FM sonography in diffuse liver disease: prospective assessment and blinded analysis

FM sonography - a signal-processing technique that uses frequency and phase information as well as amplitude data - shows promise in evaluation of patients with diffuse liver disease. In a prospective blinded review of 37 patients with biopsy-proved liver disease and 42 healthy volunteers, FM sonography was clearly superior to traditional amplitude-based (AM) sonography in distinguishing healthy from diseased subjects. Statistically significant differences were seen in accuracy (FM, 98.7%; AM, 84.8%), sensitivity (FM, 97.3%; AM, 70.3%), and negative predictive value (FM, 97.7%; AM, 78.8%). Our data also suggest that current FM sonographic techniques cannot differentiate among histologic findings associated with different hepatic parenchymal abnormalities. It is unclear, therefore, whether FM imaging can reduce the numbers of patients who require biopsy for diagnosis or the frequency of biopsy procedures in patients with known disease.     

Color flow Doppler characterization of focal hepatic lesions.

OBJECTIVE. The purpose of this study was to determine the sensitivity and specificity of color flow Doppler sonography for the specific diagnosis of focal hepatic lesions. SUBJECTS AND METHODS. Color flow Doppler images of 118 focal hepatic lesions in 108 patients were analyzed prospectively. In most patients, liver disease was suspected or known to be present before the Doppler images were obtained. Experienced sonologists obtained and interpreted all sonograms. The lesions were classified, according to their color flow pattern, into two main categories: lesions with internal vascularity and lesions with no internal vascularity. The color flow Doppler pattern of each lesion was correlated with the diagnosis of the lesion on a lesion-by-lesion basis. One hundred two lesions were proved by biopsy and 16 lesions were confirmed by evaluation with other imaging techniques. Lesions included 29 hepatocellular carcinomas, 64 metastases, one cholangiocarcinoma, and 24 benign lesions. The sensitivity and specificity of vascularity as shown by color Doppler imaging in the diagnosis of hepatocellular carcinoma were determined. RESULTS. The majority of hepatocellular carcinoma lesions (76%) had internal vascularity. Most of the metastases (67%) and benign lesions (75%) had no internal vascularity. When the presence of internal vascularity was used as the discriminating criterion, the sensitivity of color flow Doppler findings for the diagnosis of hepatocellular carcinoma was 0.76. The specificity of internal vascularity for the diagnosis of hepatocellular carcinoma vs other focal lesions was 0.69; for hepatocellular carcinoma vs metastases it was 0.67. CONCLUSION. Although most hepatocellular carcinomas have internal vascularity on color flow Doppler images, a significant number of metastases also have internal vascularity. This overlap limits the usefulness of color flow Doppler imaging for distinguishing hepatocellular carcinoma from metastatic tumors.     

Uncomplicated amebic liver abscess: prospective evaluation of percutaneous therapeutic aspiration.

The performance of therapeutic aspiration in the treatment of amebic liver abscess, advocated and practiced in many centers, is controversial. Previously, this practice has been evaluated in retrospective analyses. To test the potential benefit of therapeutic aspiration, the authors undertook a prospective randomized trial in 57 patients admitted for suspected amebic liver abscess during a 15-month period. Sixteen patients were excluded from the trial. The remaining 41 patients were randomly included in one of two study groups to receive amebicidal therapy alone or amebicidal therapy coupled with image-guided percutaneous therapeutic aspiration. All patients in the trial recovered. No statistically significant benefit was demonstrated in the aspiration group for the two objective parameters evaluated: length of hospitalization and duration of time to becoming afebrile. Subjective improvement in symptoms after aspiration was greater in the aspiration group at a marginally statistically significant level. These data do not support the adjunctive performance of percutaneous therapeutic aspiration in the treatment of uncomplicated amebic liver abscess. Amebicidals alone were equally efficacious in treating the group studied.     

Hepatic abscess

Hepatic abscess—amebic or pyogenic—can be diagnosed with great accuracy by either ultrasonography or computed tomographic (CT) scanning. Ultrasound is the modality of choice and will detect almost 100% of abscesses. Confirmation of a diagnosis of amebic liver abscess is made by the indirect hemagglutination test that should be positive in almost 100% of cases. Cultures of pus from the abscess and from the blood must be obtained in cases of pyogenic liver abscess. A positive culture of pus from the abscess has been achieved in 90% of cases. Ultrasound or CT guidance is utilized in aspiration of a hepatic abscess. In the treatment of an amebic liver abscess, metronidazole is the amebicide of choice. Open drainage is contraindicated. For cases that fail to respond to therapy with amebicides, closed drainage guided by CT or ultrasound is performed. Secondary bacterial infection of an amebic liver abscess is an extremely rare event. The identification and determination of the antibiotic sensitivity of organisms responsible for pyogenic liver abscess is a crucially important step. Unless a celiotomy is necessary to correct an intraabdominal process or the abscess is extremely large, the initial treatment of pyogenic liver abscess is a 2 week course of appropriate antibiotics followed by a 1 month course of oral antibiotics. The majority of pyogenic liver abscesses will respond to such treatment. If drainage of a pyogenic abscess is required, the preferable technique is with a percutaneous CT- or ultrasound-directed catheter. Open surgical drainage should be reserved for those cases in which a celiotomy is required for other purposes or for the patient who has failed a course of appropriate antibiotic therapy and closed percutaneous drainage is not feasible. The mortality for treatment of amebic liver abscess should be approximately zero and for pyogenic liver abscess should be less than 10%.

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Resumen El absceso hepático—amibiano o piogénico—puede ser diagnositicado con gran precisión mediante la ultrasonografía (US) o la tomografía computadorizada (TC). La ultrasonografía es la modalidad de escogencia; détecta casí el 100% de los abscesos. La confirmación del diagnóstico de absceso amibiano del hígado se hace por la prueba de hemaglutinación indirecta, la cual debe resultar positiva en prácticamente el 100% de los casos. Cultivos del pus y de la sangre deben ser realizados en los pacientes con abscesos piógenos. Se logran cultivos positivos del pus del absceso en 90% de los casos. Se utiliza la guía ultrasonográfica o de tomografía computadorizada para la aspiración del absceso.El metronidazol es el agente amebicida de preferencia en el tratamiento del absceso amibiano del hígado. El drenaje abierto está contraindicado. En los casos en que falla la terapia con amibicidos, se realiza el drenaje cerrado guiado por US o por TC. La infección secundaria de un absceso amibiano del hígado es un fenómeno extraordinariamente raro.La identificatión y determinatión de la sensibilidad antibiótica de los microorganismos responsables del absceso piógeno representa un paso crucial en su manejo. A menos que se haga necesario realizar una laparotomía para la correción del algún proceso intraabdominal o porque el absceso es excesivamente grande, el tratamiento inicial del absceso piógeno es un ciclo de antibióticos propiados de 2 semanas, seguidos de tratamiento con antibióticos orales por un mes. La mayoría de los abscesos piógenos del hígado responde a este tipo de tratamiento. Si se requiere drenaje de un absceso piógeno, la técnica de preferencia es la punción percutánea por medio de un catéter guiado por US o TC. El drenaje quirúrgico abierto debe reservarse para aquellos casos en que la laparatomía es necesaria por razones diferentes o en que hay falla en la respuesta a un ciclo de terapia antibiótica adecuada y el drenaje percutáneo no es factible.La mortalidad en el manejo del absceso amibiano del hígado debe ser nula, y para el absceso piógeno de menos de 10%.

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Résumé L'abcès hépatique amibien ou à pyogènes peut être diagnostiqué avec une grande précision soit par l'échographie, soit par la tomodensitométrie. L'échographie est la méthode de choix et détecte presque 100% des abcès. On obtient la confirmation du diagnostic d'abcès amibien par le test d'hémagglutination indirecte qui est positive dans presque 100% des cas. On doit faire des cultures de pus provenan de l'abcès et des hémocultures en cas d'abcès à pyogènes du foie. Ces cultures ont été positives dans 90% des cas. L'échographie et la tomodensitométrie aident à guider le drainage de abcès.Dans le traitement de l'abcès amibien du foie, le métronidazole est l'amibicide de choix. Le drainage à ciel ouvert est contreindiqué. Pour les cas qui ne répondent pas aux amibicides, un drainage percutané guidé par la tomodensitométrie ou l'échographie est indiqué. La surinfection d'un abcès amibien du foie est extrêmement rare.L'identification et la détermination de la sensibilité aux antibiotiques des organismes responsables de l'abcès à pyogènes est une étape extrêmement importante. A moins qu'une laparotomie soit nécessaire pour traiter une infection intraabdominale associée ou que le volume de l'abcès soit extrêmement important, le traitement initial d'un abcès à pyogènes comprend 2 semaines d'antibiotiques adaptés par voie générale suivies d'un mois d'antibiotiques par voie orale. La plupart des abcès à pyogènes répondront bien à ce traitement. Si le drainage d'un abcès à pyogènes s'avère nécessaire, la meilleure technique est percutanée avec un cathéter inséré sous contrôle tomodensitométrique ou échographique. On réservera le drainage chirurgical à ciel ouvert aux cas où une laparotomie est nécessaire pour d'autres raisons et où le malade n'a pas répondu à l'antibiothérapie adaptée et chez qui le drainage percutané est impossible à faire.La mortalité de l'abcès amibien traité devrait approcher 0% et atteindre pour l'abcès à pyogènes moins de 10%.

     

Does an infected peripancreatic fluid collection or abscess mandate operation?

OBJECTIVE: To assess the treatment of peripancreatic fluid collections or abscess with percutaneous catheter drainage (PCD). SUMMARY BACKGROUND DATA: Surgical intervention has been the mainstay of treatment for infected peripancreatic fluid collections and abscesses. Increasingly, PCD has been used, with mixed results reported in the literature. METHODS: A retrospective chart review of 1993 to 1997 was performed on 82 patients at a tertiary care public teaching hospital who had computed tomography-guided aspiration for suspected infected pancreatic fluid collection or abscess. Culture results, need for subsequent surgical intervention, length of stay, and death rate were assessed. RESULTS: One hundred thirty-five aspirations were performed in 82 patients (57 male patients, 25 female patients) with a mean age of 40 years (range 17-68). The etiologies were alcohol (41), gallstones (32), and other (9). The mean number of Ranson's criteria was four (range 0-9). All patients received antibiotics. Forty-eight patients had evidence of pancreatic necrosis on computed tomography scan. Cultures were negative in 40 patients and positive in 42. Twenty-five of the 42 culture-positive patients had PCD as primary therapy, and 6 required subsequent surgery. Eleven patients had primary surgical therapy, and five required subsequent surgery. Six patients were treated with only antibiotics. The death rates were 12% for culture-positive patients and 8% for the entire 82 patients. CONCLUSIONS: Historically, patients with positive peripancreatic aspirate culture have required operation. This series reports an evolving strategy of reliance on catheter drainage. PCD should be considered as the initial therapy for culture-positive patients, with surgical intervention reserved for patients in whom treatment fails.     

Portal vein thrombosis following endoscopic variceal sclerotherapy

The association between portal vein thrombosis (PVT) and prior endoscopic variceal sclerotherapy has been suggested but remains unproven. The aim of this study was to compare the incidence of PVT in patients who had received sclerotherapy for esophageal variceal hemorrhage to a control group of cirrhotic patients with portal hypertension who had not received sclerotherapy. Doppler ultrasound was used to assess PVT in 48 patients (group 1) who had received sclerotherapy for variceal hemorrhage as well as in 52 patients (group 3) with cirrhosis and portal hypertension who had not received sclerotherapy. Assessment of PVT was made at the time of surgery in 24 patients (group 2) who had received sclerotherapy for variceal hemorrhage, failed therapy, and had portacaval shunt surgery or received liver transplantation for liver failure. One patient had splenectomy for symptoms related to a massively enlarged spleen. The incidence of PVT in group 1 was 10%, in group 2 was 13%, and in group 3 was 10%. The incidence of PVT in the three groups was not significantly different statistically. In this controlled study of patients with cirrhosis and portal hypertension, sclerotherapy does not increase the incidence of PVT.     

Redo pullthrough for Hirschsprung disease: A single surgical group's experience

Introduction

This study presents our surgical experience for redo-pullthrough (RedoPT) for Hirschsprung disease (HD). It reviews the patient's clinical outcomes and assesses stooling patterns after RedoPT.

Methods

A retrospective review of our institution's RedoPTs as well as one author's overseas cases was performed. Stooling scores were tabulated using an established survey tool and compared to primary PT matched patients.

Results

Between 1974 and 2012, 46 individuals (52% males) underwent RedoPT, representing 3 percent of all HD pullthroughs. Median age at primary PT and RedoPT was 1 year (range 1 week–18 years) and 3.5 years (range 8 weeks–41 years), respectively. Indications for RedoPT were predominately for aganglionosis/transition zone pathology (71%); followed by stricture or an obstructing Duhamel pouch (19%), tight cuff (8%) and a twisted PT (4%). None were performed for an isolated clinical diagnosis of repeated bouts of enterocolitis. RedoPT surgical approach depended upon the initial pullthrough technique and any previous complications. Stooling scores were significantly (P < 0.05) worse in the RedoPT patients compared to the historically-matched group of children undergoing a primary PT for HD (5.5 ± 1.2 vs. 12.2 ± 1.4, primary PT versus RedoPT, respectively). When breaking down this total score into individual parameters, stooling pattern scores (1.0 ± 0.2 vs. 4.1 ± 0.4, P = 0.001) and enterocolitis scores (2.0 ± 0.4 vs. 4.2 ± 0.4, P = 0.001) were statistically worse in the RedoPT group. Patients in both groups had similar overall continence rates.

Conclusion

Appropriately selected children undergoing a RedoPT can achieve good results, with comparable continence rates to those undergoing a primary PT.     

Ultrasonography

Diagnostic sonography is experiencing a breath-taking period of technological advancement. Ultrasound contrast agents, new imaging techniques, and handheld instruments will play a role in facilitating more diagnostic power in high-end imaging and insuring more widespread use of diagnostic sonography in medicine in general.