The use of contrast-enhanced power Doppler ultrasound in the diagnosis and follow-up of inflammatory abdominal masses associated with Crohn's disease

1. Contrast-enhanced power Doppler ultrasound has a high sensitivity and specificity in the detection and evaluation of inflammatory abdominal masses associated with Crohn's disease. 2. The spatial resolution and sensitivity of this technique allows the detection of small inflammatory abdominal masses of 1 cm or above. 3. The absence of any associated X-ray radiation allows repeated examinations to be undertaken. This facilitates assessment of disease progression and response to treatment 4. The early detection of the complications of Crohn's disease may facilitate treatment by medical means rather than necessitating surgical intervention. Clinical and biochemical assessment of the complications of Crohn's disease such as abscess, stricture and fistula formation is extremely difficult. Radiological imaging is therefore widely utilized. This includes barium studies, ultrasound, computed tomography and nuclear medicine techniques. Contrast-enhanced power Doppler ultrasound has high sensitivity and specificity in the detection and evaluation of inflammatory abdominal masses associated with Crohn's disease, and compares favourably with computed tomography. The spatial resolution and sensitivity of contrast-enhanced power Doppler ultrasound enables the detection of small inflammatory abdominal masses. The absence of radiation dose to the patient allows multiple and serial examinations to be undertaken. This facilitates assessment of disease progression and response to treatment. The early detection of the extra-mural complications of Crohn's disease and the close monitoring of response to medical treatment may obviate the need for surgical intervention.     

Oral inflammatory changes as an initial manifestation of Crohn's disease antedating abdominal diagnosis

The case of a 14-year-old boy who had oral ulcers with histologic proof of granulomatous disease nine months before the diagnosis of intestinal Crohn's disease is presented. Additional extraintestinal manifestations of this case were cheilitis, anal fissures, and “metastatic” disease to the umbilicus. The diagnosis was established after the onset of abdominal symptoms. All manifestations responded rapidly to systemic prednisone, sulfasalazine, and metronidazole.     

Doppler sonography in the diagnosis of inflammatory bowel disease

Over the past few years, thanks to its ability to reveal neovascularization and inflammatory hyperemia, Doppler sonography has proved to be a valuable method for the assessment of disease activity in inflammatory bowel disease. Hypervascularization has been detected by Doppler imaging both in splanchnic vessels, in terms of flow volume and velocity, or resistance and pulsatility index on spectral analysis, and in small vessels of the affected bowel wall in terms of vessel density. In particular, power Doppler has been shown to be a highly sensitive method for evaluating the presence of flow in vessels that are poorly imaged by conventional color Doppler, and in detecting internal fistulas complicating Crohn's disease. Recently, the use of ultrasound contrast agents, such as Levovist, has been shown to improve the image quality of color Doppler by increasing the backscattered echoes from the desired regions, thus making it possible to better monitor the response to treatment and discriminate between active inflammatory and fibrotic bowel wall thickness in Crohn's disease. Additionally, Levovist-enhanced power Doppler sonography has proved to be highly sensitive and specific in the detection of inflammatory abdominal masses associated with Crohn's disease. In clinical practice, used in combination with second harmonic imaging and new generations of stable contrast agents, Doppler sonography appears to be a non-invasive and effective diagnostic tool in the diagnosis and follow-up of Crohn's disease and ulcerative colitis.     

彩色多普勒超声对克罗恩病的诊断价值

目的 探讨彩色多普勒超声对克罗恩病的诊断价值.方法 对临床腹痛位置较固定的病例经超声检查排除其他脏器疾病,进行胃肠道彩色多普勒超声常规检查,采用腹部探头和高频探头相结合的方法,重点观察和研究胃肠道管壁全层结构声像变化及其特征,同时与临床诊断和治疗及手术病理结果对照,分析总结克罗恩病的超声表现及特征,评价彩色多普勒超声诊断的临床价值.结果 30例中彩色多普勒超声检查拟诊克罗恩病22例,与临床诊断结果符合率达91%(20/22例),与手术治疗的病理结果符合率67%(4/6例).结论 克罗恩病彩色多普勒超声声像具有特异性改变,能为临床提供较准确的诊断依据,对临床决定治疗方案和疗效观察具有一定的价值.     

Contrast-enhanced ultrasound in the diagnosis of hepatocellular carcinoma

Surveillance of patients at risk of developing hepatocellular carcinoma (HCC) is based on ultrasound (US) examinations performed at either 6 or 12 month intervals. Early detection of HCC in patients with cirrhosis is a challenging issue, since the different entities that are involved in the multi-step process of hepatocarcinogenesis--such as low-grade and high-grade dysplastic nodule--share common US features. Contrast-enhanced US allows reliable detection of arterial neoangiogenesis associated with a malignant transformation. Several reports have shown that the ability of contrast-enhanced US to diagnose HCC currently approaches that of optimized multidetector computed tomography (CT) or dynamic magnetic resonance (MR) imaging protocols. The use of contrast-enhanced US to characterize nodular lesions in cirrhosis has been recently recommended by the clinical practice guidelines issued by the European Federation of Societies for Ultrasound in Medicine and Biology and the American Association for the Study of Liver Diseases. However, contrast-enhanced US has not resulted in any significant improvement in the ability of US to detect small tumor foci, since a comprehensive assessment of the whole liver parenchyma cannot be accomplished during the short duration of the arterial phase. Hence, CT or MR imaging are still mandatory for proper intrahepatic staging of the disease.     

Contrast-enhanced ultrasound in the diagnosis of pancreatic tumors

Echo-enhanced ultrasound is a newly available imaging modality for the evaluation of pancreatic lesions. Neoplasms of the pancreas tend to have a characteristic vascularization pattern. Adenocarcinomas are often hypovascularized as compared to the surrounding tissue. On the other hand, neuroendocrine tumors are hypervascularized lesions. Masses associated with pancreatitis have a different vascularization pattern depending on the degree of inflammation and necrosis. Cystadenomas frequently show many vessels along fibrotic strands. Data from prospective studies have demonstrated that based on these imaging criteria, the sensitivity and the specificity of echo-enhanced sonography in diagnosing the degree of differentiation of pancreatic masses are equal to, or greater than, 85% and 90%, respectively. In conclusion, pancreatic tumors have a different vascularization pattern in echo-enhanced ultrasound. These characteristics can be used with high a diagnostic accuracy for differentiation.     

Contrast-enhanced ultrasound versus MS-CT in blunt abdominal trauma

To evaluate the effectiveness of contrast-enhanced ultrasound (CEUS) in the diagnosis and characterization of hepatic, renal and splenic traumatic injuries versus conventional ultrasound (US) and multislice computed tomography (MS-CT).Between January 2005 and January 2007, 78 patients (48 males, 30 females, mean age 56 years) with blunt abdominal trauma were examined by conventional US, CEUS and MS-CT. CEUS employed a low-MI technique using 1.2 to 2.4 ml of SonoVue (Bracco, Italy) i.v. and a multifrequency transducer (2-4 MHz, Siemens, Sequoia, Acuson). CT examinations were performed on a 64 detector CT scanner (Somatom Sensation 16 or 64, Siemens Medical Systems, Forchheim, Germany) before and after administration of 120 ml intravenous contrast agent (Solutrast, Bracco, Milan, Italy) followed by 50 ml saline. The presence of hepatic, renal and splenic injuries was analyzed and the conspicuousness of findings was assessed.In 15 of the 78 patients conventional US identified solid organ injuries: 8 hepatic, 2 renal and 5 splenic injuries. CEUS identified 3 more injuries (2 hepatic and 1 splenic) that had been missed by conventional US. CEUS identified traumatic lesions in 18/78 patients. In one of the 18 patients even active bleeding could be identified by CEUS. In CEUS solid organ injuries appeared hypoechoic. MS-CT identified 18 solid organ injuries in 78 patients, corroborating the CEUS results.CEUS greatly improves the visualization and characterization of hepatic, renal and splenic injuries compared to conventional ultrasound and correlates well with MS-CT. The imaging technique detects even minor blood flow and is able to depict vascular structures in detail. At our institution it is used as an additional examination technique which supplements MS-CT in unclear cases. Owing to its bedside availability, CEUS provides a good alternative to MS-CT, especially in patients with contraindications to CT contrast agents (e.g. due to renal failure or severe allergy) and in hemodynamically compromised patients.     

Ultrasonography in the detection of Crohn's disease and in the differential diagnosis of inflammatory bowel disease

The diagnostic accuracy of abdominal ultrasonography in inflammatory bowel disease (IBD) has been evaluated in a prospective, randomized, blind study. A total of 181 patients (89 with Crohn's disease, 57 ulcerative colitis and 35 controls) were examined. Sensitivity and specificity of diagnosis in Crohn's disease, corrected for prevalence, were 80.8 and 79.2%, respectively, and a very similar accuracy was found in the differential diagnosis of IBD. In conclusion, ultrasonography can play a role in detecting Crohn's disease and in the differential diagnosis of chronic IBD.     

Contrast-enhanced ultrasound in diagnosis of gallbladder adenoma

<正>BACKGROUND:Gallbladder adenoma is a pre-cancerous neoplasm and needs surgical resection.It is difficult to differentiate adenoma from other gallbladder polyps using imaging examinations.The study aimed to illustrate characteristics of contrast-enhanced ultrasound(CEUS)and its diagnostic value in gallbladder adenoma.     

Bowel wall thickness at abdominal ultrasound and the one-year-risk of surgery in patients with Crohn's disease

OBJECTIVES: Abdominal ultrasound can assess the extent and localization of Crohn's disease, and an increased bowel wall thickness is the most common finding. Our aim was to correlate bowel wall thickness at ultrasound, with the risk of short-term surgical outcome in patients with Crohn's disease. MATERIALS AND METHODS: From 1997 to 2000 we performed ultrasound in 174 consecutive patients with Crohn's disease. Surgical operations were recorded over a 1-yr follow-up. Logistic regression analysis was performed to identify clinical and ultrasound risk factors for surgery. RESULTS: Fifty-two patients underwent surgery within 1 yr. Indication for surgery was strictures in most of the cases. Median bowel wall thickness was higher in patients with surgery (8 mm) than those without surgery (6 mm) (p < 0.0001). A receiver operating characteristic (ROC) curve was constructed taking into account bowel wall thickness for selecting patients with a high risk of surgery. The optimized cut-off for equally important sensitivity and specificity was calculated at 7.008 mm. The binary regression analysis showed that CDAI > 150, absence of previous surgery, stricturing-penetrating pattern, the presence of intestinal complications, and intestinal wall thickness >7 mm were associated with an increased risk of surgery. Patients with intestinal wall thickness >7 mm at ultrasound had the highest risk (OR: 19.521, 95% CI: 5.362-71.065). CONCLUSIONS: Data suggest that bowel wall thickness >7 mm at ultrasound is a risk factor for intestinal resection over a short period of time. Routine use of abdominal ultrasound during evaluation of patients with Crohn's disease may identify a subgroup that is at high risk for surgery. (Am J Gastroenterol 2004;99:1-7)     

Bowel ultrasound in Crohn's disease

Most published studies have found bowel ultrasound to be a useful tool in the management of Crohn's disease. Indeed, it has been successfully used as the imaging technique of choice in screening patients with clinically suspected Crohn's disease. In these patients, bowel ultrasound, which is well accepted by patients, non-invasive and of low cost, may be the first diagnostic tool employed for young patients and can be used in the preliminary diagnostic work-up prior to further invasive tests. The most important application of bowel ultrasound is, however, in the follow-up of patients already diagnosed with Crohn's disease, in whom it may be useful to assess the site and extent of the lesions and to ensure the early detection of intra-abdominal complications, particularly abscesses and strictures. In this regard, improving the ultrasound assessment of intramural blood flow by means of colour power-Doppler ultrasonography and intravenous contrast agents may help to differentiate fibrotic and inflammatory strictures, and to discriminate inflammatory masses from intra-abdominal abscesses. Despite several attempts to correlate ultrasound findings with clinical and biochemical activity, there are as yet no convincing data on the usefulness of ultrasound in assessing the activity of Crohn's disease. In contrast, preliminary results are in agreement regarding the usefulness of ultrasound in the assessment of postoperative recurrence and in monitoring the outcome of the disease following surgery. In fact, the persistence of a thickened bowel wall or increased high bowel wall thickening at ultrasound following surgery has been identified as an index of early surgical recurrence. How these data may be usefully employed in the management of individuals with Crohn's disease needs to be investigated in further studies.     

Evaluation of criteria for the activity of Crohn's disease by power Doppler sonography

BACKGROUND/AIM: In recent years, power Doppler sonography has been proposed as a method to assess disease activity in patients with Crohn's disease. The aim of this prospective study was to evaluate diagnostic criteria for power Doppler sonography by blinded comparison with ileocolonoscopy. METHODS: Twenty-two patients with confirmed Crohn's disease were prospectively investigated with B-mode and power Doppler sonography (HDI 5000, Philips Ultrasound) as well as ileocolonoscopy. Sonography was performed within 3 days before endoscopy. All procedures were performed by experienced examiners who were blinded to the clinical data and other results. Defined ultrasound parameters (bowel wall thickness, vascularization pattern) were used to determine a sonographic score of the activity. The degree of activity was scored from 1 (none) to 4 (high) by both ultrasound and ileocolonoscopy (pattern, extent of typical lesions). For each patient all segments of the colon and the terminal ileum were evaluated by both ultrasound and endoscopy. The weighted kappa test was used (StatXact software) for statistical analysis. RESULTS: In total, 126 bowel segments were evaluated by both ultrasound and endoscopy. The study showed a high concordance of power Doppler sonography and ileocolonoscopy (weighted kappa by region: sigmoid colon: 0.81; transverse colon: 0.78; ascending colon: 0.75; cecum: 0.84; terminal ileum: 0.82). Highest concordance was found in the descending colon (weighted kappa: 0.91; 95% CI: 0.83-0.98). CONCLUSIONS: Combination of B-mode and power Doppler sonography has a high accuracy in the determination of disease activity in Crohn's disease when compared to ileocolonoscopy. The diagnostic criteria established in this study can be useful for the evaluation of inflammatory bowel diseases by ultrasound.     

Contrast-enhanced ultrasound in the diagnosis of nodules in liver cirrhosis

Contrast-enhanced ultrasound(CEUS)using microbubble contrast agents are useful for the diagnosis of the nodules in liver cirrhosis.CEUS can be used as a problem-solving method for indeterminate nodules on computed tomography(CT)or magnetic resonance imaging(MRI)or as an initial diagnostic test for small newly detected liver nodules.CEUS has unique advantages over CT and MRI including no renal excretion of contrast,real-time imaging capability,and purely intravascular contrast.Hepatocellular carcinoma(HCC)is characterized by arterial-phase hypervascularity and later washout(negative enhancement).Benign nodules such as regenerative nodules or dysplastic nodules are usually isoechoic or slightly hypoechoic in the arterial phase and isoechoic in the late phase.However,there are occasional HCC lesions with atypical enhancement including hypovascular HCC and hypervascular HCC without washout.Cholangiocarcinomas are infrequently detected during HCC surveillance and mostly show rimlike or diffuse hypervascularity followed by rapid washout.Hemangiomas are often found at HCC surveillance and are easily diagnosed by CEUS.CEUS can be effectively used in the diagnostic work-up of small nodules detected at HCC surveillance.CEUS is also useful to differentiate malignant and benign venous thrombosis and to guide and monitor the local ablation therapy for HCC.     

Contrast-enhanced ultrasonography in the diagnosis of gallbladder disease

Background/Aims: The aim of our study was to evaluate the enhancement patterns of gallbladder disease using contrast-enhanced ultrasonography (CE-US) with the contrast agent levovist. Methodology: The subjects were 42 patients, of whom 25 had gallbladder cancer, 2 had adenoma, 5 had adenomyomatosis, 5 had cholesterol polyps and 5 had debris. We assessed the enhancement patterns of each case using CE-US with levovist and classified these patterns into 6 types: diffuse, scattered, branched, linear, homogeneous and unenhanced. Results: The enhancement of gallbladder cancer revealed various patterns. Only 4 malignant cases showed branched patterns. We speculated that branched patterns in the present study were possibly the characteristic of malignancy. CE-US easily distinguished a small polypoid lesion from debris. Using CE-US, we visualized the shape of the gallbladder cancer lesions and some areas of direct invasion to the liver, as well as metastasis. Conclusions: CE-US is a minimally invasive diagnostic technique that is useful in visualizing not only the shape of the lesion and some areas of the direct invasion to the liver, but also metastasis. The above findings suggest that imaging using a contrast agent could lead to improvements in the diagnosis of gallbladder lesions.     

Non-invasive evaluation of activity in inflammatory bowel disease by power Doppler sonography

BACKGROUND: To study the vascularization in the diseased bowel wall by power Doppler sonography in patients with inflammatory bowel disease. PATIENTS AND METHODS: The diseased bowel wall was investigated in 99 patients with inflammatory bowel disease (60 patients with Crohn's disease and 39 patients with ulcerative colitis) either with active disease or in remission by B-mode and power Doppler sonography. Disease activity was determined by clinical indices. Twenty healthy age and sex matched individuals served as controls. RESULTS: Bowel wall was thickened in active Crohn's disease (mean 7 mm, range 4-14) and ulcerative colitis (mean 5 mm, range 2-15) as compared to healthy controls (mean 2 mm, range 1-3), p < 0.001. In contrast to healthy controls blood vessels were detected in the bowel wall in 100 % of patients with active Crohn's disease and 91 % with active ulcerative colitis. Vascularization was significant decreased in patients with quiescent versus active disease in ulcerative colitis (p < 0.05), while in Crohn's disease there was no significance between active and remission phase. CONCLUSIONS: Thickened and hypervascularized bowel wall are characteristic findings in inflammatory bowel disease. A combination of B-mode and power Doppler sonography offers an additional noninvasive procedure for the determination of activity in patients with inflammatory bowel disease.     

Long-term follow-up of strictureplasty in Crohn's disease

Because Crohn's disease of the small bowel is often diffuse, strictureplasty has been advocated as an alternative or adjunct to resection(s) of strictured segments. We reviewed 116 patients with obstructive Crohn's disease undergoing 452 primary strictureplasties (Heineke-Mikulicz, 405; Finney, 47). The median age was 34 years (range, 13–72 years); the male-to-female ratio 1.41; and the median follow-up was three years (range, six months to seven years). Seventy-six patients (66 percent) had at least one previous small bowel resection. Perforative disease was present in 18 patients (15 percent), and synchronous resections were performed in 71 patients (61 percent). The median number of strictureplasties was three (range, 1–15). There was no mortality. Septic complications (intra-abdominal abscess/fistula) occurred in seven patients (6 percent), and reoperation for sepsis was needed in two patients. Relief of obstructive symptoms was achieved in 99 percent of the patients. After surgery, the median weight gain was 4 kg, and two-thirds of the patients were weaned off steroids. Symptomatic recurrence occurred in 28 patients (24 percent), and 17 patients (15 percent) needed reoperation. Rates of restricture and new stricture/perforative disease were 2.8 percent and 24 percent, respectively.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.