoma variant, with potential for a more aggressive clinical course of disease and poorer prognosis1. The ultrasound features of papillary thyroid carcinoma variants can differ from known traditional features1 and the specific sonographic findings of the hobnail variant itself have not been previously described in the literature. Case report A 53-year-old man presented with a left thyroid mass. The ultrasound features of this mass included a predominantly cystic appearance with mobile internal echoes, vascularised internal septations, and murally based solid material. These ultrasound features were deemed benign by classification standards, which led to the patient being managed with active surveillance and interval imaging. However, the mass grew quickly, and the patient underwent diagnostic hemithyroidectomy which led to hobnail variant papillary thyroid carcinoma being found on pathology. Given that papillary thyroid carcinoma variants can lead to aggressive disease, the patient underwent completion thyroidectomy and level VI lymph node clearance, on multidisciplinary team recommendation. Discussion The ultrasound features of the hobnail variant of papillary thyroid carcinoma have not been previously described in detail in the literature and, in this case, are features that would be deemed benign by classification standards. The rapid growth of the mass is what led to clinical suspicion of malignancy and resulted in diagnosis. Therefore, careful clinical correlation is advised in order to discern this difficult diagnosis and to facilitate appropriate treatment.

Incidence of Ectopic Pregnancy and its Diagnostic Accuracy by Clinical, Ultrasound and Intraoperative Findings

Introduction: In an ectopic pregnancy, most patients present with 5 to 9 weeks of amenorrhea, mild pelvic pain and vaginal spotting which triggers the evaluation of ectopic pregnancy. The presence of an extrauterine gestational sac containing a yolk sac or embryo is the most specific sonographic finding whereas an echogenic tubal ring in the adnexa is the most common finding.1 This study aimed to find the accuracy of ultrasound findings versus clinical presentation, intraoperative findings and histological findings. Methods: This is a retrospective study. All patients with histopathological diagnoses of ectopic pregnancy were included in the study and data regarding clinical diagnosis, ultrasound diagnosis and intraoperative diagnosis were retrieved and compared with their histopathological diagnosis. Result: There were 216 cases of ectopic pregnancy with an overall incidence of ectopic pregnancy was 0.88%. The sensitivity with ultrasound diagnosis was 99.52% and specificity 11.11% with positive and negative predictive values were 96.2 % and 50 % respectively and overall diagnostic accuracy of 95.83%. The sensitivity was 97.6% and specificity was 11.1% for clinical diagnosis of ectopic pregnancy. The sensitivity was 100% for intraoperative diagnosis of ectopic pregnancy with a positive predictive value is 95.83%. Conclusion: Clinical diagnosis, intraoperative findings and ultrasound findings were highly sensitive to detecting ectopic pregnancy in the study population. The overall diagnostic accuracy was highest for the ultrasound finding.

Compound heterozygous variants in DYNC2H1 in a foetus with type III short rib-polydactyly syndrome and situs inversus totalis

BackgroundShort-rib thoracic dysplasia 3 with or without polydactyly (SRTD3, OMIM: 613091) is an autosomal recessive disorder. SRTD3 presents clinically with a narrow thorax, short ribs, shortened tubular bones, and acetabular roof abnormalities. Clinical signs of SRTD3 vary among individuals. Pathogenic variants of DYNC2H1 (OMIM: 603297) have been reported to cause SRTD3.MethodsWe performed a detailed clinical prenatal sonographic characterization of a foetus with SRTD3. Trio whole-exome sequencing was used to identify causative variants in the family. The identified variants in the families were validated by Sanger sequencing and mass spectrometry. Multiple computational tools were used to predict the harmfulness of the two variants. A minigene splicing assay was carried out to evaluate the impact of the splice-site variant.ResultsWe evaluated prenatal sonographic images of the foetus with SRTD3, including abnormal rib curvature, narrow thorax, bilateral hypoplastic lungs, bilateral polydactyly, syndactyly, and foetal visceral situs inversus with mirror-image dextrocardia. We revealed novel compound variants of DYNC2H1 (NM_001377.3:c.11483T > G (p.Ile3828Arg) and c.2106 + 3A > T). Various statistical methods predicted that the variants would cause harmful effects on genes or gene products. The minigene assay findings suggested that c.2106 + 3A > T caused the skipping over exon 14, producing an exon 14 loss in the protein.ConclusionThis study identified a foetus with SRTD3 with situs inversus totalis with mirror-image dextrocardia in a Chinese family, revealing two novel compound heterozygous dynein cytoplasmic 2 heavy chain 1 (DYNC2H1) variants, expanding the phenotypic spectrum of SRTD3. The minigene study of c.2106 + 3A > T was predicted to cause an inframe exclusion of exon 14, which was predicted to have important molecular functions. Our findings strongly supported the use of WES in prenatal diagnosis and helped to understand the correlation of genotype and phenotypes of DYNC2H1. The specific sonographic findings and the molecular diagnosis helped add experience to further our expertise in prenatal counselling for SRTD3.

Significance of Follow-Up Ultrasonography 24 Hours Post-Reduction in Detecting Intussusception Recurrence.

PurposeThe objective of this study was to identify the significance of 24-hour post-reduction ultrasonography (US) in pediatric patients with intussusception.MethodsA total of 229 patients with intussusception who were treated with saline reduction at Severance Children’s Hospital between January 2014 and September 2020 were retrospectively reviewed. The 229 patients with successful saline reduction were divided into two groups: a recurrence at 24 hours group (R, n=41) and a non-recurrence group (NR, n=188). The full patient sample was divided into two groups: follow-up US (FU) or no follow-up US (NFU); the recurrence group was divided into follow-up (R-FU) and non-follow-up (R-NFU) subgroups, and stratified analyses were performed.ResultsThere were no significant differences in age, sex, laboratory findings, symptoms, and sonographic findings between the NR and R groups. In the R group, 24 patients underwent follow-up US, and 17 patients did not. Specific sonographic findings were statistically significant in the R-FU group compared to the R-NFU group (p=0.002). The R-FU group had fewer admissions (p=0.012) and longer mean hospitalization times (p<0.001) than the R-NFU group. The NFU group had a 12.2% recurrence rate, while the R-FU group recurrence rate was 25.8% (p=0.0099), suggesting that the omission of some recurrent events and follow-up US was a significant variable in the recurrence of intussusception. The median time to recurrence was 21 hours which supports the 24-hour follow-up protocol.ConclusionTwenty-four-hour follow-up US was shown to be valuable for detecting early recurrence of intussusception.

The correlation between endometrial thickness and the criteria for MTX treatment for ectopic pregnancy

Ectopic pregnancy (EP) occurs in approximately 2% of all pregnancies. A common method of treatment is methotrexate therapy, considered in haemodynamically stable patients. Endometrial thickness has been investigated as a tool for diagnosing EP. The objective of this study was to evaluate the association between endometrial thickness and the criteria for MTX treatment, in an attempt to facilitate outcome prediction. We retrospectively collected data from records of patients diagnosed with EP between 2012 and 2014 including information regarding the mode of treatment and outcome. The endometrial thickness was compared between cases that met the criteria for MTX treatment and those who did not. Of 267 cases of EP that were reviewed, 108 patients were treated with MTX. The MTX treatment success rate was 88%. Endometrial thickness was found to be significantly and inversely associated with criteria for MTX treatment. In conclusion, an association was found between the endometrial thickness and the criteria for selection of MTX treatment for EP. This may be a useful tool in treatment selection for EP. Impact Statement What is already known on this subject? Transvaginal sonography along with β-human chorionic gonadotrophin (β-hCG) monitoring is the standard for evaluation of suspected ectopic pregnancy (EP). The most specific sonographic finding for EP is the presence of a live extra uterine pregnancy. In research conducted with the purpose of finding intrauterine sonographic findings associated with EP, this condition has been shown to be correlated with a thinner endometrial lining, compared with that of an intrauterine pregnancy. What the results of this study add? The results of this study add information on the subject of methotrexate treatment success rates in correlation with the endometrial thickness. What the implications are of these findings for clinical practice and/or further research? The findings of this study contribute to the process of treatment selection for ectopic pregnancy by emphasising the association between a thick endometrium and the lower success rates of MTX treatment.

Key Features on the 3-Vessel View and 3-Vessel Tracheal View of Isolated Right Aortic Arch Anomalies.

Right aortic arch anomalies are a spectrum of malformations that include right aortic arch with mirror image branching, right aortic arch with an aberrant left subclavian artery, and double aortic arch. Although these are rare anomalies, they are of importance as they form vascular rings, which can cause symptoms in the newborn period. These anomalies are not detected with routine cardiac views, and it is only with the 3-vessel, and the 3-vessel tracheal view that they can be identified and characterized. We describe specific sonographic findings of these anomalies on the 3-vessel and the 3-vessel tracheal view.

Laterality of Single Umbilical Arteries and Associated Fetal Anomalies [05OP

INTRODUCTION: Studies have suggested that single umbilical artery (SUA) is associated with adverse obstetric outcomes including growth abnormalities and congenital anomalies. The objective of this study was to determine if laterality of a single umbilical artery (SUA) is associated with specific sonographic findings or other abnormalities. METHODS: In this retrospective cohort study, medical records of patients who received an ultrasound at the Johns Hopkins Hospital with identified laterality of the SUA from 1990 to 2017 were reviewed after IRB approval. The primary outcome was the association of isolated left or right SUA with other congenital anomalies. Secondary outcomes included laterality association with intrauterine growth restriction (IUGR) and chromosomal abnormalities. Rates of sonographic abnormalities between fetuses with a right versus left SUA were compared. Multivariate marginal logistic and Poisson regression models were used to investigate the relationship between SUA and IUGR, adjusting for possible confounders. Further analyses were done using propensity score matching. RESULTS: Left SUA fetuses had a higher percentage of other fetal abnormalities (51.1% vs. 37.0%; P=0.04). In a multivariate marginal logistic regression analysis, a sonographic left SUA was significantly associated with cardiovascular (aOR 0.43, 95% CI 0.23-0.79; P=0.03) and gastrointestinal (aOR 0.43, 95% CI 0.23-0.79; P=0.03) abnormalities. No other ultrasonographic, doppler, or chromosomal abnormalities were significantly associated with a laterality of the umbilical artery. CONCLUSION: Our study identified a significant association between a left SUA and concomitant fetal cardiac and gastrointestinal abnormalities. Laterality of the SUA may be useful in identifying concomitant fetal anomalies, but requires further prospective validation.

The prediction of Bethesda category of thyroid nodule with specific sonographic findings

The prediction of Bethesda category of thyroid nodule with specific sonographic findings

Sagging peribursal fat sign as a highly specific sonographic finding to diagnose full-thickness supraspinatus tendon tear

Diagnosing a chronic full-thickness supraspinatus tendon tear using ultrasound is challenging because tendon defects are usually obliterated with fibrous tissues, mimicking continuity of tendon. Among many direct and indirect ultrasonographic signs for full-thickness supraspinatus tendon tears, diagnostic values of indirect signs, especially sagging peribursal fat sign (SPFS), have been undervalued. To investigate whether the presence of SPFS would be suggestive of a full-thickness tear, the sensitivity, specificity and predictive value of SPFS were analyzed by regarding arthrosonography as a standard reference. Hundred and four patients with shoulder pain for more than 3 months, who underwent arthrosonography under the suspicion of full-thickness supraspinatus tendon tear were included. Suspicion of full-thickness tear was determined by substantial loss (> 50% of thickness) of fibrillary patterns in either the bursal or articular side with more than one of four indirect signs such as long biceps tendon sheath swelling, cortical irregularity, double cortex sign and SPFS. Patients with obvious tendon defect were excluded because diagnosis is too obvious to consider indirect sings. Arthrosonography was done by injecting 20 ml of fluid into the glenohumeral joint capsule followed by careful sonographic evaluation on the subacromial subdeltoid bursal space to find any fluid leaking, which would confirm the existence of true full-thickness tear, serving as a communication channel between the joint capsule and superficial space overlying the rotator cuff tendons. The SPFS was the most sensitive (88.4%) and specific (98%) to diagnose full-thickness tear among the indirect signs. When SPFS was combined with other indirect signs such as biceps tendon sheath swelling, cortical irregularity of humeral head, double cortex sign, the specificity and positive predictive value reached up to 100%. These results highlight that SPFS can be served as a strong evidence of full-thickness supraspinatus tendon tear.

The Accuracy of Point-of-Care Ultrasound in Detecting Small Bowel Obstruction in Emergency Department.

Radiological imaging plays an essential role in the evaluation of a patient with suspected small bowel obstruction (SBO). In a few studies, point-of-care ultrasound (POCUS) has been utilized as a primary imaging modality in patients with suspected SBO. POCUS has been shown to be an accurate tool in the diagnosis of SBO with multiple research studies noting a consistent high sensitivity with a range of 94–100% and specificity of 81–100%. Specific sonographic findings that increase the likelihood of SBO include dilatation of small bowel loops > 25 mm, altered intestinal peristalsis, increased thickness of the bowel wall, and intraperitoneal fluid accumulation. Studies also reported that emergency physicians could apply this technique with limited and short-term ultrasound training. In this article, we aim to review the sensitivity and specificity of ultrasound examinations performed by emergency physicians in patients with suspected SBO.

OP13.11: Placental mesenchymal dysplasia: four cases

We report prenatal diagnosis of four cases with placental mesenchymal dysplasia (PMD) and review of literature. Case 1: Primigravida of 15 weeks was referred for abnormal-appearing cystic placenta on ultrasound scanning, with hypoechoic areas. Normal fetal Doppler, and abnormal maternal Doppler. We diagnosed PMD and indicated treatment with heparin and aspirin. During third trimester intrauterine growth restriction (IUGR) was found. Caesarean section was performed at 38 w, new born was IUGR fetus. Placental pathology showed PMD. Case 2: Multiparous was sent because abnormal placental cyst. Normal fetal Doppler, abnormal maternal Doppler. PMD was diagnosed, heparin and aspirin were indicated. At 24 w, fetal mesenchymal tumours were found in liver, suprarenal and abdomen, showing an accelerated growth, with normal fetal Doppler. A decrease in fetal movements was objectified at 28 w. and finally at 29 w, fetal was death. Placental pathology showed PMD. Case 3: Primigravida of 21 w. referred with diagnosis of IUGR and partial mole. Fetus had absent diastolic flow in umbilical artery, abnormal maternal Doppler, normal ACM, multiple cystic images in placenta and HCG-B within normal values. With this findings, PMD was diagnosed. She started treatment with heparin and aspirin. At 34 w, pregnancy had to be finished due rupture of membranes, obtaining an IUGR fetus. Placental pathology showed PMD. Case 4: Patient of 23 weeks of pregnancy, obese, with normal fetus, placenta with multiple cystic images and abnormal maternal Doppler, aspirin was started. At 29 w. she presented headache, proteinuria, high blood pressure, and death. Placental pathology showed PMD. Conclusion: PMD is a rare placental disease. There are multiple theories, but the exact etiology of PMD is unclear. PMD is frequently misdiagnosis and have poor pregnancy outcome. Diagnosis should be considered with specific sonographic findings, including enlarged, cystic placenta with dilated chorionic vessels.

The Tail and the String Sign: New Sonographic Features of Subcutaneous Melanoma Metastasis

No highly specific sonographic imaging findings to evaluate melanoma spread along the lymphatic vessels have ever been described. Between January 2009 and December 2012, a consecutive group of 531 melanoma patients at their initial stage or during follow-up for nodal or extra-nodal superficial metastasis were evaluated retrospectively to assess the presence of two sonographic findings demonstrating superficial lymphatic metastasis: a “tail” sign (a thin hypoechoic prolongation from one or both poles of a superficial metastasis) and a “string” sign (multiple in-transit lesions connected to each other in a rosary image). The total number of superficial metastatic lesions was 222. The tail sign was seen in 13 of the 222 lesions (5.9%). The string sign was detected in four patients (4.5%). These signs showed a low sensitivity with a very high specificity (100%). Tail and string signs may represent an additional finding of high specificity to be employed in the differential diagnosis of melanoma patients.

Make it SIMPLE: enhanced shock management by focused cardiac ultrasound.

BackgroundShock is a spectrum of circulatory failure that, if not properly managed, would lead to high mortality. Special diagnostic and treatment strategies are essential to save lives. However, clinical and laboratory findings are always non-specific, resulting in clinical dilemmas.Main contentFocused cardiac ultrasound (FoCUS) has emerged as one of the power tools for clinicians to answer simple clinical questions and guide subsequent management in hypotensive patients. This article will review the development and utility of FoCUS in different types of shock. The sonographic features and ultrasound enhanced management of hypotensive patients by a de novo “SIMPLE” approach will be described. Current evidence on FoCUS will also be reviewed.ConclusionFocused cardiac ultrasound provides timely and valuable information for the evaluation of shock. It helps to improve the diagnostic accuracy, narrow the possible differential diagnoses, and guide specific management. SIMPLE is an easy-to-remember mnemonic for non-cardiologists or novice clinical sonographers to apply FoCUS and interpret the specific sonographic findings when evaluating patients in shock.

Sonographic and Endoscopic Findings in Cocaine-Induced Ischemic Colitis.

Cocaine-induced ischemic colitis is a recognized entity. The diagnosis is based on clinical and endoscopic findings. However, diagnostic imaging is helpful in the evaluation of abdominal symptoms and prior studies have suggested specific sonographic findings in ischemic colitis. We report sonographic and endoscopic images along with abdominal computed tomography in a case of cocaine-induced ischemic colitis.

Simplifying the Ultrasound Findings of the Major Fetal Chromosomal Aneuploidies

Sonographic aneuploidy markers and structural anomalies associated with the 5 most common chromosomal aneuploidies are organized and simplified to highlight the many sonographic findings that are commonly seen with each aneuploidy. Identification of these findings allows families to have the option to pursue prenatal genetic testing to confirm or exclude chromosomal abnormalities suggested by such prenatal ultrasound findings and make informed decisions about the subsequent management of their pregnancy. We review the most common major human chromosomal aneuploidies, including trisomies 21, 18, and 13; Turner syndrome; and triploidy. The focus is on the major structural anomalies seen with each of these, as well as ultrasound markers (findings associated with increased risk of chromosomal abnormality but also seen in normal fetuses). The role of clinical information such as maternal serum screening and new cell-free fetal DNA screening is also reviewed. As patients do not usually present for fetal ultrasound with a known diagnosis, a concise knowledge of ultrasound and clinical findings will alert radiologists to concerning cases and prompt a guided search for important associated anomalies. Fetal ultrasound can be challenging owing to the many findings and sometimes technically difficult evaluation. By simplifying the ultrasound findings seen with the major chromosomal abnormalities and highlighting the role of clinical history, we hope that an informed search for specific sonographic findings can be performed; thereby, reducing missed diagnoses.

Single Umbilical Artery: Does Side Matter?

Introduction: The aim of this study was to determine if laterality of an absent umbilical artery (AUA) is associated with specific sonographic findings, chromosomal defects or postpartum birth defects. Materials and Methods: In this retrospective cohort study, ultrasound reports and medical records of patients who received an obstetric ultrasound at the University of Iowa Hospitals and Clinics with an identified laterality of the AUA from 1989 to 2007 (n = 405) were reviewed. Rates of sonographic abnormalities between fetuses with a right versus left AUA were compared using Fisher’s exact test. Adjustments for confounding were made using logistic regression modeling. The significance level was set at 0.05. Results: Right AUAs on ultrasound demonstrate higher unadjusted rates of ultrasound abnormalities with a higher percentage of fetuses with >1 additional abnormality (51.1 vs. 37.0%; p = 0.0043). The left AUA group had a significantly higher percentage of isolated AUA (63.0 vs. 48.8%; p = 0.004). In a multivariate analysis, a sonographic right AUA was significantly associated with gastrointestinal (GI) and genitourinary (GU) abnormalities. No other ultrasonographic and umbilical artery Doppler abnormalities, chromosomal defects or postpartum birth defects were significantly associated with a specific laterality of the AUA. Discussion: Our study identified a significant association between a right AUA and concomitant fetal GI and GU abnormalities. Contrary to previous reports, we conclude that laterality of the AUA may prove to be an easily identified early marker of fetal abnormalities.

Color Doppler Twinkling Artifacts in Small-Bowel Bezoars

Small-bowel bezoars usually form in the stomach and may subsequently cause small-bowel obstruction. Bezoars associated with small-bowel obstruction have been accurately diagnosed by computed tomography, although some case reports have described the specific sonographic findings of small-bowel bezoars. Bezoars can be overlooked by sonographic examination if a dilated small-bowel loop contains a large amount of air. Twinkling artifacts on color Doppler images appear as rapidly fluctuating red and blue signals behind certain strongly reflecting structures. In this series, we hypothesize that twinkling artifacts might appear in small-bowel bezoars, and we describe the presence of twinkling artifacts in 3 cases of small-bowel bezoars presenting as small-bowel obstruction.