Contrast-enhanced ultrasonography to diagnose complicated acute cholecystitis

Usefulness of contrast-enhanced ultrasonography for biliary tract disease

Conventional ultrasonography (US) for biliary tract disease shows high time and spatial resolution. In addition, it is simple and minimally invasive, and is selected as a first-choice examination procedure for biliary tract disease. Currently, contrast-enhanced US (CEUS), which facilitates the more accurate assessment of lesion blood flow in comparison with color and power Doppler US, is performed using a second-generation ultrasonic contrast agent. Such agents are stable and provide a timeline for CEUS diagnosis. Gallbladder lesions are classified into three types: gallbladder biliary lesion (GBL), gallbladder polypoid lesion (GPL), and gallbladder wall thickening (GWT). Bile duct lesions can also be classified into three types: bile duct biliary lesion (BBL), bile duct polypoid lesion (BDPL), and bile duct wall thickening (BDWT). CEUS facilitates the differentiation of GBL/BBL from tumorous lesions based on the presence or absence of blood vessels. In the case of GPL, it is important to identify a vascular stalk attached to the lesion. In the case of GWT, the presence or absence of a non-contrast-enhanced area, the Rokitansky-Aschoff sinus, and continuity of a contrast-enhanced gallbladder wall layer are important for differentiation from gallbladder cancer. In the case of BDWT, it is useful to evaluate the contour of the contrast-enhanced medial layer of the bile duct wall for differentiating IgG4-related sclerosing cholangitis from primary sclerosing cholangitis. CEUS for ampullary carcinoma accurately reflects histopathological findings of the lesion. Evaluating blood flow in the lesion, continuity of the gallbladder wall, and contour of the bile duct wall via CEUS provides useful information for the diagnosis of biliary tract disease.

What's new in the hot gallbladder: the evolving radiologic diagnosis and management of acute cholecystitis

Acute cholecystitis (AC) is a common condition and its incidence is rising. New technologies have advanced the imaging diagnosis of AC, providing more structural and functional information as well as allowing the radiologist to distinguish AC from mimics and identify complications from both the disease and its management. Dual energy CT aids in detecting gallstones and gallbladder wall enhancement, which helps to diagnose AC and identify its complications. Similarly, contrast-enhanced and non-contrast perfusion ultrasound techniques improve detection of abnormal gallbladder wall enhancement. Advances in MR imaging including hepatobiliary contrast agents aid in characterizing post-cholecystectomy complications such as bile leaks. Newer interventional techniques have also expanded the suite of options for minimally invasive management. Lumen apposing metal stents provide more options for conservative treatment in non-surgical candidates and are compared to a standard percutaneous cholecystostomy. Radiologists should be familiar with these advanced imaging methods and intervention techniques and the value they can bring to the diagnosis and management of AC.

Contrast-enhanced ultrasound of the spleen, pancreas and gallbladder in children

Gray-scale and color/power Doppler ultrasound (US) are the first-line imaging modalities to evaluate the spleen, gallbladder and pancreas in children. The increasing use of contrast-enhanced ultrasound (CEUS) as a reliable and safe method to evaluate liver lesions in the pediatric population promises potential for imaging other internal organs. Although CEUS applications of the spleen, gallbladder and pancreas have been well described in adults, they have not been fully explored in children. In this manuscript, we present an overview of the applications of CEUS for normal variants and diseases affecting the spleen, gallbladder and pancreas. We highlight a variety of cases as examples of how CEUS can serve in the diagnosis and follow-up for such diseases in children. Our discussion includes specific examination techniques; presentation of the main imaging findings in various benign and malignant lesions of the spleen, gallbladder and pancreas in children; and acknowledgment of the limitations of CEUS for these organs.

Acute cholecystitis in recent lung transplant patients: a single-institution series of 10 cases

OBJECTIVE

To evaluate the clinical and imaging findings of acute cholecystitis in recent lung transplant patients.

METHODS

We retrospectively reviewed all abdominal ultrasounds and computed tomography (CT) scans of patients who developed acute cholecystitis in the early postoperative period following lung transplantation from November 2014 to December 2020 in a tertiary care university hospital.

RESULTS

Ten patients (4.4%) were included in this series (6 male, mean age 62.9 years ± 2.1 [standard deviation]) of a total 227 lung transplant patients performed from November 2014 to December 2020 (172 unilateral and 55 bilateral). Nine (90%) patients received a double-lung transplant and seven (70%) required extracorporeal circulation during surgery. Acute cholecystitis occurred during the initial admission for lung transplantation (average of 33 ± 25.9 days post-transplantation). Six patients (60%) died during admission with an average of 24.3 ± 21.8 days after cholecystectomy. The most frequent imaging findings were gallbladder wall discontinuity or decreased gallbladder mural enhancement (100%, 10 patients) and gallbladder distension (90%, 9 patients). All acute cholecystitis were found to be ischemic / gangrenous at surgery and/or pathology, 40% (4 patients) were hemorrhagic and 30% (3 patients) were perforated, one of them with a cholecystoduodenal fistula. Fungal cholecystitis was demonstrated at histological exam in one patient.

CONCLUSION

Acute cholecystitis in the early postoperative period after lung transplantation is an important cause of morbidity and mortality. Ischemic or gangrenous cholecystitis prevails. The key imaging findings are parietal perfusion defects and gallbladder distension, which can easily go unnoticed if not specifically looked for.

Contrast-Enhanced Ultrasound (CEUS) in Non-Traumatic Abdominal Emergencies

Conventional ultrasound imaging (US) is the first-line investigation in acute non-traumatic abdominal emergencies, but sometimes it needs further examinations, such as computed tomography (CT), to reach a certain diagnosis. Contrast-enhanced ultrasound (CEUS), through injection of contrast medium, may provide the radiologist with additional information that could not be investigated with baseline US. It could help reach a diagnosis and rapidly determine the proper therapy in an emergency setting. The purpose of this review is to explain and illustrate the various possibilities and limitations of CEUS in acute non-traumatic abdominal diseases, in particular acute inflammation, parenchymal infarcts, and hemorrhages.

Colored Doppler Ultrasound Diagnosis and Pathological Analysis of Superficial Organ and Vascular Diseases

This paper proposes a fully digital signal processing scheme for ultrasonic Doppler endoscope imaging. 200 patients with superficial tissue lumps were randomly divided into two groups: the control group and the experimental group. These two groups used conventional ultrasound examination and colored Doppler ultrasound imaging technology, respectively, to observe and compare the test method and the surgical pathological examination results. Compared with the results of the two groups, the diagnostic compliance rate of the patients in the experimental group was 99.0% significantly higher than the diagnostic compliance rate of 86.0%. At the same time, 300 patients with surgery and pathologically confirmed superficial organ lesions were selected in the hospital, and all patients were diagnosed by ultrasound to observe the diagnosis. The clinical effects of colored Doppler ultrasound to diagnose vascular lesions in the lower extremities of diabetes were discussed. The rate of arteriosclerosis in the lower extremities of the observation group was 92.32%. The more than 50% vascular stenosis rate was 45.16%. The vascular blocking rate was 16. 13% and thrombosis rate 6.45% were significantly higher than the control group 12.90%, 8.06%, 0.00%, 0.00%. In the diagnosis of superficial tissue lesions, the resolution of colored Doppler ultrasound imaging technology is relatively high, which can significantly improve the clinical diagnosis rate and has clinical application value.

Surgeon-performed point-of-care ultrasound for acute cholecystitis: indications and limitations: a European Society for Trauma and Emergency Surgery (ESTES) consensus statement

BACKGROUND

Acute cholecystitis (AC), frequently responsible for presentation to the emergency department, requires expedient diagnosis and definitive treatment by a general surgeon. Ultrasonography, usually performed by radiology technicians and reported by radiologists, is the first-line imaging study for the assessment of AC. Targeted point-of-care ultrasound (POCUS), particularly in the hands of the treating surgeon, may represent an evolution in surgical decision-making and may expedite care, reducing morbidity and cost.

METHODS

This consensus guideline was written under the auspices of the European Society of Trauma and Emergency Surgery (ESTES) by the POCUS working group. A systematic literature search identified relevant papers on the diagnosis and treatment of AC. Literature was critically-appraised according to the GRADE evidence-based guideline development method. Following a consensus conference at the European Congress of Trauma & Emergency Surgery (Valencia, Spain, May 2018), final recommendations were approved by the working group, using a modified e-Delphi process, and taking into account the level of evidence of the conclusion.

RECOMMENDATIONS

We strongly recommend the use of ultrasound as the first-line imaging investigation for the diagnosis of AC; specifically, we recommend that POCUS may be adopted as the primary imaging adjunct to surgeon-performed assessment of the patient with suspected AC. In line with the Tokyo guidelines, we strongly recommend Murphy's sign, in conjunction with the presence of gallstones and/or wall thickening as diagnostic of AC in the correct clinical context. We conditionally recommend US as a preoperative predictor of difficulty of cholecystectomy. There is insufficient evidence to recommend contrast-enhanced ultrasound or Doppler ultrasonography in the diagnosis of AC. We conditionally recommend the use of ultrasound to guide percutaneous cholecystostomy placement by appropriately-trained practitioners.

CONCLUSIONS

Surgeons have recently embraced POCUS to expedite diagnosis of AC and provide rapid decision-making and early treatment, streamlining the patient pathway and thereby reducing costs and morbidity.