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PURPOSE: Hepatic hydrothorax is defined as the accumulation of pleural effusion in a cirrhotic patient in the absence of pulmonary or cardiac disease. Peritoneal fluid can pass into the pleural space through diaphragmatic fenestrations. The demonstration of such passage is important to establish the diagnosis of hepatic hydrothorax and can be achieved by intraperitoneal injection of nuclear contrast agents. Our aim was to evaluate the ability of contrast enhanced ultrasound in the detection of peritoneal-pleural communications. MATERIALS AND METHODS: Seven patients with cirrhotic ascites and pleural effusion were studied in order to make a diagnosis of hepatic hydrothorax. SonoVue was injected into the peritoneal cavity (9.8 mL), and the peritoneal and pleural cavities were monitored by ultrasound. All patients were then studied using a nuclear scan. RESULTS: Passage of SonoVue from the peritoneal to the pleural cavities was seen in 5 patients. In 2 patients, no passage of contrast agent was detectable. Nuclear scan was consistent with contrast enhanced ultrasound in all patients. CONCLUSION: This study shows that the presence of peritoneal-pleural communications can be demonstrated by real time contrast enhanced ultrasound, whose results are comparable to those of nuclear scan. Contrast enhanced ultrasound is cheaper and could theoretically be performed wherever ultrasound facilities are available.

Focal nodular hyperplasia (FNH) is the second most common benign tumor of the liver, after hemangioma. It is generally found incidentally and is most common in reproductive-aged women, but it also affects males and can be diagnosed at any age. Patients are rarely symptomatic, but FNH sometimes causes epigastric or right upper quadrant pain. The main clinical task is to differentiate it from other hypervascular hepatic lesions such as hepatic adenoma, hepatocellular carcinoma, or hypervascular metastases, but invasive diagnostic procedures can generally be avoided with the appropriate use of imaging techniques. Magnetic resonance (MR) imaging is more sensitive and specific than conventional ultrasonography (US) or computed tomography (CT), but Doppler US and contrast-enhanced US (CEUS) can greatly improve the accuracy in the diagnosis of FNH. Once a correct diagnosis has been made, in most cases there is no indication for surgery, and treatment includes conservative clinical follow-up in asymptomatic patients.SommarioL'iperplasia nodosa focale (FNH) è il tumore epatico benigno più frequente dopo l'angioma. E' di solito rilevata in modo occasionale, per lo più nelle donne in età fertile, anche se si può riscontrare in entrambi i sessi e ad ogni età. I soggetti portatori raramente sono sintomatici, nonostante l'FNH possa essere causa di dolore ai quadranti addominali superiori. Nella gestione dell'FNH il problema clinico principale è rappresentato dalla difficoltà di differenziarla dalle altre lesioni epatiche ipervascolarizzate, come l'adenoma, l'epatocarcinoma o le metastasi ipervascolari, tuttavia utilizzando le opportune tecniche diagnostiche è oggi possibile evitare il ricorso ad esami invasivi. La Risonanza Magnetica (RM) ha una sensibilità e una specificità superiori rispetto a quelle dell'ecografia convenzionale e della Tomografia Assiale Computerizzata (TC) per la diagnosi di FNH. L'uso dell'angioecografia perfusionale (CEUS) e dell'eco-Doppler può tuttavia aumentare in modo significativo la confidenza diagnostica nell'identificazione e nella caratterizzazione dell'FNH con ultrasuoni. Una volta posta con certezza la diagnosi, nella maggior parte dei casi non ci sono indicazioni al trattamento chirurgico e nei soggetti asintomatici è raccomandato un follow-up clinico.

Safety issues should always be kept in mind when using diagnostic ultrasound, which is associated with potentially hazardous bio-effects, especially with the introduction of new technologies.To assess the level of awareness and knowledge of safety issues related to the clinical use of ultrasound among physician-members of the Italian National Society for Ultrasound.A questionnaire with 11 multiple-choice questions was sent to members of the Italian Society for Ultrasound in Medicine and Biology. The answers were forwarded from the Society's Secretariat to the investigators, who statistically analyzed the data.The mean age of the 105 respondents was 44 years. The most frequent kind of ultrasound examinations (in addition to conventional B-mode) were: Doppler (74%), contrast-enhanced US (43%), and pediatric studies (43%). Only 50-60% of the responders knew the correct definitions of the terms thermal index and mechanical index. Almost all respondents understood the bio-effects reflected by the thermal index, but only a minority knew the most likely organ target of bio-effects related to the mechanical index and what do indicate the units in which the thermal index is expressed. The majority knew that fetuses are at higher risk of damage. Few respondents were able to identify the correct safety statements included in the recommendations of the International Ultrasound Societies.In conclusion, the present findings indicate that greater efforts of National Ultrasound Societies are warranted in disseminating knowledge of the bio-effects of diagnostic ultrasound modalities among operators.Sommario INTRODUZIONE: La sicurezza nell'uso degli ultrasuoni va sempre considerata in campo ecografico, in quanto gli ultrasuoni sono in grado di indurre effetti biologici potenzialmente dannosi, soprattutto con l'introduzione di nuove tecnologie. SCOPO DELLO STUDIO: Valutare il livello di consapevolezza e di conoscenza dei medici italiani soci SIUMB sulla sicurezza nell'uso dell'ecografia nella pratica clinica. MATERIALI E METODI: Un questionario contenente 11 domande a risposta multipla è stato inviato per e-mail a soci SIUMB (Società Italiana di Ultrasonologia in Medicina e Biologia). Le risposte sono state inserite in un database elettronico ed analizzate statisticamente. RISULTATI: Sono tornati questionari da 105 soci, di età media di 44 anni i cui esami ecografici più frequentemente eseguiti, in aggiunta all'ecografia B-mode standard, erano l'ecoDoppler (74%), l'ecografia con mezzo di contrasto (43%) e l'ecografia pediatrica (43%). Solo il 50–60% conosceva la definizione corretta dell'Indice Meccanico e dell'Indice Termico. Quasi tutti i partecipanti comprendevano gli effetti biologici espressi con Indice Termico, nonostante che solo una minoranza sapesse in quale organo gli effetti biologici, in relazione all'Indice Meccanico, potevano, con più probabilità, verificarsi; analogamente solo una minoranza conosceva l'unità di grandezza per l'Indice Termico. La maggioranza era a conoscenza di come i tessuti del feto siano più suscettibili ai potenziali effetti di quelli adulti. Pochi partecipanti conoscevano le raccomandazioni delle Società Internazionali di Ultrasonologia in campo di sicurezza. CONCLUSIONI: Lo studio ha fatto emergere come sia necessaria una maggior diffusione delle conoscenze sugli effetti biologici degli ultrasuoni tra gli ecografisti italiani.

Aims: Portal venous thrombosis (PVT) is considered an absolute contraindication to liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) when neoplastic PVT cannot be excluded. Aim of the study is to assess whether imaging techniques allow evaluation of nature of PVT in HCC-patients allowing safe selection of candidates to LT. Methods: We analyzed 34 HCC-patients with PVT detected at the time of assessment for LT or developed while on the waiting list. The benign nature of the thrombus was established using the following criteria: lack of vascularization of the thrombus at contrast enhanced ultrasound with SonoVue and ceCT or ceMRI, steadiness/regression of thrombosis during follow-up, absence of mass-forming aspects of PVT on ultrasound examination, absence of features of disruption of the vessel walls, and negative biopsy of the thrombus in case of uncertainty. Patients who did not fulfill the criteria for benignity of PVT were excluded from the waiting list. Results: The outcome of 34 patients analyzed is as follows: 13 were listed and transplanted, with no sign of malignant PVT at explant pathological examination; 9 were admitted in the list and are actively waiting. Two patients died for HCC unrelated causes while actively listed. Of the remaining 10 patients, 7 were not included or excluded from the list for the suspicion or confirmation of malignant PVT, whereas 3 were included and subsequently excluded for progression of HCC without evidence of malignant PVT. Conclusions: Imaging techniques allow safe not-invasive assessment of the nature of PVT in HCC-candidates to LT.

Patients with liver disease or systemic pathology are more prone to develop portal vein thrombosis. Non-neoplastic thrombosis is characterised by absence of intrathrombotic perfusion, corresponding to marked hypoechogenicity at contrast-enhanced ultrasound. We report two cases of portal vein thrombosis in which contrast-enhanced ultrasound showed marked hypoechogenicity in the late phase. This late phase perfusional contrast pattern is consistent with non-neoplastic thrombosis, but is actually similar to that of metastatic liver lesions. Echo-guided needle biopsy indeed yielded histological results consistent with carcinoma. Repeated contrast-enhanced ultrasound showed presence of intratumoural perfusion in the arterial phase, suggestive of the neoplastic nature of the thrombus. Our cases suggest that CEUS with second generation contrast agents in patients with portal thrombosis should include the evaluation of both arterial and portal phases in order to provide accurate non-invasive diagnosis of metastatic portal vein thrombosis.

Background Contrast enhanced ultrasound (CEUS) is an imaging technique which appeared on the market around the year 2000 and proposed for the detection of liver metastases in gastrointestinal cancer patients, a setting in which accurate staging plays a significant role in the choice of treatment. Methods A total of 109 patients with colorectal (n = 92) or gastric cancer prospectively underwent computed tomography (CT) scan and conventional US evaluation followed by real time CEUS. A diagnosis of metastases was made by CT or, for lesions not visibile at CT, the diagnosis was achieved by histopathology or by a malignant behavior during follow-up. Results Of 109 patients, 65 were found to have metastases at presentation. CEUS improved sensitivity in metastatic livers from 76.9% of patients (US) to 95.4% (p <0.01), while CT scan reached 90.8% (p = n.s. vs CEUS, p < 0.01 vs US). CEUS and CT were more sensitive than US also for detection of single lesions (87 with US, 122 with CEUS, 113 with CT). In 15 patients (13.8%), CEUS revealed more metastases than CT, while CT revealed more metastases than CEUS in 9 patients (8.2%) (p = n.s.). Conclusion CEUS is more sensitive than conventional US in the detection of liver metastases and could be usefully employed in the staging of patients with gastrointestinal cancer. Findings at CEUS and CT appear to be complementary in achieving maximum sensitivity.