Large calcifications in ovaries otherwise normal on ultrasound

OBJECTIVE

To evaluate calcifications >or= 5 mm in length in ovaries that are otherwise normal on ultrasound, and to determine whether such large ovarian calcifications are an indicator of ovarian neoplasm.

METHODS

This was a retrospective study reviewing pelvic ultrasound results at our unit between October 1994 and April 2002 to identify patients with ovarian calcifications that were >or= 5 mm in maximum length in otherwise normal ovaries, and who also had follow-up imaging studies. Patient medical histories were reviewed, calcification characteristics, including number, size, shape and laterality of calcifications, were recorded and follow-up imaging studies were reviewed to assess change in size of the calcification and to see if a neoplasm had developed.

RESULTS

The study group consisted of 28 patients. The mean length of imaging follow-up was 35.2 +/- 30.7 months. The mean size of the calcifications was 7.4 +/- 2.3 (range, 5-13) mm. The calcification remained stable in all 28 patients and no ovarian neoplasms developed in any of the patients. Histological confirmation was available in one patient and this revealed dystrophic calcification in a corpus albicans.

CONCLUSION

Calcifications ranging from 5 to 13 mm in length in otherwise normal ovaries remain stable on follow-up imaging and are not an indicator of current or future ovarian neoplasm. Published by John Wiley & Sons, Ltd.

Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement

OBJECTIVES

A panel of 14 physicians practicing medicine in the United States with expertise in radiology, obstetrics and gynecology, gynecologic oncology, hysteroscopy, epidemiology, and pathology was convened by the Society of Radiologists in Ultrasound to discuss the role of sonography in women with postmenopausal bleeding. Broad objectives of this conference were (1) to advance understanding of the utility of different diagnostic techniques for evaluating the endometrium in women with postmenopausal bleeding; (2) to formulate useful and practical guidelines for evaluation of women with postmenopausal bleeding, specifically as it relates to the use of sonography; and (3) to offer suggestions for future research projects.

SETTING

October 24 and 25, 2000, Washington, DC, preceding the annual Society of Radiologists in Ultrasound Advances in Sonography conference.

PROCEDURE

Specific questions to the panel included the following: (1) What are the relative effectiveness and cost-effectiveness of using transvaginal sonography versus office (nondirected) endometrial biopsy as the initial examination for a woman with postmenopausal bleeding? (2) What are the sonographic standards for evaluating a woman with postmenopausal bleeding? (3) What are the abnormal sonographic findings in a woman with postmenopausal bleeding? (4) When should saline infusion sonohysterography or hysteroscopy be used in the evaluation of postmenopausal bleeding? (5) Should the diagnostic approach be modified for patients taking hormone replacement medications, tamoxifen, or other selective estrogen receptor modulators?

CONCLUSIONS

Consensus recommendations were used to create an algorithm for evaluating women with postmenopausal bleeding. All panelists agreed that because postmenopausal bleeding is the most common presenting symptom of endometrial cancer, when postmenopausal bleeding occurs, clinical evaluation is indicated. The panelists also agreed that either transvaginal sonography or endometrial biopsy could be used safely and effectively as the first diagnostic step. Whether sonography or endometrial biopsy is used initially depends on the physician's assessment of patient risk, the nature of the physician's practice, the availability of high-quality sonography, and patient preference. Similar sensitivities for detecting endometrial carcinoma are reported for transvaginal sonography when an endometrial thickness of greater than 5 mm is considered abnormal and for endometrial biopsy when "sufficient" tissue is obtained. Currently, with respect to mortality, morbidity, and quality-of-life end points, there are insufficient data to comment as to which approach is more effective. The conference concluded by identifying several important unanswered questions and suggestions that could be addressed by future research projects.

Sonographic and Doppler characteristics of the corpus luteum: can they predict pregnancy outcome?

OBJECTIVE

To determine whether there is a relationship between gray scale or Doppler characteristics of the corpus luteum and first-trimester pregnancy outcome.

METHODS

We conducted a prospective study of patients with spontaneous singleton pregnancies between 5 and 8 weeks' gestation. The corpus luteum size, sonographic appearance, resistive index, and peak systolic velocity were measured on transvaginal sonography. Maternal use of exogeneous progesterone was recorded. Only patients with known first-trimester outcome were included.

RESULTS

There were 201 study patients. The corpus luteum could be visualized in 197 (98%) and had a mean +/- SD size of 1.9 +/- 0.6 cm, a mean resistive index of 0.50 +/- 0.08, and a peak systolic velocity of 20.5 +/- 11.2 cm/s. There were 151 first-trimester survivors (75.1 %) and 50 spontaneous losses (24.9%). In a comparison of the survivors and losses, there was no significant difference in mean corpus luteum size (1.9 versus 1.7 cm; P = .10, t test), mean resistive index (0.50 versus 0.50; P = .71, t test), peak systolic velocity (21 versus 19 cm/s; P = .29, t test), or sonographic appearance (P = .78, chi2 test). The lack of association between corpus luteum characteristics and outcome persisted when cases were stratified by progesterone use and the presence or absence of a heartbeat on the study sonogram.

CONCLUSION

There is no apparent relationship between the characteristics of the corpus luteum and first-trimester pregnancy outcome.

Gynecologic ultrasound

For most women, pelvic sonography using a transvaginal probe is the imaging modality of choice for evaluating the uterus and adnexae. It is reliable for detecting ovarian cysts and other adnexal masses, and it can often determine if a lesion can be observed on serial examinations or if it requires more urgent attention. Uterine ultrasound is reliable for evaluating both the normal and abnormal endometrium and myometrium. In cases that are technically limited, or in those that are difficult to interpret, a tailored MR imaging examination often can be helpful.

Comparison of tubal ring and corpus luteum echogenicities: a useful differentiating characteristic

The purpose of this report is to compare the echogenicity of the tubal ring of an ectopic pregnancy and the corpus luteum with that of the ovary for improved detection of early ectopic pregnancy. In patients with ectopic pregnancy diagnosed at sonography on the basis of the presence of an adnexal tubal ring, echogenicity of the ring was compared with the echogenicity of the ovarian parenchyma. Twenty-six patients with tubal rings containing either a yolk sac or cardiac activity were included. Twenty-three (88%) of the 26 tubal rings had echogenicity equal to or greater than that of ovarian parenchyma. In 13 patients with ectopic pregnancy diagnosed on the basis of an empty tubal ring, 10 rings (77%) were more echogenic than the ovary. In 45 control patients with intrauterine pregnancy, the corpus luteum was more echogenic than the ovary in only 3 (7%). The tubal ring of an ectopic pregnancy is usually more echogenic than ovarian parenchyma, and the corpus luteum is usually equal to or less echogenic than the ovary. Echogenicity of an adnexal mass may help distinguish the tubal ring of an ectopic pregnancy from a corpus luteum.

Benign and malignant ovarian masses: selection of the most discriminating gray-scale and Doppler sonographic features

PURPOSE

To determine the gray-scale and Doppler sonographic features that best enable discrimination between malignant and benign ovarian masses and develop a scoring system for accurate diagnosis with these features.

MATERIALS AND METHODS

Gray-scale and Doppler sonographic features of 211 adnexal masses were correlated with the final diagnosis; the most discriminating features for malignancy were selected with stepwise logistic regression.

RESULTS

Twenty-eight masses were malignant and 183 benign. All masses with a markedly hyperechoic solid component or no solid component were benign. For masses with a nonhyperechoic solid component, additional features that allowed statistically significant discrimination of benignity from malignancy were, in decreasing order of importance, (a) location of flow at conventional color Doppler imaging, (b) amount of free intraperitoneal fluid, and (c) presence and thickness of septations. A scoring formula that made use of values based on the logistic regression equation had an area under the receiver operating characteristic curve of 0.98 +/- 0.01. The cutoff score with the highest accuracy had a sensitivity of 93% and specificity of 93%.

CONCLUSION

A solid component is the most statistically significant predictor of a malignant ovarian mass. A multiparameter scoring system that uses three gray-scale and one Doppler feature, developed by means of stepwise logistic regression, has high sensitivity and specificity for predicting malignancy.

Sonographic evaluation of the placental cord insertion site

OBJECTIVE

Velamentous and marginal umbilical cords are uncommon abnormalities of placental cord insertion that can entail significant fetal risk. We undertook this investigation to assess the ability of prenatal sonography to reveal abnormal insertions of the umbilical cord into the placenta.

SUBJECTS AND METHODS

Forty-six patients had both prenatal sonographic evaluation of the placental cord insertion site and postnatal pathologic examination. Distance from the insertion site to the nearest placental edge was categorized by sonography and pathology as normal if greater than 1 cm and abnormal if less than or equal to 1 cm. Sonographic and pathologic findings were compared.

RESULTS

Thirty-eight singleton and eight twin pregnancies, for a total of 54 cord insertions, were studied. Of the 43 sonographically normal insertions, 38 had normal pathologic findings, and the remaining five insertions had abnormal pathologic findings (all marginal cord insertions). All 11 insertions that showed abnormality on sonography were abnormal on pathologic examination (seven marginal and four velamentous insertions). Sonography was able to reveal a difference between the two types of abnormal insertions in only a single patient, in whom the cord insertion changed from marginal to velamentous during a 7-week interval. Sonography had an overall sensitivity of 69% (11/16), a specificity of 100% (38/38), and an accuracy of 91% (49/54) for revealing abnormal placental cord insertion sites.

CONCLUSION

Targeted sonographic examination of the placental site of umbilical cord insertion will reveal abnormal placental cord insertions, although distinguishing the specific type of abnormal insertion may require the use of color Doppler imaging.

Intradecidual sign: is it effective in diagnosis of an early intrauterine pregnancy?

PURPOSE

To determine if the intradecidual sign at sonography is effective in the diagnosis of early intrauterine pregnancy.

MATERIALS AND METHODS

In 102 pregnant patients, transvaginal sonography revealed an intrauterine fluid collection without a yolk sac or embryo. Four observers (experienced sonologist, body imaging fellow, 1st-year radiology resident, and premedical student) determined independently whether the intradecidual sign was absent, present, or indeterminate. Interpretations were limited to visualization of only the uterus.

RESULTS

Follow-up revealed intrauterine pregnancy in 91 patients (outcome normal in 48 and abnormal in 43) and ectopic pregnancy in 11 patients. Among the four reviewers, sensitivity for diagnosis of an intrauterine pregnancy was 34%-66%, specificity was 55%-73%, accuracy was 38%-65%, positive predictive value was 91%-93%, and negative predictive value was 12%-16%. Three to five ectopic pregnancies were categorized incorrectly as demonstrating the intradecidual sign, depending on the reviewer.

CONCLUSION

The intradecidual sign does not appear to be sensitive or specific in diagnosis of an early intrauterine pregnancy. When an intrauterine fluid collection is present without an embryo or yolk sac (with positive pregnancy test results), a follow-up sonogram should be obtained unless contraindicated clinically.

Hemobilia: sonographic appearances in the gallbladder and biliary tree with emphasis on intracholecystic blood

The purpose [corrected] of this study is to discuss the causes and sonographic appearances of blood in the gallbladder and biliary tree. Over a 12 year period, 18 patients with hemobilia had ultrasonographic examinations at one of three hospitals. Hemobilia was categorized as traumatic (50%), spontaneous (28%), or inflammatory (22%), with coagulopathy present in half of the cases. The sonographic appearances of intracholecystic blood varied, but with the exception of a single case, masslike intracholecystic material was present. Biliary dilatation occurred in five patients, with echogenic material visible in the extrahepatic bile duct in three of these cases.

Solid extratesticular masses evaluated with sonography: pathologic correlation

PURPOSE

To determine if the sonographic appearance of solid extratesticular masses enables distinction of benign from malignant disease.

MATERIALS AND METHODS

Sonograms of 19 patients with palpable testicular masses who underwent biopsy were reviewed retrospectively. Appearances of masses on sonograms were correlated with pathologic diagnoses.

RESULTS

All masses were well defined and ranged in size from 5.7 to 66.7 mm (mean, 21 mm). On the sonograms, five masses were within the epididymis, and six were distinct from it; seven cases were indeterminate. The epididymis was surgically absent in the remaining patient. Sonographic echogenicity ranged from hypoechoic to hyperechoic relative to that of the testis. At pathologic evaluation, there were 16 (84%) benign and three (16%) malignant lesions. Benign lesions consisted of six adenomatoid tumors, two lipomas, two epidermoid inclusion cysts, two cases of sarcoidosis, and one case each of sperm granuloma, spermatic cord leiomyoma, benign inflammatory nodule, and fibroma. The malignant lesions consisted of scrotal wall liposarcoma, epididymal leiomyosarcoma, and recurrent spindle cell malignancy of the spermatic cord. No sonographic features of masses were useful for distinguishing benign from malignant lesions.

CONCLUSION

The frequency of malignancy (16%) contrasts with prior reports that suggest a very low rate of malignancy among these masses. Sonography is useful for identifying the extratesticular location of a mass but not for distinguishing the nature of the lesion.

Role of Doppler ultrasonography in the prediction of pregnancy outcome in women with recurrent spontaneous abortion

We prospectively studied 96 patients with a history of recurrent spontaneous abortion to determine whether the resistive index of the main uterine artery or subchorionic vessels can allow prediction of pregnancy outcome. The subchorionic RI declined progressively for a mean of 0.54 at 6 weeks to 0.42 at 13 weeks (P < 10(-8), F-test). No significant difference was found in subchorionic RI values between outcomes for liveborn infants versus loss. Uterine artery RI values also declined significantly through the first trimester (P < 10(-8), F-test). Uterine artery RI values tended to be lower in pregnancies ending in loss than in successful gestations; however, there was too much overlap for this index to be clinically useful. In conclusion, first trimester RI does not allow prediction of pregnancy outcome in patients with recurrent abortion.

Sonographic evaluation of ectopic pregnancy: an update

This review addresses the use of state-of-the-art sonography to evaluate patients with possible ectopic pregnancy (EP). The technical aspects for optimizing the examination are emphasized, and the role of color and pulsed Doppler imaging is discussed. The various sonographic criteria used to diagnose EP are critically analyzed. In addition, imaging findings for some of the more unusual forms of EP are discussed. The role of sonography in the treatment of EP is briefly considered.

Increasing curvature of the normal fetal ductus arteriosus with advancing gestational age

In order to determine whether the configuration of the normal fetal ductus arteriosus changes with increasing gestational age, we prospectively collected oblique transverse sonographic images of the fetal thorax through the ductus arteriosus. Scans from 240 consecutive normal fetuses with gestational age 20 weeks or more were included in the study. The images were reviewed independently by two sonologists and the ductus arteriosus was graded as: (1) straight; (2) mildly curved (C-shaped, bending < 90 degrees from a straight line); or (3) markedly curved (C-shaped, bending > 90 degrees, or S-shaped). In cases where the two sonologists' gradings did not concur, the images were re-reviewed jointly by both sonologists and a grading was assigned by consensus. Forty-two cases were rejected, due to inadequate images. The ductus arteriosus was graded in 42 fetuses aged 20-25.9 weeks, 48 at 26-31.9 weeks, 74 at 32-37.9 weeks, and 34 at 38 weeks or more for a total of 198 cases. There was a significant trend to greater curvature with increasing gestational age (p < 0.0001). The frequency of a straight ductus arteriosus decreased steadily from 55% of fetuses aged 20-25.9 weeks to 3% of fetuses at 38 weeks or older, while the frequency of marked curvature increased from 2% in the youngest age group to 56% in the oldest. The proportion with mild curvature showed little variation throughout gestation. In summary, the configuration of the ductus arteriosus is variable but tends to become more curved as pregnancy proceeds. Marked curvature or tortuosity of the ductus arteriosus should not be misinterpreted as a great vessel anomaly.

Distal ureteral calculi: detection with vaginal US

PURPOSE

To describe the use of vaginal ultrasonography to identify distal ureteral calculi and hydroureter.

MATERIALS AND METHODS

Abdominal and vaginal sonography were performed in 13 women with distal ureteral calculi. Indications for sonography included flank pain, hematuria, and suspected appendicitis. Six patients were pregnant.

RESULTS

In each patient, vaginal sonograms demonstrated a distal ureteral calculus; in only two cases was the calculus detected with transabdominal sonography. Distal hydroureter was identified with vaginal scanning in each patient but with abdominal scanning in only two. Hydronephrosis was absent in three patients, mild in six, and moderate in four. Symmetric ureteral jets were noted at transabdominal sonography in two of nine patients. Follow-up transvaginal scans obtained shortly after passage of stones in two patients revealed swelling of the trigone but normal ureteral jets.

CONCLUSION

In symptomatic female patients, use of vaginal sonography should be considered to evaluate the distal ureter for calculi, particularly if the results of transabdominal examination are normal or inconclusive.

Sonography of the fetal posterior fossa: false appearance of mega-cisterna magna and Dandy-Walker variant

PURPOSE

To establish that incorrect scanning of the fetal posterior fossa may falsely create the appearance of a mega-cisterna magna (MCM) or Dandy-Walker variant (DWV).

MATERIALS AND METHODS

After routine sonography, 100 consecutive fetuses (gestational age range, 25-40 weeks) without abnormality underwent additional posterior fossa scanning in an attempt to create the appearance of an MCM (anteroposterior diameter larger than 10 mm) or DWV. Sonograms were obtained in a plane inferior to or angled more coronally than the routine axial plane.

RESULTS

The posterior fossa was depicted in 93 fetuses. Pseudo-MCM occurred in 35 (38%) of 93 fetuses: 12 (30%) of 40 fetuses aged 25.0-29.9 weeks, 11 (50%) of 22 fetuses aged 30.0-34.9 weeks, and 12 (39%) of 31 fetuses aged 35.0-40.0 weeks. Pseudo-DWV occurred in 40 (43%) of 93 fetuses: 20 (50%) of 40 fetuses aged 25.0-29.9 weeks, 12 (55%) of 22 fetuses aged 30.0-34.9 weeks, and eight (26%) of 31 fetuses aged 35.0-40.0 weeks.

CONCLUSION

Sonography of the posterior fossa in an angled semi-coronal plane should be avoided because it may create an appearance that mimics an abnormality.

Cervical ectopic pregnancy: results of conservative treatment

PURPOSE

To review experience with early sonographic diagnosis and fertility-preserving treatment of cervical ectopic pregnancy.

MATERIALS AND METHODS

The authors evaluated 12 consecutive cases of cervical ectopic pregnancy diagnosed with ultrasound (US) and treated with methods that successfully preserved the uterus. Gestational age, sonographic findings, means of conception, and method of treatment were recorded.

RESULTS

Gestational age at diagnosis ranged from 5.0 to 7.9 weeks. Cardiac activity was documented in nine cases. Patients were treated as follows: transvaginal US-guided injection of potassium chloride into the embryo or gestational sac (n = 6), uterine artery embolization followed by dilation and evacuation (n = 4), dilation and evacuation after ligation of uterine artery branches (n = 1), and uterine artery embolization followed by administration of systemic methotrexate (n = 1). The cervical pregnancy was successfully ablated with one treatment in all cases. No patient required hysterectomy, and only one patient required transfusion. Two patients subsequently delivered healthy babies; three other patients have been able to conceive successfully.

CONCLUSION

When cervical ectopic pregnancy is diagnosed early, US-guided termination or other conservative procedures allow preservation of the uterus, thus maintaining potential fertility.

Ovarian masses: can benign and malignant lesions be differentiated with color and pulsed Doppler US?

PURPOSE

To determine whether color and pulsed Doppler ultrasound (US) can be used to differentiate benign from malignant ovarian masses.

MATERIALS AND METHODS

Forty-four ovarian masses identified with sonography in 40 patients were confirmed at surgery (n = 35) or followed up to resolution with US (n = 9). Color and pulsed Doppler US were used to calculate the lowest pulsatility index (PI) and resistance index (RI) for each mass.

RESULTS

Color Doppler US enabled detection of arterial flow in 24 of 36 benign masses and six of eight malignant masses. PI was lower in malignant masses than in benign masses (P = .002), as was RI (P = .001). Both indexes demonstrated overlap between benign and malignant masses; therefore, no cutoff value for either index had both high sensitivity and high specificity for malignancy: For PI cutoff of 1.0, sensitivity and specificity were 100% and 46%, respectively; for RI cutoff of 0.4, 50% and 96%.

CONCLUSIONS

While PI and RI tend to be lower in malignant ovarian masses, neither index can be used reliably to differentiate benign from malignant lesions. In addition, lack of detectable flow by means of color Doppler US does not exclude ovarian malignancy.

Sonography of the fetal heart: normal variants and pitfalls

Sonographic evaluation of the fetal heart is an important part of obstetric sonography. The sonographer and sonologist should be familiar with the sonographic appearance of the normal fetal heart and with common structural abnormalities. Occasionally, normal structures in or adjacent to the fetal heart may simulate an abnormality. Although one should seek consultative sonography in instances of uncertain or questionable findings, unnecessary referral and concern may be avoided in some cases if the sonologist is familiar with normal variants and pitfalls. In this pictorial essay, we present several such pitfalls that we and others have observed in the four-chamber view (Fig. 1) and in views of the ventricular outflow tracts (Figs. 2 and 3).

Ultrasonography of the acute abdomen

During the past decade, noninvasive imaging has assumed an increasingly prominent role in the evaluation of patients who have acute abdominal conditions. Ultrasonography is often the initial diagnostic imaging modality used to examine patients who are clinically suspected of having acute cholecystitis, choledocholithiasis, and acute appendicitis. This article focuses on the clinical considerations and the ultrasonographic findings that relate to each of these conditions. In addition to describing the ultrasonographic appearances for each of these entities, this article also emphasizes useful scanning techniques that will provide optimal images.

Sonographic diagnosis of perforation in patients with acute appendicitis

The sonographic diagnosis of appendicitis can be challenging in patients with perforation. In order to detect the accuracy of specific sonographic features of appendiceal perforation, graded compression sonograms in 100 patients with surgically confirmed acute appendicitis were reviewed retrospectively. Twenty-two of these patients had perforation. A statistically significant association was found between three sonographic findings and perforation: loculated pericecal fluid, prominent pericecal fat, and circumferential loss of the submucosal layer of the appendix. No single finding had a specificity greater than 59%. By using a combination of one or more findings, the overall sensitivity of sonography for the diagnosis of perforation was 86%. The specificity, however, was only 60%. Our results suggest that in patients without a sonographically visible appendix, recognition of loculated pericecal fluid and prominent pericecal fat may be a useful indirect clue to the diagnosis of perforating appendicitis.

Sonourethrography in the evaluation of urethral stricture disease

Ultrasonography of the anterior urethra offers a dynamic three-dimensional study that can easily be repeated. It holds the promise of defining accurately, not only the exact length and severity of the strictured urethral segment, but also the extent of urethral fibrosis and the anatomy of the periurethral structures. A significant reduction in the incidence of recurrent stricture may be obtained by selecting patients for treatment on the basis of the findings of sonourethrography. Moreover, the potential exists for the use of this imaging method during internal urethrotomy to ensure a more accurate and aggressive incision of the stricture.

Abdominal lymphoma in AIDS: evaluation with US

The sonographic findings in 38 patients with abdominal lymphomas related to acquired immunodeficiency syndrome (AIDS) were reviewed. Thirty-three patients had non-Hodgkin lymphoma, and five had Hodgkin disease. Abnormal masses were detected with sonography in 33 patients (87%). Focal hypoechoic liver lesions up to 10 cm in diameter were visible in 17 patients. Several lesions were anechoic and septated, mimicking fluid. Adenopathy (at the retroperitoneum, mesentery, or porta hepatis) was seen in 15 patients. Other involved areas included bowel, omentum, spleen, kidney, and adrenal gland. AIDS-related abdominal lymphomas frequently cause extranodal masses that can be readily imaged with ultrasound. Ultrasound-guided fine needle aspiration biopsy allows a specific diagnosis to be made in many cases.

Scrotal ultrasonography and the management of testicular trauma

The early surgical repair of testicular injuries has reduced morbidity and increased testicular salvage. Orchiectomy can be avoided in about 90 per cent of cases. Ultrasound has increased our ability to diagnose parenchymal injury preoperatively and thus to advise the frightened patient more authoritatively and assure ourselves of the necessity of surgical exploration. In most cases, the patient can expect a short convalescence and preservation of his injured gonad.

Sonography in patients with suspected acute appendicitis: value in establishing alternative diagnoses

We reviewed the clinical and sonographic findings in 297 patients who had graded compression sonography for suspected acute appendicitis. The purpose of the study was to determine the accuracy of sonography in detecting other diseases in the 174 patients in this group who proved not to have acute appendicitis. Of the 174 patients without acute appendicitis, 93 patients (53%) were ultimately discharged with a diagnosis of abdominal pain of unknown origin. Of the 81 patients in whom specific diagnoses were established, sonography suggested the correct diagnosis in 57 patients (70%). A broad spectrum of diseases was detected, including: gynecologic diseases (35); visceral diseases, including hollow viscera and diseases of liver, pancreas, or spleen (18); and urinary tract abnormalities (four). This study suggests that sonography is useful in establishing alternative diagnoses in patients undergoing sonography for suspected acute appendicitis.

Early pregnancy complications: endovaginal sonographic findings correlated with human chorionic gonadotropin levels

Endovaginal sonography results were compared with quantitatively determined human chorionic gonadotropin (hCG) levels in 84 women referred for early pregnancy complications. Of the 27 with normal intrauterine pregnancies, an intrauterine gestational sac was prospectively identified in one of five cases (20%) in which hCG levels were below 500 IU/L (Second International Standard), four of five (80%) with hCG levels of 500-1,000 IU/L, and all 17 with hCG levels above 1,000 IU/L. In comparison, 17 of the 26 women with ectopic pregnancies (65%) had hCG levels greater than 1,000 IU/L, and none of the 26 had an intrauterine gestational sac. Endovaginal sonography demonstrated an adnexal mass and/or a gestational sac-like structure in 16 of the 17 cases (94%) in which hCG levels were above 1,000 IU/L, compared with only three of the nine (33%) with lower hCG levels (P less than .01). These findings indicate that an intrauterine gestational sac should be normally visualized with endovaginal sonography when the hCG level exceeds 1,000 IU/L, and that visualization of an extrauterine gestational sac and/or adnexal mass is significantly more likely in ectopic pregnancies when the hCG level exceeds 1,000 IU/L.

Acute appendicitis: sonographic criteria based on 250 cases

Two hundred and fifty consecutive patients with suspected appendicitis were examined with graded compression sonography. The initial diagnostic criterion for appendicitis was visualization of a noncompressible appendix; this was later modified to include the dimensions of the visualized appendix. The appendix was visualized in 91 of 250 patients (36%). Five adult patients with sonographically visible appendixes that were 6 mm or less in maximal diameter had either benign clinical follow-up (three patients) or a histologically normal appendix removed at surgery (two patients). However, two patients with appendixes measuring 6 mm in diameter and multiple appendicoliths had surgically confirmed acute appendicitis. Of 84 patients with visible appendixes measuring greater than 6 mm in maximal diameter, 78 had surgically confirmed acute appendicitis. In the remaining six, symptoms resolved spontaneously, and no surgery was required. In the absence of compelling clinical findings or an appendicolith, adult patients with maximal appendiceal diameters of 6 mm or less should undergo a period of close observation rather than immediate surgery. A diagnosis of appendicitis can be made in adult patients with persistent right lower quadrant pain and a visualized appendix greater than 6 mm in diameter.

Sonourethrography in the evaluation of urethral strictures: a preliminary report

A total of 17 patients with suspected stricture disease underwent conventional retrograde urethrography and sonourethrography. When the length of the stricture as assessed by each imaging modality was compared to measurements at open urethroplasty in 7 patients, sonourethrography was consistently more accurate. Distension of the urethra with saline during the ultrasound examination enabled classification of the degree of spongiofibrosis, which was confirmed by full depth biopsy in 5 patients. Sonourethrography cannot adequately image the posterior urethra, even when the transcrotal approach is used. However, because it is a dynamic 3-dimensional study and can be repeated without risk of radiation exposure, sonourethrography is preferable to radiographic retrograde urography to evaluate patients with suspected anterior urethral strictures.

Endovaginal sonographic evaluation of ectopic pregnancy: a prospective study

To determine the value of endovaginal sonography for evaluating women with a suspected ectopic gestation, we prospectively studied a group of 84 pregnant women in whom conventional transabdominal sonograms failed to show a living embryo. Of 84 patients studied, 25 had an ectopic gestation, 32 had a normal intrauterine pregnancy, and 27 had an abnormal (nonviable) intrauterine pregnancy. Endovaginal sonography, compared with transabdominal sonography, provided additional information in 50 cases (60%) and less information in only three cases (4%). Of 25 ectopic gestations, endovaginal sonography provided new information in 15 cases (60%) including detection of an extrauterine gestational sac (10 cases), extrauterine embryo (two cases), or adnexal mass (three cases) not observed on transabdominal sonography. Of 32 normal intrauterine pregnancies, endovaginal sonography provided additional information in 26 cases (81%) including detection of a yolk sac (14 cases), living embryo (11 cases), or small gestational sac (one case) not seen on transabdominal sonography. Of 27 abnormal intrauterine pregnancies, endovaginal sonography showed additional information in nine cases (33%) including detection of embryonic demise (three cases), retained intrauterine products (four cases), or a yolk sac (two cases) not seen on transabdominal sonography. Patient acceptance of endovaginal sonography was excellent; 82% of the patients preferred this method to transabdominal sonography, 13% expressed no preference, and 5% preferred transabdominal sonography. We conclude that endovaginal sonography can provide significant additional information in the majority of women who are referred for sonography with a suspected ectopic gestation. We believe that this method should become a integral part of sonographic evaluation in women who are suspected of having an ectopic gestation when conventional transabdominal sonography fails to show a living embryo.

Percutaneous drainage of periappendiceal abscesses: review of 20 patients

Twenty patients with periappendiceal abscesses diagnosed by CT underwent percutaneous catheter drainage. Eighteen (90%) of the 20 patients were successfully treated by percutaneous drainage and antibiotic therapy alone. In two of these patients, however, small recurrent abscesses were diagnosed by CT 4 and 6 weeks after drainage, but these abscesses resolved with additional antibiotic therapy. Surgery was performed in two patients in whom percutaneous drainage failed. One was a diabetic patient who had a gas-forming abscess that extended into the posterior pararenal space. Surgery was necessary in a second patient because of a technical failure of catheter insertion, which resulted in perforation of the abscess cavity and peritonitis. Abscess sinograms in eight (44%) of 18 patients showed fistulas between the abscess cavity and the base of the cecum or appendix. However, the fistulas did not pose a problem in clinical management, and all closed within 14 days. Percutaneous drainage is an effective alternative to surgery in selected patients with periappendiceal abscesses.

Deep venous thrombosis of the lower extremity: US evaluation

The sensitivity of duplex ultrasonography (US) for detecting deep venous thrombosis of the lower extremity was compared with that of venography in a prospective study of 54 patients. Doppler analysis of the common femoral vein and US imaging of the deep venous system from the common femoral vein to the popliteal vein was performed. Common femoral vein response to the Valsalva maneuver was recorded. Sonographically visible thrombi and abnormal vein compressibility were 91% sensitive for the common femoral vein, and 94% sensitive for the superficial femoral or popliteal veins, with no false-positive examinations. Abnormal Doppler flow and abnormal response of the common femoral vein to the Valsalva maneuver enabled thrombi to be detected only in the common femoral and iliac veins. Combined data allowed accurate diagnoses in all patients with deep venous thrombosis proximal to the deep calf veins. US should be the screening examination of choice for evaluating patients with suspected lower extremity deep venous thrombosis.

AIDS-related cholangitis: radiographic findings in nine patients

Acalculous inflammation of the biliary tract is a recently reported complication of the acquired immunodeficiency syndrome (AIDS). In a 33-month period, nine men with AIDS were evaluated because of right upper quadrant and/or epigastric pain, jaundice, or abnormal liver function test results. Each patient underwent ultrasonography and endoscopic retrograde cholangiopancreatography; seven also underwent computed tomography. In eight of nine patients the imaging studies disclosed intrahepatic and extrahepatic bile duct changes identical to those seen in sclerosing cholangitis (strictures, focal dilatation, thickened duct walls). Isolated papillary stenosis and ductal dilatation were present in one patient, while eight patients had some stricturing of the distal common duct. The combination of papillary stenosis and intrahepatic ductal strictures appears unique to AIDS-related cholangitis. Endoscopic papillotomy provided variable relief to symptoms and biochemical abnormalities. Cholangitis caused by cytomegalovirus and/or Cryptosporidium infection is the proposed pathophysiologic mechanism.

Acute appendicitis: high-resolution real-time US findings

High-resolution, real-time ultrasonography (US) with graded compression was used to evaluate 90 patients with clinically suspected acute appendicitis. US visualization of a noncompressible appendix was the primary criterion for a diagnosis of acute appendicitis. The overall sensitivity was 89%, the specificity was 95%, and the accuracy was 93%. When the results in women were analyzed separately (n = 49), the overall accuracy was 96%. Several important limitations of US scanning were encountered. There were three false-positive examinations in patients with a sonographically visible appendix whose symptoms spontaneously resolved. Another patient had a normal compressible appendix with a thin (2-mm), symmetric wall surrounded by ascites. There were three nondiagnostic studies (3%) due to inability to compress the cecum and right lower quadrant adequately because of exquisite tenderness (two patients) or massive ascites (one patient). When interpreted in light of the clinical examination, sonography should significantly reduce the rate of false-negative appendectomies, particularly in women.

Papillary stenosis and sclerosing cholangitis in the acquired immunodeficiency syndrome

Eight homosexual men with the acquired immunodeficiency syndrome (AIDS) presented with clinical, biochemical, and radiologic features of stenosis of the papilla of Vater and sclerosing cholangitis. This newly recognized complication of AIDS produces abdominal pain, nausea, and vomiting and may predispose patients to superimposed bacterial cholangitis. Marked elevation of serum alkaline phosphatase levels and lesser changes in hepatic aminotransferase levels are common. Although abdominal ultrasonography and computed tomography detect ductal abnormalities, endoscopic retrograde cholangiography best shows precise ductal irregularities and provides therapeutic intervention. Prompt relief of symptoms follows endoscopic sphincterotomy, often with resolution of biochemical evidence of cholestasis. Biliary tract infection with cytomegalovirus or cryptosporidia and resultant viral or coccidial cholangitis are the proposed pathophysiologic mechanisms.

Acute suppurative tenosynovitis of the hand: diagnosis with US

The sonographic findings in seven patients with surgically proved acute tenosynovitis of the hand (bacterial in six cases, of presumed viral origin in one) were reviewed. In the six patients with bacterial tenosynovitis the affected flexor tendon was larger than that of the contralateral normal digit. In five patients hypoechoic areas were identified surrounding the flexor tendon that proved to be pus at surgery. Sonography failed to depict a small amount of pus in the tendon sheath in one patient. The affected tendon of the single patient with tenosynovitis thought to be of viral origin was normal in size, but a focal tendon sheath fluid collection was detected that proved to be sterile at surgery. Sonography appears to be a useful imaging technique in the early diagnosis of acute suppurative tenosynovitis of the hand.

Pancreatic abscess: predictive value of early abdominal CT

The value of a recently reported grading system of early abdominal computed tomography (CT) for predicting development of pancreatic abscess in patients with acute pancreatitis was reassessed. When the previously described CT grading system was used in another patient population, it did not demonstrate the same degree of prognostic value of baseline CT. In this series pancreatic abscess occurred in only eight of 29 patients (28%) with grade E CT scans (with grade E representing the most severe involvement), compared with 60% in the previous series. Of 44 patients with either grade D or E baseline CT scans, abscesses developed in only 30%, with a minimum clinical follow-up of 3 months. A second grading system, which used a semiquantitative analysis of the degree of peripancreatic inflammation (a "CT severity score"), also did not strongly correlate with the future risk of abscess, The authors conclude that early abdominal CT should be performed selectively in patients with acute pancreatitis and reserved for patients who are either diagnostic dilemmas or who fail to respond to supportive treatment and have clinically suspected surgical complications such as pancreatic abscess.

Plastic wrap for US transducer sterility or sanitization

Commercially available plastic wrap can be used to encase an ultrasound transducer for sanitization purposes. If sterility is required, an individual piece of plastic wrap can be gas sterilized before the transducer is covered with it. This technique does not degrade or temporally limit the use of the transducer, it is easy to perform, and the materials are readily available.

Computed tomography of blunt trauma to the gallbladder

The CT findings are reviewed in two patients with injuries to the gallbladder following blunt abdominal trauma. In one patient with a laceration of the cystic artery a large intraluminal clot was identified within the gallbladder associated with extensive hemoperitoneum. Another patient presented with extensive bile leakage into the peritoneal cavity 72 h after blunt trauma due to laceration of the fundus of the gallbladder. The clinical features of blunt trauma to the gallbladder and the utility of CT in this entity are reviewed.

Biliary dilatation: defining the level and cause by real-time US

In a 15-month period, 110 patients with subsequently proved biliary dilatation were evaluated with ultrasound (US). The level of dilatation was defined as pancreatic, suprapancreatic, or at the level of the porta hepatis. Causes of dilatation included pancreatitis, choledocholithiasis, neoplasm, and stricture. The distal duct was examined initially on transverse scans obtained with the patient in a semierect right posterior oblique position; the proximal duct was then examined on longitudinal scans obtained with the patient in a supine left posterior oblique position. When this scanning technique was used, US indicated the level of dilatation in 91.8% of cases and suggested the correct cause in 70.9%. Because this approach markedly improves US visualization of the intrapancreatic bile duct, distal obstructing lesions, which are the most common, can be optimally examined.