Specific Sonographic Findings Research Articles

Appendicitis in the Deep Pelvis

Sonography is an excellent tool to identify the appendix in patients with abdominal pain. If a normal appendix is identified, then a search for alternative pathology can be pursued. Identifying the appendix can be challenging: the location varies, overlying bowel gas interferes, and patient size can affect the resolution. Specific sonographic findings can help identify when an appendix is inflamed. A positive appendicitis may present with varying sonographic characteristics, and the tip of the appendix may present in atypical locations. The classic location of the appendix originates off the cecum with the tip draping over the iliac vessels in the right lower quadrant. This case report describes a case of appendicitis in the deep pelvis. Sonography of the appendix bears enormous responsibility and, when done correctly, may still require clinical corroboration.

Ultrasonography by emergency medicine and radiology residents for the diagnosis of small bowel obstruction

Our objective was to study the accuracy of emergency medicine [(EM) bedside ultrasonography (BUS)] and radiology residents performed ultrasonography (RUS) in patients with suspected mechanical small bowel obstruction (SBO). After a 6-h training program, from January to June 2009, four EM residents used BUS to prospectively evaluate the patients presenting to the emergency department with suspected SBO. Then, patients underwent RUS. Outcome was determined by surgical findings if they were operated upon or self-reported the condition upon telephone follow-up at 1-month. BUS and RUS results were compared with chi2 testing. Of the 174 enrolled patients, 90 patients were BUS-positive. Of these, surgical findings agreed with the BUS findings in 84 patients. In 78 cases, BUS was negative, and 76 of these patients had benign clinical courses. Six patients were excluded from the study. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio for BUS were 97.7, 92.7, 93.3, 97.4, and 13.4%, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value for RUS were 88.4, 100, 100, and 89.1%, respectively. The diagnostic accuracy of BUS and RUS were not statistically different from each other (kappa=0.81). The presence of dilated small bowel loops (>25 mm in jejunum or >15 mm in ileum) was the most sensitive (94%) and specific (94%) sonographic finding for SBO. Abdominal sonography for the diagnosis of SBO is a new application of BUS in the emergency department. EM residents can diagnose SBO using BUS with a high-degree of accuracy, comparable with that of radiology residents.

Sonographic evaluation of pediatric localized scleroderma: preliminary disease assessment measures

BackgroundOur earlier work in the ultrasonograpy of localized scleroderma (LS) suggests that altered levels of echogenicity and vascularity can be associated with disease activity. Utrasound is clinically benign and readily available, but can be limited by operator dependence. We present our efforts to standardize image acquisition and interpretation of pediatric LS to better evaluate the correlation between specific sonographic findings and disease activity.MethodsSeveral meetings have been held among our multi-center group (LOCUS) to work towards standardizing sonographic technique and image interpretation. Demonstration and experience in image acquisition were conducted at workshop meetings. Following meetings in 2007, an ultrasound measure was developed to standardize evaluation of differences in echogenicity and vascularity. Based upon our initial observations, we have labeled this an ultrasound disease activity measure. This preliminary measure was subsequently evaluated on over 180 scans of pediatric LS lesions. This review suggested that scoring levels should be expanded to better capture the range of observed differences. The revised levels and their definitions were formulated at a February 2009 workshop meeting. We have also developed assessments for scoring changes in tissue thickness and lesion size to better determine if these parameters aid evaluation of disease state.ResultsWe have standardized our protocol for acquiring ultrasound images of pediatric LS lesions. A wide range of sonographic differences has been seen in the dermis, hypodermis, and deep tissue layers of active lesions. Preliminary ultrasound assessments have been generated. The disease activity measure scores for altered levels of echogenicity and vascularity in the lesion, and other assessments score for differences in lesion tissue layer thickness and changes in lesion size.ConclusionsWe describe the range of sonographic differences found in pediatric LS, and present our efforts to standardize ultrasound acquisition and image interpretation for this disease. We present ultrasound measures that may aid evaluation of disease state. These assessments should be considered a work in progress, whose purpose is to facilitate further study in this area. More studies are needed to assess their validity and reliability.

CAN SONOGRAPHIC FINDINGS PREDICT THE RESULTS OF LIVER ASPIRATES IN DOGS WITH SUSPECTED LIVER DISEASE?

While abdominal ultrasound and ultrasound-guided fine-needle aspiration cytology are often combined to help determine the type of liver disease in dogs, little is known about the relationship that may exist between the results of these tests. We hypothesized that specific sonographic findings, or combinations of findings, may predict results of liver ultrasound-guided fine-needle aspiration cytology. Hepatic and extrahepatic sonographic findings were recorded prospectively using a standardized form in 70 dogs with clinically suspected liver disease and in which liver ultrasound-guided fine-needle aspiration cytology was performed. The predictive value of sonographic findings in regard to the category of cytology results was assessed with stepwise logistic regression analysis. Sonographic detection of a hepatic mass (> or = 3cm; risk ratio [RR] 3.83, 95% Wald confidence intervals [95% CI] 2.42-3.93, P = 0.0036), ascites (RR 3.82, 95% CI 1.94-4.28, P = 0.0044), abnormal hepatic lymph node(s) (RR 3.01, 95% CI 1.22-4.88, P= 0.0262), and abnormal spleen (RR 3.26, 95% CI 1.20-3.85, P = 0.0274) were the most predictive of liver neoplasia on cytology. Conversely, sonographic detection of hepatic nodules (< 3cm; RR 1.97, 95% CI 0.95-2.96, P = 0.0666) was most predictive of vacuolar hepatopathy on cytology. In dogs with suspected liver disease, several sonographic findings, alone or combined, are thus predictive of liver ultrasound-guided fine-needle aspiration cytology results. In the light of the fact that ultrasound-guided fine-needle aspiration cytology of the liver has limitations, these predictabilities could influence the selection of diagnostic tests to reach a reliable diagnosis.

Prenatal imaging findings in rapidly involuting congenital hemangioma of the skull

We report two cases of rapidly involuting congenital hemangioma (RICH) of the skull diagnosed in the third trimester of gestation, and also present a brief review of the literature. In both of our cases ultrasound examination showed a soft tissue vascular mass of the skull with a specific sonographic finding: a thin hyperechogenic line over the lesion and continuous with the calvaria, suggesting a subperiosteal origin and possibly accounting for a mass effect on the underlying skull. This was slight in one case and marked in the other (and associated with involvement of the calvaria). On prenatal T2-weighted magnetic resonance imaging, the signal of each of the lesions was less marked than the hypersignal encountered in the postnatal period. Postnatal clinical and radiological follow-up over the first few months after delivery confirmed the diagnosis of RICH in each case by demonstrating a significant decrease in the size of the tumor and regression of the vascular component, with complete involution of the lesion within a year.

Presence of Cell-Free Fetal DNA in Plasma of Women with Ectopic Pregnancies,

The quantity of cell-free fetal DNA in the plasma of pregnant women changes during pregnancy and seems to be different in normal and pathologic pregnancies. We investigated the possible diagnostic applications of the detection and measurement of cell-free fetal DNA by comparing quantities found in women with ectopic (EP) or intrauterine (IUP) pregnancies. We collected blood samples from 58 women who had positive pregnancy tests and specific complaints and sonographic findings suggestive of EP and from 45 women with confirmed IUP. We performed quantitative real-time PCR analysis of the sex-determining region Y (SRY) gene to detect and measure the amount of cell-free fetal DNA. The diagnosis of EP was confirmed by histologic examination. SRY was detected in 15 EP and 14 IUP cases. The mean (SD) amount of cell-free fetal DNA was significantly higher (P<0.005) in women with EP [565 (136) genome-equivalents (GE)/mL] than in women with IUP [72 (19) GE/mL] at the same gestational age. Our results confirm that cell-free fetal DNA is present in plasma of women with EP. The finding of higher amounts of cell-free fetal DNA in EP cases than in IUP cases suggests that this method might be useful for early diagnosis of EP.

Ischiopagus conjoined twins at 9 weeks of gestation: three‐dimensional ultrasound and power Doppler findings

The incidence of conjoined twins is estimated to range from 1 in 50 000 to 1 in 100 000 births1. The most common types of conjoined twins are thoracopagus, omphalopagus and thoraco-omphalopagus1. Only about 12% are of the ischiopagus variety2, which refer to twins joined at the level of the ischium. A 30-year-old woman, gravida 2, para 1, was seen at our antenatal clinic during her 9th week of pregnancy. She denied exposure to ovulation medication prior to conception. Two-dimensional (2D) ultrasonography revealed monoamniotic twins lying face-to-face, one yolk sac (Figure 1) and two separate cardiac pulsations. The embryos were fused at the lower part of the trunk and were suspected to be twins conjoined at the level of the pelvis. Subsequently, a three-dimensional (3D) volume dataset of the embryos was acquired using transvaginal ultrasonography with power Doppler (Voluson 730 Expert, GE Medical Systems, Milwaukee, WI, USA). Vascular communication between the conjoined twins in the pubic area was accurately delineated (Figure 2). A volume dataset was acquired in the sagittal plane for subsequent analysis. The multiplanar views and surface-rendered images of the embryos were obtained to precisely delineate the level of fusion, connecting vessels and fetal contour (Figure 3). One week later, repeat scans by 3D transvaginal ultrasonography confirmed the diagnosis of conjoined twins. After counseling, the patient opted to terminate the pregnancy. After evacuation, two separate bodies and two separate upper and lower extremities were noted. The location of the conjoined site could not be identified on gross inspection of the abortus because the embryos had been destroyed during the evacuation procedure. Transvaginal two-dimensional sonography showing a single gestational sac, one yolk sac and conjoined twins lying in a mirror-image-like position. Vascular communication between the twins. This image was obtained by multiplanar analysis of the three-dimensional volume dataset acquired by transvaginal ultrasonography with power Doppler. Three-dimensional surface-rendered image showing ischiopagus twins with two normal heads, separate thorax and two separate upper and lower extremities. Early diagnosis of conjoined twins is crucial for determining subsequent management and possibly decreasing maternal morbidity (evacuation vs. hysterotomy). Specific sonographic findings of conjoined twins examined during the first trimester include inseparable fetal bodies despite manipulation of the uterus with a transvaginal probe or prolonged continuous scanning, bifid appearance of the embryo, single yolk sac3, and a single umbilical cord with more than three vessels. Recently, some reports4-8 have described early diagnosis of conjoined twins by 3D ultrasound imaging combined with power Doppler, computed tomography and magnetic resonance imaging. In this case, prenatal diagnosis of conjoined twins was established by transvaginal 2D ultrasonography and power Doppler. However, 3D imaging with surface-rendering provided clearer images of the characteristic features of ischiopagus twins and helped the parents to understand the complex anomalies present in their fetuses. Furthermore, it improved our diagnostic confidence to provide adequate early intervention. K.-H. Fang*, J.-L. Wu*, G.-P. Yeh* , P.-H. Chou*, J.-C. Hsu*, C. T.-C. Hsieh*, * Department of Obstetrics Gynecology, Changhua Christian Hospital, Changhua, Taiwan, Department of Obstetrics Gynecology, Chung-Shan Medical University, Taichung, Taiwan

Wandering spleen—the challenge of ultrasound diagnosis: Report of 7 cases

To summarize our experience with sonographic diagnosis of wandering spleen in children and assess for the typical sonographic findings of wandering spleen, complications, and possible diagnostic pitfalls. We identified all pediatric patients from 1998-2003 with a surgically confirmed diagnosis of wandering spleen. All sonographic examinations were reviewed for splenic position, size, echotexture, and parenchymal blood flow. Seven children were identified with a mean age of 9.7 years (range 4.2-15.3 years). All presented with abdominal pain. Abdominal sonography, performed in all children demonstrated a low position of the spleen (n = 6), splenomegaly (n = 4), and absence of parenchymal flow in the three patients with splenic torsion and infarction. The diagnosis was made preoperatively via sonography in five children; three required repeated hospital admissions before the correct diagnosis was established. Complications occurred in five patients (gastric obstruction [n = 1], splenic infarction [n = 3], and recurrent pancreatitis [n = 1]). The most specific sonographic finding for wandering spleen is low position of the spleen. However, if the spleen regains its normal or near-normal position, the diagnosis may be missed and the condition may recur, and result in complications.

Transvaginal sonography in the diagnosis of acute appendicitis.

To evaluate transvaginal sonography with power Doppler capacity in the diagnosis of acute appendicitis and in discriminating appendicitis from pelvic inflammatory disease. We describe transvaginal sonographic findings of six women with acute appendicitis selected from 31 women seen in an emergency room setting for clinically suspected pelvic inflammatory disease. The study population underwent gray-scale transvaginal sonography, and specific sonographic landmark findings for acute appendicitis and pelvic inflammatory disease were used. Hyperemia of any infectious complex was identified by power Doppler. Laparoscopy was performed after transvaginal sonography and was used as the gold standard. Laparoscopy showed acute appendicitis in six (19%) of the 31 patients. A thick walled non-compressible gas-containing tubular structure with a diameter exceeding 6 mm was seen by transvaginal sonography in four of the six cases, consistent with uncomplicated appendicitis. A heterogeneous complex with surrounding hyperechogenic soft tissue was seen in two cases with gangrenous appendicitis. Power Doppler detected hyperemia in all six cases. Normal adnexal structures were imaged next to the inflamed appendix. The sonographic criteria consistent with acute appendicitis were clearly different from those of acute pelvic inflammatory disease. Transvaginal sonography provides an opportunity to distinguish between appendicitis and acute pelvic inflammatory disease. Prospective trials are needed in order to evaluate the impact of transvaginal sonography in the diagnosis of acute appendicitis.

Transrectal ultrasound and biopsy in the early diagnosis of prostate cancer.

Historically, the prostate was evaluated for cancer by simple digital rectal examination, and biopsy to obtain a tissue diagnosis of cancer was performed blindly. The advent of ultrasound technology offered a new way to evaluate the prostate, and biopsy techniques were soon developed to incorporate ultrasound guidance. The authors review the role of transrectal ultrasound (TRUS) of the prostate and ultrasound-guided biopsy of the prostate in the diagnosis of prostate cancer. These techniques are traced from their origins to the current standards of care, with attention paid to developments and controversies in recent literature. Early experience with TRUS led to the description of "classic" sonographic findings of prostate cancer. To obtain a tissue diagnosis of cancer, these regions were initially targeted in ultrasound-guided biopsies. Concomitant with the development of TRUS, though, was the development of the prostate-specific antigen (PSA) assay. Over the past decade, there has been a profound stage migration due to earlier detection of prostate cancer. Most patients now diagnosed with prostate cancer have no palpable abnormality or specific sonographic findings. In response, ultrasound-guided biopsies have become more systematic, rather than lesion-specific, in nature. TRUS continues to play an important role in the evaluation of the prostate when malignancy is suspected. Although the optimal method of prostate biopsy is controversial, ultrasound is critical in ensuring accurate sampling of the gland.

Gray-scale sonographic evaluation of cervical lymphadenopathy in cat-scratch disease.

The aim of this study was to characterize the gray-scale sonographic findings in the lymph nodes of patients with cat-scratch disease (CSD). We analyzed the sonograms of cervical lymph nodes in 41 patients with proven CSD between January 1997 and October 1999. A total of 222 involved lymph nodes were detected. Involved nodes were most commonly found in the middle cervical (58%), parotid (37%), upper cervical (37%), and submandibular (17%) regions. We found acute, chronic, or abscessed lymphadenopathy in 63%, 12%, and 24% of patients, respectively. The size of involved lymph nodes ranged from 12 x 4 mm to 35 x 26 mm. The largest involved node had a short axis/long axis ratio of 0.5 or more in 61% of patients. Useful features for the differential diagnosis included markedly decreased echogenicity (100%), normal surrounding tissues (100%), and the presence of an echogenic hilum (76%). Posterior sound enhancement was significantly associated with larger and abscessed lymph nodes. Despite the absence of a specific sonographic finding for CSD, gray-scale sonography can provide clues to the diagnosis of CSD in the proper clinical setting.

"Daughter cyst" sign: a sonographic finding of ovarian cyst in neonates, infants, and young children.

The purpose of this study was to assess the value of the "daughter cyst" sign, a sonographic finding of neonatal ovarian cysts, in differentiating ovarian cysts from other cystic masses in neonates, infants, and young children. In a prospective study, 23 neonates, infants, and young children (age range, 1 day to 36 months) with a lower abdominal cystic mass underwent sonography. We defined the daughter cyst sign as the presence of a small cyst along the wall of a cystic mass. The diagnosis of ovarian cyst was made when this sign was present. Detailed pathologic correlation was available in four ovarian cysts. The size, wall thickness, and contents of the cysts were also evaluated. The 23 cystic lesions included ovarian cyst (n = 11), lymphangioma (n = 3), enteric duplication cyst (n = 3), enteric cyst (n = 1), meconium pseudocyst (n = 2), hydrometrocolpos (n = 2), and urachal cyst (n = 1). The daughter cyst sign was seen in nine (82%) of 11 ovarian cysts but in none of the other cystic lesions. Sensitivity, specificity, and positive predictive value of the daughter cyst sign for differentiating ovarian cysts from other cystic lesions were 82%, 100%, and 100%, respectively. The daughter cyst corresponded to an ovarian follicle on pathologic examination. The daughter cyst sign is a specific sonographic finding for an ovarian cyst and may be useful in differentiating uncomplicated ovarian cysts from other cystic masses in neonates, infants, and young children.

Portal hypertension in children and young adults: sonographic and color Doppler findings.

Portal hypertension is a relatively uncommon pathologic condition in children and young adults in contrast with older adults. The aim of this study is to evaluate the utility of sonography and color Doppler sonography in the diagnosis of portal hypertension in children and young patients and to evaluate the sonographic pattern of each disease. We reviewed 25 such patients who were younger than 30 years old and obtained the following sonographic findings: (1) liver cirrhosis: (a) multiple intrahepatic venovenous shunts in patients with primary Budd-Chiari syndrome and (b) intrahepatic vascular narrowing and nodular coarse parenchymal texture, with multiple very-high-echo spots along the portal vein in patients with Wilson disease; (2) congenital hepatic fibrosis: marked and developed collaterals, wide periportal echogenic band, and a heterogeneous parenchymal texture comprised of multiple high echoes but without portal thrombus; and (3) extrahepatic portal thrombosis: invisible portal lumen except as an echogenic band. Sonography and color Doppler sonography are very useful in diagnosing these portal hypertensive diseases. However, there are no specific sonographic findings, and the role of sonography is limited to follow-up observation of associated secondary hepatobiliary changes in patients with congenital biliary atresia.

Epidermoid cysts of testes and role of sonography

Four patients with histologically proved epidermoid cysts of the testicle were managed with radical orchiectomy. High-resolution testicular sonography demonstrated similar findings in all cases, but these findings were not specific and did not preclude other malignant or teratomatous lesions. The lack of both unique clinical features and specific sonographic findings would suggest that extreme caution must be used if wedge resection or enucleation is contemplated for a patient with presumed epidermoid cyst.

Three-dimensional imaging of solid breast tumors with ultrasound: preliminary data and analysis of its possible contribution to the understanding of the standard two-dimensional sonographic images.

Reconstructed three-dimensional sonographic images are presented from patients having different histological types of breast tumors. Scanning is manual and performed using two-dimensional annular array, sector transducers fitted on a mechanical arm, to provide spatial location. The three-dimensional data are displayed using two different modalities. Planar reformatted sections allow the visualization of planes reconstructed along any direction chosen by the operator. Of particular interest are the reconstructions obtained along equatorial planes of the tumors, i.e. planes parallel to the chest wall and, consequently, to the fibroglandular layer of the breast. Volume rendering is obtained using the shaded-surface visualization technique.Three-dimensional imaging provides new information and allows a better interpretation of the standard two-dimensional images. Planar reformatted sections confirm that ductal carcinomas present margin jagging on all views, including the equatorial section planes. Using the shaded-surface visualization technique, these tumors appear with a spiked outer surface. Thus, the most specific sonographic finding associated with ductal carcinomas may be that margin jagging extends over the entire periphery of the mass. On planar reformatted sections, benign tumors are surrounded by a continuous hyperechogenic rim, i.e. the rim is present irrespective of the section plane orientation. Medullary carcinomas are also surrounded by a hyperechogenic rim. However, a clearly distinctive feature of these lesions is found on planar reformatted sections: the rim is discontinuous on certain section planes. A mass can be considered benign only if its rim is continuous, i.e. if it is present all around the tumor.