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Please see the Editorial Comment by HaiThuy N. Nguyen discussing this article. Background: Use of upper gastrointestinal (UGI) series to diagnose UGI obstruction has raised concern in neonates and ...

To retrospectively assess the diagnostic performance of grey-scale ultrasound (US) characteristics and gamma-glutamyl transpeptidase (GGT) alone or combined in distinguishing biliary atresia (BA) from other cholestasis diseases in infants younger than 30 days. Between January 2012 and October 2020, the demographic characteristics, laboratory results and US characteristics of 35 BA and 52 non-BA infants younger than 30 days were retrospectively evaluated. Areas under the receiver operating characteristic curves (AUCs) were used to estimate the probability of predicting BA, which were compared by DeLong test. The diagnostic performance of gallbladder classification in identifying BA was higher than that of fibrotic cord thickness (AUC 0.900 vs. 0.771, P = 0.03). With the cutoff level of 188 IU/L, serum GGT had a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 77.1%, 69.2%, 62.8%, and 81.8%, respectively. Combined with gallbladder classification and GGT, the sensitivity, specificity, PPV, NPV and accuracy were 100.0%, 63.5%, 64.8%, 100.0% and 78.2%. Gallbladder classification was more valuable than fibrotic cord thickness in the diagnosis of BA among infants less than 30 days. Combined with gallbladder classification and GGT, the sensitivity for the diagnosis of BA can reach 100.0%.

To analyze the contrast-enhanced ultrasound (CEUS) characteristics of pediatric patients with focal liver lesions (FLLs) and develop a pediatric liver CEUS criterion to improve the diagnostic performance of CEUS in differentiating pediatric benign and malignant liver lesions. Between March 2011 and May 2020, patients < 18 years who underwent CEUS were retrospectively evaluated. The CEUS characteristics of FLLs were analyzed. A pediatric liver CEUS criterion categorized as CEUS-1 to CEUS-5 was developed. The diagnostic performance of the criterion (i.e., sensitivity, specificity, PPV, and NPV) was assessed. Chi-square and Mann-Whitney tests were used. After exclusion, the study included 130 lesions (mean diameter, 7.1 cm; range, 0.8–17.0 cm) from 130 patients (mean age, 36.0 months; range, 0.03–204.0 months; 74 boys). Hyperenhancement with washout in patients < 5 years or with early washout (≤ 45 s) was used to predict hepatoblastoma, with a sensitivity and specificity of 90.7% (95% confidence interval [CI]: 77.9%, 97.4%) and 93.6% (95% CI: 84.3%, 98.2%), respectively. Peripheral discontinuous globular hyperenhancement was used to diagnose hemangioma, with a sensitivity and specificity of 84.6% (95% CI: 65.1%, 95.6%) and 100% (95% CI: 95.4%, 100.0%), respectively. The rates of malignancies within the pediatric liver CEUS-1, CEUS-2, CEUS-3, CEUS-4, and CEUS-5 categories were 0.0%, 0.0%, 5.6%, 50.0%, and 96.1%, respectively. Besides, the incidences of hepatoblastoma in pediatric liver CEUS-3, CEUS-4, and CEUS-5 were 5.6%, 16.7%, and 67.5%, respectively. The pediatric liver CEUS criterion is useful in differentiating benign focal liver lesions from malignancies, especially hepatoblastoma from hemangioma. • Hyperenhancement with washout in patients

To compare the outcome of biliary atresia (BA) patients with and without hilar cyst on preoperative ultrasound. A single center retrospective review of patients of BA with (n = 27) and without hilar cyst (n = 27) over a 5 y period was done. The patients were analyzed using propensity score matching to reduce selection bias. All patients were diagnosed as type III BA by histologic examination and cholangiograms. Clinicopathological characteristics and survival outcomes were compared between the two groups. There were no significant intergroup differences between baseline characteristics and outcomes after Kasai portoenterostomy surgery in two groups. BA with hilar cyst group showed comparable survival outcomes to the BA without cyst group (cumulative 1-y, 2-y and 5-y overall survival rates with native liver 61.4% vs. 65.8%, P = 0.041; 45.0% vs. 49.0%, P = 0.57; 45.0% vs. 49.0%, P = 0.57). And the Kaplan–Meier survival curves showed no significant difference in cumulative survival with native liver between the two groups (P = 0.58). Type III BA with hilar cyst had no better prognosis compared with Type III BA without cyst.

Background The prognosis of patients with biliary atresia (BA) after Kasai portoenterostomy (KPE) varies, and precisely predicting the outcomes of KPE before surgery is still challenging. Methods A total of 158 patients who underwent KPE in our hospital were included in this study. The patients in the training cohort were recruited from January 2012 to October 2017 (n = 118), and then, those in the validation cohort were recruited from November 2017 to April 2019 (n = 40). Combined nomogram models were developed based on two-dimensional shear wave elastography (2D SWE) values and other biomarkers. The utility of the proposed models was evaluated by C-index. Results 2D SWE played a potentially important role in predicting native liver survival (NLS) of BA patients with a C-index of 0.69 (0.63 to 0.75) in the training cohort and 0.76 (0.67 to 0.85) in the validation cohort. The nomogram A based on 2D SWE values, age, gamma-glutamyl transferase (GGT) and aspartate aminotransferase-to-platelet ratio (APRI) had a better C-index in the training cohort [0.74 (0.68-0.80) vs. 0.66 (0.60-0.73), P = 0.017] and in the validation cohort [0.78 (0.70-0.86) vs. 0.60 (0.49-0.71), P = 0.002] than the nomogram B (without 2D SWE). Using risk score developed from nomogram A, we successfully predicted 88.0% (22/25) of patients in the training cohort and 75.0% (9/12) in the validation cohort to have survival time of less than 12 months after KPE. Conclusion The combined nomogram model based on 2D SWE values, age, GGT and APRI prior to KPE can effectively predict NLS in BA infants.

To prospectively assess whether the detection of hepatic hilar lymph nodes (LNs) contributes to the diagnosis of biliary atresia (BA). A total of 80 jaundiced infants were enrolled in this study and had abdominal ultrasound (US). The hepatic hilar LNs, the gallbladder classification, and the triangular cord (TC) thickness of all infants were evaluated. The area under the receiver operating characteristic curve (AUROC) analysis, t tests, and chi-squared tests were used to compare US signs between infants with BA and those without BA. BA was found in 45 patients and excluded in 35 patients. The length of the hepatic hilar LNs in infants with BA (median with interquartile range, 11 mm (8, 13.5)) was significantly greater than that in infants without BA (0 mm (0, 0)) (p

OBJECTIVES The aim of this study was to evaluate the influence of fasting time on the ultrasound identification and exclusion of biliary atresia in jaundiced infants through the use of the gallbladder classification scheme and to test the value of the gallbladder classification scheme in the diagnosis of biliary atresia in inexperienced individuals. METHODS A total of 188 jaundiced infants were enrolled in this study. All patients received detailed abdominal sonograms. Diagnoses were confirmed via liver biopsy, surgical findings, or follow-up. Infants were grouped into either the fasting group (fasting time ≥ 4 h) or the nonfasting group (fasting time

OBJECTIVE This study aimed to evaluate the role of preoperative two-dimensional (2D) shear wave elastography (SWE) in assessing the stages of liver fibrosis in patients with suspected biliary atresia (BA) and compared its diagnostic performance with those of serum fibrosis biomarkers. MATERIALS AND METHODS This study was approved by the ethical committee, and written informed parental consent was obtained. Two hundred and sixteen patients were prospectively enrolled between January 2012 and October 2018. The 2D SWE measurements of 69 patients have been previously reported. 2D SWE measurements, serum fibrosis biomarkers, including fibrotic markers and biochemical test results, and liver histology parameters were obtained. 2D SWE values, serum biomarkers including, aspartate aminotransferase to platelet ratio index (APRi), and other serum fibrotic markers were correlated with the stages of liver fibrosis by METAVIR. Receiver operating characteristic (ROC) curves and area under the ROC (AUROC) curve analyses were used. RESULTS The correlation coefficient of 2D SWE value in correlation with the stages of liver fibrosis was 0.789 (p < 0.001). The cut-off values of 2D SWE were calculated as 9.1 kPa for F1, 11.6 kPa for F2, 13.0 kPa for F3, and 15.7 kPa for F4. The AUROCs of 2D SWE in the determination of the stages of liver fibrosis ranged from 0.869 to 0.941. The sensitivity and negative predictive value of 2D SWE in the diagnosis of ≥ F3 was 93.4% and 96.0%, respectively. The diagnostic performance of 2D SWE was superior to that of APRi and other serum fibrotic markers in predicting severe fibrosis and cirrhosis (all p < 0.005) and other serum biomarkers. Multivariate analysis showed that the 2D SWE value was the only statistically significant parameter for predicting liver fibrosis. CONCLUSION 2D SWE is a more effective non-invasive tool for predicting the stage of liver fibrosis in patients with suspected BA, compared with serum fibrosis biomarkers.

OBJECTIVE. The purpose of this study was to evaluate the feasibility of ultrasound (US)-guided percutaneous transhepatic cholangial drainage (PTCD) and consequent percutaneous US cholangiography in managing the dilated biliary tracts of children who have undergone hepatobiliary surgery. SUBJECTS AND METHODS. Sixteen children (11 boys, five girls; age range, 3-144 months) who underwent hepatobiliary surgery from December 2016 to October 2018 and had US evidence of biliary dilatation were included. All patients had undergone US-guided PTCD because of elevated postoperative serum bilirubin levels or bile duct infection. Immediately after the PTCD procedure, diluted sulphur hexafluoride microbubbles dispersion was injected through the PTCD tube to evaluate the anastomosis and the intrahepatic bile duct tree. Laboratory results, including those of serum bilirubin measurement, liver function tests, and routine blood tests, were evaluated before and after PTCD. Nine of 16 patients also underwent percutaneous transhepatic cholangiography (PTC). The percutaneous US cholangiography findings were evaluated and compared with the PTC findings. RESULTS. Liver enzyme levels decreased after PTCD with a statistically significant difference from the values before PTCD. Percutaneous US cholangiography showed that the anastomosis in 6 of the 16 patients (37.5%) was patent and depicted the morphologic featuresof intrahepatic bile duct tree in five of these patients. In the other 10 patients, the anastomosis was completely obstructed, and percutaneous US cholangiography depicted the morphologic features of intrahepatic bile duct tree in eight patients. In the nine patients who underwent PTC, the percutaneous US cholangiographic findings were the same as the PTC findings. CONCLUSION. US-guided PTCD is helpful in relieving jaundice and inflammation in children who have undergone hepatobiliary surgery and have biliary dilatation. Findings at consequent percutaneous US cholangiography are comparable to those of PTC in depicting the anastomosis in these patients.

Background This prospective study is to evaluate the potential value of sonographic measurements in the flaccid penis for the screening of arteriogenic impotence. Methods A consecutive series of 260 Chinese males consulting for sexual dysfunction and 54 controls underwent sonographic examination. The sonographic parameters were correlated with the clinical gold standards, including the international index of erectile function (IIEF) and penile erectile hardness grading scale (EHGS). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the receiver operating characteristic curve (AUROC) of flaccid peak systolic velocity (PSV) in predicting patients with normal function were analyzed. Results The mean cavernous PSV of both sides in the patients with sexual dysfunction ranged from 7.76 to 11.12 cm/sec with a stepwise increase in IIEF and EHGS grading scale (P

To investigate the combined use of ultrasound together with clinical features to differentiate infantile hepatic hemangioma (IHH) from other focal liver lesions (FLLs) in children and to compare the efficacy of the combined method to that of CECT/MRI.The location, number, size and appearance of the tumors were evaluated in 45 children with IHH. Another 45 children with FLL were randomly selected as a control group. Independent factors for predicting IHH versus FLLs were evaluated. The diagnostic performance of the clinical and ultrasound features was compared with CECT/MRI.Compared with the control FLL group, the IHH group had a younger age at diagnosis (P = 0.008), lower alpha-fetoprotein (AFP) levels (P = 0.000), smaller lesion sizes (P = 0.000), and a higher tumor proportion with a resistance index (RI) of0.7. Multiple logistic regression analysis showed that age, size, RI and AFP were independent factors for predicting IHH. Receiver operating characteristic (ROC) curve analysis showed that the AUC (area under the curve) of the four combined independent factors was 0.881 (95% CI: 0.744-0.960), while the AUC for the CECT/MRI method was 0.905 (95% CI: 0.774-0.973), and the combined AUC for the independent factors and CECT/MRI was 0.929 (95% CI: 0.805-0.985). There were not statistically significant among the three AUCs (P 0.05).CECT/MRI was the effective diagnostic indicator for IHH. However, the combined clinical and ultrasound diagnoses, including age at diagnosis, lesion size, RI and AFP, can achieve the same effectiveness as CECT/MRI.

Purpose To evaluate the feasibility of ultrasonographically (US) guided percutaneous cholecystocholangiography (PCC) for early exclusion of biliary atresia (BA) in infants suspected of having BA with equivocal US findings or indeterminate type of BA and a gallbladder longer than 1.5 cm at US. Materials and Methods This study was approved by the ethics committee; written informed parental consent was obtained. From February 2016 to December 2016, nine infants (four boys, five girls; mean age, 60.2 days; median age, 57 days; age range, 23-117 days) with conjugated hyperbilirubinemia and gallbladder longer than 1.5 cm at US were referred for US-guided PCC after US findings were equivocal for BA (n = 7) or the type of BA was unclear (n = 2). PCC was performed with a US machine with incorporated contrast pulse sequencing, contrast-specific software, and a linear transducer by injecting diluted contrast material via an 18-gauge needle. Images from US and US-guided PCC were evaluated in consensus by two radiologists. US criteria for BA were fibrotic cord sign (2 mm) and gallbladder length-to-width ratio greater than 5.2. BA was excluded at PCC when contrast material was visualized in the gallbladder, common hepatic ducts, and common bile duct and during passage to the duodenum. Patients in whom BA was diagnosed after PCC underwent surgery or liver biopsy as the reference standard. Nonparametric and Fisher exact tests were used. Results US-guided PCC was successful in all patients. There were no procedural-related complications. BA was excluded in five of the nine patients. The median serum direct bilirubin level in these patients slightly decreased 1 week after PCC, from 91.1 μmol/L (interquartile range [IQR], 81.6-113.8 μmol/L) to 65.3 μmol/L (IQR, 57.8-74.7 μmol/L); however, this difference was not statistically significant (P = .062). BA was diagnosed in four patients, with the diagnosis confirmed at surgery (n = 2) or liver biopsy (n = 2). BA in two patients with unclear type of BA was defined as type III without patency of the common bile duct in one patient and as type III with patency of the common bile duct in the other. Conclusion In this highly selected group of infants with indeterminate type of BA or inconclusive US findings, US-guided PCC enabled the diagnosis of BA in four infants and the exclusion of BA in five. US-guided PCC may be a safe and effective tool to exclude BA early in infants with equivocal US findings.

To prospectively assess the diagnostic performance of supersonic shear wave elastography (SSWE) in identifying biliary atresia (BA) among infants with conjugated hyperbilirubinaemia by comparing this approach with grey-scale ultrasonography (US).Forty infants were analysed as the control group to determine normal liver stiffness values. The use of SSWE values for identifying BA was investigated in 172 infants suspected of having BA, and results were compared with the results obtained by grey-scale US. The Mann-Whitney U test, unpaired t-test, Spearman correlation and linear regression were also performed.The success rates of SSWE measurements in the control and study group were 100% (40/40) and 96.4% (244/253), respectively. Age, direct bilirubin, and indirect bilirubin all significantly correlated with SSWE in the liver (all P0.001). Linear regression showed that age had a greater effect on SSWE values than direct or indirect bilirubin. The diagnostic performance of liver stiffness values in identifying BA was lower than that of grey-scale US (area under the receiver operating characteristic curve [AUC], 0.790 vs 0.893, P0.001).SSWE is feasible and valuable in differentiating BA from non-BA. However, its diagnostic performance does not exceed that of grey-scale US.• SSWE could be successfully performed in an infant population. • For infants, the liver stiffness will increase as age increases. • SSWE is potentially useful in assessing infants suspected of biliary atresia. • SSWE is inferior to grey-scale US in identifying biliary atresia.

The purpose of this study was to retrospectively compare the imaging features of hepatic epithelioid angiomyolipoma (HEAML) to those of hepatocellular carcinoma negative for hepatitis B surface antigen and hepatitis C antibody (NBNC-HCC) on contrast-enhanced ultrasound (CEUS) with sulphur hexafluoride microbubbles.Twenty-two patients (4 men, 18 women) with a mean age of 42.6±10.2 (SD) years (range: 22-63 years) with histopathologically confirmed HEMAL were included in the study. Forty-four patients (30 men, 14 women) with a mean age of 57.3±15.9 years (range: 19-85 years) with histopathologically confirmed NBNC-HCC were randomly selected from our institution's database as a control group. The CEUS characteristics of the two groups were compared.On conventional ultrasound, significant differences in tumor diameter were found between HEAML (4.0±2.0 [SD] cm; range: 1.3-8.9cm) and NBNC-HCC (8.4±4.4 [SD] cm; range: 1.6-18cm) (P0.001) as well as in degrees of enhancement during the portal (P=0.001) and late phases (P=0.003), contrast distribution (P0.001) and absence of pseudocaspule (P0.001). On CEUS, hyperenhancement during the arterial phase was observed in 21/22 (95.5%) HEAMLs and in 43/44 (97.7%) NBNC-HCCs (P0.999). Homogeneous enhancement was more frequent in HEAMLs (20/22; 90.9%) than in NBNC-HCCs (13/44; 29.6%) (P0.001). Pseudocapsule was observed in 0/22 HEAMLs (0.0%) and in 36/44 NBNC-HCCs (81.8%) (P=0.017). A prolonged enhancement was observed in 5/22 HEAMLs (22.7%) and in 0/44 NBNC-HCCs (0.0%) (P0.001) during the late phase.CEUS with sulphur hexafluoride microbubbles is helpful in discriminating between HEAML and NBNC-HCC. Homogeneous enhancement and lack of pseudocapsule are suggestive features for the diagnosis of HEAML.

We aimed to investigate the feasibility of quantitative Sonazoid contrast-enhanced ultrasound (CEUS) in the diagnosis of biliary atresia (BA) at an early disease stage. First, liver tissue from 10 patients with BA and 10 patients with infantile hepatitis syndrome (IHS) was immunostained with cluster of differentiation 68 (CD68) to compare Kupffer cell counts. Then, quantitative Sonazoid CEUS was performed to evaluate the hyperplasia of the artery branches during the artery phase and changes in Kupffer cell counts during the Kupffer phase in a rat model of BA (common bile duct ligation). Based on our results, liver enhancement from Kupffer cells in BA patients was significantly higher than that in IHS patients (p = 0.0260.05). Furthermore, quantitative CEUS showed that the liver enhancement intensity of rats with bile duct ligation was substantially greater than that of rats without bile duct ligation during the artery phase 3 d post-operation and the Kupffer phase 5 d post-operation. The increased enhancement intensity in the Kupffer phase was in agreement with the increase in Kupffer cell counts in pathologic staining (18/20, 90%). In conclusion, quantitative Sonazoid CEUS can detect the hyperplasia of artery branches in artery phase and the increase of Kupffer cells in Kupffer phase in the liver of BA rats at an early disease stage. Therefore, Sonazoid CEUS could potentially be a valuable non-invasive alternative for the diagnosis of BA.

The purpose of this meta-analysis was to summarize the evidence on the accuracy of various ultrasound findings for excluding a diagnosis of biliary atresia.We searched MEDLINE and the Web of Science databases for the period from January 1990 to May 2015. To be included, studies had to satisfy two criteria. First, the data needed to include 2 × 2 contingency data on the diagnostic accuracy of ultrasound in identifying biliary atresia in at least 10 patients with and 10 patients without disease. Second, the study needed to use surgery or biopsy for biliary atresia and surgery, biopsy, clinical follow-up, or some combination of the three as the reference standard for the exclusion of biliary atresia. The methodologic quality of each study was assessed with version 2 of the Quality Assessment of Diagnostic Accuracy Studies tool. Estimated sensitivity and specificity of each ultrasound characteristic were calculated using a random-effects model.Twenty-three studies published during 1998-2015 were included. Summary sensitivity and specificity were 0.85 (95% CI, 0.76-0.91) and 0.92 (95% CI, 0.81-0.97), respectively, for gallbladder abnormalities in 19 studies; 0.74 (95% CI, 0.61-0.84) and 0.97 (95% CI, 0.95-0.99), respectively, for triangular cord sign in 20 studies; and 0.95 (95% CI, 0.70-0.99) and 0.89 (95% CI, 0.79-0.94), respectively, for the combination of the triangular cord sign and gallbladder abnormalities in five studies. Subgroup analysis of an absent gallbladder in 10 studies yielded a summary specificity of 0.99 (95% CI, 0.93-1.00).The triangular cord sign and gallbladder abnormalities are the two most accurate and widely accepted ultrasound characteristics for diagnosing or excluding biliary atresia. Other ultrasound characteristics are less valuable for diagnosis or exclusion of biliary atresia.

Aim A meta-analysis was carried out to assess the accuracies of shear wave speed imaging (SWSI) in predicting significant fibrosis (stages F2–4) and cirrhosis (stage F4). Methods A review was performed of relevant studies published until October 2015. A bivariate binomial model was used to combine the sensitivity, specificity, and the area under the summary receiver operating characteristic (AUC), and 95% confidence intervals were derived to indicate the diagnostic accuracy of imaging modalities. Results In total, 10 studies with 2182 patients were included in the analysis. The sensitivity, specificity, and AUC (with 95% confidence intervals) of SWSI were: 0.84 (0.81–0.87), 0.83 (0.77–0.88), and 0.88 (0.85–0.90) for significant fibrosis, respectively; and 0.80 (0.66–0.89), 0.93 (0.88–0.96), and 0.95 (0.92–0.96) for cirrhosis, respectively. When SWSI was compared with well-evaluated transient elastography, the AUCs for the prediction of significant fibrosis were 0.93 and 0.86, respectively. The AUCs for the prediction of cirrhosis were both 0.94. Conclusion Shear wave speed imaging is a trustworthy tool for staging hepatic fibrosis, with a high combination of sensitivity and specificity. Compared with transient elastography, SWSI showed better diagnostic performance for the prediction of significant fibrosis.

To prospectively investigate the usefulness of acoustic structure quantification (ASQ) for noninvasive assessment of liver fibrosis in patients with chronic hepatitis B (CHB). Consecutive patients with CHB scheduled for liver biopsy or partial liver resection underwent standardized ASQ examinations. The ASQ parameter, named focal disturbance (FD) ratio, were compared with METAVIR scores. The analysis was based on receiver operating characteristic (ROC) curves and multiple regression analysis. A total of 114 patients were enrolled in the final analysis. The area under the ROC curve for the FD ratio was 0.84 for significant fibrosis (≥ F2), 0.86 for severe fibrosis (≥ F3), and 0.83 for cirrhosis (= F4). The optimal cutoff values for the FD ratio were 0.25, 0.30 and 0.50 for fibrosis stages ≥ F2, ≥ F3 and = F4, respectively. The prevalence of a difference of at least two stages between the FD ratio and the histological stage was 12.3 % (14 of 114). The fibrosis stage (P

Purpose To evaluate the diagnostic performance of ultrasonography (US) in the identification and exclusion of biliary atresia with a modified triangular cord thickness metric together with a gallbladder classification scheme, as well as hepatic artery (HA) diameter and liver and spleen size, in a large sample of jaundiced infants. Materials and Methods The ethics committee approved this study, and written informed parental consent was obtained. In 273 infants with conjugated hyperbilirubinemia (total bilirubin level ≥ 31.2 μmol/L, with direct bilirubin levelindirect bilirubin level), detailed abdominal US was performed to exclude biliary atresia. Biliary atresia was found in 129 infants and ruled out in 144. A modified triangular cord thickness was measured at the anterior branch of the right portal vein, and a gallbladder classification scheme was identified that incorporated the appearance of the gallbladder and a gallbladder length-to-width ratio of up to 5.2 when the lumen was visualized, as well as HA diameter and liver and spleen size. Reference standard diagnosis was based on results of one or more of the following: surgery, liver biopsy, cholangiography, and clinical follow-up. Area under the receiver operating characteristic curve (AUC) analysis, binary logistic regression analysis, Fisher exact test, and unpaired t test were performed. Results Triangular cord thickness, HA diameter, ratio of gallbladder length to gallbladder width, liver size, and spleen size exhibited statistically significant differences (all P.05) between the group with biliary atresia and the group without. AUCs of triangular cord thickness, ratio of gallbladder length to width, and HA diameter were 0.952, 0.844, and 0.838, respectively. Logistic regression analysis demonstrated that these three US parameters were significantly associated (all P.05) with biliary atresia. The combination of triangular cord thickness and gallbladder classification could yield comparable AUCs (0.915 vs 0.933, P = .400) and a higher sensitivity (96.9% vs 92.2%), compared with triangular cord thickness alone. Conclusion By using the combination of modified triangular cord thickness and gallbladder classification scheme, most infants with biliary atresia could be identified. (©) RSNA, 2015.

OBJECTIVES The purpose of this study was to prospectively evaluate the value of sonography in working up or ruling out malrotation by 3 sonographic features (inversion of the superior mesenteric artery and superior mesenteric vein, the whirlpool sign, and an intraperitoneal transverse duodenum) and comparing it with an upper gastrointestinal (GI) contrast study. METHODS A total of 70 pediatric patients who underwent detailed abdominal sonography to rule out intestinal malrotation were included. Twenty-three of them also underwent an upper GI contrast study. Surgery or clinical follow-up was taken as the reference standard. Statistical analysis was performed with the χ(2) test. RESULTS Twenty-three patients had a diagnosis of malrotation by surgical findings. With the combination of all 3 sonographic features, the sensitivity, specificity, and accuracy of sonography for determining malrotation were 100% (23 of 23), 97.8% (46 of 47), and 98.6% (69 of 70), respectively, whereas the sensitivity, specificity, and accuracy of the upper GI study were 40% (4 of 10), 64.3% (9 of 14), and 56.5% (13 of 23; P < .001). Combined anomalies in 2 patients and complications in 2 patients were also detected by sonography. CONCLUSIONS By combining inversion of the superior mesenteric artery and superior mesenteric vein, the whirlpool sign, and an intraperitoneal transverse duodenum, sonography might be more valuable for accurately working up or ruling out pediatric malrotation than an upper GI contrast study. In addition, sonography could provide extra information, such as combined anomalies and intestinal necrosis, to help management.

We report a case of a 32-year-old woman who presented with upper abdominal pain. The physical examination revealed a palpable hard mass with a well-demarcated lower margin. Laboratory tests indicated hepatitis B viral infection. Computed tomography scan with intravenous contrast depicted a huge well-demarcated heterogeneous mass at the porta hepatis with irregular peripheral rim enhancement. Contrast-enhanced ultrasound showed peripheral irregular hyper-enhancement in the artery phase and hypo-enhancement in the portal and late phases. The postoperative histopathologic examination confirmed the diagnosis of low-grade chondrosarcoma. This is the first report of contrast-enhanced ultrasound findings of chondrosarcoma. There is some differential diagnosis to be discussed.

Metastasis of breast cancer into the gastrointestinal tract happens rarely. The diagnosis of this kind of disease is difficult because of the nonspecific symptoms and the long interval between primary manifestations and recurrence. Awareness of this condition may lead to an accurate diagnosis and an earlier initiation of systemic treatment, thus avoiding unnecessary surgical intervention. In this paper, we report a rare case of a patient with tubulolobular carcinoma metastases to the colon, presenting with abdominal pain, discomfort, and weight loss. The patient underwent radical mastectomy and received postoperative radiotherapy and chemotherapy. Ten years later, she presented with gastrointestinal tract symptoms. Surgery combined with systemic treatment was chosen for the colon lesion. Immunohistochemical staining suggested a breast origin. The patient was still living 24 months after the diagnosis of the metastasis. This is the fourth case report in our literature review.

This study aimed to summarize the first experience with ultrasound-guided percutaneous ablation treatment (PAT) for recurrent hepatoblastoma (HB) after liver resection in children. From August 2013 to October 2014, PAT was used to treat 5 children with a total of 8 recurrent HB (mean size, 1.4 ± 0.8 cm; size range, 0.7–3.1 cm), including 4 patients with 7 tumors in the liver and 1 patient with 1 tumor in the lung. Technical success was achieved in all patients (5/5, 100%). The complete ablation rate after the first ablation session was 80% (4/5) on a patient-by-patient basis and 87.5% (7/8) on a tumor-by-tumor basis. Only 1 patient developed a fever with temperature >39 °C; it lasted 4 days after radiofrequency ablation (RFA) and was resolved by conservative therapy. During the follow-up period, new intrahepatic recurrences after PAT were detected in two patients. One died due to tumor progression 4 months after ablation. The median overall survival time after PAT was 13.8 months. PAT is a safe and promising therapy for children with recurrent HB after liver resection, and further investigation in large-scale randomized clinical trials is required to determine its role in the treatment of this disease.

To explore an effective noninvasive tool for monitoring liver fibrosis of children with biliary atresia (BA) is important but evidences are limited. This study is to investigate the predictive accuracy of supersonic shearwave elastography (SSWE) in liver fibrosis for postoperative patients with BA and to compare it with aspartate aminotransferase to platelet ratio index (APRI) and fibrosis-4 (FIB-4). 24 patients with BA received SSWE and laboratory tests before scheduled for liver biopsy. Spearman rank coefficient and receiver operating characteristic (ROC) were used to analyze data. Metavir scores were F0 in 3, F1 in 2, F2 in 4, F3 in 7 and F4 in 8 patients. FIB-4 failed to correlate with fibrosis stage. The areas under the ROC curves of SSWE, APRI and their combination were 0.79, 0.65 and 0.78 for significant fibrosis, 0.81, 0.64 and 0.76 for advanced fibrosis, 0.82, 0.56 and 0.84 for cirrhosis. SSWE values at biopsy was correlated with platelet count (r = −0.426, P = 0.038), serum albumin (r = −0.670, P P = 0.041) and direct bilirubin levels (r = 0.518, P = 0.010) measured at 6 months after liver biopsy. Our results indicate that SSWE is a more promising tool to assess liver fibrosis than APRI and FIB-4 in children with BA.

The goal of the work described here was to evaluate the diagnostic efficacy of 2-D shear wave elastography (2-D SWE) in differentiating malignancy from benign focal liver lesions (FLLs). The maxima, minima, means and the standard deviations of 2-D SWE measurements, expressed in kilopascals (Emax, Emin, Emean, ESD), were obtained for 221 patients with 229 FLLs. Receiver operating characteristic curve analysis was performed to evaluate the diagnostic performance of 2-D SWE. The Mann-Whitney U-test was used to assess inter-group differences. Emax, Emin, Emean and ESD were significantly higher in the 164 malignant lesions than in the 65 benign lesions (p

To evaluate the diagnostic performance of quantitative analysis as an adjunctive diagnostic tool to contrast-enhanced ultrasound (US) for the differentiation of atypical benign focal liver lesions (FLLs) from malignancies in fatty liver. Twenty-seven benign FLLs and fifty-six malignant FLLs that appeared hyper-enhanced during the arterial phase with washout in the portal or late phase in fatty liver were analyzed. Chi-square tests and logistic regression were applied to identify the specific features. Three sets of criteria were assigned: 1) all FLLs subjected to routine contrast-enhanced US; 2) all FLLs subjected to quantification analysis and contrast-enhanced US; and 3) parts of FLLs that could not be diagnosed using contrast-enhanced US (n = 66, 75.9%) but instead were diagnosed using parametric features. The sensitivity, specificity, accuracy and area under the receiver operating characteristic curve (AUC) of the three sets of criteria were analyzed. The AUCs of the criterion set 2 were significantly higher than those of criterion set 1 (0.904 versus 0.792, P = 0.008). Criterion set 3 showed a relatively high sensitivity (90.2%) with a relatively high AUC (0.845). The quantification analysis offers improved diagnostic performance for the differential identification of atypical benign FLLs from malignancies in fatty liver.

This study aimed to summarize the first experience with ultrasound-guided percutaneous ablation treatment (PAT) for recurrent hepatoblastoma (HB) after liver resection in children. From August 2013 to October 2014, PAT was used to treat 5 children with a total of 8 recurrent HB (mean size, 1.4 ± 0.8 cm; size range, 0.7–3.1 cm), including 4 patients with 7 tumors in the liver and 1 patient with 1 tumor in the lung. Technical success was achieved in all patients (5/5, 100%). The complete ablation rate after the first ablation session was 80% (4/5) on a patient-by-patient basis and 87.5% (7/8) on a tumor-by-tumor basis. Only 1 patient developed a fever with temperature >39 °C; it lasted 4 days after radiofrequency ablation (RFA) and was resolved by conservative therapy. During the follow-up period, new intrahepatic recurrences after PAT were detected in two patients. One died due to tumor progression 4 months after ablation. The median overall survival time after PAT was 13.8 months. PAT is a safe and promising therapy for children with recurrent HB after liver resection and further investigation in large-scale randomized clinical trials is required to determine its role in the treatment of this disease.

The purpose of this series was to preliminarily evaluate the use of contrast-enhanced sonographically guided percutaneous thermal ablation in the evaluation and treatment of solid-organ bleeding by retrospectively analyzing 6 cases observed in clinical practice. Six patients who underwent contrast-enhanced sonographically guided thermal ablation for treatment of solid-organ bleeding (5 in liver and 1 in spleen) from December 2005 to August 2012 were included in this series. Clinical information, contrast-enhanced sonograms before and after ablation, and the ablation method were retrospectively collected and analyzed. In 5 of the 6 patients, the location of the bleeding lesion was clearly seen. Hemostasis was successfully achieved in 4 of these 5 patients: 1 by radiofrequency ablation and 3 by microwave ablation. Ablation failed to achieve hemostasis in 1 patient who had postbiopsy splenic arterial bleeding because the bleeding vessel was a thick branch of the splenic artery. In the sixth remaining patient, who had bleeding after liver biopsy, hemostasis failed because contrast-enhanced sonography did not precisely locate the bleeding lesion; hence, the ablation zone did not cover the whole lesion. Contrast-enhanced sonographically guided ablation can be an alternative choice for treating solid-organ bleeding because of its effectiveness and minimal invasiveness. However, it should be carefully investigated for those in whom the bleeding lesion cannot be located by contrast-enhanced sonography and in those who have bleeding in a large vessel.

To evaluate the diagnostic performance of shear wave elastography (SWE) in the differentiation of malignant and benign thyroid nodules with coexistent Hashimoto's thyroiditis (HT).Case series with chart review.Tertiary general hospital.From September 2012 to January 2014, conventional ultrasound and SWE were performed on 243 patients with 286 thyroid nodules with histologic results. The HT group consisted of 93 patients with 117 nodules. The non-HT group consisted of 140 patients with 169 nodules.In the benign and malignant nodules, there were no significant differences of the mean, minimum, or maximum SWE values between HT and non-HT groups (P = .158-.945). However, SWE values of extranodular tissue were significantly higher in the HT group (P = .000-.011). In the HT group, the maximum SWE value showed the highest area under the receiver operating characteristic curve (0.817; 95% confidence interval, .735-.900), and there were no significant differences when compared with other SWE parameters (P = .669-.848). In the multivariate analysis, hypoechogenicity (odds ratio = 9.855, P = .002), microcalcification (odds ratio = 3.977, P = .046), and maximum SWE value (odds ratio = 40.712, P.001) were independent predictors of thyroid malignancy.SWE could be performed to obtain a differential diagnosis between malignant and benign thyroid nodules, including nodules with coexistent HT. Although all the SWE parameters within a 2-mm region of interest that was placed on the stiffest region could be applied, we suggest that the maximum value of nodules harbored within a Hashimoto's gland be used.

The aims of the present study are to assess the impact factors on acoustic structure quantification (ASQ) ultrasound and find the optimal parameter for the assessment of liver fibrosis. Twenty healthy volunteers underwent ASQ examinations to evaluate impact factors in ASQ image acquisition and analysis. An additional 113 patients with liver diseases underwent standardized ASQ examinations, and the results were compared with histologic staging of liver fibrosis. We found that the right liver displayed lower values of ASQ parameters than the left (p = 0.000–0.021). Receive gain experienced no significant impact except gain 70 (p = 0.193–1.000). With regard to different diameter of involved vessels in regions of interest, the group ≤2.0 mm differed significantly with the group 2.1–5.0 mm (p = 0.000–0.033) and the group >5.0 mm (p = 0.000–0.062). However, the region of interest size (p = 0.438–1.000) and depth (p = 0.072–0.764) had no statistical impact. Good intra- and inter-operator reproducibilities were found in both image acquisitions and offline image analyses. In the liver fibrosis study, the focal disturbance ratio had the highest correlation with histologic fibrosis stage (r = 0.67, p < 0.001). In conclusion, the testing position, receive gain and involved vessels were the main factors in ASQ examinations and focal disturbance ratio was the optimal parameter in the assessment of liver fibrosis.

To evaluate the diagnostic performance of two-dimensional shear wave elastography (2D-SWE) in distinguishing malignant from benign thyroid nodules.A total of 331 focal thyroid nodules from 271 patients scheduled for fine-needle aspiration or thyroid surgery were included. After a routine conventional ultrasound evaluation, 2D-SWE examinations were performed to obtain 2D-SWE measurements on a colour-coded mapping, which were then correlated with pathology results.A total of 230 nodules were benign and 101 were malignant on pathology. The areas under the receiver operating characteristic curve (AUC) of mean and minimum values in the largest region of interest (ROI) over the whole nodule, and mean, maximum and minimum values in 2-mm ROI over the stiffest area of the nodule were 0.794, 0.673, 0.808, 0.805 and 0.799, respectively. The most accurate cut-off value, 39.3 kPa, for mean value in a 2-mm ROI achieved 66.3 % sensitivity and 84.4 % specificity to discriminate malignancy. Nodule size correlated with 2D-SWE value for malignant nodules (P 0.01). In the group of nodules ≤10 mm, the AUC was 0.730, while it was 0.883 in nodules sized 11-30 mm and 0.821 in nodules30 mm.2D-SWE is a promising diagnostic tool for discriminating malignant thyroid nodules, although the performance for nodules ≤10 mm is not satisfactory.

Visceral artery aneurysms have a potential possibility of rupture with life-threatening hemorrhage, and prompt detection and optimal treatment are required clinically. Actually, abdominal ultrasound plays a major role in detection of visceral artery aneurysms. Besides, the administration of contrast agents can highly improve the characterization of the lesion. Herein, we present two cases of giant peripancreatic artery aneurysm with emphasis on contrast-enhanced ultrasound (CEUS). Case 1 was a 54-year-old asymptomatic man who was diagnosed with a 12.1 cm × 5.2 cm splenic artery aneurysm in the absence of a clear etiologic factor. Case 2 was a 37-year-old man with a 6.3 cm × 5.3 cm pancreaticoduodenal artery pseudoaneurysm associated with chronic pancreatitis. Both diagnoses were confirmed by contrast-enhanced computer tomography (CECT) and digital subtracted angiography (DSA). Transcatheter embolization occlusion using coiling was successfully performed for both cases. Postoperative computed tomography angiography (CTA) showed complete occlusion. It is suggested that CEUS seems to be a promising diagnostic option and contributes to preoperative treatment planning for patients with peripancreatic artery aneurysm.

To comparatively evaluate shear wave elastography (SWE) and real-time elastography (RTE) in distinguishing malignant from benign thyroid nodules.49 patients with 64 focal thyroid nodules were enrolled and underwent SWE and RTE before surgery. SWE elasticity indices (mean, minimum and maximum value of 2-mm region of interest) of nodules were measured. For RTE, elastograms were assessed by Rago criteria and nodules with scores of 4 or 5 were classified as suspicious for malignancy. Surgery histopathologic results were adopted as diagnostic standard.Of the 64 nodules, 19 were papillary thyroid carcinomas and 45 were benign. SWE indices were significantly higher in malignant than benign nodules (P0.05). Areas under the ROC curves (AUC) of SWE parameters were 0.840, 0.831 and 0.788, which were not significantly different from that of RTE showed as 0.880 (P=0.148-0.482). When the most accurate cut-off, 38.3kPa for mean value was applied to predict malignancy, the diagnostic specificity, sensitivity, accuracy, positive predictive value and negative predictive value of SWE and RTE were 68.4% versus 79.0%, 86.7% versus 84.4%, 81.3% versus 78.1%, 68.4% versus 64.7% and 86.7% versus 83.3%, respectively (P=0.683-1.000).SWE as a promising tool can be performed in differentiating thyroid nodules with comparable results to RTE.

To investigate and compare contrast-enhanced ultrasound (CEUS) in the characterisation of histologically proven focal nodular hyperplasia (FNH) with contrast-enhanced computed tomography (CECT). CEUS was performed in 85 patients with 85 histologically proven FNHs. Enhancement, centrifugal filling, spoke-wheel arteries, feeding artery and central scarring were reviewed and correlated with lesion size or liver background. Independent factors for predicting FNH from other focal liver lesions (FLLs) were evaluated. Forty-seven FLLs with CECT were randomly selected for comparison of diagnostic performance with CEUS. Centrifugal filling was more common (P = 0.002) and the significant predictor (P = 0.003) in FNHs ≤3 cm. Lesion size or liver background has no significant influence on the detection rate of the spoke-wheel arteries and feeding artery (P > 0.05). Central scarring was found in 42.6 % of FNHs ≥3 cm (P = 0.000). The area under the ROC curve, sensitivity and specificity showed no significant differences between CEUS and CECT (P > 0.05), except that the sensitivity of CEUS was better for reader 1 (P = 0.041). CEUS is valuable in characterising centrifugal filling signs or spoke wheels in small FNHs and should be employed as the first-line imaging technique for diagnosis of FNH. • The confident diagnosis of focal nodular hyperplasia is important in liver imaging. • The centrifugal filling sign is useful for diagnosis of FNHs ≤3 cm. • Contrast-enhanced ultrasound and contrast-enhanced CT have similar diagnostic performance for FNH. • CEUS should be the first-line imaging technique for the diagnosis of FNH.

OBJECTIVES To prospectively evaluate the objective differential characteristics between cystic biliary atresia and choledochal cysts on sonography among neonates and young infants. METHODS Twenty-three patients who had sonographic findings of a portal cyst and a final diagnosis were included. Their final diagnoses were cystic biliary atresia in 12 patients and choledochal cysts in 11. All of them underwent detailed sonographic scanning. Data for cystic biliary atresia and choledochal cyst groups were compared by the χ(2) test for categorical variables and an unpaired t test for continuous variables. RESULTS The triangular cord sign was detected in 11 patients in the atresia group but in none in the cyst group (P < .001). Nine of 11 patients in the cyst group had dilatation of intrahepatic bile ducts, whereas none in the atresia group had that feature (P < .001). Sonography also showed sludge deposits in the cysts in 6 of 11 patients in the cyst group, whereas none in the atresia group had sludge deposits (P = .005). The mean width and length of the cysts in the cyst group were significantly larger than those in the atresia group (P< .05 for both). The mean hepatic artery diameter was significantly larger in the atresia group than in the cyst group (P < .001). The difference in gallbladder abnormalities between the atresia (n = 11) and cyst (n = 0) groups was also significant (P < .001). When all specific sonographic features were used, all patients were correctly classified into the atresia and cyst groups. CONCLUSIONS The triangular cord sign, intrahepatic bile duct dilatation, and echoic cysts might be regarded as objective sonographic features for differentiating cystic biliary atresia and choledochal cysts. Other sonographic features might be very supportive.