A.E.A. Joseph

Comparison of liver histology with ultrasonography in assessing diffuse parenchymal liver disease

To establish the accuracy of ultrasonography in assessing diffuse parenchymal liver disease we performed a prospective comparative study with histology in 50 patients with a wide range of liver disease. Liver biopsy was performed within 24 h of the ultrasound examination and ultrasonography was performed by a single operator who was unaware of clinical details of the patients. Histology was reviewed blind and the degree of steatosis graded mild, moderate or severe while increased portal fibrous tissue was graded mild, moderate or established cirrhosis. Thirty-six patients had steatosis and 31 patients had increased fibrous tissue on histology. Ultrasonography correctly identified steatosis in 32/36 (89%) patients including all patients with the severe grade. Increased fibrous tissue was correctly identified in 24/31 (77%) with a sensitivity of 100% in patients with moderate fibrosis and established cirrhosis. Specificity was 93% for steatosis and 89% for increased fibrous tissue. These results show that ultrasonography can provide a non-invasive prediction of liver histology which in moderate and severe steatosis and advanced fibrosis can be both highly sensitive and specific.

Ultrasonic patterns in inflammatory bowel disease

Ultrasound examination was performed in 90 patients with varying bowel pathology. Ultrasound reliably demonstrated thickening of the bowel. In addition, the pattern of abnormality seen in Crohns disease and ulcerative colitis was different, and corresponded to the pathological changes seen in these disease processes. The pattern of bowel abnormality seen in other bowel diseases with an inflammatory aetiology generally corresponded to either the Crohns or ulcerative colitic pattern. The appearances are described, together with findings in other non-neoplastic diseases of the bowel.

Ultrasound Findings in Renal Parenchymal Disease: Comparison With Histological Appearances

Ultrasound examination was carried out in 55 patients undergoing renal biopsy for suspected renal parenchymal disease. Analysis of sonographic and histological findings showed statistically significant positive correlations between renal size and the extent of glomerular hyper-cellularity and crescent formation and between cortical echogenicity and severity of glomerular sclerosis, crescent formation, interstitial inflammatory cell infiltration, tubular atrophy and interstitial fibrosis. Positive correlation was also observed between prominence of the medullary pyramids and glomerular sclerosis. The most marked sonographic abnormalities were seen in proliferative (including crescentic) glomerulonephritis, diabetic glomerulosclerosis and tubulo-interstitial nephritis. IgA, membranous and minimal change nephropathy were less likely to be associated with sonographic abnormalities. We conclude that certain sonographic appearances in renal parenchymal disease reflect the presence and severity of light microscopical abnormalities but, although ultrasound assessment provides a high positive predictive value for renal parenchymal disease, specific conditions cannot be distinguished.

The radiology of aseptic cavitation in pulmonary infarction.

Eight patients with aseptic cavitation of sterile pulmonary infarcts are described. All except one had left ventricular failure and/or chronic airflow obstruction. Infarcts with cavities were commonly single (75%) and right-sided (69%) and usually followed a sizeable area of consolidation (larger than 4 cm) after about 2 weeks. Of the 62% that could be localised to a segment, all were in the apical or posterior segment of an upper lobe or the apical segment of a lower lobe and the majority (85%) had scalloped inner margins and cross cavity band shadows. At the time of cavitation, 38% had additional features on the chest radiograph that were suggestive of pulmonary embolic disease. A number of cavities developed a tertiary infection and an air-fluid level but the latter feature was non-specific. Aseptic cavitation of a sterile pulmonary infarct should be considered in the differential diagnosis of any cavitating lung lesion, particularly if it shows the above features.

Paradoxical lack of ultrasound attenuation with gross fatty change in the liver

The cardinal features of hepatic steatosis on ultrasound examination are now accepted as increased echogenicity of the liver parenchyma with increased attenuation of the ultrasound beam. Three cases are presented of patients with gross diffuse fatty infiltration of the liver, who showed a paradoxical lack of posterior attenuation on ultrasound examination. These examples serve to illustrate the role of scattering in attenuation of the ultrasound beam seen in fatty livers.

Case Report: Ultrasound in the diagnosis of gallstone ileus

Recent case reports have shown that ultrasound can be useful in the diagnosis of gallstone ileus. A further patient is presented in whom the ultrasonic demonstration of dilated bowel loops, air in the gall-bladder, and an ectopic gallstone clinched the diagnosis when the plain radiographs demonstrated only small bowel obstruction. A pitfall in the ultrasound diagnosis is also discussed.

Ultrasound in the diagnosis of granulomatous liver disease.

Ultrasound is a widely used method of assessing the liver for space occupying lesions and, more recently, parenchymal liver disease. We have reviewed the ultrasound scans and reports of 11 patients with biopsy proven granulomatous liver disease. Multiple echogenic lesions 3-5 mm in diameter, each surrounded by an hypoechoic halo, were seen in the liver of all the patients and in the spleens of three patients. A specific diagnosis of granulomatous hepatitis was suggested at the time of scanning in seven patients. An abnormal liver was noted in the other four patients but no specific diagnosis was suggested. We believe that granulomata in the liver can be detected using ultrasound and, if the above appearances are seen during an ultrasound scan, a diagnosis of granulomatous hepatitis should be considered.

Correlation of 111Indium WBC scintigraphy with ultrasound in the detection and assessment of inflammatory bowel disease

111Indium (111In) WBC scintigraphy is an accurate method of assessing the extent of inflammatory bowel disease. A prospective study was performed to determine the correlation of ultrasound scanning with 111In WBC scintigraphy in the assessment of inflammatory bowel disease. Eighty-three indium and ultrasound scans were performed in 57 patients. Forty-six patients had Crohns disease and 11 patients had ulcerative colitis. The site extent of abnormality and the appearance of the bowel were recorded and compared to the findings on indium scintigraphy. Ultrasound detected 84% of indium-positive sites. If the rectum was excluded, sensitivity of detection rose to 91%. Three percent of indium-negative sites were positive on ultrasound.

A histological basis for the ‘Sonographic snowstorm’ in opportunistic infection of the liver and spleen

We report 3 cases of opportunistic infection of the liver and spleen due to Pneumocystis carinii, Candida albicans and Aspergillus with an unusual but similar sonographic appearance. In the patient with Pneumocystis we report for the first time this same appearance in the bowel and pleura. Histology showed either extensive fibrosis or focal fibrinous exudates as the underlying cause. Calcification, though present, was scanty and was not thought to be the likely explanation for the appearances.

Ultrasound detection of oesophageal varices — Comparison with endoscopy

In a prospective study of 100 patients for the detection of oesophageal varices, real-time ultrasound was both sensitive (sensitivity 82%) and specific (specificity 91%) compared with upper gastrointestinal endoscopy. All patients with large and medium sized varices were correctly identified by ultrasound. Ultrasound should be considered as an alternative to endoscopy and radiology for detection of oesophageal varices.