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0542: Use of Contrast Enhanced Ultrasonography (CEUS) in the Assessment of Focal Liver Lesions in Pediatric Patients
S78
Ultrasound in Medicine and Biology
Volume 35, Number 8S, 2009
relation of clinical, radiologic, and histologic results as well as appropriate follow-up is essential to detect the false-negative result earlier.
organs correlate with body weight, height or age, as is found in other pediatric populations.
0539
0541
Changes in Workflow Created by New Ultrasound Machines Michel Claudon, Service de Radiologie, France
Ultrasound in the Digestive Tract Hassen Gharbi, IBN ZOHR, Tunisia
The global ultrasound market is roughly twice that of CT (in dollars). There are, in most countries, no restrictions on equipment purchase, and every physician may have access, with little need for sharing equipment. Portable units, which represented up to 25% of the market last year, are used increasingly outside the traditional hospital circuit, including emergency cases, with the expectation of better management of many patients in the most critical situations, as recently supported by emergency specialists. US is also widely recommended as a control method for IV line placement. 3D imaging is a well-assessed modality for fetal imaging for a few years, providing striking images of prenatal anomalies and being shown to improve both efficiency and confidence in diagnosis for fetal imaging. This new modality opens the door for a tremendous change in daily practice and workflow, associating a short acquisition time and a delayed post-treatment and reporting phase. Contrast-enhanced ultrasound is based on the intravenous administration of microbubbles, which increase the backscattered signal, allowing real-time imaging of organs at very low output levels. Primary clinical application is focal liver lesions’ characterization and detection. This needs an adaptation of the workflow: e.g., placement of an IV line, assistance for injection, longer examination time, need for long clips storage and time for the physician for the post-treatment phase. Adaptation of the organization of the US section and optimization of the workflow is now an issue to get full benefit from new machines and modes.
US is today an important imaging modality for evaluation of the digestive tract in children. It allows simultaneous non invasive anatomic and homodynamic study. It’s of a diagnostic, prognosis, therapeutic and preventive value. It helps the physicians to confirm eventual antenatal diagnosed abnormalities and to treat children in several circumstances, exploring different congenital and acquired disorders. US exam must be carried out by high frequency convex and linear probes in all scan plans. The child is lying in supine position, in general. No premedication is needed and diet is not necessary. Doppler techniques, if available, are helpful. Normal aspect of digestive tract and variants are important to be known. Its main indications are acute and chronic abdominal pain, suspected intussusception or appendicitis, inflammatory bowel diseases, suspected hypertrophic pyloric stenosis or gastro-oesophageal reflux, blunt abdominal trauma mid gut volvulus, Schoenlein Henock purpura syndrome, mesenteric ischemia, and screening for abdominal congenital abnormalities. Checking all the intra abdominal organs must be the gold rule. The observation should include bowel wall thickness, bowel motility, bowel content, free fluid or collection in the abdomen, or any mass related to the bowel. US guided biopsy is very helpful, in particular when abdominal mass is suspected. US is needed during the follow up after medical or surgical treatment of several diseases: abscesses, ascitis, recurrencies of malignant tumors or intussusception.
0540 Sonographic Measurement of Liver, Spleen and Kidney Michael Kawooya, Makerere University/EC UREI Kampala, Uganda Background: Ultrasound scan is reliable for measurement of liver, spleen and kidney sizes. Normal measurements of these organs have been established in other populations but not in healthy African Ugandan children. Pathology of these organs commonly alters their sizes and ultrasound assessment is important in detecting pathological change in size. Objectives: To discuss the normal sonographic measurements for liver, spleen and kidneys in healthy children in Uganda, Africa and to compare these with measurements from other populations. To correlate the measurements obtained in Ugandan children with age, height and body weight and to compare this correlation with correlations from pediatric populations in other parts of the world. Methods: Data on sonographic measurements in Uganda was obtained through a cross-sectional study from June to November 2006 in five primary schools in Kampala district, Uganda. Heights and weights of 238 randomly selected healthy pupils aged 6-15 years were measured. Their liver, spleen and kidney sizes were then measured by ultrasound scan. The data was then computer processed. Literature was reviewed to compare findings from similar studies. Results: In Ugandan children, the lengths of the three organs showed the best correlation with age, height and body weight with weight showing the greatest correlation except for the spleen where height showed the greatest correlation. These observations are similar to studies from other populations. Conclusion: Normal sizes of the liver, spleen and kidneys in selected healthy Ugandan children have been documented. The lengths of these
0542 Use of Contrast Enhanced Ultrasonography (CEUS) in the Assessment of Focal Liver Lesions in Pediatric Patients Fulvia Terracciano, Endoscopy “Casa Sollievo della Sofferenza” San Giovanni Rotondo, Italy Maria Pastore, Pediatry “Casa Sollievo della Sofferenza” San Giovanni Rotondo, Italy Antonio Marseglia, Pediatry “Casa Sollievo della Sofferenza” San Giovanni Rotondo, Italy Marco Sperandeo, Internal Medicine “Casa Sollievo della Sofferenza” San Giovanni Rotondo, Italy Vito Annese, Endoscopy “Casa Sollievo della Sofferenza” San Giovanni Rotondo, Italy Angelo Andriulli, Italy CEUS has improved diagnostic capacity of ultrasound (US) in the differential diagnosis of several pathologies in adults. At the present time, there are few controlled studies on the application of CEUS in focal liver diseases in children. AIM of this study was to assess the safety and the accuracy of CEUS in evaluating focal liver lesions in pediatric patients. Methods: 35 children (22 males, age range: 5-17 years) with focal liver lesions were investigated. All patients underwent also other concomitant diagnostic methods ( Magnetic resonance (MRI), computed tomography (CT), biopsy or surgery). CEUS findings were compared with those obtained by CT and MRI. Results: The final diagnosis were: 2 HCC, 2 LNH, 6 metastasis; 13 angiomas, 4 focal steatosis, 3 liver abscess and 4 IFN. The CEUS
Abstracts performed in these patients proved high correlation diagnosis in 32 out of 35 patients evaluated (91,5%). In all patients weren’t observed side effects using this method. These results show diagnostic accuracy of CEUS and high concordance with other more invasive methods of the investigation. Conclusion: In our experience, the addition of CEUS to clinical pratice has significant impact on patient management. In patient with an incidental liver mass on sonography, for example, characterization at time of this detection reduced the time to diagnosis and decreases referrals to CT or MR scan. Ultrasound contrast agents are easy to use, no adverse events were observed in our patients. As they add no radiation for their use, they are highly appropriate in pediatric patients. 0543 e-Tracking and Intima Media thickness Thickness of Carotid Artery: Initial Eexperience in Obese Indian Children Arun S Kinare, Dr. Kinare Ultrasound Clinic Pune, India Deepa S Pandit, Agharkar Research Institute Pune, India Shashi A Chiplonkar, Agharkar Research Institute Pune, India Anuradha V Khadilkar, Hirabai Cowasji Jehangir Medical Research Institute Pune, India Vaman V Khadilkar, Hirabai Cowasji Jehangir Medical Research Institute Pune, India Objective: To investigate carotid artery stiffness and IMT in obese children as a determinant of future risk of atherosclerosis and compare them with healthy children. Methods: Stiffness of carotid artery and Intima media thickness (IMT) by e-Tracking, %body fat by DEXA and fasting serum lipids were measured for 91 children aged (6-16 yr) with obesity and 42 healthy age-matched controls. e-Tracking were assessed using an Aloka ␣ 10 equipment(Aloka co. Ltd. Japan). High frequency linear probe with a frequency range 6.67 to 13 MHz was used. e-Tracking samples were obtained in the segment 2cms prior to bifurcation while the segment used for the IMT was 1cm prior to the bifurcation. Differences between obese and control subjects were tested with the independent samples Student’s t test. Results: Body mass index (BMI) and body fat percentage was significantly higher in obese children than healthy controls (p⬍0.01). Obese children had significantly higher blood pressure, Arterial Compliance (AC) and Pulse wave velocity (PWV) than healthy controls (p⬍0.05). Plasma lipids were significantly higher in obese than non-obese children (p⬍0.05). Mean stiffness and IMT in obese children was 3.9⫾1.09, 0.32⫾0.06mm and in healthy controls was 3.4⫾0.92, 0.29⫾0.04 mm. Correlations of IMT, stiffness, AC, PWV, and blood pressure with BMI, body fat, plasma lipids are being explored. Conclusion: Stiffness of carotid artery in obese children can be considered an important marker in the evaluation of atherosclerosis. This ongoing study may give stronger correlations in future. 0545 Live Scanning Workshop: Portal Hypertension Peter Coombs, Monash Medical Centre, Australia The classification of portal hypertension (PH) is derived from the location of the cause of PH. (ie. pre-hepatic, intra-hepatic and post hepatic). Intrahepatic PH is further divided into presinusoidal (eg liver fibrosis) or post sinusoidal (eg cirrhosis). An additional classification has recently been proposed called hyperdynamic PH(1). This includes arterio-venous fistulae and malformations. These give rise to the main components requiring systematic sonographic evaluation. These are the portal venous system, the liver parenchyma and the hepato-venous drainage Portal Venous System
S79
PH is identified by the evaluation of major organs (liver & spleen), measurement of vein sizes (PV, SV and SMV) and assessment of spectral Doppler waveforms. Exclusion of thrombosis with careful b-mode and colour flow imaging is important. Much attention in clinical practise should be given to the identification of portosystemic venous collaterals. Chronic Liver Disease The presence and/or progression of chronic liver disease is an important part of the examination. Parenchymal heterogeneity, capsular nodularity with associated hepatic atrophy or hypertrophy is substantive evidence of advanced fibrosis or cirrhosis. An emphasis of this workshop will be the use of lower frequency linear transducers to show subtleties in the liver parenchyma that indicate earlier stages of fibrosis. The linear transducer is also very important in reviewing the ligamentum teres. Hepatic Veins Post hepatic PH (eg.Budd Chiari) needs to be excluded. Hepatic venous spectral can also be considered marker for chronic liver disease. This workshop will use didactic presentation, interactive activities and live scanning to communicate these aspects of the examination. 1. Robinson KA, Middleton WD, Al-Sukaiti R, Teefey SA, Dahiya N. Doppler sonography of portal hypertension. Ultrasound Q. 2009 Mar; 25(1):3-13. 0546 Live Scanning Workshop: Finger Eugene McNally, Nuffield Orthopaedic Centre, United Kingdom This demonstration will include an examination of the flexor and extensor tendons that control finger movement. It will include the flexor and extensor compartments of the wrist, the flexor and extensor tendons of the fingers and the retinacula. The retinacular examination will focus on the pulley system and dorsal hood. The routine approach to a rheumatological examination of the small joints of the hand will also be covered. (Wednesday, 2 September 2009) 0602 Difficult Areas for Radiofrequency Ablation in the Abdomen John McGahan, Davis Medical Centre, United States Ablation of tumors within the abdomen using percutaneous technique is a well accepted method of tumor treatment. There are some limitation of any percutaneous method in performance of ablation in critical regions. Newer techniques have been advocated in performance in RFA to treat tumors in difficult anatomical locations. Some of these regions that are difficult to treat include the following: I. Diaphragm. Installation of water between the diaphragm and the lesion may protect the diaphragm from thermal injury. Other technique such as intentional pneumo or hydrothorax can be utilized for performance of RFA of hepatic lesions near the dome of the liver. The different technical maneuvers will be reviewed. II. Bowel. When a hepatic or renal tumor abuts the stomach, small bowel or large intestine, mechanical means must be utilize to displace the bowel from the liver or renal neoplasm. Hydrodissection using D5W can be used to displaces the loop of the bowel from the tumor. This will thus allow coagulation of the tumor without injury to the adjacent bowel. III. Gallbladder. When performing RF ablation of tissues adjacent to the gallbladder use of chemical ablation in addition to other ablative techniques may be helpful for treatment of hepatomas. Some of these difficult areas for performing RF ablation will be reviewed and methods to avoid complications will be detailed.
Ultrasound in Medicine and Biology
Volume 35, Number 8S, 2009
relation of clinical, radiologic, and histologic results as well as appropriate follow-up is essential to detect the false-negative result earlier.
organs correlate with body weight, height or age, as is found in other pediatric populations.
0539
0541
Changes in Workflow Created by New Ultrasound Machines Michel Claudon, Service de Radiologie, France
Ultrasound in the Digestive Tract Hassen Gharbi, IBN ZOHR, Tunisia
The global ultrasound market is roughly twice that of CT (in dollars). There are, in most countries, no restrictions on equipment purchase, and every physician may have access, with little need for sharing equipment. Portable units, which represented up to 25% of the market last year, are used increasingly outside the traditional hospital circuit, including emergency cases, with the expectation of better management of many patients in the most critical situations, as recently supported by emergency specialists. US is also widely recommended as a control method for IV line placement. 3D imaging is a well-assessed modality for fetal imaging for a few years, providing striking images of prenatal anomalies and being shown to improve both efficiency and confidence in diagnosis for fetal imaging. This new modality opens the door for a tremendous change in daily practice and workflow, associating a short acquisition time and a delayed post-treatment and reporting phase. Contrast-enhanced ultrasound is based on the intravenous administration of microbubbles, which increase the backscattered signal, allowing real-time imaging of organs at very low output levels. Primary clinical application is focal liver lesions’ characterization and detection. This needs an adaptation of the workflow: e.g., placement of an IV line, assistance for injection, longer examination time, need for long clips storage and time for the physician for the post-treatment phase. Adaptation of the organization of the US section and optimization of the workflow is now an issue to get full benefit from new machines and modes.
US is today an important imaging modality for evaluation of the digestive tract in children. It allows simultaneous non invasive anatomic and homodynamic study. It’s of a diagnostic, prognosis, therapeutic and preventive value. It helps the physicians to confirm eventual antenatal diagnosed abnormalities and to treat children in several circumstances, exploring different congenital and acquired disorders. US exam must be carried out by high frequency convex and linear probes in all scan plans. The child is lying in supine position, in general. No premedication is needed and diet is not necessary. Doppler techniques, if available, are helpful. Normal aspect of digestive tract and variants are important to be known. Its main indications are acute and chronic abdominal pain, suspected intussusception or appendicitis, inflammatory bowel diseases, suspected hypertrophic pyloric stenosis or gastro-oesophageal reflux, blunt abdominal trauma mid gut volvulus, Schoenlein Henock purpura syndrome, mesenteric ischemia, and screening for abdominal congenital abnormalities. Checking all the intra abdominal organs must be the gold rule. The observation should include bowel wall thickness, bowel motility, bowel content, free fluid or collection in the abdomen, or any mass related to the bowel. US guided biopsy is very helpful, in particular when abdominal mass is suspected. US is needed during the follow up after medical or surgical treatment of several diseases: abscesses, ascitis, recurrencies of malignant tumors or intussusception.
0540 Sonographic Measurement of Liver, Spleen and Kidney Michael Kawooya, Makerere University/EC UREI Kampala, Uganda Background: Ultrasound scan is reliable for measurement of liver, spleen and kidney sizes. Normal measurements of these organs have been established in other populations but not in healthy African Ugandan children. Pathology of these organs commonly alters their sizes and ultrasound assessment is important in detecting pathological change in size. Objectives: To discuss the normal sonographic measurements for liver, spleen and kidneys in healthy children in Uganda, Africa and to compare these with measurements from other populations. To correlate the measurements obtained in Ugandan children with age, height and body weight and to compare this correlation with correlations from pediatric populations in other parts of the world. Methods: Data on sonographic measurements in Uganda was obtained through a cross-sectional study from June to November 2006 in five primary schools in Kampala district, Uganda. Heights and weights of 238 randomly selected healthy pupils aged 6-15 years were measured. Their liver, spleen and kidney sizes were then measured by ultrasound scan. The data was then computer processed. Literature was reviewed to compare findings from similar studies. Results: In Ugandan children, the lengths of the three organs showed the best correlation with age, height and body weight with weight showing the greatest correlation except for the spleen where height showed the greatest correlation. These observations are similar to studies from other populations. Conclusion: Normal sizes of the liver, spleen and kidneys in selected healthy Ugandan children have been documented. The lengths of these
0542 Use of Contrast Enhanced Ultrasonography (CEUS) in the Assessment of Focal Liver Lesions in Pediatric Patients Fulvia Terracciano, Endoscopy “Casa Sollievo della Sofferenza” San Giovanni Rotondo, Italy Maria Pastore, Pediatry “Casa Sollievo della Sofferenza” San Giovanni Rotondo, Italy Antonio Marseglia, Pediatry “Casa Sollievo della Sofferenza” San Giovanni Rotondo, Italy Marco Sperandeo, Internal Medicine “Casa Sollievo della Sofferenza” San Giovanni Rotondo, Italy Vito Annese, Endoscopy “Casa Sollievo della Sofferenza” San Giovanni Rotondo, Italy Angelo Andriulli, Italy CEUS has improved diagnostic capacity of ultrasound (US) in the differential diagnosis of several pathologies in adults. At the present time, there are few controlled studies on the application of CEUS in focal liver diseases in children. AIM of this study was to assess the safety and the accuracy of CEUS in evaluating focal liver lesions in pediatric patients. Methods: 35 children (22 males, age range: 5-17 years) with focal liver lesions were investigated. All patients underwent also other concomitant diagnostic methods ( Magnetic resonance (MRI), computed tomography (CT), biopsy or surgery). CEUS findings were compared with those obtained by CT and MRI. Results: The final diagnosis were: 2 HCC, 2 LNH, 6 metastasis; 13 angiomas, 4 focal steatosis, 3 liver abscess and 4 IFN. The CEUS
Abstracts performed in these patients proved high correlation diagnosis in 32 out of 35 patients evaluated (91,5%). In all patients weren’t observed side effects using this method. These results show diagnostic accuracy of CEUS and high concordance with other more invasive methods of the investigation. Conclusion: In our experience, the addition of CEUS to clinical pratice has significant impact on patient management. In patient with an incidental liver mass on sonography, for example, characterization at time of this detection reduced the time to diagnosis and decreases referrals to CT or MR scan. Ultrasound contrast agents are easy to use, no adverse events were observed in our patients. As they add no radiation for their use, they are highly appropriate in pediatric patients. 0543 e-Tracking and Intima Media thickness Thickness of Carotid Artery: Initial Eexperience in Obese Indian Children Arun S Kinare, Dr. Kinare Ultrasound Clinic Pune, India Deepa S Pandit, Agharkar Research Institute Pune, India Shashi A Chiplonkar, Agharkar Research Institute Pune, India Anuradha V Khadilkar, Hirabai Cowasji Jehangir Medical Research Institute Pune, India Vaman V Khadilkar, Hirabai Cowasji Jehangir Medical Research Institute Pune, India Objective: To investigate carotid artery stiffness and IMT in obese children as a determinant of future risk of atherosclerosis and compare them with healthy children. Methods: Stiffness of carotid artery and Intima media thickness (IMT) by e-Tracking, %body fat by DEXA and fasting serum lipids were measured for 91 children aged (6-16 yr) with obesity and 42 healthy age-matched controls. e-Tracking were assessed using an Aloka ␣ 10 equipment(Aloka co. Ltd. Japan). High frequency linear probe with a frequency range 6.67 to 13 MHz was used. e-Tracking samples were obtained in the segment 2cms prior to bifurcation while the segment used for the IMT was 1cm prior to the bifurcation. Differences between obese and control subjects were tested with the independent samples Student’s t test. Results: Body mass index (BMI) and body fat percentage was significantly higher in obese children than healthy controls (p⬍0.01). Obese children had significantly higher blood pressure, Arterial Compliance (AC) and Pulse wave velocity (PWV) than healthy controls (p⬍0.05). Plasma lipids were significantly higher in obese than non-obese children (p⬍0.05). Mean stiffness and IMT in obese children was 3.9⫾1.09, 0.32⫾0.06mm and in healthy controls was 3.4⫾0.92, 0.29⫾0.04 mm. Correlations of IMT, stiffness, AC, PWV, and blood pressure with BMI, body fat, plasma lipids are being explored. Conclusion: Stiffness of carotid artery in obese children can be considered an important marker in the evaluation of atherosclerosis. This ongoing study may give stronger correlations in future. 0545 Live Scanning Workshop: Portal Hypertension Peter Coombs, Monash Medical Centre, Australia The classification of portal hypertension (PH) is derived from the location of the cause of PH. (ie. pre-hepatic, intra-hepatic and post hepatic). Intrahepatic PH is further divided into presinusoidal (eg liver fibrosis) or post sinusoidal (eg cirrhosis). An additional classification has recently been proposed called hyperdynamic PH(1). This includes arterio-venous fistulae and malformations. These give rise to the main components requiring systematic sonographic evaluation. These are the portal venous system, the liver parenchyma and the hepato-venous drainage Portal Venous System
S79
PH is identified by the evaluation of major organs (liver & spleen), measurement of vein sizes (PV, SV and SMV) and assessment of spectral Doppler waveforms. Exclusion of thrombosis with careful b-mode and colour flow imaging is important. Much attention in clinical practise should be given to the identification of portosystemic venous collaterals. Chronic Liver Disease The presence and/or progression of chronic liver disease is an important part of the examination. Parenchymal heterogeneity, capsular nodularity with associated hepatic atrophy or hypertrophy is substantive evidence of advanced fibrosis or cirrhosis. An emphasis of this workshop will be the use of lower frequency linear transducers to show subtleties in the liver parenchyma that indicate earlier stages of fibrosis. The linear transducer is also very important in reviewing the ligamentum teres. Hepatic Veins Post hepatic PH (eg.Budd Chiari) needs to be excluded. Hepatic venous spectral can also be considered marker for chronic liver disease. This workshop will use didactic presentation, interactive activities and live scanning to communicate these aspects of the examination. 1. Robinson KA, Middleton WD, Al-Sukaiti R, Teefey SA, Dahiya N. Doppler sonography of portal hypertension. Ultrasound Q. 2009 Mar; 25(1):3-13. 0546 Live Scanning Workshop: Finger Eugene McNally, Nuffield Orthopaedic Centre, United Kingdom This demonstration will include an examination of the flexor and extensor tendons that control finger movement. It will include the flexor and extensor compartments of the wrist, the flexor and extensor tendons of the fingers and the retinacula. The retinacular examination will focus on the pulley system and dorsal hood. The routine approach to a rheumatological examination of the small joints of the hand will also be covered. (Wednesday, 2 September 2009) 0602 Difficult Areas for Radiofrequency Ablation in the Abdomen John McGahan, Davis Medical Centre, United States Ablation of tumors within the abdomen using percutaneous technique is a well accepted method of tumor treatment. There are some limitation of any percutaneous method in performance of ablation in critical regions. Newer techniques have been advocated in performance in RFA to treat tumors in difficult anatomical locations. Some of these regions that are difficult to treat include the following: I. Diaphragm. Installation of water between the diaphragm and the lesion may protect the diaphragm from thermal injury. Other technique such as intentional pneumo or hydrothorax can be utilized for performance of RFA of hepatic lesions near the dome of the liver. The different technical maneuvers will be reviewed. II. Bowel. When a hepatic or renal tumor abuts the stomach, small bowel or large intestine, mechanical means must be utilize to displace the bowel from the liver or renal neoplasm. Hydrodissection using D5W can be used to displaces the loop of the bowel from the tumor. This will thus allow coagulation of the tumor without injury to the adjacent bowel. III. Gallbladder. When performing RF ablation of tissues adjacent to the gallbladder use of chemical ablation in addition to other ablative techniques may be helpful for treatment of hepatomas. Some of these difficult areas for performing RF ablation will be reviewed and methods to avoid complications will be detailed.