Hyperechoic appearance of hepatic parenchyma on ultrasound examination of patients with blunt hepatic injury

Evanescent Hyperechoic Changes After Fine-Needle Aspiration Biopsy of the Thyroid in a Series With a Low Overall Prevalence of Complications

OBJECTIVES

The purpose of this study was to assess the frequency of and risk factors for fine-needle aspiration biopsy (FNAB)-related complications in Japanese patients with thyroid nodules evaluated by standard FNAB techniques.

METHODS

Six hundred fifty-three consecutive Japanese patients with 742 nodules who had undergone FNAB were enrolled. Nodule characteristics were evaluated, and thyroid volumes were measured. Fine-needle aspiration biopsy-related complications were identified on the basis of sonographic findings and patients' conditions after undergoing FNAB. Comparisons of patients' backgrounds and nodule characteristics were made between those with and without complications.

RESULTS

The prevalence rates for FNAB-related complications, including acute transient thyroid swelling after FNAB and appearance of anechoic lesions, were 0.13% and 0.94%. In this study, we could not identify risk factors for FNAB-related complications. The sudden appearance of bright hyperechoic foci within the thyroid immediately after biopsy was reported as an FNAB-related unfamiliar appearance in 5 cases. Experimental FNA using resected porcine thyroid tissue suggested that the etiology of the hyperechoic appearance may be artificial air bubbles or reversed flow of aspirated fluid.

CONCLUSIONS

Fine-needle aspiration biopsy-related complications are rare if preventive measures are performed and are not specific to Japanese patients with thyroid nodules. The sudden appearance of bright hyperechoic foci may be cause by contamination from air or fluid.

Healing of Blunt Liver Injury After Non-Operative Management: Role of Ultrasonography Follow-Up

BACKGROUND

Non-operative management of patients with blunt liver trauma has become the standard of care. Usually after initial computed tomography (CT) evaluation and a short-term intra-hospital instrumental and clinical monitoring, no other imaging assessment is routinely requested. A restriction of physical activities for a few (unfixed number of) months is the most common recommendation. A few studies investigated the re-establishment of normal hepatic parenchymal architecture, but there is no evidence of the correct length of time for a certain resumption to normal life. To understand the progression of traumatic liver damage and the time course of healing, and to indicate the correct spontaneous recovery time, a long-term sonographic followup was done.

METHODS

Forty-four patients with blunt non-operatively managed hepatic injury were selected by a retrospective review of a prospectively collected database. At admission, in accordance with the American Association for the Surgery of Trauma (AAST), all lesions were evaluated by CT and graded by the Organ Injury Scale (OIS). The progression of liver repair was followed by ultrasonographic (US) controls on days 3, 5, 10, 15, 30, and 60, and monthly up to a complete clinical recovery and sonographic disappearance of lesions.

RESULTS

One OIS grade I, 20 grade II, 13 grade III, eight grade IV, and two grade V hepatic injuries were included in the study. Forty patients were monitored until liver normalization by 218 US examinations. The median time for liver repair in OIS grades II, III, IV, and V was 30, 63, 62, and 118 days, respectively, and 75% of the patients recovered in 60, 80, and 98 days in the II, III, and IV classes, respectively.

CONCLUSION

In our experience, a long time variability for spontaneous liver repair after blunt trauma and non-operative treatment was found, but a parenchymal US normalization was evidenced in a median time shorter than that usually reported in the literature.

Clinician-performed focused sonography for the resuscitation of trauma

Traumatic death remains pandemic. The majority of preventable deaths occur early and are due to injuries or physiologic derangements in the airway, thoracoabdominal cavities, or brain. Ultrasound is a noninvasive and portable imaging modality that spans a spectrum between the physical examination and diagnostic imaging. It allows trained examiners to immediately confirm important syndromes and answer clinical questions. Newer technologies greatly increase the fidelity, accessibility, ease of use, and informatic manipulation of the results. The early bedside use of focused ultrasound as the initial imaging modality used to detect hemoperitoneum and hemopericardium in the resuscitation of the injured patient has become an accepted standard of care. Widespread dissemination of basic ultrasound skills and technology to facilitate this brings ultrasound to many resuscitative and critical care areas. Although not as widely appreciated, the focused use of ultrasound may also have a role in detecting hemothoraces and pneumothoraces, guiding airway management, and detecting increased intracranial pressure. Intensivists generally utilize a treating philosophy that requires the real-time integration of many divergent sources of information regarding their patients' anatomy and physiology. They are therefore positioned to take advantage of focused resuscitative ultrasound, which offers immediate diagnostic information in the early care of the critically injured.

Screening US and CT for blunt abdominal trauma: a retrospective study

OBJECTIVE

To assess the accuracy of screening US and CT in patients with blunt abdominal trauma admitted to the trauma centre of our General Hospital.

MATERIALS AND METHOD

The abdominal US reports of 864 primary trauma patients (139 with major and 725 with minor injuries) and 162 CT reports of a subgroup of the same subjects (64 with major and 98 with minor injuries) were reviewed and compared to the best available reference standard. The accuracy of screening US was assessed by evaluating its overall ability to distinguish negative from positive cases by showing at least one of the lesions documented by the reference standard and its specific ability to depict all lesions; CT reports were evaluated only for the method's performance in depicting all lesions.

RESULTS

Screening US exhibited a satisfactory overall ability to distinguish negative from positive patients (91.5% sensitivity and 97.5% specificity in major trauma patients versus 73.3% sensitivity and 98.1% specificity in the minor trauma group) and a satisfactory specific ability to depict all injuries in major trauma patients. In minor trauma cases sensitivity was satisfactory for free fluid but unsatisfactory for organ injuries. Of the 21/864 false negative reports (5 in patients with major and 16 in cases with minor traumas), only one affected patient management, a major trauma case, by delaying an emergency laparotomy. The performance of CT in detecting each single lesion was predictably excellent in both patient groups.

CONCLUSION

Its satisfactory accuracy for major trauma suggests that US could be employed not only to screen cases for emergency laparotomy but also as an alternative to CT. However, since major traumatic injuries generally carry an imperative indication for CT, especially as regards neurological, thoracic and skeletal evaluation, US should be employed to perform a prompt preliminary examination using a simplified technique in the emergency room simultaneously with resuscitation.

Surgeon-Performed Bedside Organ Assessment With Sonography After Trauma (BOAST): A Pilot Study From the WTA Multicenter Group

BACKGROUND

Although nonoperative management of solid organ injuries is a well-accepted practice, a rapid method to assess the progression of the injury, the early development of organ-related complications, and the frequency with which follow-up computed tomography (CT) scans are needed has yet to be determined. The use of ultrasound in this setting may provide information that would improve the rate of organ salvage and decrease the patient's morbidity. The objectives of this study were to determine whether surgeons could successfully use a bedside organ assessment with sonography after trauma (BOAST) examination to: (1) detect a solid organ injury; and (2) assess for changes in the size of the organ injury, an increase or decrease in hemoperitoneum, and the development of organ-related complications.

METHODS

A prospective, multicenter study was conducted using BOAST to evaluate patients undergoing nonoperative management of their solid organ injuries. Patients had to have: (1) a Focused Assessment for Sonography of Trauma (FAST) examination on admission; (2) a solid organ injury documented by an admission abdominal CT scan; and (3) the criteria for nonoperative management. BOAST was performed within 24 hours of admission and every 3 to 4 days to evaluate for an increase or decrease in hemoperitoneum [Ultrasound (US) heme score: from 0 = none to 3 = large], change in injury size, and organ-specific complications. BOAST results were compared with the radiologists' interpretation of the initial and follow-up CT scans, and with patient outcomes.

RESULTS

During a 22 month period, 126 patients sustained 135 solid organ injuries, 46 (34.1%) of these were seen by BOAST (Error rate = 66%). Serial US heme scores = 0 (no hemoperitoneum) were observed in 56 of 126 patients who had a combination of multi-system injury and a dropping Hgb, indicating that there was no further bleeding from the injured organ(s). Surgeons detected 13 of the 15 complications that were confirmed later by conventional imaging.

CONCLUSIONS

(1) BOAST has limitations in identifying solid organ injuries, especially those that are lower grade; (2) the US heme score is a valuable adjunct to the clinical examination in following patients with high-grade solid organ injuries and a dropping hemoglobin; and (3) although uncommon, organ-related complications may be identified using BOAST.

Blunt hepatic trauma: evaluation with contrast-enhanced sonography: sonographic findings and clinical application

OBJECTIVE

The purpose of this study was to report our initial experience in the assessment of liver trauma with real-time contrast-enhanced sonography (CES).

METHODS

From January 2000 to December 2003, there were 431 hemodynamically stable patients evaluated with sonography for blunt abdominal trauma. Among these patients, 87 were selected to undergo second-level imaging, consisting of CES and computed tomographic (CT) evaluation. Indications for further assessment were baseline sonographic findings positive for liver injury, baseline sonographic findings positive for injury to other abdominal parenchyma, baseline sonographic findings positive for free fluid only, baseline sonographic findings indeterminate, and baseline sonographic findings negative with persistent clinical or laboratory suspicion.

RESULTS

There were 23 hepatic lesions shown by CT in 21 patients. Peritoneal or retroperitoneal fluid was identified in 19 of 21 positive cases by all 3 imaging modalities. Liver injury was found in 15 patients on sonography and in 19 on CES. Contrast-enhanced sonography compared better than unenhanced sonography with the criterion standard for related injury conspicuity, injury size, completeness of injury extension, and involvement of the liver capsule. Both CES and CT showed intrahepatic contrast material pooling in 2 cases. All patients with false-negative sonographic or CES findings recovered uneventfully.

CONCLUSIONS

Contrast-enhanced sonography is an effective tool in the evaluation of blunt hepatic trauma, being more sensitive than baseline sonography and correlating better than baseline sonography with CT findings. In institutions where sonography is regarded as the initial procedure to screen patients with trauma, this technique may increase its effectiveness. In addition, CES may be valuable in the follow-up of patients with conservatively treated liver trauma.

Ultrasound in abdominal trauma

This article reviews current issues regarding the Focused Assessment with Sonography for Trauma (FAST) examination. Technical performance issues, decision-making and practice algorithms, fluid volume and scoring systems, proficiency and training, and the role of the FAST in pediatric trauma are covered. This article examines the FAST examination from a practical, evidenced-based stand-point.

The hand-held FAST: experience with hand-held trauma sonography in a level-I urban trauma center

AIMS

To describe the effectiveness of a portable hand-held ultrasound machine when used by clinicians in the early evaluation and resuscitation of trauma victims.

METHODS

The study was a prospective evaluation in a level-I urban trauma center. The focussed assessment with sonography for trauma is a specifically defined examination for free fluid known as the focused assessment with sonography for trauma (FAST) exam. Seventy-one patients had a hand-held FAST (HHFAST) examination performed with a Sonosite 180, 2.4 kg ultrasound machine. Sixty-seven examinations were immediately repeated with a Toshiba SSH 140A portable floor-based machine. This repeat scan (formal FAST or FFAST) was used as a comparison standard between the devices for study purposes. Four patients had a HHFAST only, all with positive result, two being taken for immediate laparotomy, and two having a follow-up computed tomographic (CT) scan. Patient follow-up from other imaging studies, operative intervention, and clinical outcomes were also compared to the performance of each device.

RESULTS

There were 58 victims of blunt, and 13 of penetrating abdominal trauma. One examination was indeterminate using both machines. The apparent HHFAST performance yielded; sensitivity, specificity, positive predictive value, negative predictable value, and accuracy (S, S, PPV, NPV, A) of 83, 100, 100, 98, 98%. Upon review, a CT scan finding and benign clinical course found the HHFAST diagnosis to be correct rather than the FFAST in one case. Considering the ultimate clinical course of the patients, yielded a (S, S, PPV, NPV, A) of 78, 100, 100, 97, and 97% for the HHFAST and 75, 98, 86, 97, and 96% for the FFAST. Statistically, there was no significant difference in the actual performance of the HHFAST compared to the FFAST in this clinical setting.

DISCUSSION

Hand-held portable sonography can simplify early and accurate performance of FAST exams in victims of abdominal trauma.

Ultrasound detection of blunt splenic injury

The purpose of this study was to determine the sensitivity of emergency ultrasound (US) for the detection of blunt splenic injury (BSI), and to describe sonographic parenchymal patterns. Over 3 years, 2138 emergency US were performed, and 162 patients had BSI. CT was performed for 76 patients, and there were 86 laparotomies. Seventy patients (43%) had concomitant intraabdominal injuries. Ultrasound detected free fluid in 109 patients (67%), and parenchymal injury in 31 patients (19%). There were 48 false negative US (30%). Sonographic patterns included a diffuse heterogeneous appearance, hyperechoic and hypoechoic perisplenic crescents, and discrete hypoechoic or hyperechoic areas within the spleen. Overall sensitivity of US for detection of BSI was 69%, but was 86% for grade III or higher injuries. Ultrasound is most sensitive for the detection of grade III or higher BSI based on the presence of haemoperitoneum. Ultrasound may also identify BSI on the basis of parenchymal abnormality, with a diffuse heterogeneous pattern most commonly encountered. Sonographic evaluation for both free fluid and parenchymal injury improves sensitivity of US.

Sonographic detection of blunt hepatic trauma: hemoperitoneum and parenchymal patterns of injury

OBJECTIVES

To determine the sensitivity and utility of emergency sonography for the detection of blunt hepatic injury (BHI) in patients with abdominal trauma and to describe parenchymal sonographic patterns of BHI.

METHODS

This report was a prospective clinical study in which the findings of all patients who had emergency sonograms were recorded on a data sheet by the initial sonographer and interpreting physicians. All patients with hepatic injuries during this period were identified and physical examination, laboratory, computed tomographic and intraoperative findings were compared with the prospective data sheets.

RESULTS

From January of 1995 to December of 1998, 2,622 emergency sonograms were performed, and in this group, a total of 146 patients had BHI. Emergency sonograms allowed detection of free fluid in 98 patients (67%), and parenchymal injury with no free fluid in seven patients (5%). There were 41 false negatives (28%). The most common pattern identified on a sonogram was a discrete area of increased echogenicity followed by a diffuse hyperechoic pattern. Seventy-six patients (52%) had concomitant intra-abdominal injuries, including spleen (n = 46), bowel (n = 30), and kidney (n = 19). There were 102 exploratory laparotomies performed. Abdominal tenderness or distention was present in 127 patients (87%), and 108 patients had right rib fractures (74%). Based on detection of free fluid, parenchymal injury, or both, the overall sensitivity of sonography for the detection of BHI was 72 % but was 98 % for grade III or higher injuries.

CONCLUSION

Emergency sonography is sensitive for the detection of grade III or higher liver injuries resulting from blunt abdominal trauma. Sonography may also reveal BHI on the basis of parenchymal abnormality, with a discrete hyperechoic area the most commonly encountered pattern.