Ultrasound corner

18/03/2025

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.

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.

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.

27/03/2021

A 36 year-old woman, with a history of dyspepsia with upper abdominal fullness and nausea, was admitted to the ultrasound clinic. Gastroscopy was normal and previous US scans revealed a duplicated collecting system in the left kidney and gallbladder polyps.

US scan confirmed the duplex collecting system and gallbladder polyps, no anomalies to the parenchymatous abdominal organs, regular aorta, with normal walls. The angolation between the superior mesenteric artery (SMA) and aorta (Ao) and the aortomesenteric distance were smaller than normal, with no visible distension of the first portion of the duodenum nor the stomach. Left renal vein (LRV) was mildly ectatic and mildly compressed in the aortomesenteric segment, in absence of flow acceleration. The Celiac trunk and SMA had normal flow patterns. These findings were referable to an asymptomatic superior mesenteric artery syndrome associated with the nutcracker phenomenon.

Superior mesenteric artery syndrome is a vascular compression disorder in which acute angulation of the SMA results in compression of the third portion of the duodenum, leading to obstruction. It occurs in patients with severe weight loss, that causes the thinning of retroperitoneal fat cushion between SMA and aorta. Normally the aortomesenteric distance is around 10-30 mm and the aortomesenteric angle is 30-90°.
It is often associated with the Nutcracker phenomenon. This phenomenon refers to the anatomic or pathophysiologic entity wherein the SMA compresses the left renal vein and impedes its outflow to the inferior vena cava. It is a common incidental finding on routine abdominal imaging and the patients are usually asymptomatic. When it is associated with symptoms such as hematuria, left flank pain or proteinuria, it configures the Nutcracker syndrome. Doppler US of the left renal vein is fundamental in the diagnosis of this syndrome.

23/03/2021

A 35-year-old man was admitted to the outpatient clinic for hydatid disease follow-up.
One year earlier, during investigations for abdominal discomfort, a multi-vesicular echinococcal cyst with daughter vesicles (CE2) was found in the liver. The cyst was then treated with the percutaneous technique called PAIR (Puncture, Aspiration, Injection of protoscolicidal agent and Re-aspiration). Further control exams showed a regression of the lesion.

This US scan, around ten months after treatment, shows the echinococcal cyst in the paracolecystic area and the absence of anechoic components (daughter cysts). This presentation is referable to an inactive echinococcal liver cyst (CE3b).

In the last picture, the US classification of Cystic Echinococcosis (CE), according to the WHO classification, is shown: CE1 and 2 are active echinococcal cysts, usually containing viable protoscoleces. CE3 are cysts entering a transitional stage where the integrity of the cyst has been compromised either by the host or by chemotherapy. CE4 and CE5 are inactive cysts that have lost their fertility and that are degenerating.

17/03/2021

A 84 year-old man, with a history of metastatic prostatic cancer, was admitted to the ED for altered mental status (confusion, lethargy), hypotension and diffuse abdominal tenderness on palpation, with no signs of peritoneal irritation nor fever. Point-of-care US in ED found gallbladder dilatation with cholelithiasis in absence of sonographic Murphy sign.
Low-blood pressure persisted despite IV fluids and diagnosis of septic shock in acute cholecystitis was made.
The patient was transferred to Progressive Care Unit, broad-spectrum antibiotic was administered and IV treatment with norepinephrine was started.

Bedside complete abdominal US was, then, performed. US scan found typical findings of acute cholecystitis in cholelythiasis: gallbladder distension (10 cmx4,8 cm), wall thickening (14 mm) with striation, pericholecystic fluid and signs of fistulization of gallbladder wall, suggesting gallbladder perforation. Doppler signals of gallbladder walls were increased and the lumen was occupied by conglomerates of gallstones and sludge. Bile duct was visible but normal (

13/03/2021

A 51 year-old man came to the clinic for a follow-up US scan for chronic aortic dissection, previously studied using CT angiography.

In these pictures, some typical features of aortic dissection are shown. Contrast-less micro-vascular flow imaging technique, shown in picture 3,4,5,6 and 10, helped to recognise vascular structures.
The dissection involved the abdominal aorta, originating below the renal arteries. The diameter of the aorta was normal (22 mm). No aneurysms or sign of thrombosis or hematomas were found.
The aortic lumen is divided by the intimal flap into two lumina, the real and the false one. Both lumina have similar flow signals, suggesting the presence of a distal tear in the false lumen. The dissection extended distally into the proximal segment of the left common iliac artery (pic 6).
Doppler signals of renal arteries (pic 7), celiac tripod (pic 8), superior (pic 8) and inferior mesenteric (pic 9 and 10) arteries were normal. Internal and external iliac arteries flow was normal, with triphasic doppler waveforms.

The patient had no history of hypertension or atherosclerotis and was asymptomatic. Vascular surgeons excluded surgical or endovascular indications. Tests for connective tissue disorders were negative. Further tests are needed to determine the etiology of the dissection.

08/03/2021

A 78-year-old patient was hospitalized for acute abdominal pain and vomiting, with CT findings of acute necrotic-hemorrhagic pancreatitis.
Endoscopic ultrasound excluded biliary lithiasis or stenosis; immunological and virological tests were negative. The patient had no history of alcohol abuse. She was discharged with a diagnosis of idiopathic pancreatitis.

One month later, a follow-up ultrasound was performed. B-mode showed pancreas of increased size, with a diffusely hypoechoic and dishomogeneous echo-structure (on the left). CEUS with SonoVue found complete absence of parenchymal enhancement, suggestive of diffuse necrosis (on the right).

02/03/2021

A 89 year old woman was hospitalized for acute lithiasic cholecystitis, treated with ultrasound-guided percutaneous drainage. US scan found collateral multiple hypo-anechoic lesions of the right lobe of liver, suggestive for intraparenchymal hepatic abscesses.

CEUS, here below, confirmed the diagnosis, showing the typical rim enhancement in the arterial phase and the presence of no enhancement areas inside the lesions, due to purulent avascular content of the cavities.

Bile culture was positive for E.Coli and Klebsiella Aerogenes and Ertapenem IV was prescribed. After one week of intravenous antibiotic, clinical conditions improved and control CEUS scan showed partial resolution of the abscessual areas.

23/02/2021

A 38-year-old man came to the outpatient clinic for reported reduced ostomy evacuations with associated intermittent abdominal pain.
His clinical history included HIV infection on HAART, exotoxic steatohepatitis, Kaposi's sarcoma, mucocutaneous and visceral leishmaniasis and re**al amputation surgery for squamous cell carcinoma with permanent colostomy.
Ultrasound scan of the intestinal loops showed a picture of ileo-ileal intussusception with spontaneous resolution, during the examination.
The clip shows typical features of intussusception: first, in a longitudinal view, the invagination of a proximal segment of bowel into the distal bowel lumen; then, in the transverse section, the typical cockade sign.
Further investigations are needed to characterize its etiology.