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Sonography of the gallbladder: review and update
Abstracts
Sonography of the gallbladder: Review and update Kliewer MA, Radiology, University of Wisconsin, Madison, WI The ultrasound examination of the gallbladder is one of the most common studies performed in ultrasound laboratories. And yet, this study can be fraught with difficulties, both technical and interpretive. In this talk, sonography of the gallbladder will be covered under three topics: intraluminal lesions, wall thickening, and cholecystitis. Intraluminal lesions of the gallbladder encompass such entities as gallstones, sludge, and cholesterol crystals. Occasionally, the gallbladder may be evident only as a shadowing mass in the gallbladder fossa, and therefore resemble bowel. The keys to identifying the gallbladder in this circumstance will be discussed, as will the ways to distinguish a gallbladder filled with stones from a porcelain gallbladder or emphysematous cholecystitis. Wall thickening of the gallbladder can be either focal or diffuse, and the differential diagnosis in these categories can be extensive. There are, however, certain characteristic findings of such entities as adenomyomatosis and cholesterolosis that can be useful. The special case of AIDS cholangiopathy will be examined. Acute cholecystitis has a diagnosis that is built upon accumulated clinical and sonographic evidence. The three key findings are gallstones, sonographic Murphy’s sign, and wall thickening. Technical considerations are important in the identification of these findings. The sonographic Murphy’s sign, in particular, can be over and under diagnosed if not elicited with proper technique. Finally, the use of color Doppler in the diagnosis of acute cholecystitis will be discussed. This is a controversial area, and a recommendation for the practical application of Doppler techniques will be presented.
INFERTILITY What is the significance of diagnosing polycystic ovaries on ultrasound? Tan S,* Kelly S, Obstetrics and Gynecology, McGill University, Montreal, QC, Canada Polycystic ovarian syndrome is a common endocrine disorder characterized by chronic anovulation, hyperandrogenism, and a typical ovarian morphology. The morphological appearance of polycystic ovaries may exist without any of the clinical features of PCOS. The standard ultrasound criteria of polycystic ovaries is the presence of ⱖ10 cysts measuring 2– 8 mm in diameter in association with a dense ovarian stroma. Advanced ultrasound technology also shows that polycystic ovaries have a more densely vascularized ovarian stroma with higher maximal blood flow velocities compared to normal ovaries. A diagnosis of polycystic ovaries is not only of diagnostic value but has implications for treatment. For patients having ovarian stimulation, the risk of ovarian hyperstimulation syndrome (OHSS) is significantly higher in women with polycystic ovaries. Therefore, treatment protocols can be adjusted to minimize this risk. In addition, alternative treatments such as in vitro maturation (IVM) may be more appropriate than traditional IVF for these patients. IVM involves the collection of immature oocytes and subsequent maturation in vitro. It obviates the need to administer gonadotrophins to patients and eliminates the risk of OHSS. Pregnancy rates are dependent on the number of oocytes retrieved, making patients with PCO ideally suitable for this treatment. Pregnancy rates approach those of IVF treatment where ⱖ10 oocytes are collected.
S75
The ovarian function involves foliculogenesis, luteogenesis, and hormonal production. It is integrated within a complex endocrine system, involving multiple endogenous and exogenous factors. Ultrasonography is an ideal method for conducting serial studies and identifying the morphological modifications of the ovarian cycle and those related to functional disturbances. We utilize transvaginal sonography because of its great resolution, enabling identification of small anatomical details essential to study a delicate structure, such as the ovarian follicle. Color and power Doppler allows us to study the vascular net involved with follicular development, ovulation, and the corpus luteum. The utilization of the information obtained with these methods gives us an accurate and non-invasive study of the normal ovulation and its disturbances. Presently, this study has great importance, not only in the female infertility field, but also in the correct diagnosis of ovarian functional problems in the gynecological clinic, avoiding many iatrogenic maneuvers. The abnormal ovarian cycle: Utilizing transvaginal sonography, we can identify the developmental abnormalities of the follicle and of the corpus luteum. The study of the vascular map with color Doppler increases the consistency of the diagnosis. Disturbances related to follicular development: The main disturbances are early follicular atresia, retained follicule, hydropic follicle, polycystic ovarian syndrome, luteinization of the non-ruptured follicle, and ovarian multiple retained follicles. Disturbances related to the corpus luteum: The corpus luteum is a very important structure to uterine maturation for the initial pregnancy. We can characterize some of its abnormalities, such as early atrophy, insufficient corpus luteum, persistent corpus luteum, luteinic cyst, and hemorrhagic luteinic cyst.
Fetal reduction in assisted reproduction treatment (ART) today Morin L, Obstetric and Gynecology Ultrasound Unit, McGill University Health Center, Outremont, QC, Canada Assisted reproductive technologies have contributed, in recent years, to a rise in the incidence of multiple births. To reduce the risk of extreme prematurity to a minimum, and to increase the potential for the delivery of healthy infants, it is generally accepted that multifetal reduction should be offered as a therapeutic option to a couple if there are three or more fetuses detected in the first or early second trimester. This presentation describes firstly the technical aspects of the procedure. Transabdominal versus transvaginal route is compared. Timing of the procedure as well as screening for aneuploidy, suspected malformation, and prenatal diagnosis are discussed. Secondly, pregnancy loss rate is reviewed in detail. The incidence of spontaneous miscarriage for highorder multiple is taken into consideration. Starting number and finishing number of embryos influence the risk of pregnancy loss. Review of multicenter experience is presented. Other risks of fetal reduction including infection, cervical incompetence, and preterm delivery are discussed. Thirdly, pregnancy outcomes following multifetal reduction are compared to non-reduced multiple pregnancies. More specifically, medical complication of pregnancy such as hypertensive disorders and gestational diabetes and perinatal complication such as intrauterine growth restriction and prematurity are reviewed. To finish, ethical issues to take into consideration when counseling the couple undergoing assisted reproduction technology treatments are discussed. In conclusion, multifetal reduction should be viewed as a provisional approach only until improved fertility treatments obviate its use.
NEUROLOGY Ultrasound and Doppler in functional ovarian disturbances Bailao LA, Diagnosis, Ultrasound Training Center, Ribeirao Preto, SP, Brazil
Update in sonographic evaluation of the spinal canal Riccabona M, Radiology, Penn State University Hershey Medical Center, Graz, Austria
Sonography of the gallbladder: Review and update Kliewer MA, Radiology, University of Wisconsin, Madison, WI The ultrasound examination of the gallbladder is one of the most common studies performed in ultrasound laboratories. And yet, this study can be fraught with difficulties, both technical and interpretive. In this talk, sonography of the gallbladder will be covered under three topics: intraluminal lesions, wall thickening, and cholecystitis. Intraluminal lesions of the gallbladder encompass such entities as gallstones, sludge, and cholesterol crystals. Occasionally, the gallbladder may be evident only as a shadowing mass in the gallbladder fossa, and therefore resemble bowel. The keys to identifying the gallbladder in this circumstance will be discussed, as will the ways to distinguish a gallbladder filled with stones from a porcelain gallbladder or emphysematous cholecystitis. Wall thickening of the gallbladder can be either focal or diffuse, and the differential diagnosis in these categories can be extensive. There are, however, certain characteristic findings of such entities as adenomyomatosis and cholesterolosis that can be useful. The special case of AIDS cholangiopathy will be examined. Acute cholecystitis has a diagnosis that is built upon accumulated clinical and sonographic evidence. The three key findings are gallstones, sonographic Murphy’s sign, and wall thickening. Technical considerations are important in the identification of these findings. The sonographic Murphy’s sign, in particular, can be over and under diagnosed if not elicited with proper technique. Finally, the use of color Doppler in the diagnosis of acute cholecystitis will be discussed. This is a controversial area, and a recommendation for the practical application of Doppler techniques will be presented.
INFERTILITY What is the significance of diagnosing polycystic ovaries on ultrasound? Tan S,* Kelly S, Obstetrics and Gynecology, McGill University, Montreal, QC, Canada Polycystic ovarian syndrome is a common endocrine disorder characterized by chronic anovulation, hyperandrogenism, and a typical ovarian morphology. The morphological appearance of polycystic ovaries may exist without any of the clinical features of PCOS. The standard ultrasound criteria of polycystic ovaries is the presence of ⱖ10 cysts measuring 2– 8 mm in diameter in association with a dense ovarian stroma. Advanced ultrasound technology also shows that polycystic ovaries have a more densely vascularized ovarian stroma with higher maximal blood flow velocities compared to normal ovaries. A diagnosis of polycystic ovaries is not only of diagnostic value but has implications for treatment. For patients having ovarian stimulation, the risk of ovarian hyperstimulation syndrome (OHSS) is significantly higher in women with polycystic ovaries. Therefore, treatment protocols can be adjusted to minimize this risk. In addition, alternative treatments such as in vitro maturation (IVM) may be more appropriate than traditional IVF for these patients. IVM involves the collection of immature oocytes and subsequent maturation in vitro. It obviates the need to administer gonadotrophins to patients and eliminates the risk of OHSS. Pregnancy rates are dependent on the number of oocytes retrieved, making patients with PCO ideally suitable for this treatment. Pregnancy rates approach those of IVF treatment where ⱖ10 oocytes are collected.
S75
The ovarian function involves foliculogenesis, luteogenesis, and hormonal production. It is integrated within a complex endocrine system, involving multiple endogenous and exogenous factors. Ultrasonography is an ideal method for conducting serial studies and identifying the morphological modifications of the ovarian cycle and those related to functional disturbances. We utilize transvaginal sonography because of its great resolution, enabling identification of small anatomical details essential to study a delicate structure, such as the ovarian follicle. Color and power Doppler allows us to study the vascular net involved with follicular development, ovulation, and the corpus luteum. The utilization of the information obtained with these methods gives us an accurate and non-invasive study of the normal ovulation and its disturbances. Presently, this study has great importance, not only in the female infertility field, but also in the correct diagnosis of ovarian functional problems in the gynecological clinic, avoiding many iatrogenic maneuvers. The abnormal ovarian cycle: Utilizing transvaginal sonography, we can identify the developmental abnormalities of the follicle and of the corpus luteum. The study of the vascular map with color Doppler increases the consistency of the diagnosis. Disturbances related to follicular development: The main disturbances are early follicular atresia, retained follicule, hydropic follicle, polycystic ovarian syndrome, luteinization of the non-ruptured follicle, and ovarian multiple retained follicles. Disturbances related to the corpus luteum: The corpus luteum is a very important structure to uterine maturation for the initial pregnancy. We can characterize some of its abnormalities, such as early atrophy, insufficient corpus luteum, persistent corpus luteum, luteinic cyst, and hemorrhagic luteinic cyst.
Fetal reduction in assisted reproduction treatment (ART) today Morin L, Obstetric and Gynecology Ultrasound Unit, McGill University Health Center, Outremont, QC, Canada Assisted reproductive technologies have contributed, in recent years, to a rise in the incidence of multiple births. To reduce the risk of extreme prematurity to a minimum, and to increase the potential for the delivery of healthy infants, it is generally accepted that multifetal reduction should be offered as a therapeutic option to a couple if there are three or more fetuses detected in the first or early second trimester. This presentation describes firstly the technical aspects of the procedure. Transabdominal versus transvaginal route is compared. Timing of the procedure as well as screening for aneuploidy, suspected malformation, and prenatal diagnosis are discussed. Secondly, pregnancy loss rate is reviewed in detail. The incidence of spontaneous miscarriage for highorder multiple is taken into consideration. Starting number and finishing number of embryos influence the risk of pregnancy loss. Review of multicenter experience is presented. Other risks of fetal reduction including infection, cervical incompetence, and preterm delivery are discussed. Thirdly, pregnancy outcomes following multifetal reduction are compared to non-reduced multiple pregnancies. More specifically, medical complication of pregnancy such as hypertensive disorders and gestational diabetes and perinatal complication such as intrauterine growth restriction and prematurity are reviewed. To finish, ethical issues to take into consideration when counseling the couple undergoing assisted reproduction technology treatments are discussed. In conclusion, multifetal reduction should be viewed as a provisional approach only until improved fertility treatments obviate its use.
NEUROLOGY Ultrasound and Doppler in functional ovarian disturbances Bailao LA, Diagnosis, Ultrasound Training Center, Ribeirao Preto, SP, Brazil
Update in sonographic evaluation of the spinal canal Riccabona M, Radiology, Penn State University Hershey Medical Center, Graz, Austria