Azzo Widman

Thyroid nodules: Evaluation with power Doppler and duplex Doppler ultrasound:

This study purposes a new classification of thyroid nodules blood flow by power duplex Doppler ultrasound. A total of 177 nodules were studied with B-mode scanning, power Doppler, and spectral analysis. These data were compared with cytological results from ultrasound-guided fine-needle aspiration biopsy. Univariate and multivariate logistic regression analysis were performed. The power Doppler analysis of the nodules produced 5 vascular patterns: I, absence of signal blood flow; II, exclusively perinodular blood flow; III, perinodular > central blood flow; IV, central blood flow > perinodular blood flow; V, exclusively central blood flow. Statistical analysis revealed a significant relationship between these vascular patterns and cytological results. The spectral analysis demonstrated that the resistance index were higher in nodules with malignant versus other cytology (P >0.001). The results indicate that power duplex Doppler facilitates screening of thyroid nodules at high risk for malignancy with elevated sensitivity (92.3%) and specificity (88%).

Hepatosplenic schistosomotic portal hypertension: effect of esophagogastric devascularization with splenectomy on the diameter and mean flow velocity in the portal system (ultra-sonographic Doppler study)

Racional - A esplenectomia com desconexao azigo-portal tem sido indicada para o tratamento da hemorragia digestiva pelas varizes esofagicas na hipertensao portal da esquistossomose mansonica hepatoesplenica. Todavia, esta tecnica terapeutica apresenta indices variaveis de complicacoes tromboticas precoces do sistema portal (13,3% a 53,2%). Supondo que as alteracoes circulatorias devidas ao tratamento cirurgico tenham papel preponderante neste acontecimento, procurou-se identificar elementos hemodinâmicos que, dentre os multiplos fatores causais, tenham facilitado a ocorrencia desta complicacao. Com este intuito estudou-se comparativamente, mediante ultra-sonografia com Doppler, o sistema portal de dois grupos de pacientes em condicoes clinicas semelhantes: nao-operados e com desconexao azigo-portal em fase pos-operatoria tardia (periodo superior a 6 meses). Casuistica/Metodo - Foram estudados 58 pacientes com esquistossomose mansonica hepatoesplenica e com antecedentes de hemorragia digestiva alta, divididos em dois grupos: A (29 sob controle ambulatorial: clinico e endoscopico); B (29 submetidos previamente a desconexao azigo-portal). Em todos foi feita a medida do diâmetro e da velocidade media de fluxo do sangue na veia porta e seus ramos direito e esquerdo, mediante ultra-sonografia com Doppler. Os resultados foram submetidos a analise univariada inter e intragrupo. Resultados - No grupo A (nao-operados): a veia porta apresentou diâmetro maior do que o dos ramos direito e esquerdo e nestes esta medida foi semelhante (10,6 ± 2,9, 8,0 ± 1,8, 9,1 ± 2,6 cm); a velocidade media de fluxo na veia porta e nos ramos portais foi semelhante (15,62 ± 6,17, 14,92 ± 5,33, 16,12 ± 4,18 cm/seg). No grupo B (operados): houve diminuicao de ambos os parâmetros na veia porta e seus ramos (8,8 ± 1,7, 5,2 ± 1,2, 7,5 ± 2,2 cm/12,53 ± 2,60, 8,86 ± 1,75, 9,60 ± 3,75 cm/seg). Conclusoes - Houve reducao significativa do diâmetro e da velocidade media de fluxo sanguineo no sistema portal, no pos-operatorio tardio, em pacientes com esquistossomose mansonica hepatoesplenica, submetidos a desconexao azigo-portal.

Incidence and predictors of severe liver fibrosis in HIV-infected patients with chronic hepatitis C in Brazil.

The aim of this study was to examine the incidence and factors associated with the severity of liver fibrosis in 234 coinfected patients in Brazil. Patients were cared for in our clinic, from 1996 to 2004. Eligible patients were defined as patients with documented HIV and hepatitis C virus (HCV) infections and had previously undergone a liver biopsy. Patients with persistently normal alanine aminotransferase (ALT) were also included. The variables selected for study were age, gender, risk category, history of high alcohol consumption, CD4(+) T cell count, antiretroviral therapy usage, HCV genotype and duration of HCV infection. Stage of fibrosis was scored as follows: F0, no fibrosis; F1, portal fibrosis with no septa; F2, portal fibrosis with few septa; F3, bridging fibrosis with many septa; and F4, cirrhosis. The liver fibrosis stage was F3 in 39 (16.6%) and F4 in 20(8.5%) patients. Among patients with normal ALT, the liver fibrosis stage was F3-F4 in three patients (5.6%). Predictors of severe liver fibrosis (F3-F4) by multivariate analysis were age (older patients) and genotype 3 (genotype 1 = odds ratio [OR], 0.28; 95% confidence interval [CI], 0.12 0.65). In summary, in the present study severe liver fibrosis was found in 25% of our patients and was associated with an age of more than 38 years at the time of liver biopsy as well as, HCV genotype 3. No differences were found with respect to CD4(+) T cell counts although patients with a CD4(+) T cell count greater than 50 were excluded.

Aspectos morfológicos e hemodinâmicos do baço em indivíduos normais: estudo por ultra-som Doppler

BACKGROUND: The diversity of existing techniques for the measurement of the spleen using Doppler ultrasound (Doppler-US) as well as the lack of biometrical and Doppler velocimetry reference values make the evaluation of this organ and its hemodynamics quite difficult. OBJECTIVES: To establish biometrical and hemodynamics Doppler-US standard values for healthy adult individuals. MATERIALS AND METHODS: This is a prospective study involving 44 healthy individuals (19 males and 25 females) with mean age of 37.4 ± 9.6 years (23-60 years). Morphometry (US-B mode): spleen: longitudinal (L), transversal (T) and anteroposterior (AP) axes; splenic artery diameter (AD) and splenic vein diameter (VD). Morphometrical spleen indexes: uniplanar (UI), biplanar (BI) and the splenic volume (SV). Doppler velocimetry (US-Doppler): a) splenic artery: systolic peak velocity (SPV), mean of the highest flow speeds (TAMax); pulsability index (PI) and vascular impedance resistivity index(RI); b) splenic vein: mean of the highest flow speeds (TAMax). RESULTS: Morphometry: L = 9.3 ± 1.3 cm; T= 3.9 ± 0.7 cm; AP = 8.4 ± 1.2 cm; AD = 0.3 ± 0.07 cm; VD: 0.5 ± 0.12 cm. Morphometrical spleen indexes: UI = 33.5 ± 9.9; BI = 36.7 ± 10.3; SV = 164.3 ± 62.9 cm³. Doppler velocimetry: a) splenic artery: SPV = 59.8 ± 23.6 cm/s; TAMax = 40.2 ± 15.9 cm/s; PI = 0.86 ± 0.30; RI = 0.55 ± 0.09; b) splenic vein: TAMax = 16.8 ± 8.3 cm/s. CONCLUSION: Report of biometrical and Doppler velocimetry standard values of the spleen in healthy individuals.

Contribuição da ultrassonografia para o diagnóstico das alterações histopatológicas presentes na hepatite C crônica, com ênfase na esteatose hepática: Parte I

OBJECTIVE: To evaluate the role of ultrasonography in the assessment of histopathological changes in patients with chronic hepatitis C, with emphasis on hepatic steatosis. MATERIALS AND METHODS: Liver ultrasonography results were compared with histopathological findings of liver biopsy of 192 patients with chronic hepatitis C virus infection. All the US examinations followed a single protocol, analyzing the following aspects: echogenicity, echotexture and attenuation. The patients sample was divided into two groups as follows: patients with sonographic changes and patients with no sonographic changes. Sonographic findings of both groups were compared with histopathological findings after liver biopsy. RESULTS: Statistically significant intergroup differences were observed just regarding architectural changes grades 0 and 3 and hepatic steatosis. Attenuation was the sonographic criterion that was best correlated with hepatic steatosis. CONCLUSION: The results of the present study demonstrate that, in patients with chronic hepatitis C, ultrasonography has limitations in the characterization of histopathological changes, with an intermediate rate of agreement with the diagnosis of hepatic steatosis. Considering the specificity of 77.9% and the negative predictive value of 95.5%, the authors highlight the capacity of the method to demonstrate the probability of absence of hepatic steatosis.

Determinação do tamanho do fígado de crianças normais, entre 0 e 7 anos, por ultrassonografia

OBJECTIVE: The present study was aimed at sonographically determining the liver size in healthy newborns, infants and children under 7 years of age, correlating results with age, sex, height, body weight and body mass index. MATERIALS AND METHODS: A total of 584 healthy children subdivided into 11 age groups were evaluated with measurements of the left lobe craniocaudal diameter at the midsternal line, and the craniocaudal diameter of the right lobe posterior surface at the midclavicular line. The following tests were utilized for statistical analysis: a) Pearsons correlation coefficient (correlation study); b) non-paired Students t-test (comparison of measures between sexes); c) nonlinear regression models (nomograms). RESULTS: The liver size presented a progressive growth from the birth up to the age of 7, proportionally lower than the body growth, in correlation with age, height and body weight (r > 0.70). Correlation with the body mass index was not observed (r < 0.11). There was no significant difference in liver size between male and female individuals. CONCLUSION: Liver size was sonographically determined in healthy children under the age of 7 by means of a standardized method, demonstrating a strong correlation with age and anthropometric indicators. Nomograms demonstrate the typical variations of the liver size in the population evaluated with a different growth pattern for each hepatic lobe.

VEIA PARAUMBILICAL PÉRVIA: importância hemodinâmica na hipertensão portal por esquistossomose mansônica hepatoesplênica. (Estudo com ultra-sonografia Doppler)

BACKGROUND The hemodynamical effect of the collateral portosystemic circulation upon the portal system has not yet been fully understood. The US-Doppler made possible the non-invasive study of the portal system by evaluating the parameters: flow direction, diameter and flow velocity in its vessels. AIMS To study the paraumbilical vein as a collateral portosystemic pathway and identify patterns for appraising its hemodynamic importance to the portal system. METHOD US-Doppler study of the portal system of 24 patients with Mansonis hepatosplenic schistosomic portal hypertension, previous esophagic variceal bleeding and patent paraumbilical vein with hepatofugal flow. The diameter and the mean flow velocity were measured in the paraumbilical vein and so were the mean flow velocity in the portal vein, right and left portal branches. The Pearson test (linear correlation) was applied to the portal veins mean flow velocity and the paraumbilical veins diameter and mean flow velocity. The patients were divided in four groups: D1-paraumbilical vein with diameter < 0.68 cm (n = 14), D2-paraumbilical vein with diameter > or = 0.68 cm (n = 10), V1-paraumbilical vein with mean flow velocity < 18.41 cm/seg (n = 13) and V2-paraumbilical vein with mean flow velocity > or = 18.41 cm/seg (n = 11). The mean flow velocity in the portal vein, right and left portal branches of the four groups were compared. RESULTS The paraumbilical vein diameter was 0.68 +/- 0.33 cm (range: 0.15-1.30 cm) and the mean flow velocity was 18.41 +/- 11.51 cm/seg (range: 5.73-38.20 cm/seg). The linear correlation between the portal veins mean flow velocity/paraumbilical vein diameter and the paraumbilical veins mean flow velocity showed r = 0.504 and r = 0.735, respectively. In the group D2 there was an increase in the mean flow velocity in the portal vein (17.80 +/- 3.42/22.30 +/- 7.67 cm/seg) and in the left portal branch (16.00 +/- 4.73/22.40 +/- 7.90 cm/seg). In the group V2 there was an increase in the mean flow velocity in the portal vein (16.31 +/- 3.49/21.96 +/- 5.89 cm/seg) and in the left portal branch (14.22 +/- 4.41/21.94 +/- 7.20 cm/seg). There was no change in the right portal branch (13.67 +/- 5.74/15.43 +/- 3.43 cm/seg). CONCLUSIONS In portal hypertension due to hepatosplenic schistosomiasis, the patent paraumbilical vein, with hepatofugal flow, diameter > or = 0.68 cm and mean flow velocity > or = 18.41 cm/seg causes an increase of the mean flow velocity in the portal vein and left portal branch. The best US-Doppler parameter to appraise the paraumbilical vein influence upon the portal system is the mean flow velocity. The correlation between the increase in portal veins mean flow velocity is stronger with the paraumbilical veins mean flow velocity than with its diameter. The increase in the portal veins and left portal branchs mean flow velocity may be understood as the paraumbilical veins hemodynamic influence upon the portal system. An active portosystemic collateral pathway increases the mean flow velocity in the veins segment proximal to its point of origin.

Fístulas arteriovenosas intra-hepáticas transtumorais (diagnóstico, importância e propostas de tratamento)

The authors present the angiographic aspects of four patients having an arteriovenous transhepatic transtumoral fistula (two arterioportal and two arteriovenous). The angiographic results of the occlusion with cyanoacrylate (Hystoacryl) of the right hepatic artery in one and by the infusion of Lipiodol in two are also shown. The physiopathological characteristics of each kind of fistula are discussed and the consequences of the passage of the quimioembolizing mixture through the tumor, regarding intrahepatic abscess formation, irregular clinical results and pulmonary complications are commented. These complications make the diagnosis of a transtumoral transhepatic arteriovenous fistula, previously to the chemoembolic treatment important, even though being frequently difficult, because of the reduced caliber of the feeding artery and eventual low transfistular bloodflow. The efficient occlusion of the arterioportal fistula with Histoacryl was favourably compared to the infusion of Lipiodol, which was unable to occlude the arteriovenous fistula. The contraindication to perform chemoembolic treatment of hepatic tumors, when an intrahepatic transtumoral arteriovenous fistula is present and the embolization of the fistular feeding artery is stressed. Ultrasonography using color Doppler and sono-enhancing contrast is appointed as the ideal non-invasive means of making the diagnosis of an hepatic transtumoral fistula and makes it eligible to be the first test in the algorithm for the appraisal of hepatic tumors.

Late morphologic and hemodynamic changes in the splenic territory of patients with mansoni's hepatosplenic schistosomiasis after distal splenorenal shunt. (Ultrasonography-Doppler study)

BACKGROUND The distal splenorenal anastomosis (Warrens operation) has been indicated for the treatment of high digestive bleeding caused by esophagic varices because it would ideally reduce the venous pressure in the cardiotuberositary territory without changing the mesenteric-portal venous flow. However, the changes it produce in the splenic territory have not been fully understood. AIM To appraise the late morphologic and hemodynamic changes in the splenic territory produced by the distal splenorenal anastomosis in patients with portal hypertension due to mansonis hepatosplenic schistosomiasis complicated by esophagic bleeding. METHOD Ultrasonography-Doppler study of the splenic region of 52 patients with portal hypertension due to mansonis schistosomiasis and previous bleeding by esophagic varices. They were divided in two groups: 40 non operated upon and 12 with a distal splenorerenal anastomosis. The following parameters and indices were compared between the two groups: a) morphometric parameters (splenic artery and veins diameter, splenic diameters (longitudinal, transversal and antero-posterior); b) velocimetric parameters of the splenic vessels (systolic peak velocity in the splenic artery, mean flow velocity in the splenic vein; c) biometric index of the spleen (longitudinal x transversal); volumetric index of the spleen (longitudinal x transversal x antero-posterior x 0,523); hemodynamic indices of the splenic arterys impedance: pulsatility and resistivity. RESULTS The patients with distal splenorenal anastomosis showed: a) reduction in splenic indices: volumetric (non operated 903,83 +/- 452, 77 cm / distal splenorenal anastomosis 482,32 +/- 208,02 cm (46,64%)) and biometric (non operated 138,14 +/- 51,89 cm /distal splenorenal anastomosis 94,83 +/- 39,83 cm (33,35%)); b) no change: splenic arterys diameter (non operated 0,57 +/- 0,16 cm/distal splenorenal anastomosis 0,57 +/- 0,23 cm); velocity in the splenic artery non operated 107 +/- 42,02 cm/seg/distal splenorenal anastomosis 89,81 +/- 41,20 cm/seg), resistivity (non operated 0,58 +/- 0,008/distal splenorenal anastomosis 0,56 +/- 0,06) and pulsatility (non operated 0,91 +/- 0,19/distal splenorenal anastomosis 0,86 +/- 0,15, splenic vein (non operated 1,10 +/- 0,30 cm/distal splenorenal anastomosis 1,19 +/- 0,29 cm); c) increase: mean flow velocity in the splenic vein (non operated 20,54 +/- 8,45 cm/seg/distal splenorenal anastomosis 27,83 +/- 9,29 cm/seg). CONCLUSIONS The comparison of the ultrasonography Doppler results of the two groups of patient (non operated and distal splenorenal anastomosis) showed that in patients with distal splenorenal anastomosis there was a decrease of the volume of spleen; increase in the mean flow velocity in the splenic vein; no changes in the morphologic and hemodinamyc parameters of the splenic artery neither in its velocimetric indices.