Holger Neye

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 ĸ 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 ĸ 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 ĸ: 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.

Evaluation of Diagnostic Criteria for Liver Metastases of Adenocarcinomas and Neuroendocrine Tumours at Conventional Ultrasound, Unenhanced Power Doppler Sonography and Echo-Enhanced Ultrasound

Purpose: In order to improve the differential diagnosis between liver metastases of neuroendocrine tumours and adenocarcinomas, criteria for the masses at conventional ultrasound, unenhanced power Doppler sonography and echo-enhanced ultrasound were evaluated. Methods: Seventy-three patients with histologically proven liver metastases of a neuroendocrine tumour (n = 26) or an adenocarcinoma (n = 47) were investigated by conventional ultrasound as well as unenhanced power Doppler sonography and echo-enhanced ultrasound focusing on specific properties of the lesions. Results: Liver metastases of neuroendocrine tumours and adenocarcinomas showed a different contrast behaviour with echo-enhanced sonography. A hypervascularisation at the arterial and capillary phase were found in 85% of the neuroendocrine metastases, and in 17% of the masses of adenocarcinomas, respectively (p < 0.05). Conclusions: The successful treatment of liver metastases requires a highly sensitive and specific diagnostic procedure for their differentiation. A hypervascularisation of the lesions during the arterial and capillary phase at echo-enhanced ultrasound may point to a neuroendocrine primary tumour. However, histology is the only standard of reference for the differentiation of liver metastases, and is necessary for optimal therapy.

Impact of high-resolution transabdominal ultrasound in the diagnosis of complications of Crohn's disease

Abstract Objective. Crohns disease is associated with intestinal complications such as strictures, fistulas and abscesses. As the management of the patients is influenced by the presence or absence of complication, sensitive diagnostic modalities to detect these complications are needed. The aim of this prospective study was to evaluate the diagnostic accuracy of high-resolution transabdominal ultrasound in the diagnosis of complications of Crohns disease. Material and methods . From April 2003 to July 2009, 58 patients (31 women, 27 men; mean age 36.3 years, range 13-86 years) with known Crohns disease were included in the study and investigated with high-resolution transabdominal ultrasound. The diagnosis of Crohns disease was based on clinical, endoscopic, histological, radiological and operative findings. Patients with other forms of enteritis (e.g. infectious) were excluded from the study. Twenty of the 58 patients were investigated on a second occasion with other symptoms than at the first admission. The time duration between the two ultrasound investigations was at least 3 months. Consequently, a total of 78 ultrasound investigations were done in 58 patients. With respect to their clinical symptoms, all patients were further investigated within 2 weeks after ultrasound with magnetic resonance imaging, and/or computed tomography, and/or enteroclysis, and/or endoscopy with biopsy. Together with clinical data (Crohns disease activity index) and surgical findings these investigations were used as reference procedure. Results. The sensitivity, specificity, positive predictive and negative predictive values of ultrasound were as follows: 0.86, 0.90, 0.83 and 0.92 for stenoses; 0.78, 0.95, 0.86, and 0.91 for fistulas; 0.90, 0.99, 0.90 and 0.99 for abscesses, respectively. Conclusions. High-resolution transabdominal ultrasound done by experienced examiners has an excellent diagnostic accuracy in the diagnosis of complications in patients with Crohns disease. Thus, it can be recommended as one of the primary investigative procedures for evaluation of Crohns disease.

Pancreatitis and Pseudocysts

Ultrasonography (US) is a noninvasive imaging modality which is often the first imaging technique in the evaluation of patients with pancreatic diseases. It has undergone significant advances in recent years. In this chapter the value of US in the diagnosis of pancreatitis and pseudocysts will be described and discussed. The article is focused on B-mode US, Doppler sonography and contrast-enhanced ultrasound (CEUS).

Fieber und Aphthen – die Vortäuschung einer Infektion durch einen Morbus Behçet

E aus der östlichen Türkei stammender 20-jähriger Patient wurde wegen deutlicher Verschlechterung seines Allgemeinzustands sowie Fieber stationär aufgenommen. Bei der körperlichen Untersuchung zeigten sich Aphthen im Mund und stark entzündete Augen (Abbildungen 1a und 1b). Aphthöse Veränderungen fanden sich auch an der Glans penis des Patienten. An den Streckseiten aller Extremitäten waren knotig-pustulöse Veränderungen, an den Fußsohlen aphthöse Läsionen nachweisbar (Abbildung 2a). In den Laboruntersuchungen waren die Leukozyten mit 10,7 Gpt/l (Normbereich: 4,0–10,0 Gpt/l) geringfügig erhöht, die Thrombozyten waren mit 122 Gpt/l (Normbereich: 140–450 Gpt/l) erniedrigt, das C-reaktive Protein betrug bei Aufnahme 46 mg/l (Normbereich: < 8,0 mg/l). Aufgrund der Hautveränderungen unter Einschluss der Glans penis wurde der Patient einem Facharzt für Hautund Geschlechtskrankheiten konsiliarisch vorgestellt, der den Verdacht auf eine HIV-Infektion äußerte. Im Verlauf der folgenden 2 Tage verschlechterte sich der Allgemeinzustand des Patienten deutlich, das C-reaktive Protein stieg mit 115 mg/l auf über das Doppelte seines Aufnahmewerts an. Der HIVSchnelltest konnte den Verdacht des dermatologischen Konsils nicht bestätigen, die serologische Diagnostik bezüglich einer Lues und einer Herpesinfektion war negativ. Sonographisch zeigten alle abdominellen Organsysteme einschließlich der großen Gefäße sowie der subphrenischen und der zervikalen Lymphknoten Normalbefunde. Auch im Bereich der Aphthen der rechten Fußsohle (Abbildung 2a) kam der hochauflösende Schallkopf (dynamischer Linearscanner 5–12 MHz, iU22, Philips Ultrasound, Bothell, WA, USA) zum Einsatz. Hierbei stellten sich die subkutanen Arterien korkenzieherartig verlaufend und stark durchblutet dar, ihre direkte Umgebung war echoarm verändert (Abbildung 3a). Dieses Bild wurde als eine Vaskulitis der kleinen Gefäße der Fußsohlen gedeutet, und in Zusammenschau mit den übrigen Körperveränderungen des Patienten wurde der hochgradige Verdacht auf einen Morbus Behçet geäußert. Der daraufhin durchgeführte Pathergietest wurde nach 48 h als negativ bewertet.

Diagnose eines Ileumkarzinoids mittels kontrastverstärkten Ultraschalls

E 61-jährige Frau kam mit seit Wochen bestehender Übelkeit sowie rezidivierendem Erbrechen und Durchfall zur stationären Aufnahme. Wesentliche Erkrankungen bestanden bisher nicht. Die körperliche Untersuchung war bis auf eine Gesichtsrötung (Flush-Symptomatik), die laut der Patientin in letzter Zeit unterschiedliche Intensität besaß, unauffällig. In der Ultraschalluntersuchung des Abdomens (2bis 5-MHz-Konvexschallkopf, iU22, Philips) konnten multiple (mehr als zehn) unterschiedlich echogene Leberläsionen nachgewiesen werden (Abbildung 1a). Nach intravenöser Applikation von 2,4 ml des Ultraschallkontrastmittels SonoVue® (Pulsinversionsverfahren mit einem mechanischen Index von 0,07) zeigte sich in der arteriellen Durchblutungsphase der Leber eine starke Hyperämie der Raumforderungen (Abbildung 1b). In der portalvenösen und späten Durchblutungsphase waren sie weniger vaskularisiert als das umgebende normale Lebergewebe, so dass sie als Kontrastdefekte zur Darstellung kamen (Abbildung 1c). Unter dem Verdacht auf Lebermetastasen eines neuroendokrinen Tumors wurde das übrige Abdomen nach dem Primärtumor abgesucht. Dabei fiel im terminalen Ileum ein knapp 3 cm großer, echoarmer und unscharf begrenzter Tumor auf (Abbildung 2a). Dieser wies nach erneuter

Differentiation of neuroendocrine pancreatic tumors using echo-enhanced power-doppler sonography with 2nd harmonic imaging

Objective: Differentiation of neuroendocrine from other pancreatic lesions is difficult. We investigated prospectively the value of echo-enhanced power-Doppler sonography for the differential diagnosis of neumendocrine pancreatic tumors. Patients and methods: 04 patients with a pancreatic tumor in conventional ultrasound were investigated by power-Doppler sonography with 2nd Harmonic Imaging using the echo-enhancer LevovisP (300 mg/ml, bolus i.v., Schering AG, Berlin, Germany). Previously defined criteria of signal behaviour and vascularizetion pattern of the tumors compared to the surrounding tissue were used for the ultrasound diagnoses. 17 of 19 patients with the suspected diagnosis of a neuroendocrine tumor at sonography were investigated in addition by octreotide-scintigraphy. Histological diagnoses for all patients were obtained alter surgical tumor resection or by percutaneous needle biopsy. Results: Echo-enhanced power-Doppler sonography with 2nd Harmonic Imaging allowed the differential diagnosis of neuroendocrine pancreatic tumors with a sensitivity of 100% and a specificity of 96%. Conclusion: Echo-enhanced power-Doppler sonography has a higher accuracy in the differentiation of neuroendocrine tumors from other pancreatic lesions than octrsotide-scintigraphy.