Mamiko Yamada

Clinical efficacy of contrast-enhanced ultrasonography (CEUS) in the diagnosis of ruptured hepatocellular carcinoma (HCC).

PurposeTo evaluate the role of contrast-enhanced ultrasonography (CEUS) in the diagnosis of ruptured hepatocellular carcinoma (HCC).MethodsCEUS and angiography were performed in ten cases of ruptured HCC. We evaluated whether this technique allowed us to determine the bleeding point by observing an extravasation of contrast media into the ascites.ResultsIn four of the ten cases, CEUS demonstrated an extravasation of Levovist into ascites. Angiography showed an extravasation of contrast medium in three of these four cases. In three of the remaining six cases, in which CEUS did not show the presence of contrast medium in ascites, angiography demonstrated an extravasation. In eight cases, it yielded cessation of bleeding. In two cases, embolization was not successful. The bleeding point was not determined by CEUS or angiography in one case.ConclusionCEUS allows us to differentiate active bleeding (presence of contrast medium in the ascites) from nonactive bleeding.

Portal gas in a patient with acute obstructive cholangitis: report of a case with emphasis on US findings.

Portal gas is relatively rare, and its relationship to ischemic bowel diseases has been emphasized. We report the case of a 70-year-old woman with acute obstructive cholangitis in whom portal gas was detected by ultrasonography (US) but not by computed tomography (CT). The former showed multiple echo spots moving in the portal vein. Doppler signals confirmed them to be bidirectional and spiky, which immediately led to the diagnosis of portal gas. Immediate appropriate antibiotic treatment and biliary drainage yielded the disappearance of the portal gas. We stress the usefulness of US and Doppler US for detecting and diagnosing portal gas. Our observation suggests that when portal gas is detected by US, the possibility of cholangitis should be included in the differential diagnosis.

Hepatic cyst with intracystic bleeding: contrast-enhanced sonographic findings.

Intracystic bleeding is a relatively rare complication of hepatic cysts, which is very difficult to diagnose by conventional sonography (US). Hence, a new US technique has been sought for this purpose. We present the case of a hepatic cyst with intracystic bleeding in which contrast-enhanced US showed microbubbles oozing from the cyst wall into the cystic cavity. Contrast-enhanced US is now an important diagnostic tool for diagnosing liver tumors, but contrast-enhanced US findings relating to intracystic bleeding have not been reported. Our observations suggest that this technique may be a useful new diagnostic tool for this purpose.

Malignant triton tumor in a patient with neurofibromatosis type 1

We report a case of neurofibromatosis type 1 (NF1) complicated by a malignant triton tumor (MTT), with an emphasis on B-mode sonographic (US) and contrast-enhanced US (CEUS) findings. To the best of our knowledge, this is the first report describing CEUS findings of MTT. The mass was poorly demarcated and composed of an internal echogenic area and an outer hypoechoic zone. CEUS findings showed the outer zone to be strongly enhanced, and the internal area was very poor in blood flow because of necrotic tissues.

Rupture of liver metastasis: report of a case with an emphasis on contrast-enhanced US

We present a case of liver metastasis from an uterine leiomyosarcoma in which contrast-enhanced ultrasonography (CEUS) helped determine the bleeding point and prevented a delay in devising diagnostic and therapeutic strategies. CEUS allowed us to differentiate active from nonactive bleeding on the basis of presence or absence of contrast extravasation in the ascites. CEUS is the first examination performed when liver tumor rupture is suspected. Reference to the preangiographic CEUS results is expected to provide a road map for angiography.

Analysis of posterior echoes using reconstructed vertical ultrasound images

PurposeTo evaluate the role of vertical images reconstructed using 3-D data in the analysis of posterior echoes.MethodsReconstructed vertical images of US phantoms with the following artifacts were retrieved and analyzed: acoustic shadowing (clean and dirty); posterior echo enhancement (with/without lateral shadowing); and reverberation artifacts (clean and dirty).ResultsFor acoustic shadowing, a stone and posterior clean acoustic shadowing were imaged as an echogenic mass or an echogenic ring containing a central echo-free area. However, the stone and dirty acoustic shadowing were imaged as an echogenic mass or an echogenic mass consisting of many fine echo spots disseminated throughout the whole mass. For posterior echo enhancement, when lateral shadowing is present, the cyst and posterior echo enhancement are imaged as a round anechoic mass or a triple circle consisting of a thin anechoic outer rim, an echogenic ring, and an anechoic center. However, when lateral shadowing is absent, they are imaged as a round anechoic mass or a double circle consisting of an echogenic outer rim and an anechoic center. For clean reverberation artifacts and dirty reverberation artifacts, vertical images of clean reverberation artifacts consist of either a homogeneous echogenic area or an absent signal. However, vertical images of dirty reverberation artifacts consist of a homogeneous echogenic area and an area consisting of fine echo spots.ConclusionOur study suggests that reconstructed, previously unattainable, vertical plane images help us better understand the mode of posterior echoes.

Portal-systemic shunt through the right renal vein developing following portal tumor thrombus

Despite the semi-routine use of color Doppler sonography for evaluating portal circulation abnormalities, there is a relative paucity of information on portal-systemic (P-S) shunt through the right renal vein (P-SR shunt). We report such a case. The patient was a 60-year-old woman with hepatocellular carcinoma on liver cirrhosis. Serial sonography showed an aggravation in findings; an increase in the size of the tumor was followed by formation of a portal tumor thrombus, and then occurrence of a P-SR shunt. We present this case, with a comparison between the patients clinical course and the color Doppler results. To our knowledge, this is the first report to make such a comparison in a P-SR shunt case. We also briefly review the literature.

When the gallbladder is not detected in the usual location.

A 34-year-old man visited our institution with a complaint of transitory abdominal discomfort. His medical history was significant for insulin-dependent diabetes mellitus and chronic renal failure. Biochemical data showed mild renal dysfunction and mild leukocytosis. US detected bilateral renal abnormalities consistent with chronic renal failure and an oval 6 × 7cm cystic mass behind the left hepatic lobe but did not show the gallbladder in the usual location. Careful observation showed a narrow duct connecting the right side of the mass to the common bile duct (Fig. 1). This led to the diagnosis of left-sided gallbladder. The gallbladder also contained many small stones (Fig. 2). The patient’s condition improved rapidly under conservative medical treatment, and his symptoms gradually disappeared.

A case of pelvic kidney: contrast-enhanced ultrasonographic findings

frontal part (Fig. 1c). Contrast-enhanced US examination using a Levovist solution (Schering, Berlin, Germany) provided detailed information about the hemodynamics within the mass. It showed a normal enhancement pattern in the right kidney: the cortical portion of the right kidney was enhanced, but its medulla was not enhanced between 15 and 25 s after injection of Levovist solution; both the cortical and medullary portion were enhanced between 25 and 40 s after injection, and the whole kidney was homogeneously enhanced after 40 s. The pelvic mass showed the same enhancement pattern (Fig. 2). These US and contrastenhanced US fi ndings led us to the diagnosis of pelvic kidney.

Isolated splenic granuloma: report of a case with an emphasis on ultrasound findings

There is a marked paucity of reports on contrast-enhanced ultrasonography (US) for focal splenic disease in the literature, and there are no previously reported contrast-enhanced US findings for splenic granuloma. We report the case of a 77-year-old cirrhotic woman with isolated splenic granulomas. We detail the diagnostic difficulty encountered in this case and briefly review the literature.