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Due to the relatively high complication rate, the necessity of a spleen biopsy is controversially discussed. In establishing its indication, the clinical background and performed diagnostics must be considered. Based on the medical history, imaging procedures and sonographic course, different clinical scenarios are conceivable. The aim of this review is to describe the indications of splenic biopsy considering various clinical scenarios.Aufgrund der relativ hohen Komplikationsrate wird die Notwendigkeit einer Milzbiopsie kontrovers diskutiert. Bei der Indikationsstellung sind der klinische Hintergrund und die bereits erfolgte Diagnostik zu berücksichtigen. Anhand der Anamnese, der bildgebenden Verfahren und des sonografischen Verlaufs sind unterschiedliche klinische Szenarien vorstellbar. Das Ziel der Arbeit ist es, die Indikation einer Milzbiopsie unter Beachtung unterschiedlicher klinischer Szenarien zu beschreiben.

The American College of Radiology (ACR) endorsed the Liver Imaging Reporting and Data System (LI-RADS) for standardized reporting and data collection of computed tomography (CT) and magnetic resonance (MR) imaging for hepatocellular carcinoma (HCC) in high-risk patients (liver cirrhosis). The LI-RADS imaging criteria are used to classify 'observations' from 'definitely benign' (LR-1) to 'definitely HCC' (LR-5) based on imaging criteria.Coincidently, the recent approval in the United States of a microbubble contrast agent for liver imaging (LumasonIn der Abklärung von hepatozellulären Karzinomen (HCCs) bei Hochrisikopatienten wurde zur standardisierten Befundung und Dokumentation der Kontrastmittel-Computertomografie (CECT) und Kontrastmittel-Magnetresonanztomografie (CEMRT) vor wenigen Jahren das „Liver Imaging Reporting and Data System” (LI-RADS) durch das American College of Radiology (ACR) erstellt. Die LI-RADS-Kategorisierung wird zur Klassifikation von Leberläsionen in der Leberzirrhose als sicher benigne (LR-1), intermediär (LR2 – 4) bis zu „definitiv HCC“ (LR-5) beurteilt. Seit 2014 wurde die LI-RADS-Klassifikation durch eine Arbeitsgruppe von internationalen Radiologen und Hepatologen auf die Kontrastmittelsonografie erweitert. Zeitgleich mit der Zulassung des Kontrastmittels SonoVue™ (in den USA Lumason™) wurde die Klassifikation 2016 in die LI-RADS Kategorisierung integriert und wird in diesem Artikel erläutert (CEUS-LI-RADS).

Complementary to part 1, this review summarizes indications, opportunities and applications of ultrasounds in palliative care medicine. In particular, the following topics are discussed: · Ultrasound as a non-invasive, low-threshold, bedside technique, which uniquely combines diagnostic efficacy and empathy.. · Sonographic surveillance of patients with malignant disease.. · Point-of-care application of ultrasound in palliative care services.. · Ultrasound-guided palliative interventions (drainage of effusions and other therapeutic procedures)..In Ergänzung zum ersten Teil dieser Übersicht, der auf sonografisch gestützte Interventionen in der Palliativmedizin fokussierte, erläutert die vorliegende Arbeit Indikationen und Möglichkeiten der Sonografie in der Palliativmedizin unter vier wesentlichen Aspekten: · Sonografie als non-invasives, niedrigschwelliges und bettseitiges Diagnoseverfahren, das in besonderer Weise diagnostische Effizienz und persönliche Zuwendung verbindet.. · Sonografische Nachsorge von Tumorpatienten.. · Gezielter bettseitiger Einsatz der Sonografie in der ambulanten palliativen Versorgung (point-of-care).. · Sonografisch gezielte Durchführung palliativer Entlastungspunktionen und spezieller therapeutischer Interventionen..

This review summarizes ultrasound guided interventions in palliative care medicine.

Reference values for B-mode abdominal ultrasound are controversially discussed due to the limited data in the literature. A systematic survey of data published so far is presented for the big retroperitoneal vessels and the kidneys.A literature review of reference values in the abdomen from 1970 to 2011 in healthy subjects 18 years of age and older was undertaken. According to the determination of reference intervals for laboratory values, reference values are generally determined using 95 % reference intervals and their associated 90 % confidence intervals. The diameters of the abdominal aorta and the inferior vena cava were evaluated as well as the length, width, thickness, parenchymal thickness and volume of the kidneys.61 studies were analysed. Reference values determined for the aorta vary considerably according to age and gender of the probands, measuring position and measuring technique. The upper interval limits of the 95 % reference intervals lie between 17 and 40 mm. The diameter of the inferior vena cava depends on the position of the patient, the measuring site, respiration and the resting heart rate. Normal results up to 27 mm can be encountered. Influencing factors on the size and volume of the kidneys are the side (right/left), age, gender, anthropometric parameters and the ethnic membership of the probands. For central European women, 9 cm - 12.8 cm can be regarded as the normal range of the length of the kidney and for men 9.2 cm - 13.3 cm. For the width of the kidney, interval limits were determined between 3 cm and 7.1 cm, for the thickness between 2.9 cm and 6 cm, for the parenchymal thickness between 1.1 cm and 2.3 cm and for the volume between 59 and 230 mL.Normal values are helpful in delimiting numerous pathological changes in the respective organs.

Reference values for B-mode abdominal ultrasound are controversially discussed due to the limited data in the literature. A systematic survey of the data published so far is presented for the biliopancreatic system and the spleen.A literature review of reference values in the abdomen from 1970 to 2010 in healthy subjects 18 years of age and older was carried out. According to the determination of reference intervals for laboratory values, reference values are generally determined using 95 %-reference intervals and their associated 90 %-confidence intervals. The gallbladder, gallbladder wall, bile ducts, pancreas and the spleen were evaluated.70 studies were analysed. The comparability of the data is limited, because different collectives were studied and diverse measuring techniques were used. In particular, gallbladder volume measurements reported in the literature differ substantially. Data for the size of the gallbladder are insufficient. Deducible reference values for the common hepatic duct or, respectively, the common bile duct lie between 5 and 9 mm in dependency on the measuring position and the collective analysed. The published measurement values for the size of the pancreas also vary considerably. In most of the publications the upper limit of normal for the length of the spleen amounts to around 12 cm, in young, athletic men up to 15 cm.Normal values are helpful in delimiting numerous pathological changes in the respective organs.

For many years ultrasound-guided biopsy and drainage has represented a routine part of clinical practice. Percutaneous biopsy and drainage are minimally invasive procedures for sampling tissue or the removal of fluid collections within the body. Differing image guidance techniques for the positioning of the needles/catheters are in use. This is due to the advancement of effectiveness and safety of modern guidance methods. For the management of abscesses, percutaneous drainage is more effective (depending on the size) than percutaneous needle aspiration and is being increasingly used as the first-line treatment. This shift in practice is driven by the preference for low-risk, minimally invasive procedures and thus using surgical interventions only when percutaneous drainage has been unsuccessful. However, the variety of biopsy needles and drainage systems available to the clinician can appear overwhelming. We present a literature review regarding the devices and materials currently available to achieve the most reliable results with the lowest level of complications. With regard to drainage systems, particular considerations include the consistency of fluid, path of access and guidance technique. Although we present comparisons between published studies, it is important to consider that the personal experience of the interventionalist will also have an impact on the device chosen.

Reference values for B-mode abdominal ultrasound are being controversially discussed due to the limited data in the literature. A systematic survey of data published so far is presented for liver and hepatic vessels.A literature search for reference values in the abdomen from 1970 to 2010 in healthy subjects 18 years of age and older was carried out. In accord with the determination of reference intervals for laboratory values, reference values are generally determined with the aid of 95 % reference intervals and the associated 90 % confidence intervals. Evaluated parameters were the size and volume of the liver, the portal vein diameter and cross-section and the diameters of the hepatic veins.Liver size is usually determined by its longitudinal diameter in the midclavicular line. Although not sufficiently evaluated,16 cm can be used as a reference value. Numerous methods, which are not comparable, have been described for the determination of liver volume. For the portal vein diameter, refererence intervals could be deduced from 6 studies. Data from 4 studies on the liver veins differ depending on the exact localisation of measurement.Normal values are helpful in delineating numerous pathological changes in the respective organs. Unfortunately, data are scarce and the examination technique, so far, has not been standardised sufficiently to compare data. A multicentre trial is required to standardise examination techniques and improve the quality of the results.

Ultrasound-guided punctures have been part of clinical routine for many years. Meanwhile the variety of biopsy needles has become huge, so that we can offer a special gadget for each indication and each organ. The results of investigations of the materials may help one to gain a general idea of the available possibilities and help to in the choice of the right one. In the special chapters about organs and tumour types one can find out which biopsy needles can achieve best results and guarantee the lowest possible level of complications. The path of access and possible injuries to important structures play an important role when choosing the size of the biopsy needle and the technique of puncture. Besides the results of comparative studies, the personal experience of the interventionalist is an important factor for choosing the right material because the individual's manual skills have an important impact on the results.

Ultrasonography has become increasingly important in the routine diagnostics of gastrointestinal diseases. It is first of all a morphological diagnostic method. As it not only assesses the wall structure of the gallbladder, the pancreatic duct and the whole gastrointestinal tract but also visualises motion sequences as a real-time-method, functional processes and their disruptions can especially be examined. The present authors give a review of the capacity of functional ultrasound in different anatomic zones and critically discuss its practical relevance.

Perianal and perineal ultrasound is an effective but rarely applied diagnostic modality. Transmural inflammation, fistula and abscesses in patients with inflammatory bowel disease can be delineated and perirectal tumours can be staged. The method is complementary to endorectal ultrasound. Also oblique transsphincteric fistula can be displayed in detail.

The most common pancreatic tumour is the ductal adenocarcinoma. Many other benign and malignant pancreatic neoplasms have to be recognised and now account for more than 50 % of the pancreatic lesions seen in our daily routine. An improved differential diagnosis is, therefore, mandatory and will be discussed in this review.

Ultrasound has gained acceptance in the diagnosis of diseases of the gastrointestinal tract beside the classical methods such as endoscopy and X-ray. In a previous publication we discussed the use of ultrasound in emergency diagnostics (e. g., acute appendicitis, diverticulitis/peridiverticulitis, ileus, invagination and perforation) (part 1). Because of the vast extent of this topic, in this overview we will focus on the current role of ultrasound in the detection and assessment of chronic inflammatory bowel diseases, rare forms of colitis (e. g., bacterial, pseudomembranous and neutropenic colitis as well as intestinal tuberculosis), ischaemic bowel diseases as well as diseases of the upper gastrointestinal tract. In chronic inflammatory bowel diseases, ultrasound can give important additional information such as extension, activity, complication (fistula, abscess, stenosis) and in differential diagnosis. It plays an important role in follow-up investigations and can possibly reduce the number of endoscopic examinations. There is still some debate going on about the significance of colour Doppler ultrasound in assessing the activity and differentiation of stenosis. Furthermore, ultrasound is used as a method to guide interventional therapies for abscesses (puncture and drainage). Colour Doppler ultrasound can diagnose ischaemic bowel diseases and also differentiate these from other aetiologies. Ultrasound plays a greater role in the follow-up and assessment of chronic intestinal ischaemia. In the diagnosis of stomach diseases under favourable conditions ultrasound can show changes of the stomach wall, tumours, ulcers and their complication (perforation, penetration) and disturbances of the motility. But an exclusion is not possible.

Ultrasonography has become widely accepted as a diagnostic tool for gastrointestinal diseases. It not only assesses the lumen but more importantly also the wall and the surrounding structures of the stomach and bowel. Furthermore, functional processes (peristalsis, blood flow) can be visualised and provide important information for passage and perfusion. Modern high resolution (compressive) sonography represents an ideal complementary method besides endoscopy for the gastroenterologist. It is used in emergency diagnosis in cases of acute appendicitis and peridiverticulitis. Here sonography is the method of first choice achieving a high sensitivity. The same applies to ileus, which can be diagnosed significantly earlier by sonography than with conventional X-ray methods. Meanwhile sonography can contribute considerable information to clarify pathogenesis (e. g., invagination, intususception). The detection of a perforation depends strongly on the competence of the examiner. The main advantage is the detection of a covered perforation and the genesis (e. g., ulcer). Ultrasound is less commonly considered in celiac sprue but important complementary information can be obtained. Advanced tumours of the gastrointestinal tract can easily be visualised, although early stages can hardly be detected by means of sonography. An accurate T-staging of tumours is not possible with transabdominal sonography, not least because some parts of the bowel (colon and rectum) cannot always and completely be seen. Exclusion of tumour or early detection is not possible by ultrasound. In intestinal diseases additional information besides clinical and endoscopic aspects can be achieved by ultrasound. Sonography is important for differential diagnosis and follow-up and spares the patient from more incriminatory endoscopic operations. Ultrasound is equal to other imaging methods in detecting complications (fistulas, abscess, stenosis). Due to the complexity of the topic the following review will concentrate on giving an idea of the present status of sonography in chronic inflammatory bowel disease, some less frequent intestinal infections (bacterial, pseudomembranous, neutropenic colitis, intestinal tuberculosis), the ischaemic bowel diseases as well as diseases of the upper gastrointestinal tract.

The diagnostic process, differential diagnosis and continuing routine follow-up of patients with focal liver lesions require an easily available, reliable and cost-effective diagnostic method. Ultrasound is a widely used method for the detection of liver lesions, but it has generally been regarded as inferior to contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI). Recent advances in contrast-enhanced ultrasound (CEUS) have improved the detection rate to a level similar to that attained with CT and MRI. Because of the high spatial resolution of ultrasound, CEUS can also detect metastases smaller than 1 cm. This has been demonstrated in several single-centre studies and recently also a European multi-centre study. This review focuses on the recent advances of CEUS in detecting and characterizing focal liver lesions.

Abdominal pain is a challenging complaint for both primary care and specialist physicians because it is frequently a benign complaint, but it can also be caused by serious pathology (acute abdomen) implying surgery. Physicians are responsible to determine which patients can be safely observed or treated symptomatically and which require further investigations or operation. The overall sensitivity and specificity of the history and physical examination in diagnosing the different causes of abdominal pain is poor, which is especially true for benign conditions. In contrast, the value of ultrasound in patients with acute abdomen is of utmost importance. This paper reviews a sonographic orientated approach to frequently encountered causes of the acute abdomen.

Conventional B-mode and colour duplex imaging is the first choice imaging technique after history taking and physical examination and for the interpretation of laboratory parameters. In the hands of a gastroenterologist ultrasound has become an equally important diagnostic tool as endoscopy. The constantly evolving technique with its possibility of higher resolution by use of "harmonic imaging" and signal enhancement with contrast medium is the reason for a practically relevant review of the situation. Practical references will be given for diagnostics of the liver and portal system including the spleen. The significance of the sonographic diagnosis of "fatty liver" is critically discussed. The overall importance of ultrasound to distinguish different aetiologies of diffuse liver diseases is relatively low. Nevertheless, it is a very sensitive means to detect complications of liver cirrhosis. Portosystemic shunts and typical changes in blood vessel morphology can be diagnosed by colour duplex sonography and used as indirect signs of advanced damage to liver parenchyma. In addition, ultrasound has its value in the confirmation or exclusion of dilated bile ducts as well as in the detection and differentiation of circumscribed liver lesions. The characterisation of focal liver lesions by ultrasound is sufficient in typical cases. The use of ultrasound contrast media (signal enhancers) raises the rate of differentiation and can avoid the uncritical and sequential application of radiological imaging (computed tomography [CT] or magnetic resonance imaging [MRI]). If in doubt about the nature of a lesion, a histological diagnosis remains indispensable. The examination of the spleen and its feeding vessels is regularly done in cases of diffuse parenchymal liver disease when searching for its complications, e. g., portal hypertension. Focal spleen lesions can be observed especially in the context of lymphoma (infiltration) and other bone marrow diseases. Through the application of contrast media, changes of vascularisation (e. g., infarcts) can be visualised and traumatic lesions can be diagnosed more precisely.

GALLBLADDER: Ultrasound has become widely accepted for the diagnosis of gallbladder disease. Sensitivity for cholecystolithiasis is approximately 100%. Cholezystitis including its acute and chronic complications is also a domain of ultrasound techniques. An obstruction of the bile ducts and its localization are easily recognized. Clarifying the etiology is yet another question far more difficult to answer. Ultrasound contrast agents have proven to be useful for clarification of biliary tumors. Gallbladder polyps are well detectable. Adenomas of1 cm are an indication for surgery, the detection of a vessel at the polyps' base by color duplex ultrasound is helpful. Gallbladder carcinomas as a disease of the older age with few early symptoms are usually detected at a late stage when the liver is already infiltrated. BILE DUCT SYSTEM: Even with the most modern equipment the sensitivity for choledocholithiasis is still largely dependent on the examiner's expertise und differs between 25% and 100%. Endosonography is more efficient (94-100%). Primary sclerosing cholangitis shows bile duct dilation like "a string of pearls" and typical perihepatic lymph node enlargement. Differentiation from early cholangiocarcinoma is difficult. PANCREAS: In diagnostic imaging of the pancreas ultrasound stands at the beginning of a diagnostic cascade. In contrast to other competing examinations it can be repeated at any time and without X-ray exposure. The informative value, though, is largely dependent on the examiner's expertise. Usually, a CT scan is additionally performed when ultrasound examination is incomplete or limited through examination condition or if doubts on diagnostic accuracy arise. In cases of acute pancreatitis, especially the assessment and follow-up of complications (exudation, necrosis, pseudocysts, vascular complications, and obstructive effects) are precious. Ductal adenocarcinoma seems to be less vascularized in comparison to the surrounding tissue, while endocrine tumors and macro- and microcystic adenoma are rather hypervascularized.

We report on a 49-year-old male patient who was suspected to have a malignant liver tumour with enlarged perihepatic lymph nodes because of CT and ultrasound scanning. To verify the diagnosis and procure a histological specimen, the patient underwent laparotomy. Histologically, an inflammatory pseudotumour could be confirmed. This is a rare disease which can present with fever, abdominal pain, vomiting and weight loss indicating malignancy or abscess. The definite diagnosis is often only verified by surgery.

Contrast-enhanced ultrasound techniques represent the most challenging efforts in recent ultrasound developments. Contrast-enhanced imaging of the liver will be reviewed with respect to the literature and our own experience. Echo-enhancing agents, also known as ultrasound contrast media, have improved the accuracy of liver ultrasound within recent years. The characterisation of focal liver lesions which is possible by flow characteristics and the improved detection of liver tumors give special importance to the contrast agents. The agents consist of air or gas bubbles coated with different shell media. These micro-bubbles act as strong reflectors to the ultrasound beam enhancing the backscatter signal up to 30 dB. There are differences between blood pool agents and agents with a liver-specific late phase. The agents remain in the vessels during the vascular phase and lead to enhancement of different structures (arterial, capillary, portal venous, and sinusoidal perfusion). This is the first real-time imaging technique of liver lesions that allows a unique analysis of tumor perfusion. Liver tumors known to be hyperperfused in the arterial phase (e. g., focal nodular hyperplasia, hepatocellular carcinoma, and hyperperfused metastases) can be detected and characterised. Hypoperfused tumours (e. g., liver metastases of the gastrointestinal tract) can be recognised in the portal venous phase as less perfused "black spots". Due to of the recently available improved ultrasound technology and affordable ultrasound systems, a reduction in the use of computed tomography (CT) and magnetic resonance imaging (MRI) may be possible, allowing these important technologies to be available for other indications (e. g., brain, thorax).

Hepatic blood flow has been investigated using color Doppler ultrasonography in patients with liver disease, especially in patients with portal hypertension (e. g. liver cirrhosis, portal vein thrombosis, Budd-Chiari-syndrome). Duplex examination protocols, however, differ considerably because no standard technique has been established so far. Whereas there is an agreement about the angle of the ultrasound application (60 degrees ), neither the exact location nor the relevant examination parameters have been standardized. Based on a search of the relevant literature, published examination techniques and results were analyzed. These findings are to serve as a basis for a prospective multicenter study for the determination of standard values.

Mesenterial bloodflow has been investigated routinely using colour Doppler ultrasound especially in patients with bowel disease. Examination protocols, however, differ considerably, because no standard technique has been established so far. Whereas there is agreement about the angle of ultrasonic application (60 degrees ), neither the exact location nor the relevant examination parameters have been standardized. Based on a search of the relevant literature, examination techniques and results were analysed. These findings are to serve as a basis for a prospective multi-center study for the determination of standard values.