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Ultrasound should be the first-line imaging method in the medical care of patients with inflammatory bowel disease. It can be used to differentiate between Crohn's disease and ulcerative colitis and to detect numerous complications like stenoses, fistulas, and abscesses. As the method is also highly suitable for follow-up, stressful endoscopic procedures and examinations involving radiation are less necessary. Comparison studies with MRI and CT show that ultrasound is not an inferior method and it is therefore included in all guidelines. Intensifying physician training in this method will help to ensure its comprehensive use., Competing Interests: G. Kunze received honoraria from Bracco Imaging Germany and Canon Medical Systems Germany.K. Seitz, M. Mauch and F. Petersen declare no conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

The impact factor (IF) for 2015 was recently released and this could be the time to once again reflect on its use as a metric of a journal. Problems and concerns regarding the IF have been addressed extensively elsewhere 1 2. The principle of the IF for a given year is that it represents the average number of citations of articles published in the journal in the two previous years.While authors frequently cite the IF as a determining factor for submission, the IF does not predict how many times individual articles will be cited. In a study from a peer-reviewed cardiovascular journal, nearly half of all published articles were poorly cited, i. e., less than five citations in five years 3. A similar percentage seems to apply to our journal. In nearly all journals we estimate that the majority of citations relate to a minority of the articles. Some articles are never cited. 13 % of the articles published in our journal from 2010 to 2013 have never been cited. Even authors of poorly cited articles benefit from the IF since many institutions use the combined impact factors of their published papers to measure research activity and this may be reflected in their research budgets.The competition for the printed pages in the six annual issues of Ultraschall in der Medizin/European Journal of Ultrasound (UiM/EJU) has resulted in high rejection rates (between 80 % and 90 %). One negative review with recommendation of major revision may therefore result in rejection. Peer-review fraud where the submitting author listed recommended reviewers with fake email addresses supplying fabricated peer reviews has recently been described in the New England Journal of Medicine 4. Some of the editors of our journal believe they have experienced this as well. Fabricating reviews in order to get a high IF for an article is to be considered fraud and is inexcusable.One aspect of using impact factors as a measure of the quality of a journal is that the IF only goes back two years. There may be differences between journals for different medical specialties since the citations in some areas seem to "burn out" within a few years while some articles continue to be cited even after several years. Therefore, a citation window that is longer than 2 years has been proposed 5.For this editorial we took a look at the 60 articles published in UiM/EJU in 2010. Half of them were no longer being cited in 2015. However, 10 articles were cited more than 5 times in 2015, and 5 of these were cited more than 10 times 6 7 8 9 10. It therefore seems that many of our articles have a long scientific life and generate more citations than indicated by the IF. Moreover, some articles have the highest number of citations after three years when they are no longer contributing to the impact factor. The most frequently cited articles from 2010 were multicenter studies, recommendations, and papers on hot topics like contrast-enhanced ultrasound (CEUS) and elastography, but it should be noted that there were also articles on the same topics that were poorly cited.The same trending topics continued into 2013 now topped by European guidelines and recommendations 11 12 13. 9 of the 10 most cited articles we published in 2014 were on CEUS or elastography 14 15 16 17 18 19 20 21 22, but the most cited article from that year so far has been on peripheral nerves 23. Surprisingly many good scientific papers on obstetrics/fetal US and musculoskeletal US have low citation rates 24 25 26. Our predictions for 2016 based on the topics of submitted articles in the last 12 months are that CEUS and elastography will continue to be popular topics.It is also worth mentioning that there can be a discrepancy between which titles are cited and which are accessed online. In addition to international guidelines, our CME articles are usually popular according to online access. CME articles are well established educational papers but they are rarely cited for the IF. Looking at the most read full-text recent articles on our journal's website shows that multicenter studies as well as recommendations backed by a national society or by the EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) are still important 27 28 29 30 31 32 33. Upcoming important topics appear to be pediatric use of CEUS, simulation training and the introduction of ultrasound to medical students 34 35 36 37. Some of these are also backed by EFSUMB.A recent paper on the IF of radiology journals found that subspecialty radiology journals had a higher IF than general radiology journals 38. This could prove a challenge to interdisciplinary journals like ours but we take pride in continuing to cover all aspects of ultrasound in more than 15 fields.The distribution between reviews, original articles and case reports in a journal is worth addressing. An important aspect of a journal is the publication of original scientific research articles. CME articles, pictorials and letters are important for other reasons but are cited at a lower rate. The value of case reports with regard to the IF is low since they are rarely cited 39 and we have observed that some journals have abandoned the publication of case reports, thus leaving them to spin-off journals. The rationale is that keeping case reports in a journal will only increase the denominator, thereby decreasing the IF 39. At our journal we have seen a decline in case report submissions but still want to publish them and even put one case on the front cover of every issue. Case reports still hold an educational value 40 and are important to our readers.In conclusion, a healthy mix of original articles, CME articles, reviews and case reports combined with a few international guidelines and recommendations is important to UIM/EJU. Although we see popular topics like CEUS and elastography, it is not possible to predict which articles will be read or even cited based on the topic, with multicenter studies being the exception., (© Georg Thieme Verlag KG Stuttgart · New York.)

The approval of microbubbles with the inert gas sulfur hexafluoride (SF6) and a palmitic acid shell (SonoVue(®), Bracco Geneva, CH) for the diagnostic imaging of liver tumors in adults and children by the FDA in the United States represents a milestone for contrast-enhanced ultrasound (CEUS).This warrants a look back at the history of the development of CEUS. The first publications based on echocardiographic observations of right ventricular contrast phenomena caused by tiny air bubbles following i. v. injection of indocyanine green appeared around 1970 1 2 3. A longer period of sporadic publications but no real progress then followed since, in contrast to X-ray methods, ultrasound works quite well without a contrast agent.It is noteworthy that the foundations for further development were primarily laid in Europe. The development and approval (1991) of the contrast agent Echovist(®) by a German contrast manufacturer for echocardiography unsuitable for passing through lungcapillaries 4 5 resulted in the first extracardiac indications, e. g. for detecting retrovesical reflux and tubal patency, in the mid-1980 s 6 7 8. The sensitivity of color Doppler was not able to compensate for the lack of an ultrasound contrast agent compared to CT with its obligatory contrast administration.Studies of SHU 508 - microbubbles of air moderately stabilized with galactose and palmitic acid - began in 1990 9 10 11 12 13 14 15 and the contrast agent was then introduced in 1995 in Germany as Levovist(®). The most important publications by Blomley, Cosgrove, Leen, and Albrecht are named here on a representative basis 16 17 18 19 20.SHU 508 along with other US contrast agents provided impressive proof of the superiority of CEUS for the diagnosis of liver metastases. However, practical application remained complicated and required skill and technical know-how because of a lack of suitable software on US units 21 22 23 24 25. The monograph regarding the use of contrast agent in the liver by Wermke and Gaßmann is impressive but unfortunately only available in German 26. In addition to being applied in the heart and the liver, CEUS was first used in transcranial applications 27 and in vessels 28, the kidneys 29, and the breast 30. Measurements at transit times were also of particular interest 31. It was difficult to convince ultrasound device manufacturers of the need to adapt US units to US contrast agents and not vice versa.The breakthrough came with low MI phase contrast inversion and the introduction of SonoVue(®) in many European countries in 2001. This more stable US contrast agent is easy to use and is becoming indispensable in diagnostic imaging of the liver 32 33 34 35 36 37 38 39 40. Studies have shown its excellent tolerability 41 and diagnostic reliability comparable to that of MDCT and MRI in the liver 42 43. Today it would be unimaginable to diagnose liver tumors without CEUS 44. This also applies to very small lesions 45 46.EFSUMB published the first CEUS guidelines in 2004 47 which have since been reissued and divided into hepatic 48 and extrahepatic applications 49. The first recommendations regarding quantitative assessment have also been published 50.The increasing scientific interest in CEUS is evident based on the greater number of PubMed hits for Echovist(®) (ca. 130), Levovist(®) (ca. 500) and SonoVue(®) (ca. 1500) as well as on the fact that publications regarding CEUS comprise almost 20 % of UiM/EJU articles in the last 10 years. The number of CEUS articles in UiM/EJU continues to be high 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75.In the clinical reality, CEUS has been able to become established alongside CT and MRI according to the saying "better is the enemy of good" 76 as the method of choice after B-mode ultrasound in the evaluation of liver tumor malignancy in Germany, where the technically challenging method is promoted. In the case of unclear CT and MRI findings, CEUS performed by an experienced examiner/clinician often provides the solution, particularly in the case of small lesions, and is the last resort before US-guided biopsy 45 46. However, there is a lack of competent CEUS examiners and Germany continues to be the world champion of X-ray examinations with no noticeable reverse trend. In almost every doctor's office and hospital, ultrasound costs are by far not fully covered, resulting in an extremely high frequency of CT use with CT being available to everyone regardless of insurance status.The USA is now in the starting position for CEUS. It will be exciting to see how the method will develop there. The FDA's decision to approve sulfur hexafluoride (Lumason(®) = SonoVue(®)) should be considered against the background of the radiation exposure caused by CT examinations and the fact that MRI using gadolinium-containing contrast agents is no longer considered noninvasive because of nephrogenic systemic fibrosis (NSF) and the accumulation of the agent in the cerebrum. An essential point of the campaign regarding the avoidance of diagnostic radiation exposure triggered in the USA by the publications of Brenner et al. 77 78 was that the agent was approved for use in the liver even for children 79 80 - still off label in Europe - without additional comprehensive studies due to the available scientific results and the very low side effects profile of Lumason(®) (= SonoVue(®)). It is admittedly unclear why other indications (except the heart which has been approved since 2014) are excluded even though the microbubbles as a pure blood pool contrast agent can be diagnostically used in the entire vascular system and bed of all organs. To our knowledge, there is no such restriction on the approval of X-ray contrast agents.Like echocardiography and emergency ultrasound, CEUS began in Europe but will probably only establish its final diagnostic value as a "reimport".This is a major opportunity to permanently define the role of Ultrasound as a highly valuable, patient-centered imaging method in the German health care system.This may prompt some of our international readers to reflect upon the role of CEUS in their own countries., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Autoimmune pancreatitis (AIP) is an independent, underdiagnosed, rare form of chronic pancreatitis. The goal of this study is to document ultrasound findings in histologically confirmed AIP in order to determine the diagnostic value of ultrasound., Materials and Methods: 6 of 74 DEGUM instructors for internal medicine (level 3 and 2) provided anonymized clinical and sonographic data from 17 patients with histologically confirmed AIP., Results: 9/17 patients had diffuse AIP, 8/17 had focal AIP, 14/17 suffered from upper abdominal pain, 9/17 had jaundice, and 3/9 had an elevated IgG4 level. Ultrasound showed diffuse hypoechoic organ enlargement in 9/17 cases and a hypoechoic tumor with an unclear border in 8/17 cases. AIP was verified by ultrasound-guided percutaneous core biopsy in 14 cases, by biopsy of the bile duct in 1 case, and by surgical biopsy in 2 cases. Involvement of the hepatobiliary system was present in 7/17 patients and autoimmune cholangitis was verified in 5 cases. All patients experienced remission after immunosuppressive treatment. The pancreatic duct had a normal width in 11 cases, was dilated in 5 cases, and was stenosed over a long stretch in 3 cases. Contrast-enhanced ultrasound did not show uniform signal increase but also no significantly reduced or absent perfusion., Conclusion: Ultrasound can be diagnostically useful if the clinical manifestations of AIP are known. While the diffuse form allows an ad-hoc suspected diagnosis, the focal form can only be suspected in the case of additional extrapancreatic involvement. Contrast-enhanced ultrasound (CEUS) contributes greatly to the differentiation from ductal adenocarcinoma in the case of focal AIP., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: The aim of the study was the comparison of tumor vascularization and contrast enhancement in contrast-enhanced ultrasound (CEUS) for the characterization of hepatocellular carcinoma (HCC) and intrahepatic cholangiocellular carcinoma (ICC). We present data of the subpopulations HCC and ICC examined in the DEGUM multicenter trial for the characterization of focal liver lesions in clinical practice., Materials and Methods: Based on the data of the DEGUM multicenter trial (1349 patients), all patients with histologically proven HCC (n = 278) and ICC (n = 42) were analyzed. The vascularity pattern and contrast enhancement pattern during the arterial, portal-venous and late phase were compared., Results: An underlying liver cirrhosis was found in 214/278 patients with HCC (76.9 %) and 7/42 patients with ICC (16.7 %). In CEUS, HCC showed a global arterial hyperenhancement compared to ICC (HCC: tumor center: 60.3 %; tumor periphery: 75 %; ICC: tumor center: 16.7 %; tumor periphery: 40.5 %). ICC showed an initial contrast enhancement primarily at the tumor periphery (ICC: 85.7 % vs. HCC: 61 %) followed by an early portal-venous contrast washout in the tumor center (ICC: 85.8 % vs. HCC: 49.8 %) and tumor periphery (ICC: 66.7 % vs. HCC: 32.6 %). HCC showed a delayed contrast washout (late phase hypoenhancement: HCC: 75 % vs. ICC: 92.9 %)., Conclusion: ICCs are rare in cirrhotic livers. CEUS can demonstrate differences in the vascularization patterns between HCC and ICC. HCC showed an arterial global hyperenhancement and delayed contrast washout in the late phase. ICCs are characterized by an arterial contrast enhancement at the tumor periphery with early contrast washout of the vascularized parts of the lesions in the portal-venous and late phase., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Prolonged heterogeneous liver enhancement (PHLE) is a rare phenomenon that is similar to the ultrasound findings of portal venous gas. The purpose of this report is to describe the phenomenon of PHLE after the injection of the ultrasound contrast agent SonoVue(®)., Patients and Methods: From 2000 to 2013, 13 patients with PHLE ("cloudy", "wool-like") after bolus injection of SonoVue(®) were observed. The height, weight, and body mass index (BMI) of the patients, and the number of injections were analyzed. In addition, the literature was reviewed., Results: The phenomenon occurred as early as 2 minutes after bolus contrast administration and lasted up to 5 hours on both B-mode and contrast-specific ultrasound. 8/13 (62 %) patients received two or more boluses. None of the patients experienced SonoVue(®)-related side effects or health problems. The phenomenon was not reproducible in 3 patients who received a second SonoVue(®) injection 24 hours after receiving the first., Conclusion: This phenomenon is more likely to occur in patients who receive high-dose (or multiple) injections of UCA. It may occur as early as 2 minutes after contrast administration, and therefore, may affect the evaluation of focal liver lesions in the late phase. This phenomenon should not be misdiagnosed as a pathological finding of the liver., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To evaluate the diagnostic accuracy of contrast-enhanced ultrasound (CEUS) in the differential diagnosis of small and subcentimetric liver tumors in clinical practice., Materials and Methods: 1349 patients with a hepatic tumor lacking a definite diagnosis based on B-mode ultrasound and power Doppler ultrasound were examined at 14 hospitals by CEUS using a standardized protocol (pulse/phase inversion imaging, mechanical index < 0.4). Differential diagnosis was based on the vascularity pattern and contrast enhancement pattern during the arterial, portal, and late phase according to the EFSUMB guidelines. 335 patients with focal liver lesions (FLL) ≤ 20  mm were analyzed. The tumor status established after CEUS was compared to histology (73.2 %) or in some cases to CT or MRI., Results: A definitive diagnosis based on the gold standard was possible in 329 FLLs, while 6 FLLs remained unclear even in the combined gold standard (histology and/or CT and/or MRI). The final diagnoses of ≤ 20  mm FLL with histological confirmation (n = 241) included 87 benign and 154 malignant entities. The overall diagnostic accuracy of CEUS in FLL ≤ 20  mm with histological confirmation was 83.8 %. CEUS correctly identified 144 /154 malignant FLLs (sensitivity 93.5 %) and 58 /87 benign FLLs (specificity 66.7 %). 24 /241 FLLs remained unclear after CEUS (9.9 %). CEUS misclassified 15 /241 FLLs (6.2 %; 12 benign and 3 malignant FLLs). The positive predictive value of CEUS for a malignant FLL was 92.3 % and the negative predictive value was 95.1 %. Out of 241 small FLLs with histological confirmation, 62  FLLs were ≤ 10  mm (diagnostic accuracy of CEUS 80.6 %) and 179 FLLs were > 10  mm and ≤ 20  mm (diagnostic accuracy of CEUS 84.9 %)., Conclusion: CEUS has a high diagnostic accuracy for the differential diagnosis of small and subcentimetric FLLs in clinical practice., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim: Investigation of the frequency of various solid focal liver lesions (SFLL) in noncirrhotic and cirrhotic livers with focus on the frequency of metastasis in cirrhotic livers., Material and Methods: The patient collective in the DEGUM multicenter study (n = 1349) was reevaluated and divided in subcollective A without (n = 1067) and B with cirrhosis (n = 282). 74.6 % of the various tumor entities were confirmed histologically (n = 1006)., Results: In subcollective A there were 385 patients with metastases (36.4 %) and 65 with HCC (6.1 %), whereas the most common benign lesions were hemangioma, with 237 cases (22.4 %) and FNH, with 170 cases (16.1 %). In subcollective B there were 216 cases of HCC (76.6 %) and 12 metastases (4.3 %), as well as 42 benign lesions (14.9 %). CCC was rare in both subcollective A (3.3 %) and subcollective B (2.5 %). A positive oncological history increased the probability of a malignant SFLL in subcollective A by 1.8 times, but did not do so in subcollective B., Conclusion: The frequency of various tumor entities is different in patients with and without cirrhosis of the liver. In noncirrhotic livers, malignant and benign SFLL are equally common. The most common forms are metastases, hemangiomas and FNH, CCC is rare. A positive history of extrahepatic malignancy increases the probability of a malignant SFLL. In cirrhosis, HCC dominates, HCC is 18 times as common as metastases. Benign SFLL and CCC are rare., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To discuss the difficulties of contrast-enhanced ultrasound (CEUS) in a large multi-center trial., Materials and Methods: CEUS was performed on 1349 liver lesions with an unclear diagnosis after native ultrasound using a standardized protocol (phase inversion; low MI < 0.4; Sonovue Bolus 1.2 - 4.8 ml). The early arterial, arterial, portal venous and late phase > 2 min. were documented. The diagnosis based on CEUS results was compared to the final diagnosis (histology: n = 1006; MRI: n = 269; CT: n = 269 - multiple examinations possible)., Results: Of the 1349 enclosed liver lesions, 20 could not be definitively diagnosed even using all diagnostic steps including histology (the others were proven to be benign n = 573 or malignant n = 756). Of the 1349 unclear liver lesions, 1257 could be differentiated with an accuracy of 90.3% using CEUS. The sensitivity, specificity, and positive and negative predictive value for malignant liver lesions was 95.8%, 83.1%, 88.2% and 93.7% respectively. 92 liver lesions (6.8%) could not be definitively diagnosed using CEUS. Most of them were benign (n = 67) on final diagnosis. The CEUS diagnosis was wrong for 39 lesions. However, only 8 lesions classified as benign by CEUS turned out to be malignant. In 3 cases HCC proven by histology was incorrectly diagnosed by CEUS as adenoma and 2 lesions incorrectly diagnosed by CEUS as FNH turned out to be an HCC and a metastasis. Two lesions diagnosed by CEUS as hemangiomas turned out to be an HCC and a metastasis. One lesion classified as benign by CEUS was ultimately diagnosed as a lymphoma., Conclusion: Even in this multi-center trial, CEUS proved to be an excellent method for clarifying liver lesions remaining unclear after native ultrasound. The CEUS diagnosis of benign was only incorrect in a few cases., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: The aim of this prospective multicenter study was to assess the diagnostic role of CEUS in the diagnosis of newly discovered focal liver lesions in clinical practice. One important aspect is the comparison of CEUS with magnetic resonance imaging (MRI)., Materials and Methods: From 05 / 2004 to 12 / 2006, standardized CEUS was performed prospectively on 1349 patients with focal liver lesions that had been newly detected by fundamental ultrasound in order to determine tumor differentiation and tumor entity. 269 patients had a standardized MRI after CEUS. In typical liver hemangioma and focal nodular hyperplasia (FNH), the definitive diagnosis was based on the MRI as the "diagnostic gold standard" and on clinical evidence and additional follow-up (subgroup A) or on histology (subgroup B). 262 patients met the diagnostic standard that had been set., Results: In the subcollective (n = 262), the tumor differentiation (malignant or benign) of CEUS and MRI was concordant in 225 cases (85.9%), and the assessment of tumor entity in 204 cases (77.9%). In subgroup A (n = 180), concordant results for tumor differentiation were obtained in 169 (93.2%) and for tumor entity in 160 (88.9%) cases. Liver hemangiomas (n = 122) and FNH (n = 43) were most frequent. Subgroup B (n = 82) comprised mainly malignant liver lesions (n = 55), with only a few of hemangiomas (n = 8) or FNH (n = 5). Tumor differentiation was concordant in 56 (68.3%) and tumor entity in 44 cases (53.7%). There were no statistically proven differences between CEUS and MRI., Conclusion: CEUS and MRI are of equal value for the differentiation and specification of newly discovered liver tumors in clinical practice. CEUS and MRI are extremely reliable for the differentiation of benign and malignant lesions, the diagnosis of liver hemangiomas and FNH. The characterization of metastases and HCC is also very reliable., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim: To evaluate the incidence and diagnostic accuracy of tumor-specific vascularization pattern in contrast-enhanced ultrasound (CEUS) in the differential diagnosis of liver tumors in clinical practice., Materials and Methods: From May 2004 to December 2006 1349 patients (male 677, female 672) with a hepatic tumor lacking a definite diagnosis based on B-mode ultrasound and power Doppler ultrasound were examined at 14 hospitals by CEUS using a standardized protocol (pulse/phase inversion imaging, mechanical index < 0.4). Vascularity pattern and contrast enhancement pattern were analyzed in focal lesions during the arterial, portal, and late phase. The tumor-specific diagnosis established after CEUS was compared to histology (> 75 % cases) or in some cases to CT or MRI., Results: The final diagnosis of 573 benign hepatic tumors included hemangiomas (n = 242) and focal nodular hyperplasia (n = 170), other benign lesions (n = 161). Tumor-specific vascularization pattern such as a wheel-spoke pattern and arterial hyperenhancement followed by isoenhancement in the late phase in FNH or a nodular peripheral enhancement and partial or complete fill-in pattern in hemangiomas could be assessed in the majority, but not all lesions. The diagnostic accuracy of CEUS was 83.1 % for all benign lesions and 82.2 % for hemangioma and 87.1 % for FNH. The final diagnosis of 755 malignant hepatic tumors included metastases n = 383, hepatocellular carcinoma n = 279 and other malignant lesions n = 93. Late phase hypoenhancement was seen in almost all liver metastases (94.7 %) The diagnostic accuracy of CEUS was 95.8 % for all malignant lesions and 91.4 % for liver metastases and 84.9 % for hepatocellular carcinomas., Conclusion: Tumor-specific vascularization pattern in CEUS have a high diagnostic impact on the overall high diagnostic accuracy of CEUS for the differential diagnosis of hepatic tumors in clinical practice., ((c) Georg Thieme Verlag KG Stuttgart, New York.)

Aim: The aim of our study was to evaluate the diagnostic value of Contrast-Enhanced Ultrasound (CEUS) for the characterization of focal liver lesions in a prospective multi-center study in clinical practice. For this purpose CEUS was compared with the spiral-CT (SCT), the standard radiological method., Material and Methods: 1349 patients with unclear liver lesions after fundamental ultrasound diagnostics including color doppler analysis were examined with standardized CEUS (pulse inversion method, mechanical index < 0.4) from May 2004 to December 2006 in 14 hospitals in a prospective study. The enhancement of contrast medium in the liver tumors was analyzed according to known tumor-specific vascular patterns, using standardized documentation and analysis methods for the differentiation of tumor differentiation (malign or benign) and tumor specification (entity). A subcollective of 267 patients was additionally examined by standardized SCT method. Final diagnosis was based on histology, SCT or MRI in typical findings of liver hemangioma and FNH and on proved clinical data and additional follow up., Results: The subcollective of 267 patients was divided in two subgroups. In 109 of these patients (subgroup A) there was no histological verification, diagnoses based on clear SCT-findings in 79 cases of hemangioma or FNH, as well as in 20 cases with a clear clinical diagnosis. 6 cases (5.5 %) remained unclear. In this subgroup the assessment of tumor differentiation was concordant with CEUS in 90 cases, discordant in 19 cases and the assessment of tumor specification was concordant in 82 and and discordant in 27 cases. In 158 patients (subgroup B) a histological finding was also present, only in 4 cases no definitive tumor diagnosis was achieved. In this subgroup assessment of tumor differentiation with CEUS and SCT was concordant in 124 cases and discordant in 30 cases (CEUS/SCT: sensitivity 94.0 / 90.7 %, specificity 83.0 / 81.5 %, PPV 91.6 / 91.5 %, NPV 87.5 / 80.0 %, accuracy 90.3 / 87.8 %). Tumor specification matched in 103cases and were different in 51 cases (CEUS/SCT: sensitivity 95.3 / 90.6 %, specificity 83.7 / 81.6 %, PPV 92.7 / 91.4 %, NPV 89.1 / 80.0 %, accuracy 91.6 / 87.7 %). A statistically significant difference could not be established. The analysis of particular tumor specification showed a statistically non significant slight advantage in tumor differentiation for CEUS in the case of hemangioma, FNH, HCC and metastases., Conclusion: In a multi-center approach under routine clinical conditions, this prospective study demonstrates CEUS to be of equal rank to the CT-scan in regard to the assessment of tumor differentiation and specification. No statistically significant differences could be established. CEUS should be employed before computed tomography is performed for the differentiation of liver tumors, because radiation exposure and invasive biopsies can be avoided in veritable numbers of cases, when precise clinical evaluation of the findings is implemented., ((c) Georg Thieme Verlag KG Stuttgart, New York.)

Purpose: To evaluate the diagnostic benefit of contrast-enhanced ultrasound for the differential diagnosis of liver tumors in clinical practice., Materials and Methods: From May 2004 to December 2006 1349 patients (male 677, female 672) with a hepatic tumor lacking a definite diagnosis based on B-mode ultrasound and power Doppler ultrasound were examined at 14 hospitals by contrast-enhanced ultrasound using a standardized protocol (pulse/phase inversion imaging, mechanical index < 0.4). The Tumor status was assessed based on the vascularity pattern and contrast enhancement seen in focal lesions during the arterial, portal, and late phase. The diagnosis established after contrast-enhanced ultrasound was compared to histology (> 75% cases) or in some cases to CT or MRI., Results: The final diagnosis of hepatic tumors included 573 benign hepatic tumors (hemangiomas n = 242, focal nodular hyperplasia n = 170, hepatocellular adenoma n = 19, other benign lesions n = 142) and 755 malignant hepatic tumors (metastases n = 383, hepatocellular carcinoma n = 279, other malignant lesions n= 93). The overall diagnostic accuracy of contrast-enhanced ultrasound in comparison to the correct final diagnosis based on the combined gold standard was 90.3%. Contrast-enhanced ultrasound was able to correctly assess 723/755 malignant lesions (sensitivity 95.8%) and 476/573 benign lesions (specificity 83.1%). The positive predictive value of contrast-enhanced ultrasound for the diagnosis of a malignant tumor was 95.4% and the negative predictive value of contrast-enhanced ultrasound was 95.7%., Conclusion: Contrast-enhanced ultrasound clearly improves the differential diagnosis of hepatic tumors and is very helpful in clinical practice when B-scan or power Doppler morphological criteria are missing.

A retroperitoneal perforation is a rare incident. It can occur as a complication of ERCP with papillotomy (0.2-0.5%). Leakage of contrast agent during endoscopy raises the suspicion that this complication has occurred but doesn't always give sufficient information about the leakage extent. In the case of extreme gas emission, a plain abdominal X-ray shows classic pneumoretroperitoneum. The abdominal CT scan can display small amounts of free air which is why it is used for diagnosis in such cases. Ultrasonography also provides a reliable diagnosis and is a good method for monitoring the progression of the condition. Alternative causes of pneumoretroperitoneum can be: trauma, inflammation, infection, tumor as well as ERCP and other interventional procedures, especially endoscopies. Presacral retroperitoneal pneumoradiography was used for the diagnosis of retroperitoneal tumors in the 70 s but is no longer used today. Perforations into the retroperitoneal space come from several locations in the gastrointestinal tract. In the different types of lesions the gas can penetrate the compartments and reach as far as the mediastinum, the intraabdominal cavity, subcutaneum (cervical) or the scrotal compartment (compartment shift). Based on 11 cases (7 perforations during ERCP, 2 perforation during colonoscopy, 2 cases with damage of the distal esophagus), we show the most extensive presentation of the sonographical picture of pneumoretroperitoneum. Typical signs on abdominal ultrasound are an increased echogenicity around the right kidney ("overcasted" or "covered" kidney), air dorsal to the gallbladder, around the duodenum and the head of the pancreas and especially ventral to the great abdominal vessel which can lead to the picture of "vanishing" vessels. The extent of free air is easy to assess. Even very small amounts are detectable ventral to the right kidney. In most cases, a conservative approach with no oral intake, antibiotic coverage, and analgesia in close gastroenterological-surgical cooperation is indicated. Especially after ERCP abscess formation is repeatedly described, sometimes even with a lethal outcome. Sonography is a suitable method for detecting free air in the retro-peritoneum. Pneumoretroperitoneum following bowel-perforation can be effectively shown by ultrasound, it is possible to assess the extent of free air, and sonographic monitoring of the treatment is possible and successful.