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A female with an acute onset of severe pain in the lower abdomen

Dr. Serghei Puiu, Dr, PhD

Department of Radiology and Imaging, State University of Medicine and Pharmacy “Nicoale Testemitanu”, Chisinau, Republic of Moldova

Corresponding author: Serghei Puiu
Email: puiusv@yahoo.com

Clinical History:

A 47-year-old lady was referred to our department for a second opinion before surgery regarding an ovarian mass suspect of an ovarian tumour. She had an acute onset of severe pain in the lower right abdominal quadrant one week previously, which disappeared spontaneously. When she presented in our department, she had no pain or fever. Blood tests, including tumour markers, were normal.

Transabdominal and transvaginal ultrasound scans were performed. They showed an enlarged, but well-defined right ovary, appearing as a mass (Fig. 1-2). The stroma was heterogeneous due to edema displacing the follicles peripherally (Fig. 3). An echogenic thickened fallopian tube seemed to wrap the enlarged ovary (Fig. 4 a-c). The ovarian arterial and venous flow was preserved (Fig. 5 a-b). A small fluid collection in the Douglas pouch and around the ovary was seen. There was a slight pain on transducer touch.

Figure 1. Enlarged right ovary mimicking a solid adnexal mass.
Figure 2. Enlargement (up to 139 cm3) of the right ovary.
Figure 3. Peripherally located ovarian follicles, displaced by the ovarian stromal edema. Note the heterogeneous appearance of the ovarian stroma.
Figures 4 a-c. Thickened fallopian tube surrounding the enlarged ovarian mass. Small anechoic fluid collection around the ovary. Compare the swollen right tube (thick arrow) and normal appearance of the left tube (thin arrow).
Figures 5 a-b. Present ovarian arterial and venous flow, showing typical Doppler patterns.
Figure 6 a-c. Normal appearance and vascular flow of the right ovary two months later. The right fallopian tube is difficult to visualize.

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Case of the Month June – Liver Red Flags

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Liver Red Flags

Eduardo Davino Chiovatto1
Alessandra Rodrigues Silva Chiovatto1
Marcelo Violi Schelini1
Fernando Linhares Pereira1, 2
Julia Diva Zavaris1, 2
Maria Cristina Chammas1, 2
Wagner Iared1, 3

1.) Ultrasonography Improvement and Research Center Prof. Dr. Giovanni Guido Cerri, DASA, São Paulo, Brazil. 

2.) Institue of Radiology, Hospital das Clinicas School of Medicine, University of São Paulo, São Paulo, Brazil

3.) Department of Medicine – Federal University of São Paulo, São Paulo, Brazil. 

Clinical History:

A 68-year-old female from the countryside of São Paulo was referred to our clinic for a routine ultrasound examination. She had diabetes and arterial hypertension and no history of hepatitis, alcoholism or AIDS.

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Jaundice in an infant

  Rogerio Augusto Pinto da Silva, MD
 Belo Horizonte, Minas Gerais State – Brazil

 Email: ecosala1@gmail.com

Clinical History:

A 94-days-old boy referred to ultrasound imaging due to the development of jaundice.

Figure 1. Upper left: portal vein diameter (4.8 mm) and right portal vein branch diameter (3.9 mm); Lower left: hepatic artery diameter (2.5 mm) ; Lower right: Gallbladder volume (0.025 cm3); Upper right: Portal bifurcation
Figure 2. Upper left: Splenic longitudinal axis (78.9 mm); Lower left: portal bifurcation; Right: Right liver lobe 2D-SWE (Canon i600): Median 33.8 kPa (IQR 1.8) / 3.32 m/s (IQR 0.07)

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Due to the still growing pandemia of SARS-COV-2 we have decided to show a case from a patient suffering from COVID-19 pneumonia. We thank our Italian colleagues for providing the case illustrating the different lung ultrasound findings. We thank you for your support even in these difficult times. 

Our thoughts are with you.
Kind regards

Tobias and Caroline (WFUMB Case of the Month Editors)

Ultrasound findings in COVID-19 pneumonia

Authors and affiliations

Dr. Soccorsa Sofia, Dr. Michele Spampinato

Emergency Department, Local Health Unit, Bologna, Italy

 

Clinical history

A 30-year-old man presents to the emergency department (ED) due to syncope. For the last 10 days he had had fever, cough and dyspnea. At the ED his peripheral oxygen saturation was 86%, BP 130/80, HR 88bpm, RR 20 /min and his temperature 37.4°C. He was given oxygen on a mask. Chest CT was performed and later lung ultrasound (LUS) was performed in 12 areas longitudinal/oblique views using a convex array probe followed by a linear array probe for details (figure 1).

The patient was tested positive for SARS-COV-2. On day 2 after admission the patient’s condition deteriorated, and he was transferred to the ICU. Another chest CT was performed. We show the ultrasound and CT images with corresponding legends (image 1-7 + video 1) and discuss the findings in relation to the diagnostic work-up of COVID-19 pneumonia.

Key for all figures
Image 1: Region R1, day 1, normal A-lines corresponding to normal chest CT findings (see Image 2).
Image 2: Normal chest CT findings in region R1
Image 3: Region R2, day 1, coalescent vertical artifacts erasing the A-lines. The vertical artifacts indicate a non-ventilated area of subpleural pulmonary parenchyma. Please note the sharp demarcation.
Image 4: Region R3, day 1, ring down artifact (thin arrow) appearing from a small subpleural consolidation (thick arrow).
Image 5: Region R3, day 1, non-confluent vertical artifacts indicating non-ventilated lung (arrows).
Image 6: Region L3, day 1, broad vertical artifacts below pleural thickening sharply demarcated from the normally ventilated lung parenchyma.
Image 7: CT image, day 1, corresponding to the previous ultrasound images. The small ground glass areas in L3 corresponds to the subpleural artifacts on LUS.
Image 8: Chest CT (day 2) confirming the lung consolidation. There is also “crazy paving” sign and ground glass opacities.

Video 1:  Lung consolidation in the basal segment of the lower right lobe after patient deterioration (day 2).

Discussion

Most patients with COV2 related disease present with fever, cough, muscle pain, chest discomfort and later dyspnea. More rarely sore throat and intestinal symptoms may be present. 81% of infections are mild (flu-like symptoms); 13.8% of patients develop severe disease including pneumonia and shortness of breath, usually about one week after symptom onset; 4.7% are critical and suffer from respiratory failure, septic shock and multiorgan failure; and in 2.5-7.8% of cases (depending on country and available data) the infection is fatal. The risk of death increases in older patients.

On imaging initial lesions are usually peripheral because SARS-COV-2 attacks the small distal airways. Several reports have described the findings in chest CT. Most commonly few, small, segmental ground glass opacities are seen peripherally and basal. These may deteriorate to become bilateral and multisegmental and finally consolidation and/or ARDS.

Most common LUS signs are: vertical pleurogenic artifacts with varying degree of intensity (from few to confluent). These alternate with clear demarcation to A-lines in the same area, especially in the mid- and upper lung. Pleural thickening, sometimes marked, due to the presence of numerous, small subpleural consolidations. Lobar or translobar consolidations of large size and minimal pleural effusions. The LUS features match with the site and kind on CT.

LUS is an examination, which can be carried out bedside. It may provide early information of presence of diffuse multifocal pneumonia (as in COVID-19) and its deterioration (enlarging consolidations). By doing LUS in cases with COVID-19 pneumonia, transport of patients through the hospital and unnecessary exposure of staff and other patients is avoided.

Similar LUS signs as the ones described have been observed in other kinds of viral epidemic pneumonia. If they, individually or in combination, have some specificity for COVID-19 pneumonia it should be established with further appropriate studies.

References

  1. Tsung JW et at. Prospective application of clinician-performed lung ultrasonography during the 2009 H1N1 influenza A pandemic: distinguishing viral from bacterial pneumonia. Critical Ultrasound Journal (2012) 4:16

http://www.criticalultrasoundjournal.com/content/4/1/16

  1. Zhang et al. Lung ultrasonography for the diagnosis of 11 patients with acute respiratory distress syndrome due to bird flu H7N9 infection.Virology Journal (2015) 12:176 DOI 10.1186/s12985-015-0406-1
  2. Li-Li Ren et al. Identification of a novel coronavirus causing severe pneumonia in human: a descriptive study Chinese Medical Journal (2020) Vol(No) www.cmj.org
  3. 4. Huang C et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet (2020) Jan 24 [Epub ahead of print].
  4. Chung M et al. CT Imaging Features of 2019 Novel Coronavirus (2019-nCoV). Radiology 2020; xxx:xxx–xxx https://doi.org/10.1148/radiol.2020200230
  5. Bernheim Adam et al. Chest CT Findings in Coronavirus Disease-19 (COVID-19): Relationship to Duration of Infection Radiology Feb 20 2020 https://doi.org/10.1148/radiol.2020200463
  6. Qian‐Yi Pengand Chinese Critical Care Ultrasound Study Group (CCUSG) Findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epidemic . Intensive Care Med https://doi.org/10.1007/s00134-020-05996-6

 

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The Northern Lights CEUS Artifact

By Christian Pallson Nolsøe, MD, PhD
Zealand University Hospital, Køge, Department of Surgery

Clinical History:

A 66-year-old male with a history of colon cancer was referred for US-guided biopsy to confirm small PET-positive liver-lesions suspicious of colorectal liver metastases. However, B-mode ultrasound imaging could not visualize the lesions why a Contrast-enhanced ultrasound (CEUS) study using Sonazoid was performed.

CEUS clearly demonstrated wash out of several small lesions, and a CEUS-guided biopsy was carried out at 8 minutes after contrast injection. Immediately after the procedure a strange phenomenon was seen on the B-mode image.

Figure 1. CEUS-guided biopsy of B-mode invisible lesions (white arrows) with distinctive wash out on Sonazoid study. The biopsy target is seen in the puncture line in the upper right image corner.
Figure 2. “Northern Lights” phenomenon (red arrows) was seen on B-mode scanning immediately after Sonazoid guided biopsy. This is also demonstrated in video 1 & 2.

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Case of the Month February – Scrotal pain

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Scrotal pain

Jonathan Cohen, M. D.
Department of Radiology, Rigshospitalet – Copenhagen University Hospital, Denmark

 

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Intermittent pain in the lower right quadrant of the abdomen.

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WFUMB Video of the Month October 2019

WFUMB Video of the Month October 2019

by Admin

Affiliation

Christoph F Dietrich. Medizinische Klinik 2, Caritas-Krankenhaus Bad Mergentheim, Germany.

Video and take home messages

The normal appendix is a wall layered blind-ending, tubular structure that arises from the variably located caecum. The normal appendix visualized without compression can be best seen within free fluid. The arrow indicates the orifice of the appendix.

Featured references

  • Atkinson NS, Bryant RV, Dong Y, Maaser C, Kucharzik T, Maconi G, Asthana AK, Dietrich CF. WFUMB Position Paper. Learning Gastrointestinal Ultrasound: Theory and Practice. Ultrasound Med Biol 2016;42:2732-2742.
  • Atkinson NSS, Bryant RV, Dong Y, Maaser C, Kucharzik T, Maconi G, Dietrich CF. How to perform gastrointestinal ultrasound: Anatomy and normal findings. World J Gastroenterol. 2017;23(38):6931-41.
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WFUMB Video of the Month September 2019

WFUMB Video of the Month September 2019

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Affiliation

Christoph F Dietrich, Medizinische Klinik 2, Caritas-Krankenhaus Bad Mergentheim,

Video Captions

Benign neuroendocrine pancreatic neoplasia(pNET). B-mode (video 1) and contrast enhanced ultrasound using low mechanical index technique (video 2) are shown (Hitachi Ascendus).

Take Home Message

Endoscopic ultrasound is the method of choice to diagnose and exclude small pancreatic neoplasia. Due to the high spatial resolution provided by EUS small cystic and necrotic areas are easily identified. Typical endosonographic features of pNETs are hypoechogenicity and necrotic areas in B‑mode and arterial hyperenhancement after injection of ultrasound contrast agents.

Featured reference

  • Braden B, Jenssen C, D’Onofrio M, Hocke M, Will U, Moller K, Dietrich CF et al. B-mode and contrast-enhancement characteristics of small non-incidental neuroendocrine pancreatic tumors. Endosc Ultrasound. 2017;6(1):49-54.
  • Dietrich CF, Sahai AV, D’Onofrio M, Will U, Arcidiacono PG, Petrone MC, Hocke M, et al. Differential diagnosis of small solid pancreatic lesions. Gastrointest Endosc 2016;84:933-940

 

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WFUMB Video of the Month August 2019

WFUMB Video of the Month August 2019

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Affiliation

Christoph F Dietrich. Medizinische Klinik 2, Caritas-Krankenhaus Bad Mergentheim, Germany.

Video 1 and 2

The contrast enhancement of the heart and lung after intravenous injection follows certain anatomical rules. First the right atrium (video 1, RA), right ventricle (video 1, RV), pulmonary artery, lung parenchyma (video 2, LUNG) and pulmonary veins are enhancing followed by the left atrium (video 1, LA), left ventricle (video 1, LV), coronary arteries & myocardium (video 1, MYO), aorta (video 2, AORTA), bronchial arteries (BA) and the systemic vessels (video 2 including hepatic arteries, portal venous system and liver parenchyma). In other words the venous blood from the heart to the lung parenchyma is featured, which is mandatory for the gaseous exchange. Thereafter, the systemic arterial vascular system is enhancing. In the lung the analysis of the dual blood supply allows the differentiation of lung emboli (pulmonary artery vascular supply followed by pulmonary vein washout) and neoplasia (bronchial artery vascular supply followed by bronchial vein washout). In the liver the dual blood supply allows the differentiation of malignant and benign focal liver lesion. Herewith we demonstrate the contrast enhanced ultrasound enhancement step by step in real-time [1, see also EFSUMB Case of the Month “Amyloidosis”, www.efsumb.org].

Take Home Message

The videos demonstrate the contrast phases in the lung, heart, aorta, bronchial arteries and liver in real-time.

Featured reference

Dietrich CF, Averkiou M, Nielsen MB, Barr RG, Burns PN, Calliada F, et al. How to perform Contrast-Enhanced Ultrasound (CEUS). Ultrasound Int Open. 2018;4(1):E2-E15.

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WFUMB Video of the Month July 2019

WFUMB Video of the Month July 2019

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Author and Affiliation

Alina Constantin1,  Cătălin Copăescu2,  Victor Tomulescu2,  Adrian Săftoiu3

1Gastroenterology Department, Ponderas Academic Hospital Bucharest
2Surgical Department, Ponderas Academic Hospital Bucharest
3Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy Craiova, Romania

Video and Figure 1

SPN which occurs in young women in the third decade of life has well-defined borders and variable central areas with cystic degeneration, necrosis, or hemorrhage (Figure 1a). Contrast enhanced EUS reveals  in SPN  hypoenhancement in the the arterial and venous phase (Video 1). In contrast, NETs are hyperenhancing lesions. Elastography shows stiffer tissue compared to the surrounding (Figure 1b). Biopsy and immunohistochemical staining were performed for final diagnosis.

Take Home Message

Neuroendocrine tumor (NET) and solid-pseudopapillary neoplasm (SPN) are two types of pancreatic tumor that were sometimes difficult to differentiate. Biopsy and immunohistochemical analysis obtained  by a histological needle biopsy plays a crucial role in differentiating these two tumor types, E-cadherin, chromogranin A, and β-catenin representing the most useful markers which should be employed for differentiating between NET and SPN.

Featured reference

Yusuke Ohara, Tatsuya Oda, Shinji Hashimoto. Pancreatic neuroendocrine tumor and solid-pseudopapillary neoplasm: Key immunohistochemical profiles for differential diagnosis, World J Gastroenterol 2016;22(38):8596-8604.

Figure 1a
Figure 1b
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WFUMB Video of the Month June 2019

WFUMB Video of the Month June 2019

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This was a 45-year old man with severe proteinuria. Color Doppler US of the left renal vein (LRV) in transverse plane shows severe compression between abdominal aorta and superior mesenteric artery and bright-colored jetting flow in the inferior vena cava. Measured peak flow velocity was approximately 3 meters per second which is much higher than normal velocity of 40 to 50 cm/sec. 
[Prof. Seung Hyup Kim, Professor in Radiology and Urology, Seoul National University, Korea]

Diagnosis

Nutcracker Syndrome

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WFUMB Video of the Month March 2019

WFUMB Video of the Month March 2019

by Admin

Affiliation

Christoph F Dietrich, Medizinische Klinik 2, Caritas-Krankenhaus Bad Mergentheim, Germany.

Video caption

The esophagus can be examined in the cervical region left to the thyroid. During swallowing the moving air within the esophagus can be identified.

Take Home Message

The feasibility of using swallow contrast-enhanced ultrasound (swallow-CEUS) to examine the function of the upper esophagus and to diagnose Zenker diverticulum has been shown.

Featured reference

Cui XW, Ignee A, Baum U, Dietrich CF. Feasibility and Usefulness of Using Swallow Contrast-Enhanced Ultrasound to Diagnose Zenker’s Diverticulum: Preliminary Results. Ultrasound Med Biol. 2015; 41(4): 975-81

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WFUMB Video of the Month February 2019

WFUMB Video of the Month February 2019

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Author and Affiliation

Christoph F Dietrich. Medizinische Klinik 2, Caritas-Krankenhaus Bad Mergentheim, Germany.

Video

The papilla Vateri can be displayed in real-time. Please note the functional movements of the papilla.

Take Home Message

The papilla Vateri is an anatomic structure, which should be identified as own anatomic entity. The size of the papilla is about 13 x 7 mm (own data).

Featured references

None.

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WFUMB Video of the Month January 2019

WFUMB Video of the Month January 2019

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Author and Affiliation

Christoph F Dietrich. Medizinische Klinik 2, Caritas-Krankenhaus Bad Mergentheim, Germany.

Figure and video 1

The left adrenal gland including the adrenal arterial vessels are shown using endoscopic ultrasound color Doppler imaging [Video].

Take Home Message

Endoscopic real-time ultrasound (US) using high-resolution equipment allows visualization of the left adrenal gland as a routine procedure (99 %). Adrenal arteries can be displayed under good circumstances.

Featured references

  • Dietrich CF, Wehrmann T, Hoffmann C, Herrmann G, Caspary WF, Seifert H. Detection of the adrenal glands by endoscopic or transabdominal ultrasound. Endoscopy 1997;29:859-864
  • Jenssen C, Dietrich CF. Ultrasound and Endoscopic Ultrasound of the adrenal glands. Ultraschall Med 2010; 31(3):228-250.
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WFUMB Image & video of the Month December 2018

WFUMB Image & video of the Month December 2018

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Newborn with arterial hypertension and focal renal or adrenal lesion (B-mode ultrasound, 40 mm). Contrast enhanced ultrasound allowed to solve the differential diagnosis. The complete lesion was non-enhancing (contrast injection of Sonovue™, see video). Adrenal hemorrhage is non-enhancing in contrast to adrenal neoplasia.

[Dietrich CF, Buchhorn R]

Take home messages

Contrast enhanced ultrasound (CEUS) allows diagnosis of adrenal hemorrhage and to exclude neoplasia.
CEUS is safe in newborn, children and adults [(1)].

Featured reference

1.              Sidhu PS, Cantisani V, Deganello A, Dietrich CF, Duran C, Franke D, Harkanyi Z, et al. Role of Contrast-Enhanced Ultrasound (CEUS) in Paediatric Practice: An EFSUMB Position Statement. Ultraschall Med 2017;38:33-43.

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WFUMB Video of the Month November 2018

WFUMB Video of the Month November 2018

by Admin

Author and Affiliation

Christoph F Dietrich. Medizinische Klinik 2, Caritas-Krankenhaus Bad Mergentheim, Germany.

Figure and video 1

The right adrenal gland is shown using transcutaneous B-mode [Figure 1] and the adrenal arterial vessels using color Doppler imaging [Video 1].

Take Home Message

Transabdominal real-time ultrasound (US) using high-resolution equipment allows visualization of the right adrenal gland as a routine procedure (99 %). Adrenal arteries can be displayed under good circumstances.

Featured references

  • Dietrich CF, Wehrmann T, Hoffmann C, Herrmann G, Caspary WF, Seifert H. Detection of the adrenal glands by endoscopic or transabdominal ultrasound. Endoscopy 1997;29:859-864
  • Jenssen C, Dietrich CF. Ultrasound and Endoscopic Ultrasound of the adrenal glands. Ultraschall Med 2010; 31(3):228-250.
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WFUMB Image & video of the Month October 2018

WFUMB Image & video of the Month October 2018

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Pancreatic metastasis from a rectal cancer

Alina Constantin1, Cătălin Copăescu2, Adrian Săftoiu3

  1. Gastroenterology Department, Ponderas Academic Hospital Bucharest
  2. Surgical Department, Ponderas Academic Hospital Bucharest
  3. Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy Craiova, Romania

Endoscopic ultrasound elastography (Fig. 1) + Contrast enhanced harmonic EUS (CE-EUS) (Fig. 2, Movie 1) + EUS-fine needle biopsy (FNB) (Fig. 3). Malignant pancreatic tumors are typically stiff hypoenhanced lesions.

For contrast-enhanced EUS, a peripheral rim (visible during microbubble trace imaging mode) with central hypoenhancement in the arterial and venous phase is suggestive of a pancreatic metastasis. In patients with a personal history of a colorectal cancer this indicates the need to use a histological needle biopsy followed by immunohistochemistry (IHC) analysis, performed in order to rule out pancreatic metastasis.

Featured reference

Palazo M., Role of contrast harmonic endoscopic ultrasonography in other pancreatic solid lesions: Neuroendocrine tumors, autoimmune pancreatitis and metastases. Endoscopic Ultrasound, 2016, Volume 5, Issue 6 [p. 373-376]

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WFUMB Image & video of the Month September 2018

WFUMB Image & video of the Month September 2018

by Admin

“The 90 % rule”: Conventional ultrasound to detect and exclude choledocholithiasis in biliary pancreatitis.

Conventional B-mode ultrasound allows detection and exclusion of choledocholithiasis in about 90 %.

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WFUMB Image of the Month AUGUST 2018

WFUMB Image of the Month AUGUST 2018

by Admin

Endoscopic ultrasound elastography. Soft small solid pancreatic lesions have a high predictive value to be benign.

In patients with small solid pancreatic lesions, EUS elastography can rule out malignancy with a high level of certainty if the lesion appears soft. A stiff lesion can be either benign or malignant [(1)].

Featured reference

1.         Ignee A, Jenssen C, Arcidiacono PG, Hocke M, Moller K, Saftoiu A, Will U, et al. Endoscopic ultrasound elastography of small solid pancreatic lesions: a multicenter study. Endoscopy 2018.

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