Can the status of tubal pregnancy be predicted with transvaginal sonography? A prospective comparison of sonographic, surgical, and serum hCG findings

Results of transvaginal sonography were compared prospectively with surgical findings and levels of serum human chorionic gonadotropin in 120 women with a proved tubal pregnancy. The most common sonographic finding was a saclike adnexal ring, which was seen in 74 of the women (61.7%). This finding was strongly associated with functioning trophoblasts and with an intact fallopian tube. In 39 of the women (32.5%) an adnexal mass with a complex texture was found. Of these 39 women, 20 had a tubal hematoma and six had a ruptured fallopian tube. The size of the tubal mass created by ectopic pregnancy was predicted precisely (r = .91, P less than .001), and transvaginal sonography enabled detection of hemoperitoneum with a sensitivity of 91% (68 of 75 women). This study suggests that the status of a tubal pregnancy can be predicted reliably on the basis of transvaginal sonographic findings.     

Gray-scale ultrasound in tubal pregnancy

Sonographic signs were correlated with clinical data, surgical findings, and pathology in 15 patients withtubal pregnancy. Sonograms showed absence of intrauterine gestation in 12 patients. In 3, structures resembling gestational sacs were produced by decidual reaction and blood in the uterine cavity separating the endometrial echoes. The uterus was normal in size in 6 cases. Almost all sonograms showed a pelvic mass (usually adnexal) displacing the uterus. Seven patients had predominantly sonolucent masses, 3 had complex masses, and 4 had both types. Only one woman exhibited a definite gestational sac in an extrauterine location. Four patients had a negative pregnancy test at the time of sonography. Meticulous sonographic technique and a high index of suspicion will facilitate the diagnosis of tubal pregnancy in most cases.     

Ectopic pregnancy: features at transvaginal sonography.

A retrospective review of the transvaginal sonograms of 50 women with laparoscopically confirmed ectopic pregnancy was performed to determine whether certain sonographic findings can be detected to confirm the diagnosis. Forty-seven of the 50 pregnancies were tubal. A tubal ring (a 1-3-cm mass consisting of a 2-4-mm concentric, echogenic rim of tissue surrounding a hypoechoic center) was seen in 23 of 34 (68%) ectopic pregnancies in which the fallopian tube had not ruptured, and the tubal ring could be distinguished from a corpus luteum cyst in most cases. Transvaginal sonography also depicted simple (n = 22) or particulate (bloody) (n = 13) peritoneal fluid associated with ectopic pregnancy. In each case in the series, at least one abnormal uterine, adnexal, or peritoneal finding was detected at transvaginal sonography. Because of its improved resolution of uterine and adnexal structures, transvaginal sonography is recommended as a means for detailed evaluation of patients suspected of having an ectopic pregnancy.     

Hypoechoic lesions without halo in echogenic liver. A frequent sonographic dilemma

Sonographic evaluation for the presence of hypoechoic hepatic lesions without halo was carried out in 365 consecutive patients with echogenic livers. In 115 patients (31%) such lesions could be demonstrated. Computed tomography of the liver was performed in 52 of these patients, a long term sonographic follow-up in 76, and a biopsy in 3 cases. In 103 patients the hypoechoic lesions were due to sonographic pseudolesions (PL's), probably representing normal liver tissue in otherwise diffusely fatty infiltrated livers. The PL's showed characteristic sonographic appearances such as a missing mass effect, a 'landscape'-like configuration with angulated margins and slender extensions of hypoechoic tissue. The PL's were located below the capsule, near the gallbladder (41%), and ventral to the portal vein (37%). In 75 per cent they occurred in a liver with considerably increased echogenicity. In 12 patients hypoechoic lesions were caused by circumscribed malignant or infectious involvement of the liver. They could be discriminated from PL's by their mass-like appearance in 8 subjects. In 4 of these 12 cases the foci were of PL-typical appearance, but not of PL-typical location. In the light of these results and of recently published reports a rational diagnostic approach to hypoechoic lesions without halo in echogenic livers varies, depending on such factors as known primary malignancy or site of the lesion.     

Clonorchiasis: sonographic findings in 59 proved cases

Clonorchiasis is a parasitic disease of the bile ducts that occurs in endemic areas after ingestion of the raw flesh of freshwater fish. We analyzed the sonographic findings in 59 patients with clonorchiasis, suspected prospectively from sonographic findings and proved subsequently by demonstration of eggs in their stools. Diffuse dilatation of the small intrahepatic bile ducts with no or minimal dilatation of the large intra- and extrahepatic ducts was observed in all cases. The extrahepatic ducts were patent throughout in all except one case. This characteristic finding reflects diffuse intrahepatic bile duct obstruction and resultant proximal dilatation caused by an adult worm or aggregates of worms, as worms reside diffusely in the medium and small intrahepatic bile ducts. Cholangitis and multifocal periductal fibrosis with proximal dilatation may play an additional role. Increased echogenicity of the intrahepatic bile duct wall was present in 39 cases (66%), reflecting cholangitis and periductal fibrosis. In 17 cases (29%), floating or dependent, discrete, nonshadowing, intraluminal, echogenic foci caused by adult worms in the bile were demonstrated in the gallbladder. These echogenic foci were distinguished from stones because they were fusiform, weak in echogenicity, and floated with a change in position. Clonorchiasis should be considered when sonography discloses the characteristic pattern of bile duct dilatation with increased wall echogenicity and nonshadowing, discrete, echogenic foci in the gallbladder lumen.     

Sonography of neck masses in children

The sonograms and medical records of 49 patients were reviewed to determine if there is a characteristic sonographic appearance for certain neck masses. Neck masses included: inflammatory masses (12), noninflammatory masses (23), and thyroid masses (14). Four entities including thyroglossal duct cyst, fibromatosis colli, cystic hygroma, and multiple lymphadenopathy showed characteristic sonographic appearance. Thyroglossal duct cysts were seen as midline or slightly off midline cystic masses. A sinus tract extending superiorly was nicely demonstrated in one patient. The mass in fibromatosis colli (neonatal torticollis) appeared as a well defined mass clearly within the sternocleidomastoid muscle, uniformly echogenic, but less echogenic than the normal surrounding muscle, without good through-transmission. A cystic or primarily cystic mass with linear septations was the characteristic finding of the cystic hygroma. Multiple lymphadenopathy demonstrated multiple discrete, oval, relatively hypoechoic masses along the cervical lymphatic chain. The sonographic appearance of inflammatory masses was variable, being either inhomogeneously echogenic or of mixed echogenicity. Hemangiomas were either echogenic with cystic vascular spaces or linear septations or relatively homogeneously echogenic. Intrinsic thyroid masses could be distinguished from extrinsic masses in most cases. The demonstration of calcification in a mass was useful in narrowing the differential diagnosis. Although it is not a specific finding, the presence of calcification highly suggests a neoplastic lesion, particularly neuroblastoma or teratoma. Not only can the location, extent, and internal characteristics of a mass be determined, but in certain entities, the sonographic appearance is characteristic and an accurate diagnosis can be made.     

Endovaginal sonographic diagnosis of dilated fallopian tubes

Twelve cases of fallopian tube dilatation were diagnosed in 10 patient by using endovaginal sonography. The diagnosis was confirmed by surgery in seven patients and by hysterosalpingography in three. A tubular shape was present in every case. Other sonographic features included a well-defined echogenic wall, a folded configuration, and linear echoes protruding into the tube lumen. Dilated tubes were distinguished from bowel loops by a lack of peristaltic activity and from pelvic veins by a lack of moving low-level echoes on real-time sonography. We conclude that the findings of dilated fallopian tubes on endovaginal sonography are sufficiently characteristic to allow the diagnosis to be made with this technique.     

Sonography of the postoperative shoulder

Fifty-three patients with 60 symptomatic shoulders underwent shoulder sonography for recurrent postoperative symptoms after either acromioplasty (10 shoulders) or repair of a full-thickness rotator cuff tear in addition to acromioplasty (50 shoulders). Because surgery distorts landmarks, an understanding of the surgical procedures and their characteristic sonographic appearances is essential. After acromioplasty, the characteristic sharp margination or the acromion was replaced by a less distinct, irregular surface. After repair of a cuff tear, characteristic sonographic appearances included visualization of a reimplantation trough and loss of the echogenic subdeltoid bursa. When the cuff was intact after surgery, echogenicity was abnormal in all cases (17 shoulders). Sonography accurately diagnosed recurrent cuff tears in all 26 shoulders in which surgical proof was available and confirmed an intact cuff in 10 of 11 cases. In one shoulder, a cuff hematoma was incorrectly interpreted as a full-thickness tear. These findings suggest that sonography is an effective procedure for evaluating a postoperative patient with recurrent shoulder symptoms.     

Sclerosing lobular hyperplasia: sonographic pathologic correlation

The objective was to evaluate the sonographic findings of sclerosing lobular hyperplasia (SLH) of the breast and to correlate the sonographic findings and the pathologic features. This study consisted of 9 patients with pathologically proven sclerosing lobular hyperplasia who had undergone a preoperative imaging study. We retrospectively reviewed 9 ultrasonograms and 6 mammograms. In each patient mammographic findings including, shape and margin, and ultrasonographic findings including the size, length-to-anteroposterior ratio, shape, margin, internal echo pattern, and the presence and location of internal echogenic septum, were evaluated. Histopathologic correlations focused on characteristic imaging findings. Of the 6 mammograms, 4 cases showed a lobular (3 of 6) or an oval shaped mass (1 of 6) with a partly obscured margin (4 of 6). The remaining 2 cases showed heterogeneously dense breast without visible mass. Ultrasonograms showed a lobular (5 of 9) or an oval (4 of 9) shaped mass with a circumscribed margin (9 of 9). The mean length/anteroposterior ratio was 1.98. Intratumoral echogenic septum was present in 8 cases. Six cases had a peripherally arising septum. Histopathologic review revealed that this septum was correlated to interlobular sclerosis. A peripherally arising intratumoral echogenic septum on ultrasonography seen in SLH might be explained by the interlobular sclerosis.     

Ultrasonography in acute gallbladder perforation

The files of patients with acute cholecystitis from two large university hospitals from the years 1978-1985 were employed to find the cases with acute gallbladder perforation for this study. Only those patients (n = 9) were selected for the analysis of sonographic signs of acute gallbladder perforation who had less than 48 hours of symptoms before sonography, and were operated upon within 24 hours of the sonography. Patients (n = 10) with non-complicated acute cholecystitis and identical in regard to the duration of the symptoms and the timing of the sonography and the operation formed a control group. The sonographic findings in patients with gallbladder perforation were pericholecystic fluid collections, free peritoneal fluid, disappearance of the gallbladder wall echoes, focal highly echogenic areas with acoustic shadows in the gallbladder, and an inhomogeneous, generally echo-poor gallbladder wall.     

Neonatal ovarian cysts: sonographic-pathologic correlation

The authors reviewed the prenatal (11 infants) and postnatal (17 infants) sonograms and the clinical, surgical, and pathologic findings in 17 infants with an ovarian cyst to determine the sonographic features and natural history of neonatal ovarian cysts. An uncomplicated cyst (nontwisted, nonhemorrhagic) was completely anechoic and the cyst wall was imperceptible with sonography (five cases). A twisted or hemorrhagic cyst was cystic with a fluid-debris level, cystic with a retracting clot, septated with or without internal echoes, or solid (12 cases). These complicated cysts contained liquid and/or organized hematoma. Eleven of the 12 complicated cysts had a thin, highly echogenic wall. Cyst torsion commonly occurred in utero and could be diagnosed on prenatal sonograms by a typical sonographic appearance (eight cases). All of these infants were asymptomatic after birth. Four infants with hemorrhagic or twisted cysts were symptomatic. All cysts except one that resolved spontaneously were treated surgically, including three twisted cysts that showed no change in size over a 1-8-month interval. All of the cysts were of follicular origin.     

肾上腺髓质脂肪瘤的超声诊断

目的探讨肾上腺髓质脂肪瘤的超声表现,以提高其诊断准确性。方法回顾性分析总结经病理证实的7例肾上腺髓质脂肪瘤,所有病例术前均接受超声检查,将超声结果和病理进行对照分析。结果7例肾上腺髓质脂肪瘤的声像图特点均为边界清晰,形态基本规则,内部呈均匀中等强回声或中等强回声与低回声相间,肿瘤内部未见无回声区,内部未测及血流信号。结论肾上腺髓质脂肪瘤是一种少见的良性无功能性肿瘤,具有特征性的声像图表现,超声检查可作出正确诊断,最后确诊仍依靠病理学检查。     

Sonography of malignant pleural effusion

Two hundred and ten patients with exudative pleural effusion were studied by ultrasound for sonographic signs of pleural carcinomatosis. Images were evaluated for echoes within the fluid, septations, sheet-like or nodular pleural masses, and associated lesions of the lung. Our results showed that sonographic findings of echogenic or septated fluid were unspecific for malignancy. Only the evidence of pleural masses was characteristic of malignant effusion. Ultrasound of the chest should therefore be carried out before invasive diagnostic procedures are planned. Received 31 May 1995; Revision received 12 September 1996; Accepted 14 January 1997     

Chronic pancreatitis: ultrasonic features

A retrospective analysis of 84 ultrasound examinations (in 77 patients) was performed to assess the frequency of sonographic findings in chronic pancreatitis. The findings included: inhomogeneously increased echogenicity in 53% of these examinations, focal or diffuse enlargement in 41%, focal dense echoes in 40%, pseudocyst formation in 21%, and a hypoechoic head mass in 7%. Thirteen per cent of our patients had a normal sonogram. Several presentations of chronic pancreatitis not previously described in the sonographic literature included: pancreatic or common bile duct enlargement or pseudocyst formation with otherwise normal-appearing glands. There was no direct relationship between the presence of focal high-intensity echoes within the pancreatic parenchyma and the presence of radiographic calcification. There was no difference in the frequency of ultrasonic abnormalities between patients with and without clinical evidence of pancreatic insufficiency. These results indicate that the sonographic findings in chronic pancreatitis are significantly more varied than previous reports would indicate.     

Uterine adnexal torsion: sonographic findings

Acute torsion of the uterine adnexal structures (ovary and fallopian tube) is a recognized surgical emergency, but rarely has the diagnosis been made preoperatively on the basis of imaging studies. This report describes 16 cases in which the diagnosis was suggested preoperatively on the basis of sonography and subsequently confirmed at surgery. In all of the patients studied, a pelvic or pelvoabdominal mass was present on sonography. These masses had a sonographic texture ranging from cystic to solid, depending on the presence and extent of internal hemorrhage and/or stromal edema. In the majority of patients (13 of 16), adnexal torsion was associated with a preexisting cystic adnexal mass. Eight of these had thin internal septae. The severity of symptoms was variable and did not correlate directly with the sonographic features of the pelvic mass. Consideration of this entity in the proper clinical setting and with the typical sonographic findings will facilitate prospective recognition of adnexal torsion, thereby improving the chances for salvage of the involved adnexal structures.     

Echinococcus granulosus cysts in the liver: management with percutaneous drainage

Twenty-one hepatic Echinococcus granulosus cysts (maximal diameter, 7.5 cm +/- 4.0) in 12 patients were aspirated and irrigated with hypertonic (20%) saline under sonographic guidance. All patients had signs and symptoms of a hepatic mass caused by the cysts, which had a prominent fluid component that appeared anechoic or hypoechoic, with marked enhancement of back wall echoes. The amounts of cyst fluid aspirated and of hypertonic saline used were 190 mL +/- 240 and 120 mL +/- 90, respectively. Separation of the endocyst from the pericyst and nonviability of scoleces were observed in all cysts. Mean hospital stay was 4.0 days +/- 3.4. Serial sonographic examinations revealed high-level echoes in the cyst cavity (heterogeneous echo pattern), which ultimately became uniformly echogenic (pseudotumor). After follow-up of 14.0 months +/- 5.5, maximal cyst diameter decreased to 4.1 cm +/- 3.1 (P less than .001). One patient died of unrelated causes; the remaining 11 patients experienced relief of symptoms and a decrease in liver span.     

Sonography of brain tumors in infants

Cranial sonograms of six children with brain tumors (one newborn, four infants, and one 4-year-old child) are presented. In four, sonography showed a large tumor mass and displacement of adjacent structures. In two, the tumors were demonstrated as areas of abnormal brain parenchymal echogenicity without obvious mass effect. Two of the tumors were diffusely echogenic, one was primarily cystic, and three were of mixed echogenicity. Areas of cystic degeneration and calcification within the tumors were well demonstrated. Correlation was made with cranial computed tomography (CT) in all patients; in each case sonography accurately demonstrated the location and extent of the tumor. Since sonography is used as a screening procedure in infants with a large head or an abnormal neurologic examination, sonography may be the first examination to demonstrate the tumor mass. However, since the sonographic features are not specific for neoplasms, further clarification of the process by CT should be recommended.     

妊娠黄体的超声识别在输卵管妊娠诊断中的价值

目的探讨经阴道超声对妊娠黄体的正确识别在输卵管妊娠诊断中的价值。方法对80例经临床手术及病理证实的输卵管妊娠病例进行回顾性分析,观察妊娠包块和卵巢内妊娠黄体的形态结构及两者位置关系,并将输卵管妊娠中“输卵管环”型包块及厚壁囊肿型妊娠黄体的囊壁分别与子宫内膜回声作比较。结果80例输卵管妊娠患者,检测出妊娠黄体76例,输卵管妊娠包块与妊娠黄体在同侧者65例（86％）,不同侧者11例（14％）。妊娠黄体主要形态特征为薄壁囊肿型、厚壁囊肿型、低回声型、薄壁囊肿内部点状回声型,输卵管妊娠包块主要为“输卵管环”型及低回声型。输卵管妊娠包块中的“输卵管环”囊壁大多是高于（38％）或等于（42％）子宫内膜回声;而厚壁囊肿型妊娠黄体其囊壁回声大多是低于子宫内膜回声（82％）,两者比较差异有统计学意义（P〈0．01）。结论正确认识妊娠黄体的形态结构及其与输卵管妊娠包块的不同点在输卵管妊娠的诊断中有重要的意义。     

Retained surgical sponges: CT and US appearance

The computed tomographic (CT) and ultrasonographic (US) appearances of retained surgical sponges are described. In each case, the presence of a sponge was confirmed at repeat operation. CT examinations were performed in nine patients. In six cases, a low-density mass was demonstrated; in two cases, a complex mass with areas of both low and medium density was seen. The remaining case was a high-density mass. After intravenous administration of contrast material, dense and prolonged enhancement of the rim of the mass was noted in five of eight cases. Calcification was found in four cases, and spongiform gas in one. US performed in six patients revealed an echogenic area with strong acoustic shadowing in three cases and a complex mass, a hypoechoic mass, and a cystic mass with irregular internal echoes in one case each. Granuloma caused by a retained surgical sponge should be considered as a cause of an abdominal mass in patients with a history of prior abdominal surgery.     

Computed tomography of hydrosalpinx following tubal ligation

The CT findings in three cases of surgically proven hydrosalpinx following tubal ligation are described. In every case a cystic mass of characteristic tubular shape was detected in the pelvic adnexal region. These findings can be considered diagnostic of iatrogenic hydrosalpinx.