Kim Nylund

Ultrasound and inflammatory bowel disease.

Transabdominal bowel sonography is a fast, efficient, and cheap way of examining the intestines. It is also virtually hazard-free and well accepted by patients. During the last 20 years, it has been established as a procedure for detecting bowel disease early in the diagnostic workup. Although rather unspecific, the method is sensitive for detection of bowel disease and can be applied to find the extent and location of inflammatory bowel disease. In patients with known ulcerative colitis and Crohn disease, it can also be used for follow-up because it is easily repeatable and radiation-free. Because it can be applied to find both intraluminal and peri-intestinal pathological features, it is a particularly valuable tool for the detection of complications of Crohn disease as stenosis, fistulas, and abscesses. Neither B-mode nor Doppler techniques have been proven obviously useful in categorizing disease activity, but new techniques using intravenous contrast might come closer to solving this question. Finally, recent longitudinal studies using transabdominal bowel sonography show that it can also give important prognostic information and be used for monitoring the effect of therapy.

Quantitative Contrast-Enhanced Ultrasound Comparison Between Inflammatory and Fibrotic Lesions in Patients with Crohn's Disease

The aim of this study was to determine whether there are differences in absolute blood flow between patients with Crohns disease with inflammation or fibrosis using contrast-enhanced ultrasound. Eighteen patients with fibrotic disease and 19 patients with inflammation were examined. Video sequences of contrast data were analyzed using a pharmacokinetic model to extract the arterial input and tissue residue functions with a custom software, enabling calculation of the absolute values for mean transit time, blood volume and flow. Feasibility of the examination was 89%. The fibrosis group had lower blood volume (0.9 vs. 3.4 mL per 100 mL tissue; p = 0.001) and flow (22.6 vs. 45.3 mL/min per 100 mL tissue; p = 0.003) compared with the inflammation group. There was no significant difference in mean transit time (3.9 vs. 5.5 s). In conclusion, absolute perfusion measurement in the gastrointestinal wall using contrast-enhanced ultrasound is feasible. There seems to be reduced blood volume and blood flow in patients with fibrotic disease.

Bowel Perfusion Measured with Dynamic Contrast-enhanced Ultrasound Predicts Treatment Outcome in Patients with Crohn's Disease

Background:To improve management of patients with Crohns disease (CD), objective measurements of the degree of local inflammation in the gastrointestinal wall are needed. Increased microvessel density and perfusion are typical features of acute inflammation and can be estimated with contrast-enhanced ultrasound (CEUS). The aim of the study was to investigate whether CEUS can provide prognostic information about patients treated medically for an acute exacerbation of CD. Methods:Fourteen patients with CD who received medical treatment for acute exacerbation with systemic steroids or tumor necrosis factor–&agr; inhibitors were prospectively recruited. The patients were examined with clinical scoring, blood tests, and CEUS at time 0, 1, 3, and 12 months after initiation of the treatment. Outcome was treatment efficacy or treatment failure defined as change in medical treatment after 1 month or later. The perfusion analysis was performed with a commercially available software program that analyzes the contrast intensity in a selected area, fits the data to a standardized time-intensity curve, and derives several relative perfusion parameters. Results:Six of the 14 patients had treatment failure during the study period. There was a significant difference between the groups for peak contrast enhancement (P = 0.013), rate of wash-in (P = 0.020) and wash-out (P = 0.008), and the area under the time-intensity curve in the wash-in phase (0.013) at the examination 1 month after the start of treatment. Conclusions:Perfusion analysis of the intestinal wall with CEUS 1 month after starting treatment in patients with CD can provide prognostic information regarding treatment efficacy.

Gastrointestinal Wall Thickness Measured with Transabdominal Ultrasonography and Its Relationship to Demographic Factors in Healthy Subjects

PURPOSE To describe the gastrointestinal (GI) wall thickness and the thickness of individual wall layers in healthy subjects using ultrasound and to determine whether demographic factors, the ultrasound transducer frequency, or a fasting state influences these measurements. MATERIALS AND METHODS After overnight fasting, the GI wall thickness and wall layers were measured in several regions with transabdominal, high-frequency ultrasound. 122 healthy subjects aged 23 - 79 were included. All measurements were performed with both 8 and 12-MHz transducers except for the rectum measurement (4 MHz). 23 patients were given a 300 Kcal test meal and re-examined after 30 minutes. RESULTS Wall thickness measurements of the GI tract with transabdominal ultrasonography are dependent on transducer frequency (p < 0.001), weight (p < 0.001) and age (p < 0.018). The thickness of individual wall layers in the ileum and the sigmoid colon was found to be dependent on both age (p = 0.007) and weight (p < 0.001). The mean wall thickness from the jejunum to the sigmoid colon ranged from 0.9 to 1.2 mm with standard deviations (SD) of 0.3 mm or less. The mean (SD) was 2.9 (0.8) mm in the gastric antrum, 1.6 (0.3) mm in the duodenum, and 2.1 (0.5) mm in the rectum. The gastric antrum was thinner and the ileum and sigmoid colon were thicker after the test meal (p < 0.05). CONCLUSION GI wall thickness depends on weight and age. Provided adequate measurement, an abnormal GI wall should be suspected if the thickness exceeds 2 mm except for in the gastric antrum, duodenum and rectum. Reference values for wall thickness can be used regardless of fasting state or probe frequency except for in the gastric antrum.

Ultrasound perfusion analysis combining bolus-tracking and burst-replenishment

A new signal model and processing method for quantitative ultrasound perfusion analysis is presented, called bolus-and-burst. The method has the potential to provide absolute values of blood flow, blood volume, and mean transit time. Furthermore, it provides an estimate of the local arterial input function which characterizes the arterial tree, allowing accurate estimation of the bolus arrival time. The method combines two approaches to ultrasound perfusion analysis: bolus-tracking and burst-replenishment. A pharmacokinetic model based on the concept of arterial input functions and tissue residue functions is used to model both the bolus and replenishment parts of the recording. The pharmacokinetic model is fitted to the data using blind deconvolution. A preliminary assessment of the new perfusion-analysis method is presented on clinical recordings.

Crohn's disease: Comparison of in vitro ultrasonographic images and histology

Objective. To examine some typical histological findings in Crohns disease using high-frequency ultrasound and to define the echo properties of these findings. Material and methods. Bowel resection specimens from 14 patients operated on for Crohns disease were examined with a 10 MHz linear array ultrasound transducer in a saline reservoir. Needles were placed in the specimen corresponding to the ultrasound plane. After formalin fixation, histological sections were taken according to these markings. Fifty-eight ultrasonographic images with 123 regions of interest were compared with corresponding histology. Results. A thickened muscularis mucosae (>0.3 mm) was found in 48 of 69 regions of interest on histology. Submucosa with slight to moderate fibrosis was imaged as an echo-rich layer with sporadic, echo-poor elements (36/56), while severe fibrosis was seen as an echo-rich layer with diffuse, echo-poor elements (40/55). Muscularis propria with slight to moderate fibrosis was seen as an echo-poor layer with sporadic, echo-rich elements (49/66) while severe fibrosis was seen as an echo-poor layer with diffuse, echo-rich elements (17/22). Crohns rosary was seen as echo-poor extensions of the 4th echo layer (31/50). Conclusions. Typical histological findings in Crohns disease such as a thickened muscularis mucosae and Crohns rosary can be imaged with high-frequency ultrasound in vitro. Fibrosis in the submucosa and muscularis propria is associated with decreasing and increasing echogenicity, respectively.

Visual Computing in Biology and Medicine: Interactive visual analysis of contrast-enhanced ultrasound data based on small neighborhood statistics

Contrast-enhanced ultrasound (CEUS) has recently become an important technology for lesion detection and characterization in cancer diagnosis. CEUS is used to investigate the perfusion kinetics in tissue over time, which relates to tissue vascularization. In this paper we present a pipeline that enables interactive visual exploration and semi-automatic segmentation and classification of CEUS data. For the visual analysis of this challenging data, with characteristic noise patterns and residual movements, we propose a robust method to derive expressive enhancement measures from small spatio-temporal neighborhoods. We use this information in a staged visual analysis pipeline that leads from a more local investigation to global results such as the delineation of anatomic regions according to their perfusion properties. To make the visual exploration interactive, we have developed an accelerated framework based on the OpenCL library, that exploits modern many-cores hardware. Using our application, we were able to analyze datasets from CEUS liver examinations, being able to identify several focal liver lesions, segment and analyze them quickly and precisely, and eventually characterize them.

Parametric ultrasound perfusion analysis combining bolus tracking and replenishment

The paper presents a new perfusion analysis method using ultrasound which combines burst-replenishment and bolustracking acquisition methods. It allows absolute quantification of the mean transit time, blood flow and blood volume. It is based on the concept of arterial input function and tissue residue function and is formulated as a blind-deconvolution problem. It is illustrated on recordings from Crohns disease patients.

EFSUMB Recommendations and Guidelines for Gastrointestinal Ultrasound

In October 2014 the European Federation of Societies for Ultrasound in Medicine and Biology formed a Gastrointestinal Ultrasound (GIUS) task force group to promote the use of GIUS in a clinical setting. One of the main objectives of the task force group was to develop clinical recommendations and guidelines for the use of GIUS under the auspices of EFSUMB. The first part, gives an overview of the examination techniques for GIUS recommended by experts in the field. It also presents the current evidence for the interpretation of normal sonoanatomical and physiological features as examined with different ultrasound modalities.

Illustrated ultrasound for multimodal data interpretation of liver examinations

Traditional visualization of real-time 2D ultrasound data is difficult to interpret, even for experienced medical personnel. To make the interpretation during the education phase easier, we enhance the visualization during liver examinations with an abstracted depiction of relevant anatomical structures, here denoted as illustrated ultrasound. The specifics of enhancing structures are available through an interactively co-registered computed tomography, which has been enhanced by semantic information. To assist the orientation in the liver, we partition the liver into Couinaud segments. They are defined in a rapid segmentation process based on linked 2D slice views and 3D exploded views. The semantics are interactively related from the co-registered modality to the real-time ultrasound via co-registration. During the illustrated ultrasound examination training we provide visual enhancements that depict which liver segments are intersected by the ultrasound slice.