Improved Detection of preclinical Colorectal Liver Metastases by High Resolution Ultrasound including Molecular Ultrasound Imaging using the targeted Contrast Agent BR55

PURPOSE

Aim of the present study was to investigate the sensitivity of high resolution ultrasound (HRU), standard contrast-enhanced ultrasound (CEUS) and CEUS using a novel vascular endothelial growth factor receptor 2 (VEGFR2)-targeted contrast agent for the detection of hepatic metastases in a mouse model of colorectal cancer using clinical standard technology.

MATERIALS AND METHODS

The human colon cancer cell line HT29, transfected with luciferase cDNA for in vivo bioluminescence monitoring, was injected intrasplenically into CB17.SCID mice. Mice were monitored weekly by bioluminescence and after 2 and 4.5 weeks by HRU and CEUS. Contrast media (untargeted BR1, targeted BR55) was applied and digital cine loops from the arterial phase (15 - 45 sec), portal venous phase (50 - 120 s) and late phases (3 - 5 min, 1hour) of the whole liver were analyzed. Data were correlated with postmortem histopathology.

RESULTS

Without contrast enhancement, lesions > 4 mm were reliably detected. After use of untargeted CEUS, lesions > 2 mm were reliably detected and enhanced rim vascularization and late-phase wash-out was shown. With BR55, lesions > 0.8 mm were reliably detected with excellent documentation of vascularization. A persistent contrast enhancement was seen > 30 min after injection. Contrast-enhancement patterns with BR55 significantly correlated with CD31 (R2 = 0.74) and VEGFR2-immunohistochemistry (R2 = 0.66).

CONCLUSION

Detection of metastases by HRU and CEUS was earlier and more accurate than monitoring via bioluminescence. In vivo monitoring of hepatic micrometastases can thus be performed without prior modification of cancer cells using standard technology.

Incidence of bleeding in 8172 percutaneous ultrasound-guided intraabdominal diagnostic and therapeutic interventions - results of the prospective multicenter DEGUM interventional ultrasound study (PIUS study)

PURPOSE

To analyse the incidence of bleeding after percutaneous ultrasound guided diagnostic and therapeutic intraabdominal interventions in a prospective multicentre study (DEGUM percutaneous interventional ultrasound study).

MATERIALS AND METHODS

Within a time period of 2 years diagnostic and therapeutic intraabdominal interventions (with the exclusion of ascites paracentesis) performed percutaneously under continuous ultrasound (US) guidance were prospectively assessed using a pseudonymized standardized web site entry form. Number and type of intervention, operator experience, patient characteristics, medication, lab data as well as technical aspects of the procedure and bleeding complications were analysed according to the interventional radiology standards.

RESULTS

8172 US-guided intraabdominal interventions (liver n = 5903; pancreas n = 501, kidney n = 434, lymph node = 272, biliary system n = 153, spleen n = 63, other abdominal organs and extra-organic targets n = 999) were analysed in 30 hospitals. The majority were diagnostic biopsies including 1780 liver parenchyma, 3400 focal liver lesions and 404 pancreatic lesions. 7525 interventions (92.1 %) were performed in hospitalized patients (mean age 62.6 years). Most operators were highly experienced in US-guided interventions (> 500 interventions prior to the study n = 5729; 70.1 %). Sedation was administered in 1131 patients (13.8 %). Needle diameter was ≥ 1 mm in 7162 punctures (87.9 %) with main focus on core needle biopsies (18 G, n = 4185). Clinically relevant bleeding complications with need of transfusion (0.4 %), surgical bleeding control (0.1 %) and radiological coiling (0.05 %) were very rare. Bleeding complications with fatal outcome occurred in four patients (0.05 %). The frequency of major bleeding complications was significantly higher in patients with an INR > 1.5 (p < 0.001) and patients taking a medication potentially interfering with platelet function or plasmatic coagulation (p < 0.0333).

CONCLUSION

This prospective multicentre study confirms the broad spectrum of percutaneous US-guided intraabdominal interventions. However diagnostic liver biopsies dominate with the use of core needle biopsies (18 G). Percutaneous US-guided interventions performed by experienced sonographers are associated with a low bleeding risk. Major bleeding complications are very rare. A pre-interventional INR < 1.5 and individual medication risk assessment are recommended.

New economic training model for installing ultrasound-guided drainages

Abscesses and circumscribed collections of fluid are frequently found as complications of infectious diseases or surgery. Drainage is often indicated. We have established a new, economic, easy-to-make model to learn and improve competence in installing ultrasound-guided drainage. Up to fifteen water balloons (size 30 - 50 mm) were placed in a plastic box which then was filled with instant custard powder mixed with water. Spiral computed tomography (CT) of this box was performed. Experienced (n = 8) and inexperienced examiners (n = 8) drained the balloons via a direct puncture technique using either ultrasound-guidance alone or volume navigation with image fusion (ultrasound and CT) with needle tracking. Trainees filled out a questionnaire (before and after training) asking for information on their experience in ultrasound, in installing drainages and evaluating the new model. The time needed for installing the drainage was measured. None of the participants had ever attended a course on drainage installation. Only a few of the experienced examiners (n = 3) would autonomously install a drainage into a fluid collection with a size exceeding 4 cm before training. After training all participants felt more confident in ultrasound and in installing drainages into abscesses or other fluid collections. Most of the participants rated additional volume navigation with image fusion as a helpful tool. Ultrasound-guided drainage of abscesses can be trained easily with this new and economic model. Students and physicians can improve their skills and gain confidence in performing ultrasound-guided interventions.

[A 43-year-old patient with character changes, recurrent impaired consciousness and retrograde amnesia]

A 43-year-old male patient with recurring impaired consciousness and retrograde amnesia was admitted to the department of neurology. During the neurological evaluation no pathological findings could initially be revealed but one day the patient was confused again and presented with inadequate behavior: at this time a blood glucose value of 40 mg/dl was measured. For further evaluation the patient was transferred to our department. As the reason for the impaired consciousness was suspected to be of neuroglucopenic origin a rapid adrenocorticotropic hormone (ACTH) stimulation test was first performed to rule out adrenal insufficiency. For further evaluation a fasting test was conducted: after 48 h an episode with neuroglucopenic symptoms occurred again which disappeared after intravenous administration of glucose. The laboratory results of glucose, insulin and c-peptide determined at this point in time led to the diagnosis of an insulinoma. By ultrasound examination a hypoechogenic lesion 1.5 cm in size could be shown in the head of the pancreas and was confirmed by magnetic resonance imaging (MRI). After duodenum-preserving partial pancreatic head resection with enucleation of the insulinoma no further neuroglucopenic symptoms occurred.

Image fusion with volume navigation of contrast enhanced ultrasound (CEUS) with computed tomography (CT) or magnetic resonance imaging (MRI) for post-interventional follow-up after transcatheter arterial chemoembolization (TACE) of hepatocellular carcinomas (HCC): Preliminary results

AIM

The assessment of the immediate post-interventional microcirculation and perfusion following transcatheter arterial chemoembolization (TACE) with new real time imaging fusion technique (VNav) of computed tomography (CT) or magnetic resonance imaging (MRI) with contrast enhanced ultrasound (CEUS) compared to follow-up.

MATERIAL

Following TACE an image fusion of CEUS with CT or MRI of the liver was performed in 20 patients (18 men, 2 women; age 29-75 years) with confirmed hepatocelluar carcinoma (HCC) to evaluate the post-interventional tumor vascularization and perfusion of HCC tumor lesions. Image fusion with CEUS performed immediately was compared with the result at the end of TACE (DSA), with post TACE CT (non-enhanced CT within 24 hours) and with follow up CT (enhanced CT after 6 weeks) after embolization. Ultrasound was performed using a 1-5 MHz multifrequency SonoVue transducer (LOGIQ 9/GE) after a bolus injection of 2-4ml SonoVue® with contrast harmonic imaging (CHI). Thirteen examinations were fused with a contrast enhanced CT, 7 with a MRI performed before TACE.

RESULTS

The post-interventional volume navigation image fusion of CT or MRI with CEUS showed differences regarding the residual tumor perfusion compared to other modalities. The correlation (Spearman-test) between the perfusion result at the end of TACE, non-enhanced CT after TACE and image fusion with CEUS was 0.42 and 0.50. The difference between the result at the end of TACE and the fusion with CEUS was significant (p < 0.05, Wilcoxon-test). The correlation between fusion of CEUS with CT/MRI and follow-up CT (after 6 weeks) was 0.64, the difference was not significant (p > 0.05). The differences between native CT within 24 hours after TACE and follow up CT after 6 weeks or fusion of CEUS and CT/MRI were significant (p < 0.05). The inter-observer variability was 0.61 at the end of TACE, 0.58 at non-enhanced CT (within 24 hours), 0.87 at fusion CEUS with CT/MRI and 0.74 at follow up CT after 6 weeks (Cohens Kappa test).

CONCLUSION

Image fusion with volume navigation (VNav) of CEUS with CT or MRI allows an accurate localisation of foci in patients with HCC. This exact mapping permits an easier control and evaluation of the results after TACE. The fusion of CEUS and CT or MRI allows a better evaluation of the microcirculation and the residual tumor perfusion at an earlier point of time than usual modalities of therapy control like non-enhanced CT. This might lead to a more differentiated monitoring of therapy.

Comparison between preoperative quantitative assessment of bowel wall vascularization by contrast-enhanced ultrasound and operative macroscopic findings and results of histopathological scoring in Crohn's disease

PURPOSE

Patients with Crohn's disease (CD) often undergo several radiological imaging studies, which - with the exception of MRI and US - subject patients to ionizing radiation. Thus, efforts have been made to identify the inflammation activity using ultrasound techniques. The aim of our study was to describe the perfusion pattern of the inflamed bowel wall in CD using contrast-enhanced ultrasound (CEUS) and specific quantification software for perfusion assessment. Moreover, we compared these findings with the operative macroscopic findings as well as with the transparietal histopathological findings of surgical specimens applying an advanced histopathological scoring system.

MATERIALS AND METHODS

We prospectively performed CEUS in 20 consecutive patients with proven CD and planned bowel surgery due to CD within the next 15 days. We then applied the quantification software Qontrast to obtain contrast-enhanced sonographic perfusion maps. The surgeon defined the clinical behavior of CD according to the Vienna classification. The resected segments were then assessed by a pathologist using an advanced scoring system. We compared the results of CEUS, macroscopic findings and histopathological scoring.

RESULTS

We found a strong negative correlation (r = - 0.677, p < 0.01) between the histopathological score and the time-to-peak (TTP). Moreover, we detected a strong correlation between TTP and single parameters of the histopathological scoring system.

CONCLUSION

Ultrasound as a widely available radiation-free imaging method would be preferable for assessing inflammatory activity of CD, particularly since the ultrasound findings correlate significantly with a histopathological scoring system.

Comparison between a clinical activity index (Harvey-Bradshaw-Index), laboratory inflammation markers and quantitative assessment of bowel wall vascularization by contrast-enhanced ultrasound in Crohn's disease

PURPOSE

Due to its character as a remitting inflammatory disease, patients suffering from Crohn's disease (CD) often undergo several imaging studies subjecting the mostly young patients to ionizing. Contrast enhanced ultrasound for capillary microvascular assessment might be a new diagnostic tool for identifying the activity of inflammation by ultrasound techniques.

MATERIALS AND METHODS

We prospectively evaluated 45 patients with proven Crohn's disease performing contrast enhanced ultrasound (CEUS) and laboratory assessment including C-reactive protein (CRP), leucocytes and hematocrit as well as calculating the Harvey-Bradshaw Index (HBI). Thereafter, we applied the quantification software Qontrast(®) to obtain contrast-enhanced sonographic perfusion maps.

RESULTS

Analysis of the 41 finally included patients revealed a correlation of CRP to HBI and TTP[s], respectively. Moreover, an association was found for HBI and TTP[s] and for HBI and TTP[s]/Peak [%]. Analysis of 34 patients with a Peak [%] ≥ 25 showed a close association of HBI and CRP. Besides, in these patients CRP correlated to TTP[s] and to TTP[s]/Peak [%]. We found a strong negative correlation between HBI and TTP[s] (r = -0.645, p<0.01), thus, the higher the clinical activity the shorter the time-to-peak.

CONCLUSION

Quantitative evaluation with CEUS, particularly the calculation of TTP[s] in patients with a Peak [%] ≥ 25, provides a simple method to assess the inflammatory activity in CD.

Clinical signs in the diagnosis of deep vein thrombosis

AIM

Deep vein thrombosis (DVT) is an insidious disease wherein more than 15 different clinical signs are described. The aim of this work was to focus on these clinical signs and to test them for their importance in making a diagnosis of DVT.

METHODS

All patients treated with a tentative diagnosis of DVT in the emergency department were asked to take part in the study. Out of the 254 patients who were examined in order to exclude DVT, 204 patients agreed to participate in the study. The patients who agreed to take part were tested for fifteen clinical examination signs. The Wells score was then determined.

RESULTS

Sixty-two were diagnosed with DVT. For 142 patients, DVT could be ruled out. The probability of DVT for 9 signs together is 88%, and for 3 signs is 78%. The negative predictive values are 91-95%. The combination of the clinical signs showed a specificity of 100%, independent if the patients were old, comorbid, and were diagnosed with the thrombosis in the lower limbs. The determination of the Wells score resulted in no convincing evidence for or against the diagnosis of DVT.

CONCLUSION

We suggest a modified Wells score integrating missing clinical signs with more reliable predictive values. Even with the availability of ultrasound, clinical signs have not become superfluous. They are quick to carry out, safe, cheap and an important addition to the Wells score, particularly for multimorbid and elderly patients.

Sono-hepatic-arteriography (Sono-HA) in the assessment of hepatocellular carcinoma in patients undergoing transcatheter arterial chemoembolization (TACE)

PURPOSE

The aim of our study was to evaluate sono-hepatic-arteriography in patients with hepatocellular carcinoma undergoing transcatheter arterial chemoembolization.

MATERIALS AND METHODS

We evaluated 15 patients with hepatocellular carcinoma undergoing TACE who presented in our institution from February 2006 to May 2008. All patients underwent a conventional B-mode ultrasound examination using a high-end machine and a multi-frequency transducer (2.5 - 4 MHz) before dynamic contrast-enhanced ultrasound examination was carried out. For the sono-hepatic-arteriography 1 ml SonoVue was injected as a bolus using the formerly placed intraarterial catheter. Biphasic enhanced computed tomography was performed using a 16-slice CT scanner up to 48 hours before transcatheter arterial chemoembolization and during follow-up.

RESULTS

The lesion size (of the largest lesion) ranged from 1 to 13 centimeters in their largest diameter (mean: 4.8 cm). Contrast-enhanced ultrasound diagnosed more lesions than B-mode sonography in eight cases and more lesions than computed tomography in 5 patients. The findings of sono-hepatic-arteriography were correct in fourteen cases (93.3 %). Direct impact on patient management was seen in eleven patients (73.3 %).

CONCLUSION

We were able to show that the application of an intraarterial sonographic contrast agent during embolization is able to diagnose new lesions on the one hand and to assess the embolization success on the other. This might improve transcatheter arterial chemoembolization results and patient outcome.

[Localisation of hepatic lesions to liver segments according to sonography (US), computed tomography (CT) and surgery (OP): a comparative study]

INTRODUCTION

The localisation of focal liver lesions is usually performed according to the Couinaud classification system. The exact description of localisation and size of liver lesions is especially important for surgical procedures. The aim of this prospective study was the evaluation of differences and agreements in the localisation and size of hepatic lesions as found by ultrasound (US), computed tomography (CT) and according to the intraoperative status (OP).

MATERIAL AND METHODS

32 patients (21 male, 11 female) were enrolled in the study. The results obtained from sonography, computed tomography and surgery were classified into 5 categories for localisation and for size, respectively.

RESULTS

According to the agreement between sonography and computed tomography, 25 % of all hepatic lesions were classified into category 1 (exact agreement), whereas 40.6 % were ranked into category 2 (almost exact agreement). Correlating sonography and intraoperative results, 31.3 % of the lesions were classified into category 1 and 46.9 % into category 2. In the comparison of CT with OP, 34.4 % of the lesions were found to be in category 1 and 43.8 % in category 2. Concerning the size of the lesions, almost half of the tumours (46.9 %) were classified into category 1 on the basis of the correlation between US and CT and 21.9 % on the basis of the correlation between US and OP.

DISCUSSION

The localisation and description of the size of hepatic lesions is mainly similar or even identical on the basis of the different methods. Further improvements might be achieved by the introduction of a consistent nomenclature.

Quantitative assessment of bowel wall vascularisation in Crohn's disease with contrast-enhanced ultrasound and perfusion analysis

Patients with inflammatory bowel disease (IBD) often undergo several radiologic imaging studies, which - with the exception of magnetic resonance imaging (MRI) and B-scan ultrasound (US) - subject patients to ionizing radiation. With contrast enhanced ultrasound microvascular imaging of the bowel is possible. Hence, the aim of our study was to assess the perfusion pattern of inflamed bowel walls in Crohn's disease compared with healthy volunteers quantitatively using a specific quantification software. We evaluated 4 volunteers and 20 patients with proven Crohn's disease, who went through an active episode based on clinical symptoms and complementary imaging by MRI (19 patients) and computed tomography (1 patient), respectively, with dynamic contrast-enhanced ultrasound (CEUS) using a second generation contrast agent (SonoVue, Bracco, Germany). Retrospectively, we applied the quantification software Qontrast (Bracco, Italy) to obtain contrast-enhanced sonographic perfusion maps for each lesion. Patients had significant higher peak values (median 46.86, lower quartile 37.91, upper quartile 53.20) and significant higher regional blood volume (median 2133.65, lower quartile 1202.90, upper quartile 2820.44) than volunteers. Considering the very low peak value of the healthy, it is easy to understand that the time-to-peak was significantly shorter in the volunteers (median 4.45, lower quartile 1.82, upper quartile 6.88) than in the patients (median 12.15, lower quartile 9.18, upper quartile 15.74). Our study showed clear differences between inflamed and normal bowel wall vascularity regarding all perfusion parameters. These results show that a quantitative assessment of the bowel wall vascularisation and inflammation, respectively, is possible. The software used here enables us to collect data, not only in a semi-quantitative but also in a reproducible, quantitative manner which is comparable with the evaluation of CT or MRI generated data.

Microcirculation and perfusion with contrast enhanced ultrasound (CEUS) in Crohn's disease: first results with linear contrast harmonic imaging (CHI)

AIM

To evaluate a newly introduced high resolution linear transducer for vascularization and mural perfusion assessment using contrast harmonic imaging (CHI) with quantitative time intensity curve analysis (TIC) in patients with active Crohn's disease (CD).

MATERIAL AND METHODS

We prospectively evaluated 14 consecutive patients (7 women, 7 males, age range 19-42 years, median 28 years) with histologically proven CD having an acute episode of the disease applying contrast enhanced MRI and high resolution ultrasound. For the ultrasound we used a newly introduced high resolution linear multi-frequency transducer (6-9 MHz, Logiq 9, GE). Ultrasound was performed by an experienced radiologist applying color coded Doppler sonography (CCDS), power Doppler (PD) and contrast enhanced CHI using the 'true agent detection mode'. Additionally, 5 healthy volunteers were examined by ultrasound applying CCDS, PD and CHI. After the injection of 2.4 ml ultrasound contrast agent (SonoVue) the dynamic CHI cine sequences were recorded as digital raw data for 60 seconds. Therefore we were able to perform a quantitative perfusion analysis using TIC retrospectively. CCDS, PD and CHI with TIC were compared and analyzed.

RESULTS

In all 14 patients MRI showed inflammatory changes in the terminal or pre-terminal ileum. Using PD and CCDS enlarged vessels surrounding the bowel wall were visualized in all patients. PD as well as CCDS diagnosed just in 9 of 14 patients augmented mural vessels. Having CHI with TIC increased mural contrast enhancement was diagnosed in all 14 patients. Patients with CD showed a maximum enhancement 36 s after injection with 9 dB (range 5.9-13.2 dB), while healthy volunteers reached the maximum level of 2.8 dB (range 2-3.8 dB) after 23 s (p<0.05).

CONCLUSION

Using high resolution linear transducer mural perfusion changes in active Crohn's disease can be appreciated applying CHI with TIC. This technique could be an effective dynamic imaging modality for diagnosis and especially follow-up examination to monitor treatment in CD.

[Diagnostic and therapeutic consequences of abnormal ultrasound findings]

BACKGROUND AND OBJECTIVE

The aim of this study was to evaluate the diagnostic and therapeutic consequences arising from abnormal ultrasound findings in a multidisciplinary setting in the University of Regensburg Clinical Centre.

PATIENTS AND METHODS

The results of 1162 randomly selected ultrasound examinations (on 671 males and 491 females) from a total of 14,301 at an interdisciplinary ultrasound unit were analysed. The investigators recorded the findings in a routinely used standardized manner. The records and discharge reports of each patient were then evaluated with regard to the diagnostic and therapeutic consequences of the findings.

RESULTS

There were 1843 abnormal findings in 901 patients. In 114 patients (6.2 %) no adequate diagnostic measures had been undertaken or recommended at discharge, but the reasons for the decisions taken could not be judged (value 4). 72.1 % of all patients were recruited from departments of internal medicine. However, the highest percentage of findings without adequate consequences were found to be in patients of the departments of oral and maxillofacial surgery, dermatology and nuclear medicine.

CONCLUSION

The number of ultrasound examinations that had been done without adequate consequences was comparatively low at 6.2 %. But perhaps this number can be further reduced by improved wording of the examination reports.

[The diagnostic approach to hepatocellular carcinoma]

Risk factors and symptoms of hepatocellular carcinoma (HCC): The main risk factors of HCC include infection with hepatitis B or C virus, as well as alcohol consumption. There are no specific symptoms of HCC, making early diagnosis and detection of the disease difficult. When HCC presents with specific clinical symptoms, the tumour is typically very far advanced. Surveillance in liver cirrhosis: The most common serological marker used in HCC diagnosis is alpha-fetoprotein (AFP), but other tumour markers such as the des-gamma-carboxyprothrombin (DGCP) or fractions of AFP (AFP-L3) exist and there use is discussed in this context. Surveillance should be done by sonography at 6 (to 12) months intervals. The single nodule in the cirrhotic liver: Ultrasound is the most commonly used imaging modality for detecting HCC tumour nodules with a large range of reported sensitivities. HCC may appear as a hypoechoic, isoechoic, or hyperechoic round or oval lesion with intratumoural flow signals on Doppler or power Doppler sonography. The differentiation of smaller malignant lesions in cirrhotic livers can be improved by contrast-enhanced ultrasound (CEUS). Spiral computed tomography (CT) and magnetic resonance imaging (MRI) with and without contrast enhancement play an important role in the diagnosis and staging of HCC. If the vascular pattern on imaging is not typical, biopsy becomes necessary. The patient with known HCC: Different tumour markers are used in the evaluation of tumour progression, prediction of patient outcome and treatment efficacy. Among the various staging systems used in the context of HCC, the Barcelona-Clinic-Liver-Cancer (BCLC) staging system is currently the only staging system that takes into account tumour stage, liver function, physical status and cancer-related symptoms. Beside surgical resection, non-surgical treatments such as percutaneous ethanol injection (PEI), radiofrequency thermoablation (RFTA) and trans-arterial chemoembolisation (TACE) are used. Successful tumour "bridging" with ablative therapy methods can be achieved in carefully selected patients on the waiting list for orthotopic liver transplantation. Contrast-enhanced sonography is able to control the ablation treatment of HCC.

Comparison of low and high frequency transducers in the detection of liver metastases

BACKGROUND AND AIMS

To evaluate the benefit of the additional use of a high frequency ultrasound probe (7.5 MHz) in finding suspicious liver lesions compared to the examination using a 3.5-MHz transducer only.

PATIENTS AND METHODS

One hundred and fifty-seven patients with underlying malignant disease were examined with both transducers using one of three ultrasound machines (Siemens Sonoline Elegra, GE Healthcare Logic 9, or Hitachi EUB-8500). Findings on hepatic lesions were collected on a standardised documentation sheet and evaluated by descriptive statistics.

RESULTS

Ninety-three patients (59.2% of all patients) showed no evident liver lesion on conventional ultrasound with the 3.5 MHz probe. In 29 patients (18.5%) new suspicious liver lesions were found by using the high frequency transducer. Thirteen of these 29 patients (44.8%) were suspected to suffer from diffuse infiltration of the liver with malignant lesions or at least 10 additional visible lesions. In 14 patients, no liver lesion had been known before high frequency ultrasound examination. The size of newly described liver lesions ranged from 2 mm to 1.5 cm. Time needed for the additional examination with the high frequency transducer ranged between 1 and 15 min with an average of 4.0 min.

CONCLUSION

The additional use of a high frequency transducer in patients with underlying malignant disease slightly extends the examination time, but reveals new, potentially malignant hepatic lesions in almost every fifth patient.

Ösophagobronchiale und ösophagomediastinale Fistel sowie Pleura- und Perikarderguss bei schwerer Pseudodivertikulose des Ösophagus

We describe the case of a patient who came to our hospital with deterioration of his general condition (especially with loss of weight) and progressive thoracic pain with dyspnea. We diagnosed a severe pseudodiverticulosis of the esophagus with esophagobronchial as well as esophagomediastinal fistulae. Furthermore, reactive pleural and pericardial effusions were shown and Candida was detected in a blood culture. By means of antibiotic therapy and esophageal stent implantation, a significant improvement of the clinical signs was achieved. Intramural pseudodiverticulosis of the esophagus is a rare and benign condition. Multiple triggers, for example, obstruction of the ducts due to shedding of epithelial cells, mucus, and/or submucous fibrosis are possible. Clinical signs are progressive dysphagia, caused by an inflamed stenosis of the esophagus.

[Sonographic controlled drainage of a fluid formation of the spleen in combination with pancreatitis]

With regard to acute or chronic pancreatitis various complications involving the spleen can occur, hematoma of the spleen being a rare complication. We describe the case of a patient in reduced general condition with elevated pancreatic enzymes and signs of inflammation. During multiple examinations, hematoma of the spleen, as well as hematomas close to the left adrenal gland and a larger hematoma close to the gastric wall were detected. In computed tomography and due to the laboratory parameters a pancreatitis was diagnosed. After CT-controlled puncture a communication between both formations was considered possible which was in retrospect CT-assisted not successful. Subsequently an ultrasound controlled drainage was performed, finally resulting in a restitutio ad integrum, thereby avoiding splenectomy. The described percutaneous puncture of a fluid formation in the splenic area represents a non-surgical option in the therapy of intrasplenic pancreatic fluid formations.

["Adult form" of congenital liver fibrosis]

HISTORY AND ADMISSION FINDINGS

During a routine check-up, a 37-year-old woman was found to have elevated levels of serum gamma-glutamyl transferase (gamma GTP) and IgA- and IgM-antibodies. One of the patient's brothers had died at the age of six from acute liver failure. We found a palpably enlarged liver with normal consistency and no particular helpful laboratory results.

INVESTIGATIONS

The abdominal ultrasound and computed tomography (CT) showed segmental and saccular dilatations of the biliary tract, hepatofugal flow in the portal vein, multiple collateral vessels as well as a mild splenomegaly. Histopathology revealed fibrotic liver parenchyma, a dilatated and branched biliary tract lined by cubical epithelium.

COURSE

Gastroscopy showed lowgrade esophageal varices. Seventeen months after the initial presentation there were no significant changes of the laboratory tests or the ultrasound.

CONCLUSIONS

The defective remodelling of the ductal plate ("ductal plate malformation") is associated with dysplasia of the biliary tract. Depending on the localisation of the lesions within the biliary tract and whether it is a more cystic or more fibrotic component, there are different malformations caused by ductal plate malformation. We diagnosed congenital hepatic fibrosis, because of the atypical age of presentation, it could be the "adult form" of congenital liver fibrosis.