Ultrasound corner

Ultrasound corner đź“·Ultrasonography cases from the Diagnostic and Interventional Ultrasound Unit of Dr Carla Serra.
đź“ŤIRCSS,Azienda Ospedaliero-Universitaria di Bologna.

A 86 years old man was admitted to the ultrasound clinic for the presence of relapsing fever and rise in inflammation in...
17/03/2022

A 86 years old man was admitted to the ultrasound clinic for the presence of relapsing fever and rise in inflammation indices at blood tests (PCR, WBC, PCT). A CT- scan performed two weeks before showed intrahepatic biliary tract dilatation with no other relevant finds.

US scan found a liver of regular size, slightly irregular profiles, regular echo structure. At VIII hepatic segment there was a voluminous irregular oval formation with prevailing anechoic content within it of 7.5 x 6.5 cm, similar anechoic formation to the VIs with irregular margins of 13 x 12 mm.
The exam was completed by injection of contrast medium (SonoVue) that showed rim-enhancement of the lesion at VIIIs without wash-out. This attitude was suggestive of abscess formation. The same attitude was shown by the lesion at VIs.
No other relevant finds showed by both B-mode and CEUS.
Due to suspicion of liver abscess, some days later, an US-guided pig tail drainage was placed with discharge of biliary material (sent for microbiological examination, with negative result). The drainage was fixed to the skin with a suture and left under gravity.

One week after drainage the patient came back to the US clinic for a check. The patient was better and his lab tests were improving.
At US scan the main intrahepatic abscess appears slightly reduced in size (5 x 4 cm VS 7,5 x 5,5 cm), unchanged the one at the VIs of 12 x 11 mm. Normal gallbladder, not dilatated biliary tract.
The use of contrast medium (SonoVue) confirmed intense, at the abscess, rim-enhancement and the absence of wash out. The liquid portion was very scarce. Intracavitary contrast medium was introduced (injected through the drainage) which didn’t show communication with the biliary tract, and confirmed that the residual liquid component was reduced. We proceed to wash with 10 cc of saline solution obtaining further purulent material which was collected for additional microbiological examination. At the end the drainage output was null, so we proceed to remove it.

Image 1: First exam, size of the abscess
Image 2: Second exam, size of the abscess
Image 3: Second exam: Intracavitary contrast medium injected through the drainage
Image 4: Purulent material collected by washing.

A 35 year-old man came to our attention complaining about a FUO for five months. He already got some general exams in an...
10/03/2022

A 35 year-old man came to our attention complaining about a FUO for five months. He already got some general exams in an another hospital, referred as normal. He was sent to Policlinico Sant’Orsola to better investigate his health problem. Here he had some laboratory exams - including some microbiology- that resulted normal, and a PET that didn’t show any significant uptake, except for a very subtle signal in the spleen. The hematologist sent him to our U.S. clinic to undergo a further assessment. The ultrasound showed a splenomegaly (area 50 cm2) with three oval hypoechoic lesions of 21, 9 and 5 mm. The CEUS (SonoVue) demonstrated a thin rim enhancement and central hypovascular region in all the phases, without clear washout. Suspecting Leishmaniasis (even if antibodies research resulted negative), the patient was redirected to the hematologist, who required a bone marrow biopsy for the evaluation of Leishmania PCR.

A 52 years old woman with a history of primary sclerosing cholangitis diagnosed in 2012 and undergone OLT surgery in 201...
28/02/2022

A 52 years old woman with a history of primary sclerosing cholangitis diagnosed in 2012 and undergone OLT surgery in 2016 was admitted to the ultrasound clinic because, after six years of well-being, presented an episode of fever and increase in blood tests of cholestasis index (GGT and FA) and PCR, with no other significant value’s alterations.

US scan found a liver of regular size, slightly irregular profiles, regular margins and grainy echo structure. Intrahepatic biliary tracts bilaterally dilated. Biliary tract at hepatic hilum was regular in size with irregular profile and without stones inside. Furthermore there was a subtly hypoechoic area of hepatic parenchyma at hilum (2,5 cm of maximum diameter). Normal flow at the anastomoses and regular hepatic artery resistance indexes (RI 0.62 and 0,58 left and right respectively).

The exam was completed by injection of contrast medium (SonoVue) that confirmed dilatation of intrahepatic biliary tracts bilaterally, and an interruption of biliary tract at the hilum at the point of irregularity of the biliary tract evidenced at B-mode. Moreover at the hilum the hipoechoic area shown by B-mode showed wash-in during the arterial phase and weak wash-out during late stage as from inflammation.
Due to the suspicion of relapse of the underlying disease has been prescribed a CT scan and then a rivalutation by hepatologist of reference.

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