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Primary biliary tract neuroendocrine tumors (NETs) are extremely rare tumors that account for 0.2-2% of all gastrointestinal neuroendocrine tumors. The typical presentation is with jaundice and other symptoms related to biliary obstruction.We present a case of right hepatic duct NET in a 27-year-old female patient, asymptomatic, presented for a routine ultrasound examination that revealed moderate dilatation of the intrahepatic biliary ducts and a 20 mm hyperechoic lesion in the right hepatic biliary duct. Additional imaging was performed with the presumptive diagnosis of cholangiocarcinoma. After surgery, the histopathological and immunohistochemical report was conclusive for the diagnosis of G2 well-differentiated NET. [ABSTRACT FROM AUTHOR]

Background and Aim: Contrast enhanced ultrasound (CEUS) has been proven to be a reliable method for the characterization of focal liver lesions (FLL). The aim of this paper was to evaluate the performance of CEUS for the diagnosis of liver hemangiomas in a large cohort of patients.Material and Method: We performed a multicentre prospective study which included successive CEUS examinations from fourteen centers from Romania. CEUS examinations were performed in de novo FLL, using low mechanical index ultrasound, following an intravenous bolus of 2.4 ml SonoVue. CEUS was considered conclusive for hemangioma if a typical pattern was present following contrast (centripetal fill in during the arterial phase, hyperenhanced lesion during venous and late phases). In all cases a reference method was available (contrast CT or MRI or biopsy). The trial was registered in clinicaltrials.gov (Identifier NCT01329458).Results: During February 2011 - May 2015, 1153 CEUS examinations were performed for the evaluation of de novo FLL. Out of the 1153 de novo FLL, 238 cases were diagnosed as hemangiomas by CEUS (typical enhancing pattern). Contrast CT/MRI and biopsy diagnosed additional 24 hemangiomas. From the 238 cases diagnosed as hemangiomas by CEUS, in 11 the final diagnosis was different. Considering contrast CT/MRI and biopsy as reference methods, CEUS had 90.4% sensitivity, 98.8% specificity, 95.4% positive predictive value, 97.4% negative predictive value, resulting in 96.9% diagnostic accuracy for the diagnosis of hemangiomas.Conclusion: CEUS is a sensitive and very specific method for the diagnosis of hemangiomas. [ABSTRACT FROM AUTHOR]

Unlabelled: The Aim: of this study was to summarize the spectrum of pancreatic pathology assessed by contrast enhanced ultrasound (CEUS) in a single Gastroenterology Center and to emphasize its accuracy in assessing two of the most important pancreatic lesions: solid tumors and necrotic lesions in acute pancreatitis. Material and Methods: Our retrospective study included 197 patients with pancreatic lesions (de novo pancreatic masses; acute, severe pancreatitis; other pathologies) evaluated by CEUS from October 2009 to May 2013, in which a reference method (contrast CT/MRI) was available. Results: A conclusive diagnosis was established according to the EFSUMB Guidelines in 87.8% of the 197 cases. In 87.3% cases there was a perfect concordance between CEUS and the reference method (contrast CT/MRI). 95 examinations were made for pancreatic solid masses: 41.1% (39) were hypoenhanced, 34.7% (33) were hyperenhanced, and 20% (19) were isoenhancing - chronic pancreatitis and autoimmune pancreatitis - while in 4.2% (4) cases CEUS was inconclusive. 60 examinations were made in severe acute pancreatitis and in 50% (30) cases pancreatic necrosis was diagnosed. 42 examinations were performed for other lesions: 64.2% (27) pancreatic pseudocysts, 11.9% (5) cystic tumors, 23.8% (10) other pathologies (abscesses, fibrosis, etc). CEUS accuracy for solid tumors was 92.9%. For necrotic lesions the accuracy was 97.4%. Conclusions: CEUS has turned to be a good method for the characterization of different pancreatic pathologies and for evaluating acute pancreatitis. CEUS was conclusive in 90% cases and it should be considered as a first line imaging method in clinical practice. [ABSTRACT FROM AUTHOR]

Aims: Ultrasound (US) is an essential diagnostic and educational tool in medical practice, and its effective implementation into medical curricula is critical. This study aimed to compare the efficacy of two disparate educational approaches-an optional semester course and a specifically curated intensive workshop-on the learning curve of medical students in abdominal ultrasonography. Material and methods: Engaging fourth and fifth-year medical students, this study, incorporated both theoretical and practical elements of US, providing participants with hands-on experience and evaluative assessments pre- and post-training. Students were segregated into two groups: one experienced a 14-hour optional semester course and the other a 6-hour intensive workshop, both yielding distinct teaching methodologies yet aspiring for synonymous educational outcomes. Results: Involving a total of 93 participants, findings elucidated that regardless of the educational method employed, post-training identification of US structures exhibited a significant enhancement compared to pre-training. Interestingly, no substantial disparities were discerned between the two educational approaches nor gender-based differences in learning outcomes. Conclusions: This investigation provides pivotal insights into the versatile utility of different educational strategies in abdominal US training for medical students, affirming that varied pedagogical methods can achieve comparable augmentations in student proficiency. Further research is paramount to ascertain the optimal integration of US education into medical curricula, considering aspects such as duration, depth, and mode of delivery. [ABSTRACT FROM AUTHOR]

Aim: Nonalcoholic Fatty Liver Disease (NAFLD) is increasing in frequency in daily practice and evaluation of liver steatosis, fibrosis and inflammation severity are essential for prognosis assessment. The aim was to evaluate the usefulnessof a new liver steatosis quantification system - Ultrasound-Guided Attenuation Parameter (UGAP) from General Electric Healthcare, using Controlled Attenuation Parameter (CAP) as the reference method.Material and Method: 179 consecutive subjects, in whom liver steatosis was assessed in the same session using UGAP, implemented on LOGIQ E10 system (GE Healthcare), and CAP (FibroScan, EchoSens). To discriminate between steatosis stages by CAP, we used the cut-offs recommended by the manufacturer: S1 (mild) - 230 dB/m, S2 (moderate) - 275 dB/m, S3 (severe) - 300 dB/m.Results: We classified our cohort by means of CAP into the following groups: S0 (no steatosis): 48/176 (27.2%), S1 (mild): 56/176 (31.6%), S2 (moderate): 14/176 (7.3%) and S3 (severe): 59/176 (33.9%). The mean UGAP values increased with the steatosis grade and for each group were the following: S0: 198.3±25.7 dB/m, S1: 216.86±26.3 dB/m, S2: 237.79±26.3 dB/m, and S3: 270.8±31.62 dB/m respectively (p<0.001). A very good positive correlation was found between UGAP and CAP values (r=0.73, p<0.0001). The best cut-off values for predicting different grades of liver steatosis using CAP as the reference were: S1 - 192.5 dB/m (AUC 0.83); S2 - 231 dB/m (AUC 0.90) and S3 - 248 dB/m (AUC 0.91).Conclusion: UGAP seems to be a good method for liver steatosis quantification and correlates strongly with CAP values. [ABSTRACT FROM AUTHOR]

Aim: Reliable liver stiffness measurements (RLSM) using Transient Elastography (TE) with the standard M probe are difficult to obtain in overweight (BMI≥25kg/m2) and obese (BMI>30kg/m2) patients. The aim of our paper was to assess the feasibility of TE in daily practice using both M and XL probes. Material and Method: We studied retrospectively 3235 patients with chronic liver disease assessed by TE first by the M probe (standard probe – transducer frequency 3.5 MHz), and if the measurements were unreliable, with the XL probe (transducer frequency 2.5 MHz). Reliable measurements were defined as the median of 10 valid measurements with a success rate ≥ 60% and an interquartile range < 30%. Results of liver elasticity were expressed in kilo Pascals (kPa). Results: RLSM by M probe were obtained in 62.2% (2015/3235) patients, and by XL probe in 1011/1220 (80%) of patients with unreliable measurements by M probe; thus we obtained RLSM in 93.5% of 3235 cases. In overweight patients we obtained RLSM in 89.9% (1039/1156) cases: in 63.1% (729) by M probe and in 26.8% (310) by XL probe. In obese patients we obtained RLSM in 83.8% (746/890): in 18.4% (164) by M probe and in 65.4% (582) by XL probe. Thus, by using both probes, RLSM were obtained in 1785 (87.2%) of overweight and obese patients. Conclusion: The feasibility of the M probe was 62.2% in our Department. Reliable measurements using M or XL probe allowed the evaluation of liver stiffness in 93.5% of cases. By using both M and XL probes, reliable LSM by TE can be obtained in the majority of obese and overweight patients (87.2%). [ABSTRACT FROM AUTHOR]

Unlabelled: Liver abscess is a potentially lethal condition that requires prompt recognition and adequate treatment for a good outcome. The aim of this study was to assess the value of contrast enhanced ultrasound (CEUS) in the management of liver abscesses in the clinical practice of a single centre.Material and Methods: A retrospective analysis was performed including all patients diagnosed with liver abscesses during 5 years (2010-2014) in a tertiary Department of Gastroenterology and Hepatology. The demographic data, the presence of risk factors, the cause of liver abscess, the B-mode conventional US aspect, the CEUS appearance and the patient's outcome were documented and analyzed.Results: The study group included 41 patients diagnosed with liver abscesses (17 women and 24 men, mean age 63.3+/-13.2 years), 16/41 (39%) of them with diabetes mellitus. A single lesion was found in 28 (68.3%) patients, and 13 (31.7%) patients had multiple abscesses. The CEUS study was conclusive for the diagnosis of liver abscess in clinical context in 38/41 cases (92.7%). All conclusive cases presented rim enhancement in the arterial phase and no enhancement in the liquid areas. The honeycomb appearance with septa enhancement was present in 17/41 (41.5%) patients. Washout of the marginal rim was found in 22/41 (53.6%) lesions.Conclusions: In our group the most frequent CEUS features found were the rim enhancement in the arterial phase and the presence of no enhancement areas, followed by the honeycomb appearance. CEUS was able to be conclusive for the diagnosis of liver abscess in almost 93% of cases. [ABSTRACT FROM AUTHOR]

The use of liver elastography has substantially developed in the past few years; the introduction of novel elastographic methods (Transient Elastography, point Shear Wave Elastography, Real Time Shear Wave Elastography, Strain Elastography) has changed the perspective in the evaluation of liver disease. The ongoing research in this area is mainly focused on diffuse liver diseases and for predicting liver cirrhosis complication. This guideline created under the auspice of Romanian Society of Ultrasound in Medicine and Biology is intended to accustomize the clinician with the current practical use of liver elastography and has been issued to help in maximizing the clinical benefit for the patients with chronic liver diseases. [ABSTRACT FROM AUTHOR]

Aim: To analyze how many measurements are needed for non-invasive assessment of liver stiffness (LS) by means of 2D-Shear Wave Elastography (2D-SWE) and if the use of mean of median values of 2D-SWE measurements is needed.Methods: We evaluated 449 consecutive subjects (with or without chronic liver disease) by means of Transient Elastography (TE) and 2D-SWE. We compared the correlation of LS assessed by TE with 2D-SWE measurements when using either the median of 5 valid 2D-SWE measurements or the mean of 3 or 5 valid 2D-SWE measurements.Results: We obtained reliable LS measurements by TE in 330/449 subjects (73.5%). From these, in 281 subjects we obtained 5 valid 2D-SWE measurements. The correlation of LS assessed by TE with 2D-SWE values was similar when we used the median value of 5 valid 2D-SWE measurements, the mean value of 5 valid 2D-SWE measurements or the mean value of 3 valid 2D-SWE measurements: r =0.683, r=0.711 and r=0.691, respectively. There were no significant differences between the median value of 5 valid 2D-SWE measurements; the mean value of 5 valid 2D-SWE measurements; or the mean value of 3 valid 2D-SWE measurements: 7.6 kPa, 7.7 kPa and 7.6 kPa, respectively.Conclusions: Our study showed that it is enough to perform 3 valid 2D-SWE measurements and to use the mean value of these measurements. [ABSTRACT FROM AUTHOR]

Introduction: Contrast-enhanced ultrasound (CEUS) uses second generation microbubble contrast agents and is considered to be a useful imaging method for focal liver lesions (FLLs) characterization. Aim: To observe if CEUS increases the diagnostic performance of benign FLLs as compared with standard ultrasonography examination (US). Patients and Methods: This is a single centre study developed during September 2009- December 2011 in the Department of Gastroenterology and Hepatology, in Timisoara. We evaluated 386 benign FLLs diagnosed by means of CEUS. Before performing CEUS, all FLLs were examined by US and Power Doppler techniques. At CEUS, the benign nature of a lesion was established by the absence of washout in the portal and late phase. The typical features observed using contrast, allowed their classification in a particular type of pathology, according to the 2008 EFSUMB Guidelines. Results: From 386 benign FLLs, 81 (20.9%) of them were diagnosed in patients with chronic liver disease, while 305 (79.1%) were in patients without chronic hepatopathy. In 355 (92%) cases CEUS established a particular type of pathology. The most frequent lesions were: hemangiomas (37.5%), focal fatty alterations (24.8%), complex cysts (10.7%) and regenerative nodules (11.8%). Based on US we correctly estimated the positive diagnosis in 55.7% cases and using CEUS, the diagnostic performance increased up to 92%. Conclusions: In our study, by means of US the estimate positive diagnosis was made in 55.7% of cases. CEUS properly characterized 92% of benign FLLs and increased the diagnostic performance of these lesions, as compared with US. [ABSTRACT FROM AUTHOR]

Aim: The aim of our study was to assess the influence of liver residual mass in cirrhotic patients on the liver stiffness (LS), measured by ARFI elastography. Methods: Two hundreds eleven cirrhotic patients were enrolled. To evaluate the liver residual mass, the Child-Pugh and MELD scores were used and 10 valid ARFI measurements were performed. The correlation between Child-Pugh, MELD scores and the LS were evaluated. Results: Valid ARFI measurements were not obtained in 3 patients. A direct, very low correlation between the LS values and the Child-Pugh (r=0.264, p<0.001) and MELD scores (r=0.194, p=0.005) was found. A direct, low correlation between LS measurements and total bilirubin (r=0.271, p<0.001) and an inverse, low correlation with albumin (r=-0.270, p<0.001), prothrombin time (r=-0.196, p=0.006), cholinesterase (r=-0.241, p=0.003) was obtained. The LS mean values were statistically significant higher in patients with Child-Pugh class B vs. A (p=0.002) and in Child-Pugh C vs. A (p<0.001). The values were not significantly different in patients with Child-Pugh B vs. C (p=0.06). Conclusions: Higher values of LS measurements by means of ARFI could be an indicator of decreased liver functional reserve, evaluated by means of Child Pugh or Meld scores. [ABSTRACT FROM AUTHOR]

Unlabelled: Portal vein thrombosis (PVT) is a relatively common complication in patients with liver cirrhosis and hepatocellular carcinoma, but might also occur in the absence of liver disease. Ultrasound (US) is the first imaging method used for assessing PVT. the Purpose: To evaluate the utility of contrast-enhanced ultrasound (CEUS) for the differentiation between benign and malignant PVT. Materials and Methods: from October 2009 to October 2010, 38 PVTs were evaluated by means of ultrasound (standard, Doppler and CEUS). 29 PVT were in patients with liver cirrhosis and 9 in subjects without liver cirrhosis. Results: 15 of 38 patients (39.5%) had benign PVT and 23 patients (60.5%) had malignant PVT. Results of CEUS examination were conclusive in 37/38 (97.2%) of the examinations for PVT, allowing the differentiation between benign and malignant thrombosis. When the result was inconclusive, another imaging method was performed (MRI). Conclusion: CEUS is a very good method for the evaluation of benign or malignant nature of portal vein thrombosis. [ABSTRACT FROM AUTHOR]

Aim: To establish the influence of different factors on the correlation between liver stiffness (LS) measurements by ARFI and liver fibrosis, evaluated by liver biopsy (LB). We assessed the following factors: the success rate (SR) and interquartile range (IQR) interval, the place where ARFI was performed, liver steatosis, the quality of the specimen obtained by LB. Methods: We studied 471 patients: 82 with LB, 82 healthy volunteers and 307 with cirrhosis. We performed 10 valid ARFI measurements, a median value was calculated, expressed in meters/second. Results: Valid measurements were not obtained in 11 patients. There was a direct, strong, correlation (r=0.694) between ARFI and fibrosis (p<0.0001). There were no statistically significant differences between the mean ARFI values obtained in segments V vs. VIII (p=0.89). Considering the IQR and SR, the correlation of ARFI with fibrosis was: for IQR<30% and SR ≥ 60%: r=0.722 and for IQR>30% and/or SR ≤ 60%: r=0.268 (p=0.0001). The quality of the liver specimen (2-3 cm long vs. >3 cm) did not influence the correlation of ARFI with fibrosis. Conclusions: To obtain the best correlation between ARFI and fibrosis, IQR must be <30% and SR ≥ 60%. These technical parameters must be introduced to improve the ARFI value for LS evaluation. [ABSTRACT FROM AUTHOR]

Aim: Contrast-Enhanced Ultrasound (CEUS) is an imaging method that can discriminate between hepatocellular carcinoma (HCC) and other liver lesions. The purpose of this study is to present our experience concerning the use of CEUS in the characterization of HCCs. Material and Method: We included in our study all the patients evaluated in our Department from September 2009 to October 2010, with focal liver lesions (FLLs) on abdominal ultrasound (US) that were diagnosed as HCCs after CEUS examination, also patients with chronic liver disease with focal liver lesions highly suspected to be HCCs but with an inconclusive pattern on CEUS. One hundred patients with 148 HCCs were included. The enhancement pattern of the nodules was evaluated according to the 2008 EFSUMB Guidelines. Nodules displaying arterial hyperenhancement with "washout" in the portal/venous phase on CEUS were considered diagnostic for HCC. Nodules considered indeterminate after CEUS were evaluated by contrast-enhanced CT or MRI for diagnosis. Results: Among the 100 patients included, 96 were patients with chronic liver disease and 4 were patients without known liver disease. 71 patients had a solitary nodule, 16 patients had two nodules and 13 patients had three or more nodules. 112 HCCs had a typical enhancement pattern and 36 nodules were considered indeterminate after CEUS and were sent to CT/ MRI for diagnosis. Conclusions: 75.7% of the studied liver nodules were diagnosed by CEUS as HCCs, thus CEUS is an easy method, convenient to perform, avoiding other expensive examinations. [ABSTRACT FROM AUTHOR]

Unlabelled: The AIM of this paper is to establish the values of liver stiffness (LS) assessed by means of ARFI in patients without known liver pathology and considered healthy subjects. Material and Method: the study group was composed of 82 subjects without known liver pathology, healthy volunteers or patients from other departments of our hospital who did not have altered liver laboratory tests. 76 patients had ARFI valid measurements (47 women and 29 men, mean age 34.5 +/-14.3 years). In each subject abdominal ultrasound was performed (patients with steatosis or any other signs of chronic liver pathology were excluded) as well as ARFI (using Siemens Acuson S2000). The median value of 10 measurements was calculated, expressed in m/s; we considered valid only the measurements with IQR<30%, SR>60%, similar to transient elastography. Mean ARFI values and mean values according to age and gender were evaluated. Results: valid ARFI measurements were obtained in 76/82 patients (92.6%). The mean value of ARFI measurements in normal individuals was 1.15+/-0.21 m/s. There were no significant differences between the mean ARFI values in men vs. women (1.16+/-0.21 vs. 1.14+/-0.22m/s, p=0.67), also among different age groups (p>0.05). Conclusion: In our study the mean LS value obtained by ARFI in healthy subjects was 1.15 m/s. [ABSTRACT FROM AUTHOR]

Aim: to present the practice of two experienced centres concerning the use of contrast enhanced ultrasound (CEUS) in the characterization of focal liver lesions (FLL). Material and Method: A prospective, bicentric study, between 09.2009-09.2010 was undertaken and 729 FLL (506-Center A, 223-Center B) were evaluated. A CEUS examination was considered conclusive, if the FLL had a typical enhancement pattern according to EFSUMB Guidelines. Results: From the 729 cases with FLL, 389 (53.4%) were patients without known and 340 (46.6%) with known chronic liver disease. CEUS was conclusive for the diagnosis in 597/729 cases (82%) and allowed the positive diagnosis of benign vs. malignant lesion in 662/729 (90.8%) FLL. For each center independently (Center A vs. Center B) the situation was as follows: conclusive for the diagnosis 390/506 (77.1%) vs 207/223 (92.8%) (p<0.0001), conclusive for the differentiation benign/malignant 449/506 (88.7%) vs. 213/223 (95.5%) (p=0.0032). Conclusion: In our bicentric study, CEUS was conclusive for diagnosis in 82% of FLL and the benign or malignant character of a lesion was demonstrated in 90.8% of cases. Thus, when faced with an uncharacteristic FLL on standard ultrasound, our local strategy in both centers was to perform CEUS as a first-line investigation thus avoiding other expensive examinations. [ABSTRACT FROM AUTHOR]

Liver metastases are the most frequent malignancies of the liver. The grayscale sonographic appearance of metastases varies: they can be hypoechoic, hyperechoic, they can present a peripheral halo, they can have an infiltrative or cystic appearance. On contrast enhanced ultrasound (CEUS), in the arterial phase, liver metastases can be hyperenhancing (hypervascular ones) or hypoenhancing (hypovascular ones). All liver metastases present wash-out in the portal and late phases, a typical enhancement pattern. CEUS sensitivity is superior to standard ultrasound for the diagnosis of liver metastases being similar to the one of contrast CT. [ABSTRACT FROM AUTHOR]

Aim: To establish the values of spleen stiffness (SS) assessed by Acoustic Radiation Force Impulse (ARFI) in healthy subjects and in cirrhotic patients, and to evaluate its predictive value for the presence of cirrhosis and for the presence and severity of esophageal varices (EV). Patients and Methods: Our study included 82 subjects (15 healthy volunteers, 57 cirrhotic patients, 10 with various grade of liver fibrosis), 38 women and 44 men. Of these, 42 cirrhotic patients had varices, 30 had significant EV and 11 had a history of variceal bleeding. We performed 10 measurements in each patient expressed in meters/second (m/s) and a median value was obtained. Results: The mean SS values (m/s) were: 2.04+/-0.28 in healthy subjects and 3.10+/-0.55 in cirrhotic patients (p<0.001). For a cut-off value of >2.51 m/s of SS, ARFI had 85.2% Se, 91.7% Sp, 95.8% PPV, 73.3% NPV, 87.1% accuracy (AUROC=0.91) for predincting liver cirrhosis. No significant differences regarding SS were observed between patients with and without EV, also between those with and without a history of variceal bleeding. Conclusion: SS evaluated by means of ARFI had a very good predictive value for the presence of cirrhosis (AUROC=0.91, accuracy=87.1%), but could not predict the presence or severity of EV, also the risk of variceal bleeding. [ABSTRACT FROM AUTHOR]

Aim: to assess the accuracy of transient elastography (TE) and Acoustic Radiation Force Impulse (ARFI) for liver fibrosis assessment, as compared to percutaneous liver biopsy (LB) in patients with chronic hepatitis. Patients and Methods: Our study included 71 patients (P) (54 with HCV and 17 with HBV chronic hepatitis) in which we compared TE and ARFI to the LB (evaluated according to the Metavir scoring system). Results: On LB, from the 71P, 6P (8.4%) had F1, 25P (35.2%) had F2, 24P (33.8%) had F3 and 16P (22.5%) had F4. A direct, strong, linear correlation (Spearman r=0.707) was found between TE measurements and fibrosis (p<0.0001) and a weaker one, between ARFI and fibrosis (rho=0.469; p<0.0001). TE measurements were also correlated with ARFI measurements r=0.532, p<0.0001. By comparing the AUROC curves, TE and ARFI had similar predictive values for the presence of significant fibrosis (F greater or equal to 2 Metavir): AUROC ARFI=0.649, AUROC TE=0.731 (p=0.476); and cirrhosis (F=4 Metavir): AUROC ARFI=0.868, AUROC TE= 0.936 (p=0.294) Conclusion: LS measurements assessed by means of TE correlate better than those assessed by means of ARFI to the histological fibrosis in patients with HBV and HCV chronic hepatitis. Both methods have excellent predictive values for the presence of cirrhosis. [ABSTRACT FROM AUTHOR]

Background and Aim: Contrast enhanced ultrasound (CEUS) has a well established place in the characterization of focal liver lesions (FLL). The aim of this paper was to evaluate the usefulness of CEUS in the assessment of liver hemangiomas., Material and Method: We included in a prospective study all the CEUS examinations performed during a 13 months period for the evaluation of de novo FLL, using a Siemens Acuson S2000™ Ultrasound System, following an intravenous bolus of 2.4 ml SonoVue® CEUS was considered conclusive for hemangioma if a typical pattern was present following contrast (centripetal fill in during the arterial phase, hyperenhanced lesion during venous and late phases)., Results: During September 2009 - October 2010, 413 CEUS examinations were performed in our department for the evaluation of de novo FLL. Out of the 413 cases, based on standard ultrasound, 43 were suspected hemangiomas, 125 were uncharacteristic lesions and 245 were suspected for other types of lesions (metastases, focal nodular hyperplasias, hepatocellular carcinomas etc). Out of the 413 de novo FLL, 64 cases (15.5%) were diagnosed as hemangiomas by CEUS (typical CEUS pattern). MRI diagnosed 7 additional hemangiomas in inconclusive CEUS cases, so 90.1% (64/71) of the hemangiomas were diagnosed by CEUS alone. Out of the 125 uncharacteristic lesions on standard ultrasound, 29 cases were diagnosed after CEUS as hemangiomas. Thus, CEUS diagnosed additional 40.8% (29/71) hemangiomas as compared to standard ultrasound, without the need of more expensive imaging methods., Conclusion: CEUS is a reliable method for the diagnosis of hemangiomas, also allowing a precise characterization of FLL. This method diagnosed additional 40% hemangiomas in comparison with standard ultrasound (for atypical ultrasound hemangiomas) and finally, CEUS diagnosed correctly 90% of this type of lesions, all with typical enhancement pattern according to the EFSUMB guidelines.

Unlabelled: Contrast enhanced ultrasound (CEUS) has a well established role for the evaluation of focal liver lesions (FLL). The AIM of our paper was to evaluate if CEUS is a cost-efficient method for the first line evaluation of FLL., Material and Method: We performed a prospective study that included all the CEUS evaluations performed in our Department during a 6 months period (September 2009-March 2010). CEUS evaluation was performed with a Siemens Acuson S2000TM Ultrasound System following an intravenous bolus injection of 2.4 ml SonoVue(R) (Bracco). A CEUS examination was considered conclusive if, following contrast, the FLL had a typical enhancement pattern(after EFSUMB Guidelines 2008), allowing its classification as hemangioma, FNH, adenoma, hepatocellular carcinoma, metastasis, fatty-free area, focal fatty infiltration. We compared the costs of a CEUS positive diagnosis, to the cost of contrast CT and/or contrast MRI positive diagnosis. We also included the additional costs of CT and/or MRI, if CEUS was not conclusive. The cost of CEUS was calculated as the cost of 1/2 vial of SonoVue + the cost of abdominal ultrasound (150 + 30 = 180 RON). The costs of contrast CT scan and MRI were 285 and 650 RON respectively (mean costs practiced in Timisoara)., Results: In our study were included 316 FLL: 163 (51.6 %) in patients without hepatitis and 153 (48.4 %) in patients with chronic hepatopathies (in 133 cases liver cirrhosis and in 20 cases chronic hepatitis). CEUS was conclusive in 250 (79.1%) of the 316 cases, the cost for the evaluation of these patients being 45,000 RON. For the other 66 patients, the diagnosis cost will include the cost of CEUS + the cost of contrast CT: 30,690 RON. If contrast MRI was used for the differential diagnosis, the cost would be 54,780 RON. So the total cost of diagnosing 316 FLL would be 75,690 RON or 99,780 RON. If contrast CT would be used as the first line diagnosis for the 316 FLL, the cost would be 90,060 RON, by CEUS saving 14,370 RON, or 45.5 RON/lesion (using contrast CT for the differential diagnosis). If contrast MRI would be used as the first line diagnosis, the cost would be 205,400 RON, by CEUS saving 105,620 RON, or 334.2 RON/lesion (using contrast MRI for the differential diagnosis)., Conclusion: CEUS is a cost-efficient method as a first line diagnosis of FLL as compared to first line contrast-CT or first-line MRI.

Liver cirrhosis is a major risk factor for the development of hepatocellular carcinoma, hence the need to screen those patients by means of liver ultrasound every 6 months. The differential diagnosis between a regenerative nodule, a dysplastic one and hepatocellular carcinoma is made based on a contrast imaging method (CEUS, MRI or CT) as they all have comparative sensitivities.

The pancreas is a challenge for the beginner in ultrasonography, but patience, perseverance and experience will lead to a complete and correct evaluation of the organ in almost all cases. A correct examination of the pancreas requires the patient's fasting 7 to 8 hours before the examination. Transverse and longitudinal upper epigastric sections are used to visualize the pancreas, as well as oblique intercostal and subcostal sections (especially for the head and tail). The best ultrasound windows are obtained by using high epigastric sections (that avoid the colon), also by using transgastric sections and sections that use the left liver lobe as an acoustic window. In order to better visualize the pancreas, it is useful to invite the patient to drink 500-700 ml of still water 10-15 minutes before the examination. To highlight the pancreas, we will start by viewing the landmarks: posterior--the porto-splenic axis and anterior--the gastric antrum and/or the left liver lobe. The echogeneity of the normal pancreas can vary, from hypoechoic to hyperechoic, all normal, provided that the pancreatic parenchyma structure is fine and homogeneous. The Wirsung duct can be visualized in some of the cases, especially in thin patients, its normal maximum diameter should be < 2 mm. For a correct evaluation of the pancreas all its segments must be visualized: head, uncinate process, body, and tail - the latter being the most difficult to visualize.