Second-trimester echogenic bowel and chromosomal abnormalities

OBJECTIVE

Our objective was to examine the outcomes of pregnancies in which echogenic bowel was detected in the second trimester.

STUDY DESIGN

Twenty-two cases with a prospective diagnosis of echogenic bowel were reviewed. Karyotypic studies were performed in 19 cases, and 17 families had deoxyribonucleic acid-based risk assessment for cystic fibrosis. The echogenicity of the bowel was retrospectively reviewed and graded as mild or bright.

RESULTS

Five cases of trisomy 21 and one case of trisomy 18 were detected; four of these had other ultrasonographic abnormalities. Twenty-seven percent of fetuses with echogenic bowel were aneuploid. Risk was greatest for cases with brightly echogenic bowel. No cystic fibrosis mutations were detected. The diagnosis of echogenic bowel was reproducible.

CONCLUSION

Brightly echogenic bowel in the second trimester was found to be associated with a significant risk of fetal aneuploidy.

Fetuses aren't small children

Although great strides in prenatal diagnosis have been made by sonography, interpretation has been complicated by failure to recognize fundamental differences between the uterine and extra-uterine environment. Furthermore, extrapolation of knowledge concerning the same disorders in childhood to fetuses produces misleading information about diagnosis and often, prognosis.

The Radiological Society of North America. Diamond Jubilee lecture. Seeing with sound

The concept of making images from reflected sound waves is not new. Its origin, however, was not in medicine, but in industrial warfare. Much present-day technology derives from U.S. Navy research in World War II. Introduction to medicine began at the war's completion, but practical applications have been available only for the past 2 decades. In this short span, ultrasonography has been applied to nearly all specialties of medicine. It is now an indispensable adjunct to diagnosis, and in some areas, such as obstetrics, modern practitioners could not function without it. It is estimated that by the year 1991, 25% of all imaging studies (worldwide) will be sonograms. While such widespread use invariably leads to turf and training problems, the end result has been very positive for patients.

The reliability and predictive value of an amniotic fluid scoring system in severe second-trimester oligohydramnios

Sixty-two cases of oligohydramnios diagnosed by ultrasound between 13-28 weeks' gestation were reviewed. Three experienced ultrasonographers used a subjective scale to rate the oligohydramnios as mild, moderate, severe, or anhydramniotic. Interobserver reliability was excellent (intraclass correlation coefficient 0.81). The overall perinatal mortality rate was 43%, and the incidence of pulmonary hypoplasia was 33%. One-third had lethal congenital anomalies. The frequency of adverse outcome correlated strongly with the most severe degrees of oligohydramnios; 88% of the fetuses with severe oligohydramnios or anhydramnios had lethal outcomes, compared with 11% in the mild/moderate group. The presence of an anuric urinary tract anomaly was associated with the most severe grades of oligohydramnios and was uniformly fatal. Pulmonary hypoplasia was diagnosed in 60% of the severe group versus 6% in the moderate group. We conclude that subjective grading of oligohydramnios by experienced observers is both reliable and predictive of outcome. The finding of severe oligohydramnios in the second trimester is highly predictive of poor fetal outcome and should stimulate a thorough search for etiology and consideration of intervention. Moderate grades of reduced amniotic fluid may be managed with relative optimism.

Sonographic evaluation of the fetal stomach: significance of nonvisualization

The stomach was successfully visualized in 1051 (98%) of 1071 consecutive sonograms obtained in 995 fetuses after 14 weeks gestational age. All patients were studied prospectively. Stomach nonvisualization was associated with an abnormal outcome in 55% of the fetuses studied after 14 weeks and in 100% of the fetuses studied after 19 weeks. Fetal abnormalities included gastrointestinal and CNS malformations. Oligohydramnios was often present. The absence of a stomach on fetal sonograms obtained after 14 weeks gestational age strongly suggests fetal abnormality. Repeat sonograms should be obtained in all such cases.

Follow-up of infants with bilateral renal disease detected in utero. Growth and renal function

We studied 69 infants who had urinary tract abnormalities detected by antenatal ultrasound examination. There were 21 intrauterine or immediate neonatal deaths; in all 21 infants, severe bilateral renal disease incompatible with life was found at autopsy. Six of the live-born infants with abnormal results of antenatal ultrasound examinations had a normal urinary tract after birth. Of the remaining 42 infants, the prenatal diagnosis was confirmed with renal ultrasound and other studies during the first week of life. Twenty-one of 42 infants had bilateral renal disease. We obtained follow-up data on 19 of 21 of these infants. Twelve of 19 had obstructive uropathy that was treated surgically. After one to 51 (mean, 18) months of follow-up, renal function varied. Ten of 19 patients had a calculated glomerular filtration rate greater than or equal to 79 mL/min/1.73 m2. One infant required long-term ambulatory peritoneal dialysis. Renal function (glomerular filtration rate, 74 +/- 5 mL/min/1.73 m2) and growth (height percentile, 41 +/- 8) were unexpectedly good considering the severity of the urinary tract abnormalities. Prenatal detection of bilateral renal disease followed by careful medical and surgical management results in a favorable outcome with good growth and renal function.

Sonography of gallstones and biliary dilatation without a visible aetiology: the infrequency of obstructing choledocholithiasis

This paper describes 50 consecutive patients who sonographically had gallbladder stones and dilated bile ducts, but no visible aetiology for the dilatation. We reviewed these cases to determine the frequency of choledocholithiasis in this setting. Common duct stones caused obstruction in only 36% of these patients. Other aetiologies included strictures due to chronic pancreatitis or prior stone passage in 24% of the patients, and malignant obstruction in 16%. In 24% of the patients, no cause was found for biliary dilatation; common duct stones or obstructing tumours were excluded in the group. Since aetiologies other than stones are likely in a majority of cases, further preoperative workup (CT, percutaneous transhepatic cholangiography, ERCP) or intraoperative cholangiography (if the patient requires urgent cholecystectomy) is indicated. The additional studies should provide a diagnosis, help determine whether or not the common duct should be explored, or avoid unnecessary operation in case of incurable malignancy.

Gallbladder and bile duct abnormalities in AIDS: sonographic findings in eight patients

Gallbladder and biliary tract abnormalities were observed on sonography in eight patients with AIDS. The studies were obtained to evaluate right upper quadrant pain (two patients), tenderness (three patients), and abnormal liver function tests (eight patients). The two major sonographic findings were gallbladder wall thickening (eight patients), which often was marked, and bile duct dilatation (two patients). Gallbladder wall thickness varied from 4 to 15 mm and was greater than 1 cm in four patients. Follow-up sonograms in five patients showed increasing wall thickness in four and decreasing thickness in one, but these findings did not correlate well with the clinical status of the patient. Pericholecystic fluid was shown in three cases. None of the patients had gallstones. Common bile duct dilatation varied from 12 to 15 mm; no specific cause for dilatation was found by cholangiography. Mycobacterium avium intracellulare was recovered from the gallbladder in one patient, and Cryptosporidium was recovered from the duodenum in two patients. AIDS should be considered in the differential diagnosis of gallbladder wall thickening or bile duct dilatation in the appropriate clinical setting. These findings may indicate opportunistic infection of the biliary tract. A disparity may exist between the mild symptoms and signs (or lack of symptoms and signs) related to the gallbladder and bile ducts and the sometimes marked sonographic abnormalities.

Perfluorochemicals as US contrast agents for tumor imaging and hepatosplenography: preliminary clinical results

In animals, perfluorochemicals (PFCs) are effective ultrasound (US) contrast agents that produce hepatic, splenic, and tumor enhancement. The use of Fluosol-DA 20%, an emulsion of perfluorodecalin and perfluorotripropylamine, was studied in nine non-critically ill patients with cancer who had liver lesions. US studies without Fluosol were compared with studies obtained 24, 48, and 72 hours after Fluosol infusion. Vital signs and extensive laboratory analyses are performed before and after Fluosol infusion. Liver metastases from colonic, pancreatic, and gastric carcinoma exhibited rim or diffuse enhancement after a Fluosol dose of 1.6 g/kg or greater. Fluosol produced echogenic enhancement of the liver and spleen relative to kidney at a dose of 2.4 g/kg, allowing the detection of nonenhancing lesions. In addition, Fluosol at a dose of 1.6 g/kg or greater allowed detection of lesions not seen before contrast medium was administered in three of the seven patients studied. There was a mild increase in the level of serum glutamic oxaloacetic transaminase in two patients, one given 2.4 and the other 3.2 g/kg of Fluosol. Mild and transient allergic reactions without change in vital signs were experienced by two patients.

MR imaging of the scrotum: normal anatomy

High-resolution magnetic resonance (MR) imaging with a surface coil was utilized to evaluate the normal scrotum. Scrotal contents, spermatic canal, and inguinal regions were visualized within the same field of view. Differences in signal intensity in the testis, epididymis, tunica albuginea, fluid, fat, and spermatic cord allowed for clear delineation of these structures in detail. The high contrast and spatial resolution of MR imaging, coupled with the wide field of view and absence of ionizing radiation, make MR imaging well suited for evaluation of the scrotum.

MR imaging of the scrotum: pathologic conditions

The utility of high-resolution magnetic resonance (MR) imaging in studying a variety of intratesticular and extratesticular pathologic conditions was assessed. The high magnetic signal intensity of the testis provided an excellent background for visualization of intratesticular abnormalities. Except for old blood, all intratesticular processes were less intense than testis, especially on T2-weighted images. The visualization of the tunica albuginea is a distinct advantage, allowing its assessment in cases of trauma or testicular tumors. Epididymal and spermatic cord abnormalities were easily recognized. All pathologic conditions were best seen on T2-weighted images acquired in the coronal plane. Balanced images allowed for tissue characterization.

Real-time breast sonography: application in 300 consecutive patients

Sonography, disappointing as a primary screening method, has emerged as the single most helpful adjunct to mammography in evaluation of the clinically and/or mammographically abnormal breast. Sonography can reliably diagnose simple cysts presenting as palpable masses or as indeterminate, nonpalpable lesions on mammography. However, differentiation of benign from malignant solid masses cannot be reliably accomplished by sonography. The expense of an automated breast sonographic scanner has deterred many radiologists from the purchase of such a unit. The authors have used both an automated breast scanner and a real-time 10-MHz hand-held unit. This paper describes their experience with the real-time unit, demonstrating both normal and pathologic anatomy. Special emphasis has been placed on the sonographic diagnosis of a simple cyst because this lesion was the cause of one-quarter of all palpable masses and nonpalpable, mammographically dominant masses. Cysts are sharply marginated and anechoic. Posterior enhancement visible in 78 of 80 cysts was not demonstrable on all images in 25% of cysts.

B-mode ultrasonic echo determination of depth of thermal injury

A high-resolution high-frequency prototype B-mode ultrasonic scanning device was utilized to determine the depth of burn in a pilot study of five burned patients. Comparisons with clinical evaluations and histopathological studies of burn wound biopsies of the same burned areas failed to show any substantive improvement in predicting the depth of burn by ultrasonic scanning techniques. Current ultrasonic scanning is of no practical value to the burn surgeon for differentiating precisely between the depth of a deep dermal burn and a full skin thickness thermal injury.

Prenatal ultrasonographic diagnosis of congenital adenomatoid malformation of the lung. Correlation with pathology and implications for pregnancy management

Congenital cystic adenomatoid malformation of the lung is an uncommon malformation. The solid type III variety is the rarest and carries the poorest prognosis. This report describes the prenatal diagnosis of a case of congenital cystic adenomatoid malformation type III at 24 weeks' gestation. The pathologic features of the malformation and the etiology and prognostic significance of hydramnios and anasarca are discussed. This case indicates that the malformation can be diagnosed early enough to allow for therapeutic intervention.

Large umbilical cord: a normal finding in some fetuses

We report two cases in which the umbilical cords of fetuses were large on prenatal ultrasound scans. The pregnancies terminated uneventfully, however, and the babies were healthy at birth and on follow-up visits. We discuss the various etiologies of a large umbilical cord and conclude that, although a large cord may suggest the presence of an underlying abnormality, in some instances it may represent a normal finding.

Objective measurement of hypertrophic burn scar: a preliminary study of tonometry and ultrasonography

Many people are burned each year and subsequently develop hypertrophic burn scars. An objective means for quantitatively measuring scar characteristics would be useful in monitoring resolution of the individual patient's scars as well as in evaluating different treatment protocols. Two methods for quantitative measurement of hypertrophic scars were evaluated in 4 patients at 8 scar sites over a 2-month period. A specially designed tonometer, the cicatrometer, assesses scar firmness and pliability. It is shown to provide a simple noninvasive means for objectively evaluating the progress of scar maturation and therapy. High-resolution ultrasonic scanning is shown to provide an objective, quantitative measurement of hypertrophic scar thickness, which can be compared between patients. This allows for the design of controlled trials comparing different treatment protocols.

Neuroblastoma metastatic to the testis: ultrasonographic screening as an aid to clinical staging

Secondary testicular tumors are rare, and to our knowledge only a few cases of metastatic neuroblastoma to the testicle have been presented in the literature. We report two cases in which high resolution ultrasonography was helpful in establishing the diagnosis of metastatic neuroblastoma. Because accurate staging is important in the choice of therapy, an aggressive search for the presence of metastatic disease is essential. The small size of the testes in young children makes physical examination difficult, and sonography can be of value.

Perfluorochemicals as liver- and spleen-seeking ultrasound contrast agents

In this study, Fluosol-DA, 20 per cent (composed of perfluorodecalin and perfluorotripropylamine) was tested as a liver-specific ultrasound contrast agent. Twelve normal rabbits were scanned, utilizing the Picker Microview (10 MHz), prior to and two days following the intravenous administration of 24 ml/kg of Fluosol (or 4.8 g/kg of perfluorochemicals) emulsion to ten of the rabbits and 24 ml/kg of Ringer's solution to two rabbits as control. In all ten rabbits given Fluosol, liver echogenicity increased relative to that of the kidney, whereas the liver remained less echogenic than the kidney in the two rabbits given Ringer's solution. Four independent reviewers correctly identified all rabbits that received Fluosol and both rabbits that received Ringer's solution. It is demonstrated that, similar to PFOB, Fluosol serves as an echogenic contrast material for ultrasound and opacifies the normal rabbit liver.

Occult spinal dysraphism in infants: screening with high-resolution real-time ultrasound

Spinal dysraphism refers to incomplete embryologic development of the dorsal midline. Frequently it is not clinically obvious, and lack of treatment can lead to progressive neurological damage. Early diagnosis of occult defects can allow appropriate surgical intervention and prevent neurological deficits. The authors have used high-resolution real-time ultrasound to screen infants with various cutaneous lumbosacral markers, all of whom were at risk of occult spinal dysraphism. Preliminary results suggest that ultrasound is a reliable screening procedure and could obviate the need for more costly and invasive tests.

Perfluoroctylbromide: a liver/spleen-specific and tumor-imaging ultrasound contrast material

The effect of perfluoroctylbromide (PFOB) on liver and tumor echogenicity was evaluated in rabbits. The echogenicity of the kidney, which is not affected by PFOB, was used as the basis for comparison in the liver studies. For the liver echogenicity study, sonography was performed on four rabbits, two with PFOB and two without PFOB, and four rabbits prior to and following the intravenous administration of 5 ml/kg PFOB. All livers were equal to or less echogenic than kidney in the control animals. All livers became more echogenic than kidney two days after administration of PFOB. The effect of PFOB on tumor echogenicity was evaluated in 18 rabbits with VX2 tumor implanted in the liver. Ultrasound studies of all rabbits were performed by the same physician before and two days after half the rabbits had received PFOB (5 ml/kg intravenously). The reviewers correctly identified all rabbits that received PFOB by visualization of an echogenic rim around the hepatic tumors.

High-resolution real-time ultrasonography of neonatal kidneys

A high-resolution real-time ultrasound system was used to evaluate 43 neonates who had problems referable to the kidney. In addition to a review of normal anatomic features portrayed by this instrument, a variety of pathologic states are illustrated. The system offers the dual advantages of superior spatial resolution and rapid survey capability when compared with traditional articulated-arm contact scanners. As with all sonographic investigations, functional immaturity or depressed organ function is no hindrance to obtaining diagnostic examinations.

Antenatal ultrasonic evaluation of acardiac monsters

Acardiac monster represents a rare but serious complication of monozygotic twin pregnancy. Antenatal recognition is important because of accompanying obstetrical problems, including polyhydramnios, dystocia, and uterine rupture. While pathologic findings are varied, characteristic sonographic findings allow accurate prenatal diagnosis. Acardia must be distinguished from sacrococcygeal teratoma, omphalocele and macerated fetus.

Induction of ovulation and pregnancy with pulsatile luteinizing hormone releasing factor: dosage and mode of delivery

The efficacy of intravenous and subcutaneous routes for pulsatile delivery of differing dosages of synthetic luteinizing hormone releasing factor (LRF) for ovulation induction were evaluated sequentially in two patients with presumed deficiency of endogenous LRF: isolated gonadotropin deficiency and pituitary stalk transection with hyperprolactinemia. Observations were made of the amplitude and duration of the induced LH-FSH pulses, of follicular growth and ovulation (via ultrasound), and of ovarian steroids. Remarkable differences in each of these parameters were found between the two modes of LRF delivery. LRF pulses administered subcutaneously resulted in inappropriate gonadotropin secretion, arrest of follicular development, elevated ratios of E1/E2 and androgens/estrogens, and the appearance of acne - features of polycystic ovary syndrome. In contrast, the first intravenous course of pulsatile LRF induced orderly follicular maturation and ovulation with subsequent pregnancy in both subjects. From these findings we conclude that, in these patients, the intravenous mode of delivery of LRF pulses was superior to the subcutaneous route at all doses tested.

Maternal ultrasonography for the antenatal diagnosis of surgically significant neonatal anomalies

The increased use of ultrasonography in the management and evaluation of pregnancy has provided a unique opportunity to observe the anatomy of the developing fetus from 12 weeks gestation until term. Twenty-eight surgically important anatomic abnormalities have been diagnosed in utero by sonographic examinations at our affiliated institutions over the past three and a half years. These include ascites (five cases), gastroschisis (four cases), omphalocele (three cases), sacrococcygeal teratoma, cystic hygroma, hydrocele, duodenal atresia, multicystic kidney (two cases each), and one each of jejunal atresia, conjoined twins, ureteropelvic junction obstruction, urethral valves, urethral agenesis, and hydronephrosis secondary to reflux. Prenatal diagnosis by ultrasonographic examination has signifcantly improved perinatal management. Elective caesarean section has benefited infants with lesions causing dystocia, such as sacrococcygeal teratoma, omphalocele, and conjoined twins. Advance notification of surgeons and neonatalogists has reduced the delays of postnatal evaluation and treatment that contribute, significantly, to complications and death. In addition, transfer of the pregnant mother carrying an infant with a significant surgical anomaly to a center with facilities for neonatal surgery and specialized postoperative care can be properly planned for in advance. In the near future, intrauterine fetal surgery or palliative intervention may provide increased salvage of patients with obstructive uropathy and diaphragmatic hernia, both of which carry high mortality rates secondary to in utero damage. Sonography has proven useful in following the dilatation of either intestinal or urinary tract structures in utero. In our hands, maternal sonography has improved the surgical care of the newborn and may open a new frontier of intrauterine fetal surgery in the future.

Parathyroid adenoma: accuracy of preoperative localization by high-resolution real-time sonography

To assess the accuracy of high-resolution sonography of the parathyroid glands, a consecutive series of sonograms in 58 patients was reviewed. The study population was limited to patients thought clinically to have primary hyperparathyroidism and likely to have one enlarged adenomatous gland. Patients with renal failure or other evidence of secondary hyperparathyroidism were excluded. Typical sonographic features of parathyroid adenoma were observed. An overall accuracy of 92% was obtained for the identification of surgically confirmed parathyroid gland enlargement due to adenoma.

Ultrasonic demonstration of the inflamed appendix: case report

Ultrasound was used to visualize a grossly inflamed nonperforated appendix in a child with acute leukemia. The characteristic sonographic pattern of the gastrointestinal tract was altered, and showed thickening of the bowel wall. In this case, use of ultrasound as an initial screening procedure in a patient with abdominal complaints aided diagnosis of gastrointestinal tract abnormality prior to more traditional studies.

Sonography of the thickened gallbladder wall: a nonspecific finding

Twenty cases of sonographically visualized thickening of the gallbladder wall were reviewed and the clinical diagnoses compiled. In only eight of these patients was cholecystitis considered responsible for the finding. The rest had hepatitis, alcoholic liver disease with hypoproteinemia, heart failure, renal disease, and multiple myeloma; however, all lacked clinical evidence of gallbladder disease. Because of these findings, caution is urged in making the diagnosis of cholecystitis on the basis of wall thickening alone.

Ultrasonic imaging of the carotid arterial system

The ability of a B-mode, real-time, high frequency ultrasonic imager to diagnose carotid arterial disease was evaluated in 81 carotid arteries. The imager was relatively sensitive in detecting the presence of significant stenosis but was relatively insensitive in its ability to quantitate the degree of stenosis. The imager was unable to detect the presence of ulcerations. The oculoplethysmograph had a greater sensitivity, specificity and accuracy than the ultrasonic imager in diagnosing carotid arterial stenosis in the same group of patients. Ultrasonic imaging appears to be useful as a screening test of cerebrovascular disease when used in combination with the oculoplethysmographic test.

High resolution real-time sonography of hemodialysis vascular access complications

Chronic hemodialysis requires an adequately functioning, surgically created vascular access. Many operative techniques have been devised, and each is subject to a variety of complications that significantly shorten the life span of any shunt. Among these are stenosis, thrombosis, aneurysm, pseudoaneurysm, and infection. High resolution sonography is a promising means to evaluate most of these complications. To determine the potential capability of the technique for detecting graft complications, a retrospective review of 30 hemodialysis patients examined with high resolution sonography is presented. Sonographic findings in normal grafts and in a variety of vascular access problems are illustrated.

High-resolution real-time ultrasonography of thyroid nodules

High-resolution real-time ultrasonography was used to evaluate 98 patients with palpable abnormalities of the thyroid and positive isotopic studies. It confirmed 37 of 73 (51%) suspected solitary nodules. Of 25 patients thought to have multinodular goiter, sonography was supportive in 21 (84%). In patients with adenoma or adenomatous nodules, characteristic features included a sonolucent "halo". Colloid nodules tended to be more sonolucent than normal thyroid tissue, whereas Hashimoto thyroiditis was characterized by an enlarged gland and decreased echogenicity.

Intrauterine diagnosis of renal anomalies by ultrasonography

The diagnosis of renal disease was made antenatally in three patients by ultrasonographic examination. In two cases a multicystic kidney was detected in utero and removed shortly after delivery. In another case, a hydronephrotic kidney was detected in utero; repair was then performed early, before symptoms developed in the infant. Antenatal diagnosis of renal disease by ultrasonography may help reduce morbidity and mortality in some cases.

Accuracy of ultrasonography in diagnosis of hepatocellular disease

Retrospective evaluations were made of abdominal echograms in 61 patients who underwent liver biopsy within 3 weeks after ultrasound study. Without knowledge of clinical or biopsy data, determinations were made by two independent observers of: (1) liver size, (2) beam penetration, (3) echogenicity, (4) vascularity, (5) ancillary abnormality, and (6) diagnostic impression. Using these parameters, the presence of generalized parenchymal disease was identified in 81% of reviews of patients with cirrhosis. Thus, in patients with known cirrhosis, there was a 19% false negative rate. In normal patients, 76% were correctly called normal by the reviewers. However, in 24% generalized parenchymal disease was suggested (24% false positive). Patients with fatty liver could not be reliably distinguished from patients with cirrhosis, nor could patients with hepatitis be easily separated from those with normal livers. In all of these determinations, the combination of several features provided more diagnostic accuracy than any single echographic finding.

High-resolution ultrasonography of scrotal pathology

A prototype high-resolution (10-MHz) real-time ultrasonic system was used to study 22 patients who were ultimately proved to have intra- and extratesticular tumors, scrotal fluid collections, and inflammatory processes. In 5 of 6 patients with primary testicular masses, there were areas of decreased echogenicity within the testis when compared with surrounding normal tissue. In general, the method was highly effective in differentiating and characterizing testicular and extratesticular processes.

Ultrasonography of jaundice

Ultrasonography is proposed as a valuable first step in the study of the jaundiced patient. Utilizing modern gray scale technology, it is nearly always possible to determine whether or not dilatation of the biliary tree is present. In the presence of diffuse liver disease without obstruction, some assessment of the state of the parenchyma can often be made. In patients with obstruction, its severity and level are usually easy to determine. It may be considerably harder to correctly diagnose the etiology of the obstruction, and more invasive investigations will then be required.