The appearance and significance of extrapleural fluid after esophageal atresia repair

OBJECTIVE

The objective is to describe the appearance and evaluate the significance of postoperative extrapleural fluid collections in neonates who have undergone esophageal atresia repair in which an extrapleural surgical approach was used.

CONCLUSION

Extrapleural effusion in a neonate who has undergone repair of esophageal atresia by an extrapleural approach is associated with a high incidence of anastomotic leakage. Such patients may also be at increased risk for developing a delayed esophageal stricture. On chest radiography, these extrapleural effusions look like fluid in the pleural space.

[Significance of the hypoechoic area around the long biceps tendon in shoulder sonography--underlying pathology]

OBJECTIVE

The objective was to evaluate the sonographic sign of a hypoechoic area ("halo-sign") around the long biceps tendon as an equivalent of intraarticular effusion.

METHODS

Part 1: Ten patients scheduled for shoulder arthroscopy underwent ultrasonography immediately before surgery. If there was no hypoechoic area around the long biceps tendon 30 ml of NaCl-solution (0.9%) were injected into the joint. After repetitive passive motion the patient underwent a second ultrasonography. Part 2: Ten consecutive patients with a hypoechoic area around the long biceps tendon underwent shoulder arthroscopy. During this procedure they were examined for intraarticular effusion. Patients with rheumatoid disease were excluded from the study.

RESULTS

Part 1: In 9 of 10 patients a hypoechoic area around the long biceps tendon was induced by injection into the joint. The area was 1.07 +/- 0.13 cm2. In one case we could not induce the described phenomenon. Part 2: In all patients with a hypoechoic area around the long biceps tendon an intraarticular effusion was found at arthroscopy.

CONCLUSION

A hypoechoic area around the long biceps tendon correlates with fluid in the synovial sheet and indicates effusion within the glenohumeral joint.

Pictorial review: Subperitoneal spaces of the broad ligament and sigmoid mesocolon--imaging findings

In this report, we illustrate the imaging findings of diseases in the subperitoneal space of the broad ligament and sigmoid mesocolon and discuss the pathways of subperitoneal spread of disease. The subperitoneal space of the broad ligament and sigmoid mesocolon is continuous with that of the parietal peritoneum overlying the pelvic wall. Extraperitoneal diseases originating in the pelvis can extend, via the abdominopelvic vasculature or fascial-defined compartment, superiorly into the retroperitoneal compartments of the abdomen.

Colour Doppler induced streaming: an indicator of the liquid nature of lesions

As sound waves traverse tissue, interaction with reflecting or absorbing obstacles results in a transfer of momentum from the wave to the medium. This generates a local force in the direction of propagation. If this occurs in a fluid medium, sufficient pressure may be generated to cause flow--"streaming". Generally, it is difficult to demonstrate this streaming in images using the usual diagnostic B-mode intensities, but the increased intensities in a colour Doppler (or power) region of interest enhance the phenomenon. This allows streaming to be both visualized by the motion of small particles and detected by colour change on the colour Doppler B-mode image. Borders of streaming between the simple grey scale image and the colour region may be easily seen, with retrograde flow in the regions subjected to a lower intensity. This phenomenon has been demonstrated in ocular, scrotal, thyroid, breast, ovarian and inflammatory collections or lesions, confirming the liquid nature, occasionally of fluid which is very echogenic due to contained debris. The technique is recommended as another tool which is available to most general ultrasound departments and will assist in the characterization of tissue.

Ultrasound in the diagnosis and management of fluid collection complications following abdominoplasty

A 6-year prospective study of 80 abdominoplasties is reported. Type and incidence of complications are presented with particular attention toward the incidence of fluid collection following abdominoplasty, such as seroma and hematoma. Ultrasound was performed in 56 patients (70%), with normal findings in 27 patients (48%). Accurate diagnosis of fluid collection in 29 patients (51.8%), seroma in 24 (42.8%), and hematoma in 5 (9%) was confirmed with the aid of ultrasound. The advantage of early radiological diagnosis alerted the surgeon for positive findings of fluid collection areas in the abdominal wall, which resulted in close observation and early intervention whenever indicated. Ultrasound of the abdominal wall following abdominoplasty provides a noninvasive, accurate, and low-cost method of diagnosing fluid collection in the abdominal wall. This method, if performed routinely postabdominoplasty, will aid the surgeon in managing potential complications such as wound-healing problems, infection, and patient discomfort.

Diagnostic accuracy of transvaginal ultrasound in detecting free pelvic fluid

OBJECTIVE

To evaluate the diagnostic accuracy of transvaginal ultrasonography in detecting and measuring free pelvic fluid.

STUDY DESIGN

Eighty-two patients undergoing diagnostic or therapeutic laparoscopy at a tertiary care center were prospectively assessed before surgery by transvaginal ultrasound. Free pelvic fluid was measured in two ultrasonographic planes. These measurements were compared to the volume of fluid aspirated during laparoscopy.

RESULTS

The mean volumes reported for transvaginal ultrasound were significantly lower than those observed at laparoscopy (mean milliliters +/- SEM, 2.54 +/- 0.5 versus 9.42 +/- 1.3, P < .001). The smallest volume of free pelvic fluid that was consistently detected by ultrasound was 8 mL. Whenever no fluid or < 1 mL was detected by transvaginal ultrasound, a small volume of fluid was found at laparoscopy (mean milliliters +/- SEM, 1.6 +/- 0.47). The sensitivity of transvaginal ultrasound was 83% and specificity was 69%.

CONCLUSION

Transvaginal ultrasound is a sensitive method of detecting the presence of > 8 mL of free pelvic fluid and therefore is an important diagnostic tool in the assessment of pelvic pathology associated with increased peritoneal fluid.

Pelvic extension of retroperitoneal fluid: analysis in vivo

OBJECTIVE

The purposes of this study were to describe the pathway of fluid flow from the retroperitoneal space into the pelvic extraperitoneal space on CT in vivo, to clarify the relation between its occurrence and the site or amount of retroperitoneal fluid, and to delineate the anatomic relation between the retroperitoneal spaces and the pelvic extraperitoneal space.

MATERIALS AND METHODS

We reviewed the CT scans of 37 patients with retroperitoneal fluid collections. Patients who had undergone pelvic laparotomy and patients who had either fascial thickening alone or fluid within muscle (such as the psoas muscle or iliac muscle) alone were excluded.

RESULTS

Fluid extension into the pelvic extraperitoneal space was seen in six patients (16%). Extension by the infrarenal extraperitoneal space was seen in all six of these patients, but extension by properitoneal fat was seen in only one of the six patients. In patients with large amounts of fluid in the infrarenal extraperitoneal space, we frequently saw extension into the pelvic extraperitoneal space. Extension of pancreatic fluid into the infrarenal extraperitoneal space occurred in only 15% of the 37 patients. However, it occurred in both patients with ruptured abdominal aortic aneurysms. Three pathways from the infrarenal extraperitoneal space into the pelvic extraperitoneal space were seen: extension dorsally medial to the iliac vessels (n = 6), extension dorsally lateral to the iliac vessels (n = 1), and extension medially into the prevesical space (n = 2). Coexistence of two of these three pathways was seen in three patients.

CONCLUSION

In vivo, extension of retroperitoneal fluid into the pelvic extraperitoneal space is not rare and occurs more often by the infrarenal extraperitoneal space than by properitoneal fat. Extension of retroperitoneal fluid to the infrarenal extraperitoneal space can be attributed less frequently to sources distant to the pelvic cavity such as pancreatic fluid. Such extension often derives from sources that can produce large amounts of retroperitoneal fluid such as ruptured abdominal aortic aneurysms. Of the three pathways from the infrarenal extraperitoneal space to the pelvic extraperitoneal space, dorsal extension medial to the iliac vessels is the most common, and multiple pathways often coexist.

Free echogenic pelvic fluid: correlation with hemoperitoneum

Echogenic fluid is an important extrauterine finding of ectopic pregnancy. The purpose of this study was to determine how accurately echogenic fluid correlates with hemoperitoneum at surgery. Transvaginal sonography was performed in 831 consecutive patients referred to rule out ectopic pregnancy over a 36 month period. Scans were retrospectively evaluated for the presence or absence and echogenicity of free pelvic fluid. Subsequently, 185 patients had a laparotomy or laparoscopy and had documentation of the presence or absence of hemoperitoneum. On transvaginal sonography 125 patients had echogenic fluid, 30 patients had anechoic fluid, and 30 patients had no fluid. Of the 125 patients with echogenic fluid, 122 (98%) patients had hemoperitoneum; none of the patients with anechoic fluid or no detected fluid had hemoperitoneum (0%). Echogenic fluid had a sensitivity of 100%, specificity of 95%, positive predictive value of 98%, and an accuracy of 98% for detecting hemoperitoneum. This study demonstrates that echogenic fluid detected by transvaginal ultrasonography accurately correlates with hemoperitoneum detected at surgery in patients with suspected ectopic pregnancy.

Angle-closure glaucoma as an initial presentation of systemic lupus erythematosus

PURPOSE

To study a patient with bilateral uveal effusions and secondary glaucoma as an initial manifestation of systemic lupus erythematosus.

DESIGN

A case report.

METHODS

The patient presented with bilateral uveal effusions and angle-closure glaucoma. A detailed ocular examination with ultrasonography and a comprehensive medical evaluation with laboratory testing were performed.

RESULTS

The ocular examination revealed bilateral uveal effusions with angle-closure and elevated intraocular pressures. A systemic evaluation revealed bilateral pleural effusions and laboratory values consistent with systemic lupus erythematosus. After medical and laser therapy failed to lower the intraocular pressure, partial thickness sclerectomies, linear sclerostomies, and choroidal drainage were successful in controlling the glaucoma.

CONCLUSIONS

Uveal effusion with secondary glaucoma can be a presenting sign for systemic lupus erythematosus. If antecedent ocular abnormalities are not present, a systemic evaluation is warranted in assessing a patient with uveal effusions and secondary angle-closure glaucoma. Partial-thickness sclerectomies, linear sclerostomies, and choroidal drainage may be effective in lowering intraocular pressure.

Ultrasound and operative evaluation of arthritic shoulder joints

OBJECTIVE

To assess the diagnostic value of ultrasonography (US) in the evaluation of arthritic shoulder joints.

METHODS

Twenty shoulders of 20 inpatients with arthritis were evaluated by US one day before the shoulder operation. Changes in the subacromial-subdeltoid bursa, biceps tendon and tendon sheath, rotatof cuff, and glenohumeral joint were recorded and compared with findings at operation.

RESULTS

In the detection of effusion/hypertrophy in the subacromial-subdeltoid bursa, US had a sensitivity of 93% and a specificity of 83%. For a biceps tendon rupture US had a sensitivity of 70% and a specificity of 100%. US missed three intraarticular biceps tendon ruptures. For effusion/hypertrophy in the biceps tendon sheath US had a sensitivity of 100% and a specificity of 83%. For a rotator cuff tear US had a sensitivity of 83% and a specificity of 57%. US missed two small longitudinal rotator cuff tears. Three thin membranous, but intact, rotator cuff tendons were classified as full thickness tears by US. Synovial effusion/hypertrophy was detected by US and at operation in all of the 12 glenohumeral joints that were evaluable at surgery.

CONCLUSION

US is a reliable method in experienced hands for the evaluation of inflammatory changes of an arthritic shoulder. In advanced stages of rheumatoid shoulder joints, however, US is not useful, because destructive bone changes and tendon ruptures change the normal anatomy and restrict shoulder motions, limiting the visibility of US.

Pleural fluid: accuracy of computed tomography in differentiating exudates from transudates

PURPOSE

To determine the accuracy of computed tomography in differentiating pleural exudates from transudates when reviewed subjectively by two experienced radiologists in a community hospital.

METHODS

Computed tomography scans of 55 consecutive patients who had a thoracenteses within 10 days of the study were retrospectively reviewed independently by two experienced staff radiologists. They were asked to evaluate subjectively parietal pleural thickness (anterior, lateral, posterior), attenuation of extra-pleural fat, and categorize pleural fluid as loculated or free flowing. Radiographic findings were correlated with biochemical results of thoracentesis (Light's criteria) to assess the accuracy of computed tomography in differentiating pleural exudates from transudates.

RESULTS

For the diagnosis of an exudate, pleural thickening alone had the best sensitivity and specificity (50%, 100%, respectively) with an accuracy of 55%.

CONCLUSION

Subjective evaluations for increased pleural thickness have a high accuracy for diagnosing pleural exudates.

Anatomical communications of the perirenal space

There are controversies over the anatomical communications between the perirenal space and the adjacent extraperitoneal spaces. Clinical studies, mainly based on CT, show fluid collections extending into the adjacent space; into the bare area of the liver on the right, into the superior extraperitoneal space on the left, towards the midline from each perirenal space, and into the lower retroperitoneal space of the abdomen and pelvis. There are certain constant anatomical barriers limiting free extension of fluid or pathology. The pattern of fluid collection in the perirenal space and extension into the adjacent extraperitoneal space is relatively consistent although it varies with the amount and nature of the pathological fluid collection. This pictorial review illustrates anatomical barriers and CT findings of perirenal fluid collections and their extension into adjacent extraperitoneal spaces.

Common causes of knee effusions in spinal cord injury: a random study

Patients with spinal cord injury are predisposed to knee effusions owing to osteoporosis, heterotopic ossification, trauma, and benign hydrarthrosis. This retrospective review discusses 11 patients with spinal cord injury and knee effusions seen during two years. One objective is to correlate the initial diagnosis based on clinical findings with the final diagnosis based on synovial fluid analysis and radiographic studies. Another is to describe the variety and complexity of clinical situations that involve knee effusions in spinal cord injury. The initial diagnosis was different from the final diagnosis in all of our cases. The final diagnoses were trauma (6 cases), pseudogout (2 cases), spasticity, fracture of the tibial plateau, septic joint, and tears of the anterior cruciate and lateral collateral ligaments. Knee effusions in this unique population must be carefully investigated to avoid erroneous diagnoses based on the initial clinical presentation, which can be complicated by multiple medical problems.

Fluid-fluid level in an intraosseous ganglion

A case of an intraosseous ganglion with a fluid-fluid level visualised on MR imaging is presented. We discuss its possible pathogenesis and review other lesions that may exhibit this sign.

Ultrasound evaluation of the acromioclavicular joint

OBJECTIVE

To evaluate the value of ultrasonography in assessing arthritic acromioclavicular (AC) joints.

METHODS

One hundred twenty-six AC joints of 63 healthy subjects (2 groups) were prospectively examined by ultrasound to determine the-normal limits of capsular distention and the width of the joint space. Thirty-three AC joints of 32 patients with chronic arthritis were evaluated by ultrasound and, for comparison, by radiography, computed tomography (CT), and magnetic resonance imaging (MRI).

RESULTS

The mean ultrasonographic distance of the joint capsule from the bone rim was 2.2 mm +/- standard deviation (SD) 0.5 mm in 21-32-year-old control subjects and 2.9 +/- 0.7 mm in 37-81-year-old control subjects. The mean width of the joint space was 4.1 +/- 0.9 mm and 3.5 +/- 0.9 mm in the same control groups, respectively. In detecting soft tissue changes in arthritic AC joints MRI was better than ultrasound. In revealing bony surface changes, CT was the best method and radiography was least sensitive but quite specific. Our most prominent finding was that ultrasound is able to exclude joint inflammation; when the ultrasonographic distance of the joint capsule from the bone rim was < 3 mm, there was no synovial hypertrophy or effusion on MRI scans.

CONCLUSION

Ultrasound can detect AC joint changes reliably. It is able to exclude joint inflammation. Effusion in the AC joint may reflect inflammation, but may also be a sign of degeneration.

Ultrasonography in the early diagnosis of hip joint involvement in juvenile rheumatoid arthritis

OBJECTIVE

To determine the value of ultrasonography in detection of early alterations and subsequent evolution of hip joint disease in patients with juvenile rheumatoid arthritis (JRA).

METHODS

Hip joints of 53 patients were evaluated clinically, by conventional radiography and ultrasound. Ten children free of signs/symptoms related to rheumatic diseases were chosen as a control group. Nine patients were followed up 28 months after baseline examinations. The clinical, radiological, and ultrasound evaluations were repeated.

RESULTS

Conventional radiography showed alterations in 10 patients (18.9%) who had shown clinical manifestations of advanced disease of the hip joint while ultrasound detected abnormalities in asymptomatic patients who had had normal radiographs. Ultrasound revealed the occurrence of 47.2% involvement in the hips of patients with JRA. Thus, ultrasound was apparently more sensitive than conventional radiographs in diagnosing changes in the hip joints of patients with JRA. Further, such involvement was found with greater frequency in the systemic and polyarticular types of JRA, in children less than 5 years of age, in those with longer duration of disease, and in those who belonged to a poorer functional class. In 3 of 9 patients who initially had normal radiographs and altered ultrasound, we found severe hip alterations upon reevaluation by radiography, after a period ranging from 21 to 39 months.

CONCLUSION

Ultrasonography is a method of diagnosis that must be considered in hip joint evaluation of patients with JRA.

Sonographic evaluation of hip effusion in children. Improved visualization with the hip in extension and abduction

PURPOSE

To assess the difference in the sonographic appearance of hip effusions when the hip was placed in the extended and abducted position as compared to a neutral position.

MATERIAL AND METHODS

Twenty-one consecutive children (aged 2-14 years) with hip pain or limping were examined for hip effusions by means of ultrasound. The capsule-femoral-neck distance, the presence of joint fluid, and the shape of the anterior capsule were compared in hips in slight extension and abduction with those in hips in a neutral position.

RESULTS

Of the 11 positive hip effusions, the maximal distance between the capsule and femoral neck was significantly larger (p < 0.005) in the extended and abducted hip position than in the neutral hip position, with a mean difference of 1.6 mm. Convex bulging of the anterior capsule was more confidently diagnosed in 3 hip effusions in the extended and abducted hip, and better visualization of fluid between the capsule and femoral neck was achieved in 4 joint in this posture.

CONCLUSION

The study demonstrated an improvement in the sonographic detection of hip effusion in the extended and abducted position compared to the neutral position.

Sonography and MRI in the evaluation of painful arthritic shoulder

We evaluated 31 painful shoulders of 30 patients with chronic arthritis by ultrasonography (US) and compared the results with those of magnetic resonance imaging (MRI). Both US and MRI revealed effusion in the subacromial-subdeltoid (SA-SD) bursa, biceps tendon sheath (BTS) and glenohumeral (GH) joint, but MRI was more accurate in depicting joint inflammation because of its ability to visualize synovial hypertrophy. US visualized biceps tendon ruptures equally well as MRI. MRI was better able to reveal full-thickness tear of the supraspinatus tendon, whereas US showed better other changes of the supraspinatus tendon (degeneration or partial-thickness tear). Both of the imaging methods were able to depict erosions of the humeral head, but the locations occasionally differed. Inexpensive and easily available US can be recommended as the first imaging method for the detection of soft-tissue changes in the arthritic shoulder, but in rotator cuff problems both methods may be needed.

Radiographic pulmonary infiltrates

The finding of a pulmonary infiltrate on chest radiograph may represent a spectrum of pathologic entities in the acutely ill hospitalized adult. Timely intervention depends on the advanced practice nurse's ability to devise a differential diagnosis based on the characteristics of the infiltrate and the clinical setting. Pulmonary infiltrates are described as interstitial or alveolar, diffuse or focal. Their presentation may be chronic or acute in nature. Understanding the nuances of chest radiographic interpretation provides the foundation on which the infiltrate is described and is therefore the first step in establishing the differential diagnosis. Thorough clinical assessment and thoughtful requisition of diagnostic studies are used to discriminate the disorders found in the differential diagnosis. Using an organized approach to describe the radiographic abnormality and define its clinical context, the advanced practice nurse can efficiently establish a diagnosis so that the work of treatment may begin.

[Benign non-organ-related diseases of the retroperitoneal space]

Because of the anatomic localisation of the retroperitoneal space, the detection and elucidation of pathology in the retroperitoneum calls for clinical acumen and the utilisation of imaging techniques. During the past two decades, efforts spearheaded by the work of M. A. Meyers led to an enhanced understanding of retroperitoneal anatomy and pathology. Conventional radiographic techniques are often incapable of detecting and/or characterising retroperitoneal abnormalities. Sonography may be limited by patient-dependent-factors. CT is unaffected by bowel gas and provides discrete cross-sectional images of the organs, fascial planes and retroperitoneal compartments, making it an ideal tool for assessment of retroperitoneal disease. In clinically stable patients MRT may be a useful modality for providing helpful and additional information in characterising retroperitoneal abnormalities. In this review article the diagnostic possibilities of benign not organ-related diseases of the retroperitoneum are described. This is intended to give the reader an insight into the etiology and distribution patterns of retroperitoneal fluid and gas collections as well as into diagnosis and differential diagnosis of benign retroperitoneal diseases. The diagnostic impact of the different imaging modalities is discussed.

Breast intraductal masses: US-guided fine-needle aspiration after galactography

PURPOSE

To evaluate ultrasonographic (US)-guided fine-needle aspiration (FNA) of intraductal masses performed immediately after galactography and to compare cytologic findings from US-guided FNA with those from nipple discharge.

MATERIALS AND METHODS

In 36 patients with nipple discharge from a single duct in one breast and intraductal masses diagnosed at galactography, US was performed to detect intraductal lesions and perform FNA before removal of the galactographic catheter. Cytologic analysis of nipple discharge, excisional biopsy, and histopathologic evaluation were performed in all patients.

RESULTS

Cytologic analysis revealed 23 nonpapillary benignancies, seven papillomas, five indeterminate cases, and one carcinoma. US-guided FNA cytologic analysis revealed 16 papillomas, 10 nonpapillary benignancies, five indeterminate cases, and three carcinomas. The two carcinomas misdiagnosed as papillomas at US-guided FNA cytologic analysis were papillary in situ carcinomas, while the three carcinomas correctly identified were invasive (only one was detected with cytologic analysis of nipple discharge). With cytologic analysis of nipple discharge, nine (25%) of 36 diagnoses were correct, and with US-guided FNA, 18 (50%) were correct (P = .0352).

CONCLUSION

Compared with cytologic analysis of nipple discharge, US-guided FNA cytologic analysis seems to add useful information for tailored surgical planning.

Pancreatic fluid collections prior to intervention: evaluation with MR imaging compared with CT and US

PURPOSE

To evaluate the ability of magnetic resonance (MR) imaging to depict solid debris within pancreatic collections prior to intervention and to help assess drainability, as well as to compare MR findings with those obtained at computed tomography (CT) and ultrasound (US).

MATERIALS AND METHODS

Nineteen collections in 18 patients were evaluated with MR imaging, CT, and US prior to drainage. Prospective, blinded interpretations of imaging studies by three independent readers (each interpreted all the images obtained with only one modality) evaluated collection characteristics (debris, consistency, septation, wall thickness, and irregularity) and predicted drainability. Findings were compared with clinical diagnosis and clinical outcome of drainage.

RESULTS

MR imaging and CT depicted all collections; US failed to depict two collections. In nine patients with subacute necrotic collections, solid debris was seen in eight (89%) at MR imaging, in two (22%) at CT, and in eight (89%) at US. In seven patients with pseudocysts, debris was seen in two (28%) at MR imaging and in none at CT, as well as in six (100%) of six at US. A collection was defined as "not drainable" on the basis of the depiction of solid necrotic debris more than 1 cm in diameter. With this definition, statistically significant differences between sensitivity and specificity values, respectively, were found for the prediction of actual drainability: MR imaging, 100% and 100%; CT, 25% and 100%; US, 88% and 54%.

CONCLUSION

Predrainage MR imaging should be performed in patients with subacute pancreatic collections to avoid infectious complications from unrecognized necrotic debris that cannot be removed with use of standard pseudocyst drainage techniques.