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Jacobsen RB, Hebelka H, Gatzinsky V, Elfvin A, Dangardt F. Ultra-high-frequency ultrasound (48-70 MHz) is a promising tool for improved gastrointestinal diagnostics in infants. Acta Paediatr 2024. [PMID: 38953873 DOI: 10.1111/apa.17342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/20/2024] [Accepted: 06/24/2024] [Indexed: 07/04/2024]
Abstract
AIM To investigate the clinical feasibility of ultra-high-frequency abdominal ultrasound (UHFUS) scans of preterm and term infants. METHODS Prospectively, 19 healthy term newborn infants were examined with conventional ultrasound (CUS) (Toshiba, Aplio i700, linear probe 14L5) and UHFUS (Visualsonics VevoMD, linear probes UHF48 and UHF70) according to a standardised protocol. Measurements of wall thickness were performed for; stomach, small intestine, colon and peritoneum. Five preterm infants, with or without suspected necrotising enterocolitis (NEC), were also examined with UHF48. Of these, only one was later diagnosed with NEC. RESULTS Differences between CUS and UHFUS (UHF48) were found in measurements of thickness; for peritoneum 0.25 versus 0.13 mm (p < 0.001), small intestine 0.76 versus 0.64 mm (p = 0.039) and colon 0.7 versus 0.47 mm (p < 0.001) in healthy term infants. Gaining frequency from 46 to 71 MHz showed a mean reduction in measurements of peritoneum from 0.13 to 0.09 mm (p < 0.001). One preterm infant with NEC showed a fivefold and twofold increase in peritoneal and gastrointestinal wall thickness respectively, compared to healthy preterm infants. CONCLUSION UHFUS was a clinically feasible, promising method with potential to improve gastrointestinal diagnostics in infants. Lower peritoneum thickness and gastrointestinal wall thickness were demonstrated with UHFUS compared to CUS, suggesting an overestimation by CUS.
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Affiliation(s)
- Ronni Bengtson Jacobsen
- Department of Paediatrics, Neonatal Department, Aalborg University Hospital, Aalborg, Denmark
- Region Västra Götaland, Department of Paediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hanna Hebelka
- Department of Radiology, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Vladimir Gatzinsky
- Region Västra Götaland, Department of Paediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Elfvin
- Region Västra Götaland, Department of Paediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Frida Dangardt
- Region Västra Götaland, Paediatric Heart Center, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Gulinac M, Kiprin G, Tsranchev I, Graklanov V, Chervenkov L, Velikova T. Clinical issues and challenges in imaging of gastrointestinal diseases: A minireview and our experience. World J Clin Cases 2024; 12:3304-3313. [PMID: 38983422 PMCID: PMC11229912 DOI: 10.12998/wjcc.v12.i18.3304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/25/2024] [Accepted: 05/06/2024] [Indexed: 06/13/2024] Open
Abstract
Imaging techniques play a crucial role in the modern era of medicine, particularly in gastroenterology. Nowadays, various non-invasive and invasive imaging modalities are being routinely employed to evaluate different gastrointestinal (GI) diseases. However, many instrumental as well as clinical issues are arising in the area of modern GI imaging. This minireview article aims to briefly overview the clinical issues and challenges encountered in imaging GI diseases while highlighting our experience in the field. We also summarize the advances in clinically available diagnostic methods for evaluating different diseases of the GI tract and demonstrate our experience in the area. In conclusion, almost all imaging techniques used in imaging GI diseases can also raise many challenges that necessitate careful consideration and profound expertise in this field.
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Affiliation(s)
- Milena Gulinac
- Department of General and Clinical Pathology, Medical University of Plovdiv, Plovdiv 4002, Bulgaria
- Medical Faculty, Sofia University St. Kliment Ohridski, Sofia 1407, Bulgaria
| | - Georgi Kiprin
- Department of Gastroenterology, MHAT Eurohospital, Plovdiv 4000, Bulgaria
| | - Ivan Tsranchev
- Department of Forensic Medicine and Deontology, Medical University of Plovdiv, Plovdiv 4000, Bulgaria
| | - Vasko Graklanov
- First Department of Internal Diseases, Medical University of Plovdiv, Plovdiv 4000, Bulgaria
| | - Lyubomir Chervenkov
- Department of Diagnostic Imaging, Medical University Plovdiv, Plovdiv 4000, Bulgaria
| | - Tsvetelina Velikova
- Medical Faculty, Sofia University St. Kliment Ohridski, Sofia 1407, Bulgaria
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3
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Surak A, Altit G, Singh Y. Targeted Neonatal Echocardiography: Basics of Knobology 101. Am J Perinatol 2024. [PMID: 38503304 DOI: 10.1055/s-0044-1782652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Targeted neonatal echocardiography (TNE) is essential when approaching hemodynamic instability in neonates. Competency in this field requires standardized training, including robust hands-on experience. Proficiency in understanding the key elements of ultrasound knobology is indispensable for optimal acquisition of imaging. This is a narrative review summarizing the key elements of knobology in TNE. Literature review was mainly done through PubMed. There was no funding allocated for the production of this manuscript. KEY POINTS: · Robust and structured training is essential. · Understanding knobology is required to achieve competency in TNE. · Optimizing knobology is critical for an accurate hemodynamic interpretation report.
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Affiliation(s)
- Aimann Surak
- Department of Pediatrics, Philip Charles Etches Neonatal Intensive Care Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Gabriel Altit
- Division of Neonatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Yogen Singh
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, California
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Krugliak Cleveland N, St-Pierre J, Kellar A, Rubin DT. Clinical Application of Intestinal Ultrasound in Inflammatory Bowel Disease. Curr Gastroenterol Rep 2024; 26:31-40. [PMID: 38243153 PMCID: PMC11025373 DOI: 10.1007/s11894-024-00915-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 01/21/2024]
Abstract
PURPOSE OF REVIEW Intestinal ultrasound (IUS) is a non-invasive, accurate, and well-tolerated tool that provides real-time assessment of inflammatory bowel disease (IBD) activity and is therefore an ideal monitoring tool. This review describes the evolving role of IUS in each phase of clinical management of IBD. RECENT FINDINGS Accumulating evidence has demonstrated that IUS is an excellent tool for the assessment of suspected IBD, with a very high negative predictive value. It accurately assesses disease activity, disease complications, and in the pre-treatment phase, provides a benchmark for subsequent follow-up. IUS can detect early therapeutic response and correlates well with other established monitoring modalities with arguably superior predictive capabilities and ability to assess a deeper degree of remission, transmural healing (TH). IUS has a crucial role in the management of IBD and has ushered in a new era of monitoring with more rapid evaluation and the opportunity for early optimization, deeper therapeutic targets, and improved outcomes.
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Affiliation(s)
- Noa Krugliak Cleveland
- Inflammatory Bowel Disease Center, University of Chicago, 5841 S. Maryland Ave MC 4076, Chicago, IL, 60637, USA.
| | - Joëlle St-Pierre
- Inflammatory Bowel Disease Center, University of Chicago, 5841 S. Maryland Ave MC 4076, Chicago, IL, 60637, USA
| | - Amelia Kellar
- Inflammatory Bowel Disease Center, University of Chicago, 5841 S. Maryland Ave MC 4076, Chicago, IL, 60637, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago, 5841 S. Maryland Ave MC 4076, Chicago, IL, 60637, USA
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5
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Dolinger MT, Kellar A. Point-of-Care Intestinal Ultrasound in Pediatric Inflammatory Bowel Disease. Curr Gastroenterol Rep 2023; 25:355-361. [PMID: 37624558 DOI: 10.1007/s11894-023-00892-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE OF REVIEW Intestinal ultrasound (IUS) is an emerging non-invasive point-of-care tool utilized by pediatric gastroenterologists for accurately detecting and monitoring inflammatory bowel disease (IBD) activity. In this article, we reviewed the evidence supporting and technique to perform IUS for children with IBD. RECENT FINDINGS IUS technique can visualize the colon from the distal sigmoid until the cecum and the terminal ileum without the need for bowel preparation, fasting, or sedation in children with IBD. IUS has been shown to be accurate to endoscopy in children with ulcerative colitis and Crohn's disease. IUS may be the most accurate biomarker to follow as a marker of treatment response that is predictive of endoscopic outcomes in children with IBD. Multiple studies have demonstrated that IUS can be performed at the point-of-care for IBD activity assessment in children. Recent studies have demonstrated the accuracy of IUS to endoscopy and magnetic resonance enterography with an ability to be repeated as a monitor of treatment response for tight control monitoring.
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Affiliation(s)
- Michael Todd Dolinger
- Icahn School of Medicine at Mount Sinai, New York; Division of Pediatric Gastroenterology, Susan and Leonard Feinstein Inflammatory Bowel Disease Center, 17 E 102nd Street, 5th floor east, New York, NY, 10029-5204, USA.
| | - Amelia Kellar
- Icahn School of Medicine at Mount Sinai, New York; Division of Pediatric Gastroenterology, Susan and Leonard Feinstein Inflammatory Bowel Disease Center, 17 E 102nd Street, 5th floor east, New York, NY, 10029-5204, USA
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Alrashed R, AlHarbi H, Ali B, Mubarah A, AlGhamdi F. Is Bleeding Gastrointestinal Stromal Tumor Associated With Higher Mortality and Morbidity? Cureus 2023; 15:e47398. [PMID: 38021903 PMCID: PMC10657152 DOI: 10.7759/cureus.47398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Gastrointestinal stromal tumor (GIST) is the most common primary mesenchymal tumor of the gastrointestinal tract. The clinical presentation of GIST varies widely and ranges from being asymptomatic to being a life-threatening emergency in the form of gastrointestinal bleeding or bowel obstruction. Multiple prognostic factors have been identified for GIST, including, most importantly, larger tumor size (>5 cm), higher mitotic activity (>5 per 50 high-power fields), rupture of the mass, site of the mass, and personal history of GIST. Objective In this paper, we aim to study bleeding in gastrointestinal tumors as a predictor for morbidity and mortality and investigate possible factors influencing bleeding in GIST. Method A retrospective study design was used. Electronic medical records of 39 patients diagnosed with GIST in Prince Sultan Military Medical City in Riyadh between January 2015 and December 2020 were retrieved. Normal variables were presented as mean and standard deviation, while non-normal variables were presented as median and interquartile range. Student t-test or Mann-Whitney test was used to compare quantitative data when appropriate. The distribution of recurrence and survival was plotted with the Kaplan-Meier curve and compared between the two groups (bleeding and non-bleeding groups) with the log-rank test. Factors affecting recurrence and mortality were assessed using univariable Cox regression. Result A total of 39 cases of GIST tumors were included in this study. Patients were categorized according to the presentation into two groups: patients with no bleeding (n= 28) and those presented with bleeding (n= 11). The gender distribution was equal. The mean age was 58.14± 12.46 in patients with non-bleeding GIST and 58.18± 16.01 in patients with bleeding GIST. The most common location of GIST was the stomach (22 cases, 56%). Neither group had any significant differences regarding age (P-value = 0.993), gender (P-value = 0.648), tumor location (P-value = 0.057), size (P-value = 0.250), cluster of differentiation (CD) markers, histological types (P-value = 0.692), and shape (P-value = 0.079). There was no significant difference in recurrence between both groups (log-rank P = 0.972). There was no significant difference in survival between both groups (Log-rank P = 0.506). Conclusion We concluded that bleeding GIST was not a significant predictor for recurrence rate or higher mortality. This can help in the debate of whether bleeding GIST should be added as an independent factor in risk stratification. Despite that, further studies are needed to identify more variables that can add more accuracy to the pre-existing risk stratification systems.
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Affiliation(s)
- Rema Alrashed
- Department of Surgery, Prince Sultan Military Medical City, Riyadh, SAU
| | - Hussam AlHarbi
- Department of Surgery, AlKharj Armed Forces Hospital, Riyadh, SAU
| | - Bandar Ali
- Department of Surgery, Prince Sultan Military Medical City, Riyadh, SAU
| | - Alanoud Mubarah
- Department of Surgery, Prince Sultan Military Medical City, Riyadh, SAU
| | - Faisal AlGhamdi
- Department of Surgery, Prince Sultan Military Medical City, Riyadh, SAU
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Nasuno M, Shimazaki H, Nojima M, Hamada T, Sugiyama K, Miyakawa M, Tanaka H. Serum leucine-rich alpha-2 glycoprotein levels for predicting active ultrasonographic findings in intestinal lesions of patients with Crohn's disease in clinical remission. Medicine (Baltimore) 2023; 102:e34628. [PMID: 37565885 PMCID: PMC10419375 DOI: 10.1097/md.0000000000034628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/14/2023] [Indexed: 08/12/2023] Open
Abstract
This study aimed to investigate the cutoff value of leucine-rich alpha-2 glycoprotein (LRG) in predicting active intestinal ultrasonography (IUS) findings in patients with Crohn's disease (CD) in clinical remission. Data were retrospectively collected from patients with CD evaluated using LRG and undergoing IUS from September 2020 to August 2022. Patients with a Harvey-Bradshaw Index of ≤4 were included and those who underwent intestinal resection were excluded. Bowel wall thickness and stratification and blood flow signal using superb microvascular imaging (SMI) were used to assess ultrasonography findings. SMI signals were categorized into 4 grades following the Limberg score. Receiver operating characteristic curves were constructed and the area under the curve was calculated to determine the LRG cutoff values for predicting active IUS findings and were compared with those of C-reactive protein. This study included 213 patients. The LRG cutoff values to predict active bowel wall thickness, loss of bowel wall stratification, and SMI of ≥1, ≥2, and 3 were 14.6 μg/mL, 14.6 μg/mL, 14.6 μg/mL, 14.6 μg/mL, and 16.9 μg/mL, respectively, with significantly higher areas under the curve in SMI of ≥1 and 3 than in C-reactive protein. The best LRG cutoff value for predicting active IUS findings was 14.6 μg/mL in patients with CD in clinical remission, suggesting that LRG is better than C-reactive protein for detecting active IUS findings in CD.
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Affiliation(s)
| | | | - Masanori Nojima
- Center for Translational Research, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
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8
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Necas M, Thomas S, Prout K. Transient intussusception - What the sonographer needs to know. Australas J Ultrasound Med 2023; 26:191-198. [PMID: 37701765 PMCID: PMC10493360 DOI: 10.1002/ajum.12352] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Intussusception is typically considered an acute emergency; however, the increased utilisation of medical imaging has revealed that intussusceptions can also be transient, asymptomatic and possibly physiologic. Sonographers should be aware of three categories of intussusceptions: (i) persistent intussusceptions resulting in acute abdomen and requiring urgent intervention, (ii) transient symptomatic intussusceptions which may be amenable to a 'wait-and-see' strategy and (iii) transient asymptomatic intussusceptions which almost always involve the small bowel. In particular, the incidental discovery of enteroenteric intussusceptions in children should not be confused with acute pathology. In adults, sonographers should be mindful of the frequent presence of pathological lead points and further investigations may be warranted. In this literature review, we provide an overview of transient intussusceptions, highlight important differences between children and adults and describe sonographic appearances of various intussusceptions and their mimics.
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Affiliation(s)
- Martin Necas
- Ultrasound DepartmentWaikato HospitalHamiltonNew Zealand
| | - Stacey Thomas
- Ultrasound DepartmentWaikato HospitalHamiltonNew Zealand
| | - Kara Prout
- Ultrasound DepartmentWaikato HospitalHamiltonNew Zealand
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9
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Nishida M, Hasegawa Y, Hata J. Basic practices for gastrointestinal ultrasound. J Med Ultrason (2001) 2023; 50:285-310. [PMID: 36087155 PMCID: PMC10354189 DOI: 10.1007/s10396-022-01236-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 06/07/2022] [Indexed: 11/28/2022]
Abstract
The standard diagnostic modalities for gastrointestinal (GI) diseases have long been endoscopy and barium enema. Recently, trans-sectional imaging modalities, such as computed tomography and magnetic resonance imaging, have become increasingly utilized in daily practice. In transabdominal ultrasonography (US), the bowel sometimes interferes with the observation of abdominal organs. Additionally, the thin intestinal walls and internal gas can make structures difficult to identify. However, under optimal US equipment settings, with identification of the sonoanatomy and knowledge of the US findings of GI diseases, US can be used effectively to diagnose GI disorders. Thus, the efficacy of GIUS has been gradually recognized, and GIUS guidelines have been published by the World Federation for Ultrasound in Medicine and Biology and the European Federation of Societies for Ultrasound in Medicine and Biology. Following a systematic scanning method according to the sonoanatomy and precisely estimating the layered wall structures by employing color Doppler make diagnosing disease and evaluating the degree of inflammation possible. This review describes current GIUS practices from an equipment perspective, a procedure for systematic scanning, typical findings of the normal GI tract, and 10 diagnostic items in an attempt to help medical practitioners effectively perform GIUS and promote the use of GIUS globally.
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Affiliation(s)
- Mutsumi Nishida
- Diagnostic Center for Sonography, Hokkaido University Hospital, N14 W5, Kita-ku, Sapporo, 060-8648, Japan.
| | - Yuichi Hasegawa
- Department of Clinical Laboratory, Japanese Red Cross Narita Hospital, Narita, Japan
| | - Jiro Hata
- Department of Laboratory Medicine (Endoscopy and Ultrasound), Kawasaki Medical School Hospital, Okayama, Japan
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10
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Gonzalez-Vivo M, Zugazaga A, Cusco JMD, Naranjo-Hans D, Casajoana A, Carot L. Jejunal gist simulating a uterine myoma: A case report. Int J Surg Case Rep 2023; 106:108257. [PMID: 37137174 PMCID: PMC10165388 DOI: 10.1016/j.ijscr.2023.108257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/05/2023] Open
Abstract
INTRODUCTION A small bowel gastrointestinal stromal tumor (GIST) is a rare neoplasm of the gastrointestinal tract. The manifestation of bleeding is a diagnostic challenge and could present as a life-threatening situation that needs urgent intervention. PRESENTATION OF CASE 64-year-old woman consulted for episodes of melena and anemia. The upper and lower endoscopies were not diagnostic. Capsule endoscopy (CE) revealed a probable jejunal hemangioma, however double-balloon enteroscopy and magnetic resonance imaging (MRI) did not show any intestinal nodule but MRI show a pelvic mass apparently related to the uterus confirmed by a gynecologist. Even so, the patient returned with melena, and a contrast-enhanced computed tomography (CT) scan again identified a pelvic mass, highlighting that its vascularization drained into the superior mesenteric territory and seemed to invade the jejunum, with active bleeding, suspicious for jejunal GIST. A laparotomy was performed to remove the jejunal mass. Histopathology and immunohistochemical studies confirmed the diagnosis. DISCUSSION Bleeding is a common symptom in small bowel GISTs but its diagnoses could be difficult because its location. In most cases, gastroscopy and colonoscopy are not useful and CE or imaging studies are necessary to find the cause of bleeding. Moreover, it has recently proved that bleeding is a prognostic risk factor because it is related to tumor rupture and tumor invasion of blood vessels. CONCLUSION In this case, bleeding caused by small bowel GIST was misdiagnosed in endoscopic procedures and the clinical management was delayed. CT angiography was the most effective investigation to detect the source of bleeding.
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Affiliation(s)
- Maria Gonzalez-Vivo
- Department of Gastroenterology, Hospital del Mar, Barcelona, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.
| | - Ander Zugazaga
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Radiology, Hospital del Mar, Barcelona, Spain
| | - Josep Maria Dedeu Cusco
- Department of Gastroenterology, Hospital del Mar, Barcelona, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Dolores Naranjo-Hans
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Pathology, Hospital del Mar, Barcelona, Spain
| | - Anna Casajoana
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Section of Gastrointestinal Surgery, Hospital del Mar, Barcelona, Spain
| | - Laura Carot
- Department of Gastroenterology, Hospital del Mar, Barcelona, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
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Lin WC, Chang CW, Chen MJ, Wang HY. Intestinal Ultrasound in Inflammatory Bowel Disease: A Novel and Increasingly Important Tool. J Med Ultrasound 2023; 31:86-91. [PMID: 37576427 PMCID: PMC10413392 DOI: 10.4103/jmu.jmu_84_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/18/2022] [Accepted: 10/26/2022] [Indexed: 08/15/2023] Open
Abstract
New and efficacious medical therapies have become available that have greatly enhanced clinicians' ability to manage inflammatory bowel diseases (IBDs). IBD activity should be assessed regularly in scheduled examinations as the part of a treat-to-target strategy for IBD care. The gold-standard approach to investigating IBD is colonoscopy, but this is an invasive procedure. Intestinal ultrasound (IUS) has played a crucial role in recent years regarding the assessment of IBD activity because it is noninvasive, safe, reproducible, and inexpensive. IUS findings could inform changes in therapeutic interventions for IBDs; this would necessitate fewer endoscopies and enable faster decision-making processes. Furthermore, patients are accepting and tolerant of IUS examinations. This review outlines the current evidence and gives indication regarding the use of IUS in the management of IBDs.
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Affiliation(s)
- Wei-Chen Lin
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- Mackay Medical College, Taipei, Taiwan
| | - Chen-Wang Chang
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- Mackay Medical College, Taipei, Taiwan
| | - Ming-Jen Chen
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- Mackay Medical College, Taipei, Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- Mackay Medical College, Taipei, Taiwan
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Cleveland NK, Picker EA, Dolinger MT, Rubin DT. The Arrival of Intestinal Ultrasound for Inflammatory Bowel Disease Care in the United States. Gastroenterol Hepatol (N Y) 2023; 19:147-154. [PMID: 37706105 PMCID: PMC10496276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Intestinal ultrasound (IUS) is a noninvasive and highly reliable point-of-care tool to evaluate inflammation of the bowel. It offers comparable accuracy to endoscopy and magnetic resonance enterography. Although IUS has been incorporated into the management of inflammatory bowel disease (IBD) in other parts of the world, it has only recently arrived in the United States. However, barriers to integration of IUS into IBD care in the United States have included a lack of adoption by leading centers, lack of educational opportunities, and an unclear path for remuneration. This article provides information about the use of IUS in IBD, reviews the data comparing existing modalities of assessment of IBD with IUS, and summarizes strategies to overcome existing barriers to IUS implementation, including the newly available US-based training pathway and appropriate billing practice.
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Affiliation(s)
| | - Emma A. Picker
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois
| | - Michael T. Dolinger
- Susan and Leonard Feinstein Inflammatory Bowel Disease Clinical Center, Mount Sinai Hospital, Icahn School of Medicine, New York, New York
| | - David T. Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois
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13
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Intestinal Ultrasound for the Pediatric Gastroenterologist: A Guide for Inflammatory Bowel Disease Monitoring in Children: Expert Consensus on Behalf of the International Bowel Ultrasound Group (IBUS) Pediatric Committee. J Pediatr Gastroenterol Nutr 2023; 76:142-148. [PMID: 36306530 PMCID: PMC9848217 DOI: 10.1097/mpg.0000000000003649] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Crohn disease and ulcerative colitis are chronic inflammatory bowel diseases (IBD) often diagnosed in childhood. A strict monitoring strategy can potentially alter the disease course and facilitate early effective treatment before irreversible bowel damage occurs. Serial colonoscopy in children, the gold standard for monitoring, is impractical. Accurate, real-time, noninvasive markers of disease activity are needed. Intestinal ultrasound is an accurate, noninvasive, real-time, point-of-care, cross-sectional imaging tool used to monitor inflammation in pediatric IBD patients in Europe, Canada, and Australia. It is now emerging in a few expert centers in the United States as a safe, non-radiating, inexpensive, bedside tool used by the treating gastroenterologist for real-time decision-making. Unlike the standard biomarkers of pediatric IBD activity, C-reactive protein, and fecal calprotectin, intestinal ultrasound (IUS) facilitates disease localization, characterizes severity, extent, and accurately detects complications. Perhaps most importantly, IUS may enhance shared understanding and ease the burden of treatment decision-making for both the gastroenterologist and the patient. There is a lack of standardization for bedside IUS among pediatric gastroenterologists. The purpose is to outline a standardized approach to pediatric bedside IUS, including basic equipment requirements and technique, patient selection, preparation and positioning, technical considerations and limitations, documentation of mesenteric and luminal features of IBD, characterization of penetrating disease and strictures, and provide a proposed pediatric IUS monitoring algorithm to guide care.
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Chronische Diarrhoe. COLOPROCTOLOGY 2022. [DOI: 10.1007/s00053-022-00654-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Wüstner M, Radzina M, Calliada F, Cantisani V, Havre RF, Jenderka KV, Kabaalioğlu A, Kocian M, Kollmann C, Künzel J, Lim A, Maconi G, Mitkov V, Popescu A, Saftoiu A, Sidhu PS, Jenssen C. Professional Standards in Medical Ultrasound - EFSUMB Position Paper (Short Version) - General Aspects. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2022; 43:456-463. [PMID: 35850146 DOI: 10.1055/a-1854-2936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This first position paper of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) on professional standards presents a common position across the different medical professions within EFSUMB regarding optimal standards for the performing and reporting of ultrasound examinations by any professional ultrasound operator. It describes general aspects of professionality that ensure procedure quality, effectiveness, efficiency, and sustainability in virtually all application fields of medical ultrasound. Recommendations are given related to safety and indication of ultrasound examinations, requirements for examination rooms, structured examination, systematic reporting of results, and management, communication and archiving of ultrasound data. The print version of this article is a short version. The long version is published online.
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Affiliation(s)
- Matthias Wüstner
- Central Interdisciplinary Sonography, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Maija Radzina
- Radiology Research laboratory, Riga Stradins University, Riga, Latvia
- Diagnostic Radiology Institute, Paul Stradins Clinical University Hospital, Riga, Latvia
| | | | - Vito Cantisani
- Department of Radiology, "Sapienza" University of Rome, ROME, Italy
| | - Roald Flesland Havre
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | | | | | - Milan Kocian
- Anästhesie und Intensiv, Asklepios Klinik Burglengenfeld, Germany
- Visual Medicine s. r. o., Olomouc, Czech Republic
| | - Christian Kollmann
- Center for Medical Physics & Biomedical Engineering, Medical University Vienna, Austria
| | - Julian Künzel
- Otorhinolaryngology, University of Regensburg, Germany
| | - Adrian Lim
- Imaging, Imperial College, London, United Kingdom of Great Britain and Northern Ireland
| | - Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, "L. Sacco" University Hospital, "L. Sacco" University Hospital, Milan, Italy
| | - Vladimir Mitkov
- Diagnostic Ultrasound Division, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Alina Popescu
- Gastroenterology, University of Medicine and Pharmacy Timisoara, Romania
| | - Adrian Saftoiu
- Res Ctr Gastroenterol Hepatol, University of Medicine and Pharmacy of Craiova, Romania
| | - Paul S Sidhu
- Radiology, King's College London, United Kingdom of Great Britain and Northern Ireland
| | - Christian Jenssen
- Klinik für Innere Medizin, Krankenhaus Märkisch Oderland Strausberg/Wriezen, Germany
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16
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Wüstner M, Radzina M, Calliada F, Cantisani V, Havre RF, Jenderka KV, Kabaalioğlu A, Kocian M, Kollmann C, Künzel J, Lim A, Maconi G, Mitkov V, Popescu A, Saftoiu A, Sidhu PS, Jenssen C. Professional Standards in Medical Ultrasound - EFSUMB Position Paper (Long Version) - General Aspects. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2022; 43:e36-e48. [PMID: 35850145 DOI: 10.1055/a-1857-4435] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This first position paper of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) on professional standards presents a common position across the different medical professions within EFSUMB regarding optimal standards for the performing and reporting of ultrasound examinations by any professional ultrasound operator. It describes general aspects of professionality that ensure procedure quality, effectiveness, efficiency, and sustainability in virtually all application fields of medical ultrasound. Recommendations are given related to safety and indication of ultrasound examinations, requirements for examination rooms, structured examination, systematic reporting of results, and management, communication and archiving of ultrasound data. The print version of this article is a short version. The long version is published online.
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Affiliation(s)
- Matthias Wüstner
- Central Interdisciplinary Sonography, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Maija Radzina
- Radiology Research laboratory, Riga Stradins University, Riga, Latvia
- Diagnostic Radiology Institute, Paul Stradins Clinical University Hospital, Riga, Latvia
| | | | - Vito Cantisani
- Department of Radiology, "Sapienza" University of Rome, ROME, Italy
| | - Roald Flesland Havre
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | | | | | - Milan Kocian
- Anästhesie und Intensiv, Asklepios Klinik, Burglengenfeld, Germany
- Visual Medicine s. r. o., Olomouc, Czech Republic
| | - Christian Kollmann
- Center for Medical Physics & Biomedical Engineering, Medical University Vienna, Austria
| | - Julian Künzel
- Otorhinolaryngology, University of Regensburg, Germany
| | - Adrian Lim
- Imaging, Imperial College, London, United Kingdom of Great Britain and Northern Ireland
| | - Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, "L. Sacco" University Hospital, "L. Sacco" University Hospital, Milan, Italy
| | - Vladimir Mitkov
- Diagnostic Ultrasound Division, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Alina Popescu
- Gastroenterology, University of Medicine and Pharmacy, Timisoara, Romania
| | - Adrian Saftoiu
- Res Ctr Gastroenterol Hepatol, University of Medicine and Pharmacy of Craiova, Romania
| | - Paul S Sidhu
- Radiology, King's College London, United Kingdom of Great Britain and Northern Ireland
| | - Christian Jenssen
- Klinik für Innere Medizin, Krankenhaus Märkisch Oderland Strausberg/Wriezen, Germany
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17
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Vallone G, Pizzicato P, Rossi E, Brunese L. The Role of Ultrasound in Chronic Intestinal Diseases in Pediatric Patients. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2022; 43:436-455. [PMID: 36198305 DOI: 10.1055/a-1891-6421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Chronic inflammatory bowel diseases (IBD) are chronic disorders of the gastrointestinal tract, with an increasing incidence in pediatric populations. Ultrasound of the intestinal wall represents the first-line imaging technique in children since it is a noninvasive method, is free of ionizing radiation, and is inexpensive. Furthermore, the absence of intestinal wall thickening has a good negative predictive value for IBD, which is greater for Crohn's disease than for ulcerative colitis. Ultrasound is used for the diagnosis of disease, for the differential diagnosis in IBD, in the follow-up of known IBD, in the definition of the site and extent of the disease, for the diagnosis of intestinal complications, for the evaluation of disease activity, in the definition of prognostic parameters, and in the post-operative follow-up.
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Affiliation(s)
- Gianfranco Vallone
- Radiodiagnostic, University of Molise, Department of Medicine and Health Sciences Vincenzo Tiberio, Campobasso, Italy
| | | | - Eugenio Rossi
- Radiodiagnostic, A.O.R.N. Santobono-Pausilipon, Napoli, Italy
| | - Luca Brunese
- Radiodiagnostic, University of Molise, Department of Medicine and Health Sciences Vincenzo Tiberio, Campobasso, Italy
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18
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Bohra A, Van Langenberg DR, Vasudevan A. Intestinal Ultrasound in the Assessment of Luminal Crohn’s Disease. GASTROINTESTINAL DISORDERS 2022; 4:249-262. [DOI: 10.3390/gidisord4040024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Crohn’s disease is a chronic inflammatory disease affecting the gastrointestinal tract. Expert guidelines now recommend regular objective assessments as part of a treat-to-target approach. Intestinal ultrasound provides a noninvasive, patient-friendly modality for assessing Crohn’s disease without the risk of radiation exposure and does not require fasting or bowel preparation. Enhancement techniques, including oral and intravenous contrast, can improve disease-activity and complication detection. Due to its acceptability, intestinal ultrasound can be performed frequently, allowing for closer disease-activity monitoring and treatment adjustments. There have been significant advances in the utility of intestinal ultrasound; particularly for assessing disease activity during pregnancy and fibrosis detection utilising elastography. This review provides a comprehensive overview of performing intestinal ultrasound, the diagnostic accuracy, role in disease-activity monitoring, and recent advances in utilising ultrasound for the assessment of luminal Crohn’s disease.
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19
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Huang CY, Chu SE, Chang CJ, Chiu YC, Chiang WC, Huei-Ming Ma M, Sun JT. Man with a Sore Throat. Ann Emerg Med 2022; 79:451-484. [DOI: 10.1016/j.annemergmed.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Indexed: 11/01/2022]
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20
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Chen WJ, Luo LL, Dong ZX, Wu J, Gu XX, Bian ZL. Application of transabdominal ultrasound in Crohn's disease. Shijie Huaren Xiaohua Zazhi 2022; 30:364-369. [DOI: 10.11569/wcjd.v30.i8.364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Crohn's disease (CD), a chronic nonspecific intestinal inflammatory disorder of uncertain origin, is collectively referred to as inflammatory bowel disease with ulcerative colitis. In recent years, with the increasing incidence of CD, a greater demand has been put forward for disease diagnosis and inflammatory activity monitoring. With the development of ultrasound technology, transabdominal ultrasound has become more relevant for the diagnosis and follow-up of CD, providing an effective non-invasive examination tool for patients. This review summarizes several transabdominal ultrasound modalities and associated techniques that are presently being developed and utilized in clinical practice, describes the ultrasound manifestations of CD, and discusses the value and prospect of transabdominal ultrasonography in CD.
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Affiliation(s)
- Wei-Jie Chen
- Nantong University, Nantong 226001, Jiangsu Province, China
| | - Lei-Lei Luo
- Department of Gastroenterology, Affiliated Nantong Third Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Zhi-Xing Dong
- Nantong University, Nantong 226001, Jiangsu Province, China
| | - Jing Wu
- Department of Gastroenterology, Affiliated Nantong Third Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Xing-Xing Gu
- Department of Gastroenterology, Affiliated Nantong Third Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Zhao-Lian Bian
- Department of Gastroenterology, Affiliated Nantong Third Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
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21
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Wilkens R, Dolinger M, Burisch J, Maaser C. Point-of-Care Testing and Home Testing: Pragmatic Considerations for Widespread Incorporation of Stool Tests, Serum Tests, and Intestinal Ultrasound. Gastroenterology 2022; 162:1476-1492. [PMID: 34995530 DOI: 10.1053/j.gastro.2021.10.052] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 10/13/2021] [Accepted: 10/28/2021] [Indexed: 12/12/2022]
Abstract
Breaking through the biologic therapy efficacy plateau for inflammatory bowel disease requires the strategic development of personalized biomarkers in the tight control model. After risk stratification early in the disease course, targeted serial monitoring consistently to assess clinical outcomes in response to therapy allows for quick therapeutic adjustments before bowel damage can occur. Point-of-care intestinal ultrasound performed by the treating gastroenterologist is an accurate cross- sectional biomarker that monitors intestinal inflammation in real-time, enhances patient care, and increases shared understanding to help achieve common treatment goals. Combining intestinal ultrasound during a clinic visit with existing serum and stool biomarkers in a home testing setup with electronic health monitoring allows for an optimized, patient-centered personalized treatment algorithm that may improve treatment outcomes. Here, we review the current state, pragmatic considerations, and future implications of point-of-care testing and home testing for noninvasive inflammatory bowel disease monitoring in the tight control model.
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Affiliation(s)
- Rune Wilkens
- Gastrounit, Division of Medicine, Copenhagen University Hospital Hvidovre, Hvidovre, Copenhagen, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, University of Copenhagen, Hvidovre Hospital, Denmark; Digestive Disease Center, Copenhagen University Hospital - Bispebjerg & Frederiksberg, Copenhagen, Denmark.
| | - Michael Dolinger
- Susan and Leonard Feinstein Inflammatory Bowel Disease Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Johan Burisch
- Gastrounit, Division of Medicine, Copenhagen University Hospital Hvidovre, Hvidovre, Copenhagen, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, University of Copenhagen, Hvidovre Hospital, Denmark
| | - Christian Maaser
- Inflammatory Bowel Disease Outpatient Unit, Department of Geriatric Medicine, University Teaching Hospital Lueneburg, Lueneburg, Germany
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22
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Cicero G, Ascenti G, Blandino A, Booz C, Vogl TJ, Trimarchi R, D'Angelo T, Mazziotti S. Overview of the Large Bowel Assessment Using Magnetic Resonance Imaging: Different Techniques for Current and Emerging Clinical Applications. Curr Med Imaging 2022; 18:1031-1045. [PMID: 35362386 DOI: 10.2174/1573405618666220331111237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/29/2022] [Accepted: 02/21/2022] [Indexed: 11/22/2022]
Abstract
Radiological assessments of the small and large bowel are essential in daily clinical practice. Over plain film X-ray and ultrasound, cross-sectional techniques are considered the most comprehensive imaging modalities. In fact, computed tomography and magnetic resonance imaging take great advantage of the three-dimensional appraisal and the extensive evaluation of the abdominal cavity, allowing intestinal evaluation as well as detection of extra-intestinal findings. In this context, the chief advantage of computed tomography is the fast scan time, which is crucial for emergency cases. Nonetheless, it is undeniably impaired using ionizing radiation. As the awareness of radiation exposure is a topic of increasing importance, magnetic resonance imaging is not only becoming a mere alternative but also a primary imaging technique used in assessing intestinal diseases. Specifically, the evaluation of the large bowel through MRI can be still considered relatively uncharted territory. Although it has demonstrated superior accuracy in the assessment of some clinical entities from inflammatory bowel disease to rectal carcinoma, its role needs to be consolidated in many other conditions. Moreover, different technical methods can be applied for colonic evaluation depending on the specific disease and segment involved. This article aims to provide a thorough overview of the techniques that can be utilized in the evaluation of the large bowel and a discussion on the major findings in different colonic pathologies of primary interest.
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Affiliation(s)
- Giuseppe Cicero
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
| | - Giorgio Ascenti
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
| | - Alfredo Blandino
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
| | - Christian Booz
- Division of Experimental and Translational Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Thomas J Vogl
- Division of Experimental and Translational Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Renato Trimarchi
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
| | - Silvio Mazziotti
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
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23
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Hata J, Imamura H. The Use of Transabdominal Ultrasound in Inflammatory Bowel Disease. Korean J Radiol 2022; 23:308-321. [PMID: 35213095 PMCID: PMC8876649 DOI: 10.3348/kjr.2021.0692] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/11/2021] [Accepted: 12/20/2021] [Indexed: 11/18/2022] Open
Abstract
Transabdominal ultrasound (TAUS) is useful in all aspects of lesion screening, monitoring activity, or treating/diagnosing any related complications of inflammatory bowel disease. Its ability to screen or diagnose complications is almost the same as that of other methods, such as CT or MRI. Moreover, its noninvasiveness makes it a first-line examination method. A TAUS image depicting ulcerative colitis will show large intestinal wall thickening that is continuous from the rectum, which is mainly due to mucosal layer thickening, while for Crohn’s disease, a TAUS image is characterized by a diversity in the areas affected, distribution, and layer structure. Indicators of activity monitoring include wall thickness, wall structure, and vascular tests that use Doppler ultrasound or contrast agents. While all of these have been reported to be useful, at this time, no single parameter has been established as superior to others; therefore, a comprehensive evaluation of these parameters is justified. In addition, evaluating the elasticity of lesions using elastography is particularly useful for distinguishing between fibrous and inflammatory stenoses. However, the lack of objectivity is the biggest drawback of using ultrasound. Standardizing and popularizing the ultrasound process will be necessary, including scanning methods, equipment settings, and image analysis.
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Affiliation(s)
- Jiro Hata
- Division of Endoscopy and Ultrasound, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan.
| | - Hiroshi Imamura
- Division of Endoscopy and Ultrasound, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan
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24
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Limantoro I, Lee AF, Rosenbaum DG. Spectrum of bowel wall thickening on ultrasound with pathological correlation in children. Pediatr Radiol 2022; 52:1786-1798. [PMID: 35513727 PMCID: PMC9072154 DOI: 10.1007/s00247-022-05376-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 03/04/2022] [Accepted: 04/01/2022] [Indexed: 11/30/2022]
Abstract
Applications for bowel US in children have been well described; however, less focus has been placed on patterns of bowel wall architectural change in specific disease states. This pictorial essay reviews normal bowel wall architecture and covers a variety of inflammatory, infectious, vascular and neoplastic disorders outside the neonatal period as seen on US, with illustrative pathological correlation. A thorough understanding of normal and abnormal bowel wall architecture can enrich sonographic interpretation and provide a valuable adjunct to appropriate clinical investigation.
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Affiliation(s)
- Ione Limantoro
- Department of Radiology, British Columbia Children’s Hospital, University of British Columbia, 4500 Oak St., Vancouver, BC V6H 3N1 Canada
| | - Anna F. Lee
- Department of Pathology and Laboratory Medicine, British Columbia Children’s Hospital, University of British Columbia, Vancouver, BC Canada
| | - Daniel G. Rosenbaum
- Department of Radiology, British Columbia Children’s Hospital, University of British Columbia, 4500 Oak St., Vancouver, BC V6H 3N1 Canada
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25
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Fan X, Han H, Sun Z, Zhang L, Chen G, Mzee SAS, Yang H, Chen J. Prognostic Value of Bleeding in Gastrointestinal Stromal Tumors: A Meta-Analysis. Technol Cancer Res Treat 2021; 20:15330338211034259. [PMID: 34323156 PMCID: PMC8330451 DOI: 10.1177/15330338211034259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: Gastrointestinal bleeding is the most common clinical manifestation of gastrointestinal stromal tumor. It is of great significance to the prognosis of patients. But the results are controversial. The purpose of this study was to evaluate the relationship between gastrointestinal bleeding and clinical prognosis in patients with GIST. Methods: A systematic literature search was performed in Pumbed, Cochrane Library, EMBASE, ClinicalTrials.gov, CNKI, VIP and wanfang databases with the pattern of unlimited languages. 12 studies with 2781 individuals were included in the final analysis. The overall survival (OS), recurrence-free survival/disease-free survival (RFS/DFS) and related factors affecting bleeding in patients with gastrointestinal stromal tumor (GIST) were extracted. Hazard ratio (HR) and 95% confidence interval (CI) were used for in the meta-analysis. Results: A total of 12 articles were included in the study, including 2781 patients with GIST, including 845 patients with gastrointestinal bleeding. The OS of GIST patients with gastrointestinal bleeding was significantly worse (HR = 2.54, 95% CI = 1.13-5.73, P = 0.025). But there was no significant difference in RFS between gastrointestinal bleeding patients and non-bleeding patients (HR = 1.35, 95% CI = 0.70-2.61, P = 0.371). Further analysis of the related factors of GI bleeding in GIST patients was observed, besides the aging factor (HR = 1.02, 95% CI = 0.69-1.50, P = 0.929), Small intestinal stromal tumor (HR = 0.56, 95% CI = 0.41-0.76, P < 0.001), tumor diameter ≥ 5 cm (HR = 2.09, 95% CI = 1.20-3.63, P = 0.009), Mitotic index ≥ 5/50 HPF (HR = 1.66, 95% CI = 1.11-2.49, P = 0.014) and tumor rupture (HR = 2.04, 95% CI = 1.0-3.82, P = 0.026) all increased the risk of GI bleeding in patients with GIST. Conclusions: The OS of GIST patients with GI bleeding was worse than non-GI bleeding, but had no significant effect on RFS. Nevertheless the aging factor, the location of GIST in the small intestine, tumor diameter ≥ 5 cm, Mitotic index ≥ 5/50 HPF and tumor rupture all increased the risk of GI bleeding in patients with GIST.
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Affiliation(s)
- Xin Fan
- Department of Gastrointestinal Surgery, Affiliated 191612Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - He Han
- Department of Gastrointestinal Surgery, Affiliated 191612Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Zhiyu Sun
- Medical College, Jiangsu University, Zhenjiang, Jiangsu, China
| | - Liwen Zhang
- Department of Gastrointestinal Surgery, Affiliated 191612Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Gong Chen
- Medical College, Jiangsu University, Zhenjiang, Jiangsu, China
| | - Said Abdulrahman Salim Mzee
- Department of Gastrointestinal Surgery, Affiliated 191612Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Hanqing Yang
- 567917Wujin People's Hospital, Changzhou, Jiangsu, China
| | - Jixiang Chen
- Department of Gastrointestinal Surgery, Affiliated 191612Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
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26
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Bowel Ultrasound in Inflammatory Bowel Disease: How Far in the Grayscale? Life (Basel) 2021; 11:life11070649. [PMID: 34357022 PMCID: PMC8308056 DOI: 10.3390/life11070649] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/27/2021] [Accepted: 07/03/2021] [Indexed: 01/23/2023] Open
Abstract
Bowel ultrasound (BUS) is a non-invasive and accurate technique for assessing activity, extension of disease, and complications in inflammatory bowel diseases. The main advantages of BUS are its safety, reproducibility, and low costs. Ancillary technologies of BUS (i.e., color Doppler and wave elastography) could broaden the diagnostic power of BUS, allowing one to distinguish between inflammation and fibrosis. Considering the costs and invasiveness of colonoscopy and magnetic resonance, BUS appears as a fast, safe, and accurate technique. The objective measures of disease allow one to make clinical decisions, such as optimization, switch, or swap of therapy. Previous studies reported a sensitivity and a specificity of more than 90% compared to endoscopy and magnetic resonance. Lastly, transperineal ultrasound (TPUS) is a promising approach for the evaluation of perianal disease in Crohn’s disease (CD) and disease activity in patients with ulcerative proctitis or pouchitis. Bowel ultrasound is being incorporated in the algorithm of managing inflammatory bowel diseases. Transmural healing evaluated through ultrasonography is emerging as a complementary target for disease treatment. In this review, we aimed to summarize and discuss the current evidence on BUS in the management of inflammatory bowel diseases and to address the challenges of a full validation of this technique.
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27
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Role of Intestinal Ultrasound in the Management of Patients with Inflammatory Bowel Disease. Life (Basel) 2021; 11:life11070603. [PMID: 34201630 PMCID: PMC8305052 DOI: 10.3390/life11070603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/13/2021] [Accepted: 06/18/2021] [Indexed: 12/11/2022] Open
Abstract
Intestinal ultrasound (IUS) has gained popularity as a first line technique for the diagnosis and monitoring of patients with inflammatory bowel diseases (IBD) due to its many advantages. It is a non-invasive imaging technique with non-ionizing radiation exposure. It can be easily performed not only by radiologists but also by trained gastroenterologists at outpatient clinics. In addition, the cost of IUS equipment is low when compared with other imaging techniques. IUS is an accurate technique to detect inflammatory lesions and complications in the bowel in patients with suspected or already known Crohn’s disease (CD). Recent evidence indicates that IUS is a convenient and accurate technique to assess extension and activity in the colon in patients with ulcerative colitis (UC), and can be a non-invasive alternative to endoscopy. In patients with IBD, several non-specific pathological ultrasonographic signs can be identified: bowel wall thickening, alteration of the bowel wall echo-pattern, loss of bowel stratification, increased vascularization, decreased bowel peristalsis, fibro-fatty proliferation, enlarged lymph nodes, and/or abdominal free fluid. Considering the transmural CD inflammation, CD complications such as presence of strictures, fistulae, or abscesses can be detected. In patients with UC, where inflammation is limited to mucosa, luminal inflammatory ultrasonographic changes are similar to those of CD. As the technique is related to the operator’s experience, adequate IUS training, performance in daily practice, and a generalized use of standardized parameters will help to increase its reproducibility.
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28
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Zhao JY, Gao X, Zhuang H, Wu YT, Luo Y, Jing JG, Zhang Y. Using shear wave elasticity in normal terminal ileum of a healthy southwest Chinese population: a pilot study of reference elasticity ranges. Quant Imaging Med Surg 2021; 11:2677-2687. [PMID: 34079733 DOI: 10.21037/qims-20-877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Elastography has not been widely applied to the gastrointestinal tract. The bowel wall's normal elasticity values are still unknown and are necessary for studies of gastrointestinal diseases. This study explores the feasibility of using shear wave elastography (SWE) to measure the terminal ileum wall stiffness in healthy subjects and establish the corresponding normal ranges of elasticity values. Methods This observational study recruited 139 healthy adult volunteers from April to July 2020. All examinations were performed in the anterior terminal ileum wall. Shear wave velocity (SWV) and Young's modulus (E) values were measured in the midline on longitudinal sections and replicated different operators' obtained data. Also, bowel wall thickness (BWT) and depth were recorded. Subgroups were classified according to the volunteers' gender, age, body mass index (BMI), BWT, and depth. The intra-class correlation coefficient was calculated to analyze inter- and intra-operator consistency, and independent t-tests and one-way analysis of variance were used to explore the differences in variables. Results The inter- and intra-operator agreements were good to excellent by different operators and in the replicated measurements (intra-operator consistency: 0.963; inter-operator consistency: 0.842). In all volunteers, the mean SWV was 1.08±0.25 m/s, the mean E value was 3.84±1.84 kPa, and the median BWT was 2 mm. SWV and E did not show significant differences according to gender (P=0.589), age (P=0.738), BMI (P=0.678), depth (P=0.375), or BWT (P=0.410). BWT did not show significant differences according to age (P=0.142), BMI (P=0.863), or depth (P=0.368). Conclusions SWE can be used in terminal ileum wall stiffness measurements with good reliability, and the SWE values do not appear to vary significantly according to different physiological factors. The corresponding elasticity ranges of the terminal ileum in normal adults were acquired.
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Affiliation(s)
- Jie-Ying Zhao
- Department of Ultrasound, West China Hospital of Sichuan University, Chengdu, China
| | - Xin Gao
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu, China
| | - Hua Zhuang
- Department of Ultrasound, West China Hospital of Sichuan University, Chengdu, China
| | - Yu-Ting Wu
- Department of Ultrasound, West China Hospital of Sichuan University, Chengdu, China
| | - Yuan Luo
- Department of Ultrasound, West China Hospital of Sichuan University, Chengdu, China
| | - Ji-Gang Jing
- Department of Ultrasound, West China Hospital of Sichuan University, Chengdu, China
| | - Yan Zhang
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu, China
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29
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Rosano N, Gallo L, Mercogliano G, Quassone P, Picascia O, Catalano M, Pesce A, Fiorini V, Pelella I, Vespere G, Romano M, Tammaro P, Marra E, Oliva G, Lugarà M, Scuderi M, Tamburrini S, Marano I. Ultrasound of Small Bowel Obstruction: A Pictorial Review. Diagnostics (Basel) 2021; 11:diagnostics11040617. [PMID: 33808245 PMCID: PMC8065936 DOI: 10.3390/diagnostics11040617] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/19/2021] [Accepted: 03/26/2021] [Indexed: 12/29/2022] Open
Abstract
Small bowel obstruction (SBO) is a common condition requiring urgent attention that may involve surgical treatment. Imaging is essential for the diagnosis and characterization of SBO because the clinical presentation and results of laboratory tests may be nonspecific. Ultrasound is an excellent initial imaging modality for assisting physicians in the rapid and accurate diagnosis of a variety of pathologies to expedite management. In the case of SBO diagnosis, ultrasound has an overall sensitivity of 92% (95% CI: 89–95%) and specificity of 93% (95% CI: 85–97%); the aim of this review is to examine the criteria for the diagnosis of SBO by ultrasound, which can be divided into diagnostic and staging criteria. The diagnostic criteria include the presence of dilated loops and abnormal peristalsis, while the staging criteria are represented by parietal and valvulae conniventes alterations and by the presence of free extraluminal fluid. Ultrasound has reasonably high accuracy compared to computed tomography (CT) scanning and may substantially decrease the time to diagnosis; moreover, ultrasound is also widely used in the monitoring and follow-up of patients undergoing conservative treatment, allowing the assessment of loop distension and the resumption of peristalsis.
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Affiliation(s)
- Nicola Rosano
- Department of Radiology, Ospedale del Mare, ASL NA1 Centro, 80147 Napoli, Italy; (M.C.); (A.P.); (V.F.); (I.P.); (I.M.)
- Correspondence: (N.R.); (S.T.)
| | - Luigi Gallo
- Department of Radiology, Università degli Studi della Campania Luigi Vanvitelli, 80138 Napoli, Italy; (L.G.); (P.Q.); (O.P.)
| | - Giuseppe Mercogliano
- Department of Radiology, University of Naples “Federico II”, 80131 Napoli, Italy;
| | - Pasquale Quassone
- Department of Radiology, Università degli Studi della Campania Luigi Vanvitelli, 80138 Napoli, Italy; (L.G.); (P.Q.); (O.P.)
| | - Ornella Picascia
- Department of Radiology, Università degli Studi della Campania Luigi Vanvitelli, 80138 Napoli, Italy; (L.G.); (P.Q.); (O.P.)
| | - Marco Catalano
- Department of Radiology, Ospedale del Mare, ASL NA1 Centro, 80147 Napoli, Italy; (M.C.); (A.P.); (V.F.); (I.P.); (I.M.)
| | - Antonella Pesce
- Department of Radiology, Ospedale del Mare, ASL NA1 Centro, 80147 Napoli, Italy; (M.C.); (A.P.); (V.F.); (I.P.); (I.M.)
| | - Valeria Fiorini
- Department of Radiology, Ospedale del Mare, ASL NA1 Centro, 80147 Napoli, Italy; (M.C.); (A.P.); (V.F.); (I.P.); (I.M.)
| | - Ida Pelella
- Department of Radiology, Ospedale del Mare, ASL NA1 Centro, 80147 Napoli, Italy; (M.C.); (A.P.); (V.F.); (I.P.); (I.M.)
| | - Giuliana Vespere
- Department of Gastroenterology, Ospedale del Mare, ASL NA1 Centro, 80147 Napoli, Italy;
| | - Marina Romano
- Department of Surgery, Ospedale del Mare, ASL NA1 Centro, 80147 Napoli, Italy; (M.R.); (P.T.)
| | - Pasquale Tammaro
- Department of Surgery, Ospedale del Mare, ASL NA1 Centro, 80147 Napoli, Italy; (M.R.); (P.T.)
| | - Ester Marra
- Department of Surgery, University of Naples “Federico II”, 80131 Napoli, Italy;
| | - Gabriella Oliva
- Department of Internal Medicine, Ospedale del Mare, ASL NA1 Centro, 80147 Napoli, Italy; (G.O.); (M.L.)
| | - Marina Lugarà
- Department of Internal Medicine, Ospedale del Mare, ASL NA1 Centro, 80147 Napoli, Italy; (G.O.); (M.L.)
| | - Mario Scuderi
- Department of Emergency A.O.E. Cannizzaro, 95126 Catania, Italy;
| | - Stefania Tamburrini
- Department of Radiology, Ospedale del Mare, ASL NA1 Centro, 80147 Napoli, Italy; (M.C.); (A.P.); (V.F.); (I.P.); (I.M.)
- Correspondence: (N.R.); (S.T.)
| | - Ines Marano
- Department of Radiology, Ospedale del Mare, ASL NA1 Centro, 80147 Napoli, Italy; (M.C.); (A.P.); (V.F.); (I.P.); (I.M.)
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De Voogd F, Wilkens R, Gecse K, Allocca M, Novak K, Lu C, D’Haens G, Maaser C. A Reliability Study: Strong Inter-Observer Agreement of an Expert Panel for Intestinal Ultrasound in Ulcerative Colitis. J Crohns Colitis 2021; 15:1284-1290. [PMID: 33420784 PMCID: PMC8328294 DOI: 10.1093/ecco-jcc/jjaa267] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Intestinal ultrasound [IUS] is a promising and non-invasive cross-sectional imaging modality in the diagnosis and monitoring of ulcerative colitis [UC]. Unlike endoscopy, where standardized scoring for evaluation of disease activity is widely used, scoring for UC with IUS is currently unavailable. Therefore, we conducted a study to assess the reliability of IUS in UC among expert sonographists in order to identify robust parameters. METHODS Thirty patients with both clinically active [25] and quiescent [five] UC were included. Six expert sonographers first agreed upon key IUS parameters and grading, including bowel wall thickness [BWT], colour Doppler signal [CDS], inflammatory fat [i-fat], loss of bowel wall stratification [BWS], loss of haustrations and presence of lymph nodes. Thirty video-recorded cases were blindly reviewed. RESULTS Inter-observer agreement was almost perfect for BWT (intra-class correlation coefficient [ICC]: 0.96) and substantial for CDS [κ = 0.63]. Agreement was moderate for presence of lymph nodes [κ = 0.41] and fair for presence of i-fat [κ = 0.36], BWS [κ = 0.24] and loss of haustrations [κ = 0.26]. Furthermore, there was substantial agreement for presence of disease activity on IUS [κ = 0.77] and almost perfect agreement for disease severity [ICC: 0.93]. Most individual parameters showed a strong association with IUS disease activity as measured by the six readers. CONCLUSION IUS is a reliable imaging modality to assess disease activity and severity in UC. Important individual parameters such as BWT and CDS are reliable and could be incorporated in a future UC scoring index. Standardized acquisition and assessment of UC utilizing IUS with established reliability is important to expand the use of IUS globally.
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Affiliation(s)
- Floris De Voogd
- Amsterdam University Medical Center, Department of Gastroenterology and Hepatology, Amsterdam, The Netherlands,Corresponding author: Dr F. de Voogd, Amsterdam University Medical Centers, Department of Gastroenterology and Hepatology, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Rune Wilkens
- Gastrounit, Division of Medicine, Hvidovre Hospital, Copenhagen, Denmark
| | - Krisztina Gecse
- Amsterdam University Medical Center, Department of Gastroenterology and Hepatology, Amsterdam, The Netherlands
| | | | - Kerri Novak
- Division of Gastroenterology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Cathy Lu
- Division of Gastroenterology, Department of Medicine, University of Calgary, Alberta, Canada
| | - Geert D’Haens
- Amsterdam University Medical Center, Department of Gastroenterology and Hepatology, Amsterdam, The Netherlands
| | - Christian Maaser
- Outpatient’s Department of Gastroenterology, University Teaching Hospital Lueneburg Germany
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31
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Gokli A, Dillman JR, Humphries PD, Ključevšek D, Mentzel HJ, Rubesova E, Takahashi MS, Anupindi SA. Contrast-enhanced ultrasound of the pediatric bowel. Pediatr Radiol 2021; 51:2214-2228. [PMID: 33978797 PMCID: PMC8113288 DOI: 10.1007/s00247-020-04868-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/13/2020] [Accepted: 09/30/2020] [Indexed: 01/03/2023]
Abstract
Contrast-enhanced ultrasound (CEUS) has emerged as a valuable modality for bowel imaging in adults and children. CEUS enables visualization of the perfusion of the bowel wall and of the associated mesentery in healthy and disease states. In addition, CEUS images can be used to make quantitative measurements of contrast kinetics, allowing for objective assessment of bowel wall enhancement. Bowel CEUS is commonly applied to evaluate inflammatory bowel disease and to monitor treatment response. It has also been applied to evaluate necrotizing enterocolitis, intussusception, appendicitis and epiploic appendagitis, although experience with these applications is more limited. In this review article, we present the current experience using CEUS to evaluate the pediatric bowel with emphasis on inflammatory bowel disease, extrapolating the established experience from adult studies. We also discuss emerging applications of CEUS as an adjunct or problem-solving tool for evaluating bowel perfusion.
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Affiliation(s)
- Ami Gokli
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Jonathan R. Dillman
- grid.239573.90000 0000 9025 8099Department of Radiology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Paul D. Humphries
- grid.420468.cUniversity College London Hospital NHS Trust, Great Ormond Street Hospital for Children, London, UK
| | - Damjana Ključevšek
- grid.29524.380000 0004 0571 7705Department of Radiology, University Children’s Hospital Ljubljana, Ljubljana, Slovenia
| | - Hans-Joachim Mentzel
- grid.275559.90000 0000 8517 6224Section of Pediatric Radiology, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Jena, Germany
| | - Erika Rubesova
- grid.240952.80000000087342732Department of Radiology, Lucile Packard Children’s Hospital, Stanford University Medical Center, Stanford, CA USA
| | - Marcelo S. Takahashi
- Pediatric Radiology Department, Diagnósticos da America (DASA), São Paulo, Brazil
| | - Sudha A. Anupindi
- grid.25879.310000 0004 1936 8972Department of Radiology, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA 19104 USA
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32
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Dietrich CF, Shi L, Wei Q, Dong Y, Cui XW, Löwe A, Worni M, Ferraioli G. What does liver elastography measure? Technical aspects and methodology. Minerva Gastroenterol (Torino) 2020; 67:129-140. [PMID: 33267564 DOI: 10.23736/s2724-5985.20.02787-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Elastography can be thought as an extension of the ancient technique of palpation. After giving a short introduction to the history of elastography, the different technologies that are nowadays available and the physics behind them, the article focuses on the assessment of liver stiffness in patients with diffuse liver disease using shear wave elastography (SWE). Practical advices on how to perform the SWE techniques and on the factors that should be considered for a correct interpretation of the results are given. This paper aimed to provide a practical guide for beginners and advanced clinical users to better understand technical aspects, methodologies and terminology.
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Affiliation(s)
- Christoph F Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Beau Site, Salem und Permanence, Hirslanden, Bern, Switzerland -
| | - Long Shi
- Department of Ultrasound, Jingmen N. 2 People's Hospital, Jingmen, China
| | - Qi Wei
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin-Wu Cui
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Axel Löwe
- Department Allgemeine Innere Medizin (DAIM), Kliniken Beau Site, Salem und Permanence, Hirslanden, Bern, Switzerland
| | - Mathias Worni
- Department of Visceral Surgery, Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara University Hospital, Basel, Switzerland.,Swiss Institute for Translational and Entrepreneurial Medicine, Stiftung Lindenhof, Campus SLB, Bern, Switzerland.,Department of Surgery, Clinic Beau Site, Bern, Switzerland
| | - Giovanna Ferraioli
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
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33
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Hollerweger A, Maconi G, Ripolles T, Nylund K, Higginson A, Serra C, Dietrich CF, Dirks K, Gilja OH. Gastrointestinal Ultrasound (GIUS) in Intestinal Emergencies - An EFSUMB Position Paper. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2020; 41:646-657. [PMID: 32311749 DOI: 10.1055/a-1147-1295] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
An interdisciplinary group of European experts summarizes the value of gastrointestinal ultrasound (GIUS) in the management of three time-critical causes of acute abdomen: bowel obstruction, gastrointestinal perforation and acute ischemic bowel disease. Based on an extensive literature review, statements for a targeted diagnostic strategy in these intestinal emergencies are presented. GIUS is best established in case of small bowel obstruction. Metanalyses and prospective studies showed a sensitivity and specificity comparable to that of computed tomography (CT) and superior to plain X-ray. GIUS may save time and radiation exposure and has the advantage of displaying bowel function directly. Gastrointestinal perforation is more challenging for less experienced investigators. Although GIUS in experienced hands has a relatively high sensitivity to establish a correct diagnosis, CT is the most sensitive method in this situation. The spectrum of intestinal ischemia ranges from self-limited ischemic colitis to fatal intestinal infarction. In acute arterial mesenteric ischemia, GIUS may provide information, but prompt CT angiography is the gold standard. On the other end of the spectrum, ischemic colitis shows typical ultrasound features that allow correct diagnosis. GIUS here has a diagnostic performance similar to CT and helps to differentiate mild from severe ischemic colitis.
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Affiliation(s)
- Alois Hollerweger
- Department of Radiology, Hospital Barmherzige Brüder, Salzburg, Austria
| | - Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, "L.Sacco" University Hospital, Milan, Italy
| | - Tomas Ripolles
- Department of Radiology, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Kim Nylund
- Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | - Antony Higginson
- Department of Radiology, Queen-Alexandra-Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom of Great Britain and Northern Ireland
| | - Carla Serra
- Internal Medicine and Gastroenterology, S. Orsola University Hospital, Bologna, Italy
| | - Christoph F Dietrich
- Department of General Internal Medicine Kliniken Hirslanden Beau-Site, Salem und Permanence, Bern, Switzerland
| | - Klaus Dirks
- Gastroenterology and Internal Medicine, Rems-Murr-Klinikum Winnenden, Germany
| | - Odd Helge Gilja
- Haukeland University Hospital, National Centre for Ultrasound in Gastroenterology, Bergen, Norway
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Hoffmann T, Fusco S, Blumenstock G, Sadik S, Malek NP, Froehlich E. Evaluation of bowel wall thickness by ultrasound as early diagnostic tool for therapeutic response in Crohn's disease patients treated with ustekinumab. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2020; 60:1212-1220. [PMID: 33233006 DOI: 10.1055/a-1283-6550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Ustekinumab was approved for the treatment of patients with moderate to severe CD 2. Development of predictors for selecting patients responding to ustekinumab has to be the next step. US offers a noninvasive method with great sensitivity in detecting CD activity 11. AIM To evaluate BWT by BS as early diagnostic tool for treatment response in CD patients treated with ustekinumab at week 8. METHODS This is a prospective monocentric study. Twenty-three CD patients had BS at the time of first and second application. BS was performed by one of 2 experienced DEGUM certificated sonographers, with evaluation by both independently and blindly. Primary endpoint was substantial sonographic response defined as decrease of BWT ≥ 1 mm. Secondary endpoint was concordance between sonographic and clinical response, defined as decrease of CDAI ≥ 70 points and sonographic and biochemical response defined as decrease of CRP ≥ 0.5 mg/dl. RESULTS At week 8, BS detected in 10 of 23 patients a substantial decrease of BWT ≥ 1 mm; in 7, a decrease < 1 mm. Compared to baseline, all 17 patients showed generally improved blood data and 16/17 generally improved clinical data. Of those with a decrease of BWT ≥ 1 mm, we observed a substantial decrease of CDAI ≥ 70 points in 9/10 patients and a substantial decrease of CRP ≥ 0.5 mg/dl in 8/10 patients. CONCLUSION Our study suggests that sonographic measurement of BWT can be a helpful parameter for selecting patients responding early to ustekinumab and for providing assistance in terms of further treatment interval at week 8.
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Affiliation(s)
- Tatjana Hoffmann
- Medizinische Klinik I, Gastroenterologie, Gastrointestinale Onkologie, Hepatologie, Infektiologie und Geriatrie, Uniklinik Tübingen, Germany
| | - Stefano Fusco
- Medizinische Klinik I, Gastroenterologie, Gastrointestinale Onkologie, Hepatologie, Infektiologie und Geriatrie, Uniklinik Tübingen, Germany
| | | | - Saman Sadik
- Medizinische Klinik I, Gastroenterologie, Gastrointestinale Onkologie, Hepatologie, Infektiologie und Geriatrie, Uniklinik Tübingen, Germany
| | - Nisar P Malek
- Medizinische Klinik I, Gastroenterologie, Gastrointestinale Onkologie, Hepatologie, Infektiologie und Geriatrie, Uniklinik Tübingen, Germany
| | - Eckhart Froehlich
- Medizinische Klinik I, Gastroenterologie, Gastrointestinale Onkologie, Hepatologie, Infektiologie und Geriatrie, Uniklinik Tübingen, Germany
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The role of point of care ultrasound in radiology department: update and prospective. A statement of Italian college ultrasound. Radiol Med 2020; 126:636-641. [PMID: 33146845 DOI: 10.1007/s11547-020-01301-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023]
Abstract
Ultrasound, in its new point-of-care conception, has been called the stethoscope of the future. Goal-directed bedside ultrasound examination, performed by a healthcare provider to answer a specific diagnostic question or guide an invasive procedure, is currently revolutionizing medical practice. It is used by various specialties in multiple clinical contexts for procedural, diagnostic, and screening applications. Point-of-care ultrasound is also a strategic technique in clinical radiology; it brings the radiologist closer to the patient (in interaction and understanding) like interventional and angiography procedures and, as an integrative imaging modality, is a vital radiological tool for decision-making in many situations. In this commentary, we present our observations on the use of ultrasound, in a sincere appeal to refrain from omitting ultrasound as a diagnostic technique in this era of deep professional change, in which radiologists must return to being a true clinical semiologist.
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37
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Martínez Pérez MJ, Blanc García E, Merino Bonilla JA. Bowel ultrasound: examination techniques and normal and pathologic patterns. RADIOLOGIA 2020; 62:517-527. [PMID: 33127091 DOI: 10.1016/j.rx.2020.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 08/31/2020] [Accepted: 09/17/2020] [Indexed: 12/11/2022]
Abstract
Ultrasound is being increasingly used to study the digestive tract because it has certain advantages over other techniques such as endoscopy, CT enterography, and MR enterography. Ultrasound can be used to evaluate the bowel wall and the elements that surround it without the need for contrast agents; its ability to evaluate the elasticity and peristalsis of these structures is increasing interest in its use. This article describes the techniques and modalities of bowel ultrasound, as well as the normal features of the bowel wall and contiguous structures. It uses a practical approach to review the main pathological findings and their interpretation, and the different patterns of presentation, which will help orient the diagnosis.
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Affiliation(s)
- M J Martínez Pérez
- Servicio de Radiodiagnóstico, Hospital Universitario Doctor Peset, Valencia, España.
| | - E Blanc García
- Servicio de Radiodiagnóstico, Hospital Universitario Doctor Peset, Valencia, España
| | - J A Merino Bonilla
- Servicio de Radiodiagnóstico, Hospital Santiago Apóstol, Miranda de Ebro, Burgos, España
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38
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Zander D, Hüske S, Hoffmann B, Cui XW, Dong Y, Lim A, Jenssen C, Löwe A, Koch JBH, Dietrich CF. Ultrasound Image Optimization ("Knobology"): B-Mode. Ultrasound Int Open 2020; 6:E14-E24. [PMID: 32885137 PMCID: PMC7458857 DOI: 10.1055/a-1223-1134] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 07/16/2020] [Indexed: 12/21/2022] Open
Abstract
Ultrasound is a ubiquitous and indispensable diagnostic and therapeutic tool in
medicine. Due to modern equipment and automatic image optimization, the
introduction of ultrasound imaging currently requires only little technical and
physical knowledge. However, in-depth knowledge of the device functions and
underlying mechanisms is essential for optimal image adjustment and
documentation. From a medical as well as an aesthetic point of view, the goal
should always be to achieve the best possible image quality. The first part of
this article provides an overview of the handling of ultrasound systems,
fundamental adjustments, and their optimization in B-mode ultrasound.
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Affiliation(s)
- David Zander
- Ruprecht Karls University Heidelberg Medical School, Heidelberg, Germany
| | - Sebastian Hüske
- Ruprecht Karls University Heidelberg Medical School, Heidelberg, Germany
| | - Beatrice Hoffmann
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, United States
| | - Xin-Wu Cui
- Medical Ultrasound, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Yi Dong
- Ultrasound Department, Zhongshan Hospital Fudan University, Shanghai, China
| | - Adrian Lim
- Imaging Department, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Christian Jenssen
- Klinik für Innere Medizin, Krankenhaus Märkisch-Oderland GmbH, Strausberg and Brandenburg Insitute for Clinical Ultrasound at Medical University Brandenburg, Neuruppin, Germany
| | - Axel Löwe
- Department of General Internal Medicine, Hirslanden Clinics Beau Site, Salem and Permanence, Switzerland
| | - Jonas B H Koch
- Department of General Internal Medicine, Hirslanden Clinics Beau Site, Salem and Permanence, Switzerland
| | - Christoph F Dietrich
- Department of General Internal Medicine, Hirslanden Clinics Beau Site, Salem and Permanence, Switzerland
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39
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The pediatric stomach - masses and mass-like pathology. Pediatr Radiol 2020; 50:1180-1190. [PMID: 32474774 DOI: 10.1007/s00247-020-04697-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/22/2020] [Accepted: 04/23/2020] [Indexed: 02/06/2023]
Abstract
Diagnostic imaging of pediatric gastric masses often provides a challenge for the practicing radiologist. Radiologists should be aware of this relatively unusual pathology, particularly in cross-sectional imaging findings. We will review pediatric gastric masses and mass-like lesions, focusing on neoplastic and inflammatory etiologies.
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Ibrahim HMM, El-Ashker MR. Reference Values and Repeatability of Transabdominal Ultrasonographic Gastrointestinal Tract Thickness and Motility in Healthy Donkeys (Equus asinus). J Equine Vet Sci 2020; 92:103153. [PMID: 32797781 DOI: 10.1016/j.jevs.2020.103153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/30/2020] [Accepted: 06/01/2020] [Indexed: 01/03/2023]
Abstract
The present study aimed to provide reference ranges for the wall thickness and motility pattern of the gastrointestinal tract from a sample of donkeys (Equus asinus) population using B-mode ultrasonography. In the present study, 30 clinically healthy donkeys (Equus asinus) (15 males and 15 females), aged 2-20 year old and weighed 100-280 kg were randomly selected for B-mode ultrasonographic scanning of the abdomen. The wall thickness of the stomach, duodenum, jejunum, left colon, right colon, and cecum was assessed. Moreover, the motility pattern of the duodenum, jejunum, left colon, right colon, and cecum was evaluated over a period of 3 minutes. Abdominal ultrasonographic scanning of the gastrointestinal tract of healthy donkeys explored that the stomach, duodenum, jejunum, left colon, right colon, and cecum could be visualized easily. The wall thickness of the stomach, duodenum, jejunum, left colon, right colon, and cecum was 7.0 ± 0.9 mm, 3.3 ± 1.0 mm, 5.4 ± 0.6 mm, 5.1 ± 0.5 mm, 5.4 ± 0.5 mm, and 5.4 ± 0.6 mm, respectively. The thickest part of the gastrointestinal tract is the stomach, whereas the thinnest part is the duodenum. The motility pattern of the duodenum, jejunum, left colon, right colon, and cecum was 7.7 ± 1.3 contractions/3 minutes, 6.9 ± 1.1 contractions/3 minutes, 4.1 ± 1.2 contractions/3 minutes, 5.5 ± 1.3 contractions/3 minutes, and 4.0 ± 0.8 contractions/3 minutes, respectively. Both the duodenum and jejunum contractions were significantly higher than that of the left colon, right colon, and cecum. This is the first study reporting the reference values for both the wall thickness and motility pattern of the gastrointestinal tract in healthy donkeys (Equus asinus) in Egypt. Good knowledge of these standard and reference values of the wall thickness and motility pattern of gastrointestinal tract structures represents a step in the early diagnosis of the gastrointestinal disorders, including colic in such animal species.
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Affiliation(s)
- Hussam M M Ibrahim
- Department of Internal Medicine, Infectious and Fish Diseases, Faculty of Veterinary Medicine, Mansoura University, Mansoura, Egypt.
| | - Maged R El-Ashker
- Department of Internal Medicine, Infectious and Fish Diseases, Faculty of Veterinary Medicine, Mansoura University, Mansoura, Egypt
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Abstract
Deep invasive gastrointestinal endometriosis (DIGIE) is a frequent and severe presentation of endometriosis. Although most cases invade the rectosigmoid colon, DIGIE can involve any portion of the gastrointestinal tract from the stomach to the rectum, and is commonly multifocal and multicentric. Although histopathologic confirmation with surgery remains the gold standard for diagnosis, ultrasound (US) and magnetic resonance imaging (MRI) are the key non-invasive imaging modalities for initial assessment. US may be preferred as a screening study because of its easy availability and low-cost. Pelvic MRI and magnetic resonance enterography (MRE) provide substantial advantages for disease mapping in the pre-operative period, particularly in extensive bowel endometriosis. Although medical management of DIGIE with hormonal therapy can help control symptoms, disease course can be relentless and require surgical intervention. Surgical options depend on, the location; length; depth; circumference; multicentric or multifocal disease. With procedures including simple excision, fulguration of superficial lesions, shaving, disc excision, and segmental resection. A successful treatment outcome is largely dependent on good communication between the treating surgeon and the radiologist, who can provide vital information for effective surgical planning by reporting the key elements that we elaborate upon in this paper.
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Ultrasound Signs in the Diagnosis and Staging of Small Bowel Obstruction. Diagnostics (Basel) 2020; 10:diagnostics10050277. [PMID: 32375244 PMCID: PMC7277998 DOI: 10.3390/diagnostics10050277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/24/2020] [Accepted: 04/30/2020] [Indexed: 12/16/2022] Open
Abstract
Ultrasound (US) is highly accurate in the diagnosis of small bowel obstruction (SBO). Because the indications for and timing of surgical intervention for SBO have changed over the past several decades, there is a widespread assumption that the majority of patients with simple SBO may be conservatively managed; in this scenario, staging SBO is crucial. This study evaluated the association between morphological and functional US signs in the diagnosis and staging (simple, decompensated and complicated), and the associations and prevalence of US signs correlated with clinical or surgical outcome. The US signs were divided into diagnostic (dilated bowel loops and altered kinesis) and staging criteria (extraluminal free fluid, parietal and villi alterations). We performed a retrospective, single-center cohort, observational study examining the prevalence of morphologic and functional US signs in the staging of simple, decompensated and complicated SBO. The most significant US signs were dilated bowel loops (100%), hypokinesis (90.46%), thickened walls (82.54%) and free fluid (74.60%). By linear regression, free fluid was positively correlated to US staging in both univariate and multivariate analysis; that is, the more advanced the stage of SBO, the more probable the presence of free fluid between the bowel loops. In univariate analysis only, we found a positive correlation between US staging/thickened walls and the prominence of valvulae conniventes. Additionally, the multivariate analysis indicated that parietal stratification and bowel jump kinesis were negative predictors for US staging in comparison to other US signs. In addition, we found significant associations between conservative treatment or surgery and hypokinesis (p = 0.0326), akinesis (p = 0.0326), free fluid (p = 0.0013) and prominence of valvulae conniventes (p = 0.011). Free fluid in particular was significantly less present in patients that were conservatively treated (p = 0.040). We conclude that the US staging of SBO may be crucial, with a valuable role in the initial diagnosis and staging of the pathology, saving time and reducing total radiation exposure to the patient.
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Saftoiu A, Napoleon B, Arcidiacono PG, Braden B, Burmeister S, Carrara S, Cui XW, Fusaroli P, Gottschalk U, Hocke M, Hollerbach S, Iglesias-Garcia J, Jenssen C, Kitano M, Larghi A, Oppong KW, Sahai AV, Sun S, Burmester E, Di Leo M, Petrone MC, Santos E, Teoh AYB, Hwang JH, Rimbas M, Sharma M, Puri R, Kahaleh M, Dietrich CF. Do we need contrast agents for EUS? Endosc Ultrasound 2020; 9:361-368. [PMID: 32675463 PMCID: PMC7811706 DOI: 10.4103/eus.eus_20_20] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
We recently introduced a series of articles that dealt with controversies in EUS. In Part I, the authors discussed which clinical information is necessary prior to EUS and whether other imaging modalities are required before embarking on EUS examinations. Part II focuses on technical details and controversies about the use of EUS in special situations. In this article, important practical issues regarding the application of contrast-enhanced EUS in various clinical settings are raised and controversially discussed from different points of view.
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Affiliation(s)
- Adrian Saftoiu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Bertrand Napoleon
- Digestive Endoscopy Unit, Hopital Privé J Mermoz Ramsay Générale de Santé, Lyon, France
| | - Paolo Giorgio Arcidiacono
- Pancreatico/Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Barbara Braden
- Johann Wolfgang Goethe University Frankfurt, Germany; Translational Gastroenterology Unit I John Radcliffe Hospital I Oxford OX3 9DU UK
| | - Sean Burmeister
- Surgical Gastroenterology unit, Groote Schuur Hospital, Cape Town, South Africa
| | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | - Xin Wu Cui
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei, China
| | - Pietro Fusaroli
- Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Bologna/Imola Hospital, Imola, Italy
| | - Uwe Gottschalk
- Department of Medical, Dietrich Bonhoeffer Klinikum, Neubrandenburg, Germany
| | - Michael Hocke
- Medical Department, Helios Klinikum Meiningen, Germany
| | - Stephan Hollerbach
- Department of Gastroenterology, Allgemeines Krankenhaus Celle, Celle, Germany
| | - Julio Iglesias-Garcia
- Department of Gastroenterology and Hepatology, Health Research Institute of Santiago de Compostela (IDIS), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Märkisch Oderland Strausberg/Wriezen; Brandenburg Institute of Clinical Ultrasound, Medical University Brandenburg, Neuruppin, Germany
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | | | - Anand V Sahai
- Center Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Siyu Sun
- Endoscopy Center, ShengJing Hospital of China Medical University, Shenyang, Liaoning province, China
| | | | - Milena Di Leo
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | - Maria Chiara Petrone
- Pancreatico/Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Erwin Santos
- Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Anthony Y B Teoh
- Department of Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, China
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA 94305, USA
| | - Mihai Rimbas
- Gastroenterology Department, Colentina Clinical Hospital Internal Medicine Department, Carol Davila University of Medicine Bucharest, Romania
| | - Malay Sharma
- Department of Gastroenterology, Jaswant Rai Speciality Hospital, Meerut, Uttar Pradesh, India
| | - Rajesh Puri
- Interventional Gastroenterology, Institute of Digestive and Hepatobiliary Sciences Medanta the Medicity Gurugram, Haryana, India
| | - Michel Kahaleh
- Department of Gastroenterology, The State University of New Jersey, New Jersey, USA
| | - Christoph F Dietrich
- Johann Wolfgang Goethe University Frankfurt, Germany; Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei, China; Department Allgemeine Innere Medizin, Kliniken Hirslanden, Beau Site, Salem und Permanence, Bern, Switzerland
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Rimbas M, Larghi A, Fusaroli P, Dong Y, Hollerbach S, Jenssen C, Săftoiu A, Sahai AV, Napoleon B, Arcidiacono PG, Braden B, Burmeister S, Carrara S, Cui XW, Hocke M, Iglesias-Garcia J, Kitano M, Oppong KW, Sun S, Di Leo M, Petrone MC, B Teoh AY, Dietrich CF. How to perform EUS-guided tattooing? Endosc Ultrasound 2020; 9:291-297. [PMID: 32883923 PMCID: PMC7811726 DOI: 10.4103/eus.eus_44_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Recently, we introduced a series of papers describing on how to perform certain techniques and controversies in EUS. In the first paper, "What should be known before performing EUS examinations, Part I," the authors discussed clinical information and whether other imaging modalities should be needed before embarking in EUS examination. In Part II, some technical controversies on how EUS is performed are discussed from different points of view by providing the relevant available evidence. Herewith, we describe on how to perform EUS-guided fine needle tattooing (FNT) in daily practice. The aim of this paper is to discuss pros and cons for several issues including historical remarks, injecting material, technical approach, and how to perform EUS-FNT including argues in favor and against.
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Affiliation(s)
- Mihai Rimbas
- Gastroenterology and Internal Medicine Departments, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania; Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS; CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
| | - Pietro Fusaroli
- Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Bologna/Imola Hospital, Imola, Italy
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Stephan Hollerbach
- Department of Gastroenterology, Allgemeines Krankenhaus Celle, Celle, Germany
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus MärkischOderland, Strausberg and Brandenburg Institute for Clinical Ultrasound, Neuruppin, Germany
| | - Adrian Săftoiu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Anand V Sahai
- Center Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Bertrand Napoleon
- Digestive Endoscopy Unit, Hopital Privé J Mermoz Ramsay Générale de Santé, Lyon, France
| | - Paolo Giorgio Arcidiacono
- Pancreatico/Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Barbara Braden
- Johann Wolfgang Goethe University, Frankfurt, Germany & Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Sean Burmeister
- Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa
| | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | - Xin Wu Cui
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Michael Hocke
- Medical Department, Helios Klinikum, Meiningen, Germany
| | - Julio Iglesias-Garcia
- Department of Gastroenterology and Hepatology, Health Research Institute of Santiago de Compostela (IDIS), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | | | - Siyu Sun
- Department of Gastroenterology, ShengJing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Milena Di Leo
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | - Maria Chiara Petrone
- Pancreatico/Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Anthony Y B Teoh
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Christoph F Dietrich
- Department Allgemeine Innere Medizin, Kliniken Hirslanden, Beau Site, Salem und Permanence, Bern, Switzerland
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Wang MQ, Lee MY, El Teo H. Ultrasound in the evaluation of necrotic bowel in children: A pictorial essay. ULTRASOUND (LEEDS, ENGLAND) 2019; 27:207-216. [PMID: 31762778 DOI: 10.1177/1742271x18814864] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 10/19/2018] [Indexed: 11/16/2022]
Abstract
Necrotic bowel is a serious condition involving death of gastrointestinal tissue. The diagnosis is difficult to make clinically, and plain radiography is often inconclusive. Ultrasonography is an inexpensive, portable and readily available complementary diagnostic tool. In some cases, ultrasonography can detect features of necrotic bowel earlier than plain radiography or when plain radiography is equivocal and does not correlate with the clinical findings. This pictorial essay aims to compare the ultrasonography features of normal bowel and necrotic bowel in children. The role of ultrasonography and the ultrasonographic features of necrotic bowel will be illustrated by discussing some of the causes of necrotic bowel in children. Correlation with plain radiographs and pathological specimens is made. Frequent causes of necrotic bowel in neonates include necrotising enterocolitis, malrotation with small bowel volvulus and incarcerated inguinal hernias. Causes in older children include intussusception, complications of Meckel's diverticulum, post-surgical adhesions, internal hernias and vasculitic abnormalities. Ultrasonography features suggestive of necrotic bowel include persistently dilated loops of aperistaltic bowel, increase or decrease of bowel wall thickness, intramural or portal venous gas, loss of bowel wall perfusion, and free intraperitoneal gas and fluid. The diagnosis of necrotic bowel may be made earlier on ultrasonography than on abdominal radiographs alone. This pictorial essay will familiarise the reader with the role of ultrasonography and the ultrasonographic features of necrotic bowel through a wide range of conditions that may cause necrotic bowel in children. Familiarity with these findings will facilitate timely imaging diagnosis of necrotic bowel before complications develop.
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Affiliation(s)
- Mark Qw Wang
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore, Singapore
| | - Margaret Yw Lee
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore, Singapore
| | - Harvey El Teo
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore, Singapore
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Nojiri H, Miyagawa K, Yamaguchi H, Koike M, Iwase Y, Okuda T, Kaneko K. Intraoperative ultrasound visualization of paravertebral anatomy in the retroperitoneal space during lateral lumbar spine surgery. J Neurosurg Spine 2019; 31:334-337. [PMID: 31100724 DOI: 10.3171/2019.3.spine181210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 03/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Lumbar surgery via a lateral approach is a minimally invasive and highly useful procedure. However, care must be taken to avoid its potentially fatal complications of intestinal and vascular injuries. The object of this study was to evaluate the usefulness of intraoperative ultrasound in improving the safety of lateral lumbar spine surgery. METHODS A transvaginal ultrasound probe was inserted into the operative field, and the intestinal tract, kidney, psoas muscle, and vertebral body were identified using B-mode ultrasound. The aorta, vena cava, common iliac vessels, and lumbar arteries and their associated branches were identified using the color Doppler mode. RESULTS The study cohort comprised 100 patients who underwent lateral lumbar spine surgery, 92 via a left-sided approach. The intestinal tract and kidney lateral to the psoas muscle on the anatomical approach pathway were visualized in 36 and 26 patients, respectively. A detachment maneuver displaced the intestinal tract and kidneys in an anteroinferior direction, enabling confirmation of the absence of organ tissues above the psoas. In all patients, the major vessels anterior to the vertebral bodies and the lumbar arteries and associated branches in the psoas on the approach path were clearly visualized in the Doppler mode, and their orientation, location, and positional relationship with regard to the vertebral bodies, intervertebral discs, and psoas were determined. CONCLUSIONS When approaching the lateral side of the lumbar spine in the retroperitoneal space, intraoperative ultrasound allows real-time identification of the blood vessels surrounding the lumbar spine, intestinal tract, and kidney in the approach path and improves the safety of surgery without increasing invasiveness.
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Affiliation(s)
- Hidetoshi Nojiri
- 1Department of Orthopedic Surgery, Juntendo University; and
- 2Department of Orthopedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Kei Miyagawa
- 2Department of Orthopedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Hiroto Yamaguchi
- 2Department of Orthopedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Masato Koike
- 2Department of Orthopedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Yoshiyuki Iwase
- 2Department of Orthopedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | | | - Kazuo Kaneko
- 1Department of Orthopedic Surgery, Juntendo University; and
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Abstract
Ultrasound (US) is an important imaging tool and the most commonly used imaging modality worldwide. Although US requires expertise to be performed at the highest quality levels, basic US exams can be learned by most physicians and medical technologists with knowledge of human anatomy and with physical examination skills. The full potential of US is achieved when it is more than a pure “imaging modality”, but instead an integrated clinical, physical, and imaging assessment in which the examiner interacts directly and personally with the patient. Specific diagnostic US knowledge is strongly encouraged for specialist training in clinical disciplines.
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The pediatric gastrointestinal tract: ultrasound findings in acute diseases. J Ultrasound 2019; 22:409-422. [PMID: 30758808 DOI: 10.1007/s40477-018-00355-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/15/2018] [Indexed: 02/07/2023] Open
Abstract
The study of the gastrointestinal tract by imaging, particularly using ultrasound, is a required instrument for diagnosis of acute and chronic gastrointestinal pathologies in pediatric age. Actually, ultrasound plays an increasing role in the evaluation of gastrointestinal tract in neonatal and pediatric patients because of their small body habitus and the presence of less fat tissue in the abdominal wall and peritoneal cavity. Ultrasound has certain advantages, thanks to the new wide-spectrum frequency probes able to assess a detailed study of the morphological aspects and functional characteristics of bowel loops, adding a new dimension to the imaging of this body system. In this paper, we review anatomy, ultrasound technique and sonographic findings of bowel pathology frequently encountered in neonatal and pediatric emergency setting.
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Dietrich CF, Arcidiacono PG, Braden B, Burmeister S, Carrara S, Cui X, Di Leo M, Dong Y, Fusaroli P, Gilja OH, Healey AJ, Hocke M, Hollerbach S, Garcia JI, Ignee A, Jürgensen C, Kahaleh M, Kitano M, Kunda R, Larghi A, Möller K, Napoleon B, Oppong KW, Petrone MC, Saftoiu A, Puri R, Sahai AV, Santo E, Sharma M, Soweid A, Sun S, Teoh AYB, Vilmann P, Jenssen C. What should be known prior to performing EUS? Endosc Ultrasound 2019; 8:3-16. [PMID: 30777940 PMCID: PMC6400085 DOI: 10.4103/eus.eus_54_18] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Direct referral of patients for EUS – instead of preprocedural consultation with the endosonographer – has become standard practice (like for other endoscopic procedures) as it is time- and cost-effective. To ensure appropriate indications and safe examinations, the endosonographer should carefully consider what information is needed before accepting the referral. This includes important clinical data regarding relevant comorbidities, the fitness of the patient to consent and undergo the procedure, and the anticoagulation status. In addition, relevant findings from other imaging methods to clarify the clinical question may be necessary. Appropriate knowledge and management of the patients’ anticoagulation and antiplatelet therapy, antibiotic prophylaxis, and sedation issues can avoid unnecessary delays and unsafe procedures. Insisting on optimal preparation, appropriate indications, and clear clinical referral questions will increase the quality of the outcomes of EUS. In this paper, important practical issues regarding EUS preparations are raised and discussed from different points of view.
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Affiliation(s)
- Christoph F Dietrich
- Medical Department 2, Caritas-Krankenhaus, Uhlandstr 7, D-97980 Bad Mergentheim, Germany; Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Paolo Giorgio Arcidiacono
- Pancreatico/Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Barbara Braden
- Translational Gastroenterology Unit I John Radcliffe Hospital I Oxford OX3 9DU, UK
| | - Sean Burmeister
- Surgical Gastroenterology unit, Groote Schuur Hospital, Cape Town, South Africa
| | - Silvia Carrara
- Humanitas Clinical and Research Center- IRCCS- Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Milan, Italy
| | - Xinwu Cui
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Milena Di Leo
- Humanitas Clinical and Research Center- IRCCS- Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Milan, Italy
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Pietro Fusaroli
- Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Bologna/Imola Hospital, Imola, Italy
| | - Odd Helge Gilja
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen and Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Andrew J Healey
- General and HPB Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Michael Hocke
- Medical Department, Helios Klinikum Meiningen, Germany
| | - Stephan Hollerbach
- Department of Gastroenterology, Allgemeines Krankenhaus Celle, Celle, Germany
| | - Julio Iglesias Garcia
- Department of Gastroenterology and Hepatology, Health Research Institute of Santiago de Compostela (IDIS), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - André Ignee
- Medical Department 2, Caritas-Krankenhaus, Uhlandstr 7, D-97980 Bad Mergentheim, Germany
| | | | - Michel Kahaleh
- Department of Gastroenterology, The State University of New Jersey, New Jersey, USA
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Rastislav Kunda
- Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark; Department of Surgery and Department of Advanced Interventional Endoscopy, University Hospital Brussels, Brussels, Belgium
| | - Alberto Larghi
- Digestive Endoscopy Unit, IRCCS Foundation University Hospital, Policlinico A. Gemelli, Rome, Italy
| | - Kathleen Möller
- Medical Department I/Gastroenterology, SANA Hospital Lichtenberg, Berlin, Germany
| | - Bertrand Napoleon
- Digestive Endoscopy Unit, Hopital Privé J Mermoz Ramsay Générale de Santé, Lyon, France
| | | | - Maria Chiara Petrone
- Pancreatico/Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Adrian Saftoiu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Rajesh Puri
- Interventional Gastroenterology, Institute of Digestive and Hepatobiliary Sciences Medanta the Medicity, Gurugram, Haryana, India
| | - Anand V Sahai
- Center Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Erwin Santo
- Department of Gastroenterology and Liver Diseases, Tel Aviv, Sourasky Medical Center, Tel Aviv, Israel
| | - Malay Sharma
- Department of Gastroenterology, Jaswant Rai Speciality Hospital, Meerut, Uttar Pradesh, India
| | - Assaad Soweid
- Endosonography and advanced therapeutic endoscopy, Division of Gastroenterology, The American University of Beirut, Medical Center, Beirut, Lebanon
| | - Siyu Sun
- Endoscopy Center, ShengJing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Anthony Yuen Bun Teoh
- Division of Upper Gastrointestinal and Metabolic Surgery, Department of Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Peter Vilmann
- GastroUnit, Department of Surgery, Copenhagen University, Hospital Herlev, Denmark
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Maerkisch-Oderland, D-15344 Strausberg and Brandenburg Institute of Clinical Ultrasound at Medical University Brandenburg, Germany
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Dong Y, Braden B, Klinger C, Ripolles T, Dietrich CF. Ultrasound findings in extragenital endometriosis. J Ultrason 2018; 18:247-254. [PMID: 30427131 PMCID: PMC6442214 DOI: 10.15557/jou.2018.0036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
We present a report on ultrasound findings in extragenital endometriosis and a literature review accompanied by illustrations. Intestinal endometriosis should be considered in female patients of reproductive age who present with constipation, gastrointestinal bleeding, nausea, vomiting, cramp-like abdominal pain, diarrhoea and pelvic pain. Although definitive preoperative diagnosis of endometriosis is difficult, clinical suspicion and appropriate imaging might prevent extensive surgical procedures with higher morbidity. Contrast-enhanced ultrasound is an efficient non-invasive imaging method without any radiation exposure that supports the early diagnosis of intestinal endometriosis and may help assess the vascularization of endometriotic lesions within the distinct layers of the intestinal wall.
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Affiliation(s)
- Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | | | - Tomás Ripolles
- Department of Radiology, Dr Peset Universitary Hospital, Valencia, Spain
| | - Christoph F Dietrich
- Medizinische Klinik 2, Caritas-Krankenhaus Bad Mergentheim, Bad Mergentheim, Germany
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