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The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in the many established and emerging applications.Die aktualisierte Version der EFSUMB-Leitlinien für die Anwendung von nicht-hepatischem kontrastverstärktem Ultraschall (CEUS) befasst sich mit der Verwendung von Mikrobläschen Ultraschall-Kontrastmitteln außerhalb der Leber in zahlreichen etablierten und neu entstehenden Einsatzbereichen.

The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in the many established and emerging applications.Die aktualisierte Version der EFSUMB-Leitlinien für die Anwendung von nicht-hepatischem kontrastverstärktem Ultraschall (CEUS) befasst sich mit der Verwendung von Mikrobläschen Ultraschall-Kontrastmitteln außerhalb der Leber in zahlreichen etablierten und neu entstehenden Einsatzbereichen.

Ultrasound is the modality of choice for the initial assessment of the gall bladder and the biliary tree. This article details normal ultrasound appearances of the biliary tree, as well as appearances of biliary obstruction, biliary cirrhosis, biliary gall-stones, developmental disorders, cholangiopathies and cholangiocarcinoma.

Ultrasound is the modality of choice for the initial assessment of the gall bladder and the biliary tree. This article is the first of two, and details normal ultrasound appearances of the gall bladder, as well as appearances of cholecystitis, sludge, adenomyomatosis, polyps, carcinoma and parasites.

Microbubbles as an ultrasound contrast agent allow characterization of focal liver lesions. This article summarizes the ultrasound appearances and enhancement characteristics of benign liver lesions, focal fatty sparing and focal fatty change, and blunt liver trauma.

Colorectal cancer is often preventable if the precursor adenoma is detected and removed. Although ultrasound is clearly not one of the widely accepted screening techniques, this non-invasive and radiation-free modality is also capable of detecting colonic polyps, both benign and malignant. Such colon lesions may be encountered when not expected, usually during general abdominal sonography. The discovery of large colonic polyps is important and can potentially help reduce the incidence of a common cancer, whereas detection of a malignant polyp at an early stage may result in a curative intervention. This pictorial review highlights our experience of sonographic detection of colonic polyps in 43 adult patients encountered at our institutions over a 2-year period. 4 out of 50 discovered polyps were found to be malignant lesions, 3 polyps were hyperplastic, 1 polyp was a hamartomatous polyp and the rest were benign adenomas. The smallest of the detected polyps was 1.3 cm in diameter, the largest one was 4.0 cm (mean 1.7 cm; median 1.6 cm). In each case, polyps were discovered during a routine abdominal or pelvic examination, particularly when scanning was supplemented by a brief focused sonographic inspection of the colon with a 6–10 MHz linear transducer. In this paper, we illustrate the key sonographic features of different types of commonly encountered colonic polyps in the hope of encouraging more observers to detect these lesions, which may be subtle.

Aim To assess the effect of cine frame rate on the accuracy of the detection of pulmonary nodules at computed tomography (CT). Materials and methods CT images of 15 consecutive patients with (n = 13) or without (n = 2) pulmonary metastases were identified. Initial assessment by two thoracic radiologists provided the “actual” or reference reading. Subsequently, 10 radiologists [board certified radiologists (n = 4) or radiology residents (n = 6)] used different fixed cine frame rates for nodule detection. Within-subjects analysis of variance (ANOVA) was used to evaluate the data. Results Eighty-nine nodules were identified by the thoracic radiologists (median 8, range 0–29 per patient; median diameter 9 mm, range 4–40 mm). There was a non-statistically significant trend to reduced accuracy at higher frame rates (p = 0.113) with no statistically significant difference between experienced observers and residents (p = 0.79). Conclusion The accuracy of pulmonary nodule detection at higher cine frame rates is reduced, unrelated to observer experience.

Transabdominal ultrasound is increasingly chosen as the initial imaging technique in the radiological work-up of bowel abnormalities in adults because ultrasound can provide substantial information about gastrointestinal disorders. In the presence of pathological changes in the intestine, sonographic findings, such as thickening of the bowel wall, changes in the perienteric fat and vascularity, have recognizable and reproducible appearances (Kuzmich et al, 2009). Although the diagnostic quality of ultrasound can be compromised by bowel gas and obesity, ultrasound has a number of strengths, including its ability to allow real-time correlation between the sonographic findings and the area of maximum tenderness combined with excellent spatial resolution, wide availability, lack of radiation and its non-invasive nature. This article illustrates the key sonographic features of commonly encountered bowel disorders in adults and highlights ultrasound techniques that may assist in diagnosis.

Continuous ambulatory peritoneal dialysis (CAPD) is used to treat end-stage renal failure in an increasing number of patients. CAPD has an advantage over hemodialysis in that it allows patients greater freedom to perform daily activities; it also provides other clinical benefits. However, the long-term effectiveness of CAPD is limited by complications, which have various causes. Complications with an infectious cause include bacterial peritonitis, tuberculous peritonitis, and infections of the catheter exit site and tunnel. Noninfectious complications include catheter dysfunction, dialysate leakage, hernias, and sclerosing encapsulating peritonitis. Many imaging modalities-radiography, ultrasonography, peritoneal scintigraphy, computed tomography (CT), and magnetic resonance (MR) imaging-are useful for characterizing these complications. CT peritoneography and MR peritoneography are techniques specifically suited to this purpose. Imaging plays a critical role in ensuring that complications are detected early and managed appropriately.

Context: Contrast-enhanced ultrasound is a real-time imaging technique with the capability of visualizing perfusion patterns. Since tumour growth is associated with changes in vascularisation, this modality is under research for imaging of various tumour types. Studies have shown promising results for the diagnosis of prostate cancer for various imaging techniques; however, the exact value of each technique is still unclear. Objective: To determine the value of contrast-enhanced ultrasound (CEUS) in the detection, localisation, and follow-up of treatment for prostate cancer. Evidence acquisition: In the period 2002-2006, research in four European centres regarding CEUS of the prostate was coordinated in a combined program. This paper describes and combines the results of these studies. Evidence synthesis: Various techniques were developed and researched during the period of this program. Studies showed that prostate cancer could be visualized and localized in up to 78%. Visualization of the tumour enabled better detection; targeted biopsies lead to fewer biopsies per session without loss of detection rate. A combined approach offered the highest detection rate. CEUS could be used to visualize the effects of high-intensity focussed ultrasound and hormonal therapy for prostate cancer with success, and identified patients with an early relapse. Unfortunately, pretreatment evaluation could not identify the nonresponders beforehand. Conclusions: This research project was a first step towards routine use of CEUS in the clinical detection and follow-up of prostate cancer; and new combined studies are initiated. (C) 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved

A wide range of disorders affect the kidneys and ultrasonography is often the modality of choice in the initial assessment. This article reviews the ultrasound appearances of some common adult kidney disorders encountered in daily practice.

Although there is a wide variety of scrotal pathology, the clinical features are not always particularly discriminatory. These may include pain, generalized swelling or a focal mass. Ultrasound examination of the testes with a high-frequency linear transducer is the primary (and usually the only) diagnostic modality required for evaluation of the testes. This article outlines the technique of scrotal ultrasound and illustrates some of the more common testicular and extratesticular pathologies encountered.

Recent developments in the surgical and oncological management of breast cancer and the understanding of the complex genetic basis of the disease have been paralleled by advances in breast imaging. Breast ultrasound (US) has a key role in the assessment of breast disease, together with mammography, clinical examination and needle biopsy.

Deep vein thrombosis (DVT) is a common clinical condition, which may cause pulmonary embolus in as many as 20% of those affected (Baxter, 1997). The evolution of real-time venous ultrasound in the 1980s provided a rapid, non-invasive and relatively cheap alternative test for DVT. Such techniques now have a reported sensitivity and specificity in detecting femoral or popliteal vein thrombus of >95% and >98% respectively. Other indications for venous ultrasound are included in Table 1.

Ultrasonography (US) is often the initial imaging modality employed in the evaluation of renal diseases. Despite improvements in B-mode and Doppler imaging, US still faces limitations in the assessment of focal renal masses and complex cysts as well as the microcirculation. The applications of contrast-enhanced US (CEUS) in the kidneys have dramatically increased to overcome these shortcomings with guidelines underlining their importance. This article describes microbubble contrast agents and their role in renal imaging. Microbubble contrast agents consist of a low solubility complex gas surrounded by a phospholipid shell. Microbubbles are extremely safe and well-tolerated pure intravascular agents that can be used in renal failure and obstruction, where computed tomographic (CT) and magnetic resonance (MR) imaging contrast agents may have deleterious effects. Their intravascular distribution allows for quantitative perfusion analysis of the microcirculation, diagnosis of vascular problems, and qualitative assessment of tumor vascularity and enhancement patterns. Low acoustic power real-time prolonged imaging can be performed without exposure to ionizing radiation and at lower cost than CT or MR imaging. CEUS can accurately distinguish pseudotumors from true tumors. CEUS has been shown to be more accurate than unenhanced US and rivals contrast material-enhanced CT in the diagnosis of malignancy in complex cystic renal lesions and can upstage the Bosniak category. CEUS can demonstrate specific enhancement patterns allowing the differentiation of benign and malignant solid tumors as well as focal inflammatory lesions. In conclusion, CEUS is useful in the characterization of indeterminate renal masses and cysts.

Perforation of gastrointestinal (GI) tract by ingested bone fragments, toothpicks and dentures is rare but remains an important life-threatening condition, and the outcomes are poorer when the diagnosis is delayed. Invariably, clinical and radiographic diagnosis is difficult as most patients will have no recollection of ingesting a foreign body, whereas these subtle objects are often not visible on radiographs. In search for the diagnosis, CT is the modality of choice, but ultrasound imaging may be first requested in patients presenting with symptoms of acute appendicitis, cholecystitis, pyelonephritis or pelvic inflammatory disease when an ingested foreign body is not considered. Although ultrasound has limited value in depicting a foreign body, it can frequently uncover secondary signs of perforation. However, the rarity of this condition combined with non-specific clinical presentation and the propensity of these small perforating objects to be subtle makes establishing the correct diagnosis by the radiologist challenging. Therefore, understanding of the appearances of GI perforation seen on CT images or general abdominal ultrasound will aid the radiologist in the diagnosis of this important yet often unsuspected condition. This will lead to earlier diagnosis and surgical management. In this article, we illustrate the spectrum of CT, radiographic and ultrasound imaging features seen in GI perforation caused by swallowed bone fragments, toothpicks, cocktail sticks and dentures.

Fractures in children differ from those in adults in a number of ways. The immature skeleton is more elastic resulting in incomplete fractures (torus and greenstick) as well as fractures without cortical disruption. In addition the periosteum is more elastic and thicker than in adults. Also children's bones heal quicker and remodel more readily. However, there are areas of structural weakness, which adults do not possess, in the epiphyseal growth plates and zones of cartilage hypertrophy. Therefore fractures at these sites are common.

Patients who present to emergency departments following neck trauma are frequently investigated with plain radiographs. The great majority of radiographs will be normal, but interpreting these films can be a daunting task for a junior doctor as the findings may be subtle and the consequences of missing an injury may be catastrophic. The process can be made simpler by understanding which patients require X-rays, developing a systematic approach to reading the films and being able to decide whether further investigation is required. A basic comprehension of the types of cervical spine trauma is useful as well as understanding the principles of stable and unstable injuries.

Wrist and hand injuries account for approximately 15% of casualty department attendances. Recognition of injuries in this area is important as apparently minor injuries can result in significant loss of function. Early detection and appropriate management usually results in full recovery of normal function.

Lower limb trauma is extremely common, with foot and ankle radiographs frequently simultaneously requested, as clinically it is often difficult to elucidate the exact site of trauma. Careful clinical assessment is imperative to minimize the amount of unnecessary radiographs. Plain radiographs remain the first-line investigation, but interpretation can be difficult because of the variety of possible injuries, and their sometimes subtle appearances. Understanding of normal anatomy is key to avoiding errors in the management of these injuries. This article provides a systematic approach to interpreting ankle and foot radiographs and describes the common conditions requiring these X-rays along with radiological signs.

Upper limb trauma is extremely common, with the elbow joint frequently injured. This usually occurs secondary to direct trauma or as a result of a fall onto an outstretched arm. Plain radiographs remain the first-line investigation in these patients, but interpretation can be difficult because of the variety of possible injuries, and their sometimes subtle appearances. Understanding of the anatomy, especially in the developing elbow, is key to avoiding errors in the management of these injuries. This article provides a systematic approach to interpreting elbow and forearm radiographs and describes the common conditions requiring these X-rays along with radiological signs.

To evaluate in a prospective multicenter study whether conventional ultrasonographic (US) characterization of liver lesions can be improved by imaging during the liver-specific phase of SH U 508A uptake in the microbubble-specific agent detection imaging mode.One hundred forty-two patients with liver lesions underwent conventional gray-scale and color Doppler US and SH U 508A-enhanced US. Two radiologists blindly read digital cine clips and assigned scores for confidence in diagnosis of benignancy or malignancy, diagnosis of specific lesion types, and relative difference in SH U 508A uptake between the lesion and the liver parenchyma (ie, subjective conspicuity score [SCS]). Comparisons were made to see whether the addition of agent detection imaging led to improved diagnostic performance.Receiver operating characteristic analysis revealed improved discrimination of benign and malignant lesions for readers 1 (P =.049) and 2 (P.001). The number of patients with a correct diagnosis of benignancy or malignancy assigned by readers 1 and 2, respectively, improved from 114 and 113 to 125 and 128 with agent detection imaging (reader 1: P =.027; reader 2: P =.008; McNemar test). Specific diagnoses were made more accurately with agent detection imaging: At McNemar testing, the number of correct lesion type determinations increased from 83 to 92 (P =.022) for reader 1 and from 85 to 99 (P.001) for reader 2. Both readers assigned high scores for differences in SH U 508A uptake between the liver parenchyma and the lesion for metastases and cholangiocarcinomas and low scores for uptake differences in most of the benign lesions. Hepatocellular carcinomas (HCCs), hemangiomas, and adenomas had more variable uptake differences. Fourteen of 22 hemangiomas were assigned an SCS of less than 50%, and 22 (reader 1) and 15 (reader 2) of 31 HCCs were assigned an SCS of greater than 50%.With use of SH U 508A-enhanced agent detection imaging, liver lesion characterization and diagnostic performance are significantly improved.

The aim of this study was to determine whether the accuracy of diagnosis of a spectrum of chest pathology was affected by the imaging technique used, and to compare conventional film/screen, hard copy computed (phosphor plate) radiography (CR) and soft copy CR (PACS) images.For each of 44 patients who had a CT examination of the thorax, PA and lateral chest radiographs were produced using conventional film, hard copy CR and soft copy PACS images. Five radiologists independently scored all images for the presence of abnormalities. The data were analysed in two stages using the result of the CT scan as the reference standard diagnosis: firstly, to investigate differences in abnormality scores between image modalities and observers using ROC analysis; secondly, to investigate the agreement of the diagnoses with the reference standard by the analysis of kappa scores.The ROC analyses and comparison of kappa scores showed no differences between image modalities (P=0.72, P=0.87), but highly significant differences between observers (P0.001, P=0.003).The detection of chest lesions did not vary between conventional film, CR hard copy and PACS soft copy images. For all three image types, there were statistically significant differences between observers.

Background: A previous pilot study showed that early arrival time of a microbubble in a hepatic vein is a sensitive indicator of cirrhosis. Aim: To see if this index can also grade diffuse liver disease. Patients: Thirty nine fasted patients with histologically characterised disease were studied prospectively. Nine patients had no evidence of liver fibrosis, 10 had fibrosis without cirrhosis, and 20 had cirrhosis (five Child’s A, seven Child’s B, and eight Child’s C). Methods: Bolus injections of a microbubble (Levovist; Schering, Berlin) were given intravenously, followed by a saline flush. Time intensity curves of hepatic vein and carotid artery spectral Doppler signals were analysed. Hepatic vein transit time (HVTT) was calculated as the time after injection at which a sustained signal increase >10% of baseline was seen. Carotid delay time (CDT) was calculated as the difference between carotid and hepatic vein enhancement. Results: Diagnostic studies were achieved in 38/39 subjects. Both HVTT and CDT became consistently shorter with worsening disease, as follows (means (SD)): HVTT: no fibrosis 44 (25) s, fibrosis 26 (8) s, Child’s A 21 (1) s, Child’s B 16 (3) s, and Child’s C 16 (2) s; CDT: no fibrosis 31 (29) s, fibrosis 14 (6) s, Child’s A 8 (1) s, Child’s B 4 (4) s, and Child’s C 3 (3) s. These differences were highly significant (p

The radiological surveillance of cirrhosis to detect the development of hepatocellular carcinoma (HCC) is problematic because no highly sensitive and specific imaging investigation is available. Ultrasound is typically the first modality used but is less accurate than other imaging modalities. We report the first case of a patient with cirrhosis in whom US imaging with liver-specific microbubbles detected an HCC prior to its detection by MR. The use of liver-specific microbubble US contrast agents is an exciting development in the detection of HCC in chronic liver disease and may help to rectify some of the shortcomings of US.

Ultrasound (US) has undergone dramatic changes since its inception three decades ago; the original cumbersome B-mode gantry system has evolved into a high resolution real-time imaging system. This review describes both recent advances in ultrasound and contrast media and likely future developments. Technological advances in electronics and computing have revolutionized ultrasound practice with ever expanding applications. Developments in transducer materials and array designs have resulted in greater bandwidths with improvements in spatial and contrast resolution. Developments in digital signal processing have produced innovations in beam forming, image display and archiving. Technological advances have resulted in novel imaging modes which exploit the non-linear behaviour of tissue and microbubble contrast agents. Microbubble contrast agents have dramatically extended the clinical and research applications of ultrasound. Not only can Doppler studies be enhanced but also novel non-linear modes allow vessels down to the level of the microcirculation to be imaged. Functional and quantitative studies allow interrogation of a wide spectrum of tissue beds. The advent of tissue-specific agents promises to improve the sensitivity and specificity of ultrasound in the detection and characterization of focal liver lesions to rival that of computed tomography (CT) and magnetic resonance imaging (MRI). Ultrasound has recently moved into therapeutic applications with high intensity focused ultrasound (HIFU) and microbubble assisted delivery of drugs and genes showing great promise.

We investigated the reproducibility of Doppler enhancement indices following intravenous bolus injections of Levovist (Schering AG, Berlin) microbubbles. We also aimed to determine whether observations from animal studies suggesting that aspirin potentiates microbubble enhancement were reproducible in humans. In five healthy volunteers, time enhancement profiles of Doppler intensity following repeated bolus injections of Levovist were acquired from the common carotid artery, hepatic vein and kidney using spectral and power Doppler before and after oral aspirin (600 mg). Peak enhancement (PE), area under the curve (AUC) and decay slopes (lambda) were calculated. Hepatic vein contrast arrival time (AT) was determined subjectively. Well-defined carotid enhancement was seen in 19/20 injections. Reproducibility was high (r > 0.8). PE and AUG were unaffected by aspirin, but lambda was slightly reduced (P = 0.02). Renal power Doppler profiles were well defined (10/10) with no significant changes of AUC, PE or lambda after aspirin. Our study demonstrates good reproducibility of carotid spectral Doppler time intensitometry with Levovist in man. Aspirin does not have a significant effect on enhancement indices except carotid spectral Doppler decay. We conclude that aspirin is unlikely to potentiate microbubble enhancement, as seen in animal studies.

High-intensity focused ultrasonography is the only completely non-invasive thermal therapy. To date its applications have been limited but clinical indications are expanding with enhanced technological advances that have increased the accuracy of targeting and decreased the duration of treatment times. We report its first use for rectal cancer.

Microbubbles as an ultrasound contrast agent allow characterization of focal liver lesions. This article summarizes the ultrasound appearances and enhancement characteristics of malignant liver lesions, and also discusses its potential use for ultrasound-guided intervention and ablation of liver lesions.

Ultrasound microbubble contrast agents are effective and safe echo enhancers. An ingenious array of methods are employed to achieve stability and provide a clinically useful enhancement period. Microbubbles enhance ultrasound signals by up to 25 dB (greater than 300-fold increase) due to resonant behaviour. This is used to rescue failed Doppler studies and may be extended to image the microcirculation of tumours and the myocardium using non-linear modes. Functional studies open up a whole range of applications by using a variety of active and passive quantitation techniques to derive indices from the transit of contrast through a tissue of interest. This has been especially successful in the detection of liver metastases and cirrhosis and shows great promise as a clinical tool. It also has great potential in measuring microcirculatory flow velocity. The demonstration that some microbubbles are not just pure blood pool agents but have a hepatosplenic specific phase has extended the versatility of ultrasound. Imaging of this stationary phase with non-linear modes such as phase inversion and stimulated acoustic emission, has improved the sensitivity and specificity of ultrasound in the detection and characterisation of focal liver lesions to rival that of CT and MR.

Twenty consecutive patients with known liver malignancies underwent ultrasonography (US) in conventional B mode and in pulse-inversion mode in the late hepatic-specific parenchymal phase after intravenous administration of SH U 508A, a microbubble US contrast agent. Two experienced readers assessed subjective and objective conspicuity, number of lesions, and smallest lesion diameter in each mode. Subjective and objective conspicuity were improved with pulse-inversion mode, and smaller lesions were depicted with pulse-inversion mode than with conventional B mode, improving the detection of metastases less than 1 cm in size.

The knee is particularly susceptible to traumatic injury because of the variety of compressive, load-bearing and rotational forces that may act upon it. Injuries may be the result of high-impact trauma such as falls from a height or road traffic accidents, or a result of low-velocity sporting injuries. They may be associated with significant complications such as vascular injury, compartment syndrome, bony non-union, avascular necrosis and osteoarthritis. The majority of fractures are visible on plain radiographs although detectable injuries are sometimes subtle. Simple guidelines are available in order to help decide which injuries do not require investigation with radiographs.

Shoulder injuries are a common presentation to emergency departments. The patient's history is important in determining the mechanism of injury and most fractures or dislocations will be apparent on clinical examination. Conventional (Xray) radiography provides the mainstay of traumatic shoulder imaging and it is important to request the appropriate views to avoid misinterpretation. Computed tomography (CT) may be used as a second-line investigation in complex fractures that require surgical intervention. It is important to remember that musculotendinous and cartilaginous injuries may not be apparent on plain radiographs and that ultrasound and magnetic resonance imaging (MRI) may be used to image these structures in selected cases.

This article discusses important emergency conditions that may be diagnosed on the abdominal radiograph highlighting the key radiological signs that should be recognized.

OBJECTIVE. This article aims to illustrate the spectrum of sonographic findings in perforation of the small bowel due to a variety of causes and discusses the potential role of sonography in the diagnosis. CONCLUSION. Although sonography is not the first-line investigation of choice in suspected small intestinal perforation, an understanding of the characteristic appearances seen during general abdominal sonography may aid the radiologist in the early diagnosis. Recognition of small bowel perforation on general abdominal sonography will shorten the time to diagnosis and ultimate surgical management.

Ultrasonography is the standard modality to image the scrotum because it can provide information about volume, echo texture, tissue stiffness and functional information that includes macrovascularization and microvascularization. Indeed, ultrasound imaging is indicated in the presentation of acute scrotal pain and swelling to differentiate between testicular torsion, infarction and inflammation, as well as being the modality of choice when an intrascrotal mass is suspected. Advances in ultrasonography technology have produced new innovative techniques for imaging the scrotum, including grey-scale ultrasound, Doppler ultrasonography, contrast-enhanced ultrasonography and real-time sonoelastography. Each of these techniques provides information that can be useful when diagnosing diseases and disorders of the testicles. Consequently, the standard approach to accurate diagnosis should rely on multiparametric ultrasonography techniques, rather than just one or two techniques in isolation.

Transrectal ultrasound (TRUS) was first developed in the 1970s. TRUS-guided biopsy, under local anaesthetic and prophylactic antibiotics, is now the most widely accepted method to diagnose prostate cancer. However, the sensitivity and specificity of greyscale TRUS in the detection of prostate cancer is low. Prostate cancer most commonly appears as a hypoechoic focal lesion in the peripheral zone on TRUS but the appearances are variable with considerable overlap with benign lesions. Because of the low accuracy of greyscale TRUS, TRUS-guided biopsies have become established in the acquisition of systematic biopsies from standard locations. The number of systematic biopsies has increased over the years, with 10-12 cores currently accepted as the minimum standard. This article describes the technique of TRUS and biopsy and its complications. Novel modalities including contrast-enhanced modes and elastography as well as fusion techniques for increasing the sensitivity of TRUS-guided prostate-targeted biopsies are discussed along with their role in the diagnosis and management of prostate cancer.

OBJECTIVE. The purpose of this article is to illustrate the spectrum of sonographic findings in perforated pyloroduodenal peptic ulcer and discuss the potential role of sonography in the diagnosis. CONCLUSION. Although sonography is not the first-line investigation of choice in suspected perforated peptic ulcer, understanding of the characteristic appearances seen during general abdominal sonography may aid the reader in the diagnosis of this important and sometimes overlooked cause of nonspecific abdominal pain. This may shorten time to the diagnosis and ultimate surgical management.

Increasing evidence supports a role for contrast-enhanced ultrasound in the assessment of blunt abdominal trauma. Accurate definition of organ injury can be demonstrated, as well as extension to solid organ capsule and even vascular injury. Low-dose contrast is needed for renal imaging, to avoid obscuration of deeper structures from intense cortical enhancement. The liver should be evaluated in the arterial phase for active bleeding and in the late phase for lacerations. The spleen is best assessed in the delayed phase, thereby limiting misinterpretation of early heterogeneous contrast uptake. Typical sonographic features of traumatic injuries of the solid abdominal organs are described. Although contrast-enhanced computed tomography is the gold standard modality for imaging abdominal organ traumatic injury, contrast-enhanced ultrasound has developed a role in the emergency setting, particularly in low-energy injuries and in follow-up of traumatic injuries.

To conduct a dose testing analysis of perfluorobutane microbubble (NC100100) contrast-enhanced ultrasound (CEUS) to determine the optimal dose for detection of liver metastases in patients with extra-hepatic primary malignancy. 157 patients were investigated with conventional US and CEUS. CEUS was performed following intravenous administration of perfluorobutane microbubbles (using one dose of either 0.008, 0.08, 0.12 or 0.36 μL/kg body weight). Three blinded off-site readers recorded the number and locations of metastatic lesions detected by US and CEUS. Contrast enhanced CT and MRI were used as the “Standard Of Reference” (SOR). Sensitivity, specificity and accuracy of liver metastasis detection with US versus CEUS, for each dose group were obtained. Dose group analysis was performed using the Chi-square test. 165 metastases were present in 92 patients who each had 1–7 lesions present on the SOR. Sensitivity of US versus CEUS (for all doses combined) was 38% and 67% (p = 0.0001). The 0.12 dose group with CEUS (78%) had significantly higher sensitivity and accuracy (70%) compared to other dose groups (p

To assess the effect of changing from an "appointment" to a "same-day" ultrasound (US) service on referral pattern, departmental workload, and patient satisfaction.To reduce US waiting time of 3 weeks for routine examinations, a "same-day" service was started for outpatients and general practitioner (GP) patients in September 2006. To examine the effect of this change a retrospective assessment was performed of workload during 1 week in June 2006 (appointments only) and the same week in 2008, 22 months after the implementation of the new service. Distance travelled by patients and waiting time was recorded. Patient satisfaction with the service was assessed by questionnaire in September 2008.Hospital referrals remained stable, but GP referrals increased from 99 to 367 (270%) and distance travelled by patients increased from a median of 3.1 km (range 0.1-12.1 km) in 2006 to 4.8 km (range 0.2-19.8 km) in 2008 (p0.001). Non-local GP referrals increased from 20/99 in 2006 (20%) to 198/367 in 2008 (54%). The increased workload was managed by flexible working by radiologists and two additional sonographers. Departmental waiting time increased for all patients with same-day patients waiting a median of 35 min (interquartile range 19-60 min). Ninety-one percent (79/87) of same-day patients rated the service excellent or good, but many requested better information on the waiting time.There is a demand from GPs for same-day US, and it is feasible in a large hospital with flexible radiology working and increased sonographic staffing. Unless adjacent hospitals offer a similar service, continuing rise in demand could overwhelm the service.

Ultrasound is widely used in the imaging of many musculoskeletal conditions (Van Holsbeeck and Introcaso, 2001; McNally, 2005). Advances in technology, including higher resolution probes, power Doppler sonography, extended field-of-view imaging and compound imaging, have expanded its applications in musculoskeletal disorders.

Ultrasound is widely used as the first-line imaging modality in the assessment of the acute abdomen and in trauma (Marincek, 2002). Ultrasound has the advantages of low cost, real-time bedside imaging, accessibility, portability, lack of ionizing radiation, noninvasiveness, and multiplanar imaging. Ultrasound is also uniquely interactive and by asking the question ‘Where does it hurt?’ frequently directs the operator to the pathology. Doppler allows the detection of alteration in vascularity which may be a feature of inflammation, trauma and neoplasia.

Ultrasound is widely used in the imaging of many paediatric conditions. Children are excellent candidates for ultrasound examination as they are generally smaller than adults with less body fat allowing excellent quality images to be obtained. In addition, ultrasound has several advantages over other cross-sectional imaging modalities used in paediatrics, including the lack of exposure to ionizing radiation, the avoidance of intravenous and oral contrast agents and the relative ease with which examinations can be performed without the need for sedation (De Bruyn, 2005). This article will focus on some aspects of paediatric abdominal ultrasound, namely renal tract abnormalities, common paediatric abdominal tumours and some common conditions presenting as acute abdominal emergencies.

Ultrasound has become the investigation of choice for patients with palpable thyroid gland abnormalities because of its high anatomical resolution, wide availability, low cost and lack of radiation exposure. This article reviews the indications for thyroid ultrasound, examination techniques and the sonographic features of both benign and malignant thyroid pathology. Particular emphasis is placed on the role of ultrasound, in combination with fine needle aspiration cytology (FNAC), in evaluating thyroid nodules for malignancy.

Functional CT can demonstrate acute quantitative increases in perfusion, permeability and fractional vascular volume in the prostate gland of patients with prostate cancer following radiotherapy (RT). We hypothesize that these quantitative changes can also be demonstrated visually by presenting them as colour parametric maps using custom software. 21 patients with prostate cancer were studied before, and 1-2 weeks after, RT. Repeated CT scans through a single section of the prostate was performed following contrast injection. Capillary permeability, fractional vascular volume and tissue perfusion were calculated and converted to colour maps using a customized Matlab imaging programme. Five "expert" and five "novice" radiologists scored pairs of randomized prostate images as an "increase", "decrease" or "no change" in intensity following RT. Kappa (kappa) statistics was used to assess the concordance of opinions. Significant quantitative increases in all indices occurred after RT, and almost all of the parametric images were scored as an increase in intensity following RT (perfusion = 95%, permeability = 88%, volume = 84%). There was substantial agreement between the experts and novices (kappa: perfusion = 0.93, permeability = 0.80, volume = 0.90), as well as within the expert (kappa: perfusion = 1, permeability = 0.86, volume = 1) and novice (kappa: perfusion = 0.82, permeability = 0.78, volume = 0.78) groups. Functional colour maps of the prostate can reliably portray the hyperaemic response following RT in a group with quantitative increases in perfusion, permeability and fractional vascular volume, and provides a potentially accessible and convenient method for image analysis by radiologists of varying experience.

Background Diagnostic decisions in clinical imaging currently rely almost exclusively on visual image interpretation. This can lead to uncertainty, for example in dementia disease, where some of the changes resemble those of normal ageing. We hypothesized that extracting volumetric data from patients' MR brain images, relating them to reference data and presenting the results as a colour overlay on the grey scale data would aid diagnostic readers in classifying dementia disease versus normal ageing. Methods A proof-of-concept forced-choice reader study was designed using MR brain images from 36 subjects. Images were segmented into 43 regions using an automatic atlas registration-based label propagation procedure. Seven subjects had clinically probable AD, the remaining 29 of a similar age range were used as controls. Seven of the control subject data sets were selected at random to be presented along with the seven AD datasets to two readers, who were blinded to all clinical and demographic information except age and gender. Readers were asked to review the grey scale MR images and to record their choice of diagnosis (AD or non-AD) along with their confidence in this decision. Afterwards, readers were given the option to switch on a false-colour overlay representing the relative size of the segmented structures. Colorization was based on the size rank of the test subject when compared with a reference group consisting of the 22 control subjects who were not used as review subjects. The readers were then asked to record whether and how the additional information had an impact on their diagnostic confidence. Results The size rank colour overlays were useful in 18 of 28 diagnoses, as determined by their impact on readers' diagnostic confidence. A not useful result was found in 6 of 28 cases. The impact of the additional information on diagnostic confidence was significant (p < 0.02). Conclusion Volumetric anatomical information extracted from brain images using automatic segmentation and presented as colour overlays can support diagnostic decision making.

Radiology is a rapidly changing and expanding speciality with little formal training in its different modalities during medical school. Very few patients will be seen in a hospital without requiring some form of imaging. Indeed a significant proportion of the foundation doctor's workload involves organizing and interpreting diagnostic tests carried out within the imaging department.

Ultrasound is the first-line imaging investigation in gynaecological disorders. It has the advantages of being readily available and inexpensive as well as avoiding the use of ionizing radiation. Common indications for performing pelvic ultrasound include menstrual disorders, pelvic pain, symptoms suggestive of a pelvic mass and postmenopausal bleeding. This article summarizes the technical aspects and anatomy relevant to gynaecological ultrasound before describing the conditions commonly encountered during sonographic assessment of the female pelvis.