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ZusammenfassungIn der Abklärung von hepatozellulären Karzinomen (HCCs) bei Hochrisikopatienten wurde zur standardisierten Befundung und Dokumentation der Kontrastmittel-Computertomografie (CECT) und Kontrastmittel-Magnetresonanztomografie (CEMRT) vor wenigen Jahren das „Liver Imaging Reporting and Data System” (LI-RADS) durch das American College of Radiology (ACR) erstellt. Die LI-RADS-Kategorisierung wird zur Klassifikation von Leberläsionen in der Leberzirrhose als sicher benigne (LR-1), intermediär (LR2 – 4) bis zu „definitiv HCC“ (LR-5) beurteilt. Seit 2014 wurde die LI-RADS-Klassifikation durch eine Arbeitsgruppe von internationalen Radiologen und Hepatologen auf die Kontrastmittelsonografie erweitert. Zeitgleich mit der Zulassung des Kontrastmittels SonoVue™ (in den USA Lumason™) wurde die Klassifikation 2016 in die LI-RADS Kategorisierung integriert und wird in diesem Artikel erläutert (CEUS-LI-RADS).

The aim of the series of papers on controversies of biliopancreatic drainage procedures is to discuss the pros and cons of the varying clinical practices and techniques in ERCP and EUS for drainage of biliary and pancreatic ducts. The first part focuses on indications, clinical and imaging prerequisites before ERCP, sedation options, post-ERCP pancreatitis (PEP) prophylaxis, and other related technical topics. In the second part, specific procedural ERCP-techniques including precut techniques and its timing as well as management algorithms are discussed. In addition, controversies in EUS-guided bile duct and pancreatic drainage procedures are under preparation.

The aim of the series of papers on controversies of biliopancreatic drainage procedures is to discuss pros and cons of the varying clinical practices and techniques in ERCP and EUS for drainage of biliary and pancreatic ducts. While the first part focuses on indications, clinical and imaging prerequisites prior to ERCP, sedation options, post-ERCP pancreatitis prophylaxis, and other related technical topics, the second part discusses specific procedural ERCP techniques including precut techniques and their timing as well as management algorithms. In addition, reviews on controversies in EUS-guided bile duct and pancreatic drainage procedures are under preparation.

Patients with unresectable pancreatic cancer have a poor prognosis. The analysis of prognostic factors before treatment may be helpful in determining the best therapeutic strategies. The aim of the PEACE study is to assess the vascularity of pancreatic malignant tumors using contrast-enhanced harmonic EUS (CEH-EUS) and to clarify the prognostic value of tumor vascularity in patients with locally advanced and metastatic pancreatic cancer. Hereby, we present the protocol of a prospective, nonrandomized, single-arm, multicenter study aiming to assess changes in tumor vascularity using CEH-EUS before and 2 months after treatment initiation in patients with unresectable, locally advanced/metastatic pancreatic cancer and to examine the correlation between vascular changes and treatment response, progression-free survival, and overall survival.

Ultrasonography is a ubiquitous and indispensable diagnostic and therapeutic tool in medicine. Due to modern equipment and automatic image optimization, nowadays the introduction of ultrasound imaging requires only little technical and physical knowledge. However, profound knowledge of the device function repertoire and underlying mechanisms are essential foroptimal image adjustment and documentation. From a medical as well as an aesthetic point of view, the goal should always be to achieve the best possible image quality. This article provides an overview of handling of ultrasound systems, fundamental adjustments and their optimization in Doppler ultrasound.

In Ergänzung zum ersten Teil dieser Übersicht, der auf sonografisch gestützte Interventionen in der Palliativmedizin fokussierte, erläutert die vorliegende Arbeit Indikationen und Möglichkeiten der Sonografie in der Palliativmedizin unter vier wesentlichen Aspekten

“How to perform contrast-enhanced ultrasound (CEUS)” provides general advice on the use of ultrasound contrast agents (UCAs) for clinical decision-making and reviews technical parameters for optimal CEUS performance. CEUS techniques vary between centers, therefore, experts from EFSUMB, WFUMB and from the CEUS LI-RADS working group created a discussion forum to standardize the CEUS examination technique according to published evidence and best personal experience. The goal is to standardise the use and administration of UCAs to facilitate correct diagnoses and ultimately to improve the management and outcomes of patients.

Background: Fusion imaging is an accepted method in abdominal imaging allowing a simultaneous display of reference imaging with a live ultrasound (US) investigation. For prostate cancer, promising results have been published for endorectal US (ERUS)-guided biopsy of suspicious lesions in magnetic resonance imaging (MRI). To our knowledge, no other indication for the fusion of ERUS with MRI has been reported so far. Methods: We report on three patients scheduled for ERUS due to anorectal fistulae after treatment (n = 2) or rectal carcinoma (n = 1), which were scheduled for real-time virtual onography (RVS), a method for the fusion of MRI imaging with US. Results: In all patients, RVS was successful. The course of the fistulae could be defined and the success of the treatment could be confirmed. In the patient with rectal carcinoma, the lymph nodes suspicious in MRI could be identified. Conclusions: MRI/ERUS fusion has the potential for follow-up of anorectal fistulae and abscesses, and staging of anal and rectal tumors.

Hepatic (biliary) cystic tumor (HBCT) is a rare focal cystic liver lesion, which has been rarely described in the literature. In our current multicenter, retrospective study, we aimed to analyze contrast enhanced ultrasound (CEUS) features and its diagnostic performance in histologically proved HBCT.Twenty-three patients with single HBCT were retrospectively analyzed. Histologically, 17 (73.9%) were benign hepatic (biliary) cystadenoma (HBCA), 6 (26.1%) were hepatic (biliary) cystadenocarcinoma (HBCAC). All CEUS examinations were assessed by two independent radiologists in consensus. Criteria of CEUS imaging evaluation included the contrast enhancement pattern of lesion (hypoenhancing, hyperenhancing, isoenhancing in comparison to the surrounding liver parenchyma) during the arterial, portal venous and late phases.After injection of ultrasound contrast agents, most of the HBCTs (78.3%, 18/23) had typical honeycomb enhancement pattern of the cystic wall, septa or mural nodules. Comparing between HBCA and HBCAC, hyperenhancement of the honeycomb septa during the arterial phase was more common in HBCA (p = .047). However, hypoenhancement during the portal venous and late phases was the characteristic of HBCAC (p = .041).The EFSUMB algorithm for CEUS for characterization of solid focal liver lesions is also applicable to HBCT. CEUS evaluation can avoid further diagnostic investigations or invasive biopsy procedure.

Background and aims: The introduction of a new type of small handheld ultrasound device brings greater portability and affordability in a different setting. The basic ultrasound approach with these handheld devices has been defined by European Federation of Societies of Ultrasound in Medicine and Biology (EFSUMB) as “EchoScopy”. The current study aimed to assess the image quality, indications and limitations of a portable pocket “EchoScopy” performed first compared with a high-end ultrasound system (second) in abdominal diseases.Material and methods: Three hundred consecutive patients (158 males and 142 females, age 55±19 [18-96]) years) were included. The ultrasound examinations were performed firstly by an EchoScope (Vscan™ Dual Probe) and secondly with a high-end ultrasound system (HEUS, GE Logiq E9). Compared with the always excellent image quality using HEUS, the image quality of the EchoScope was graded as good, sufficient or non-sufficient.Results: Out of all 300 patients, 221 had focal lesions, 31 patients were found with diffuse pathological findings, 20 with ascites, 25 after liver puncture and 45 without any pathological findings. The image quality of the pocket device was considered as being good or sufficient to delineate the pathology in 265/300 (88%). The detection rate of the EchoScope for abdominal focal lesion was 172/221 (78%). The higher frequency of the Dual Probe was helpful in 35/300 (12%).Conclusions: EchoScopy has proven to display sufficient image quality to answer specific questions, e.g., detection of ascites, splenomegaly, bile duct enlargement, hydronephrosis and other pathological findings which can be judged by “yes/no”.

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

This is the second part of the series on interventional ultrasound guidelines of the Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). It deals with the diagnostic interventional procedure. General points are discussed which are pertinent to all patients, followed by organ-specific imaging that will allow the correct pathway and planning for the interventional procedure. This will allow for the appropriate imaging workup for each individual interventional procedure (Long version).

Local ablative therapies have become an important part in the portfolio of treatment for patients with malignant tumors especially in the liver. Although percutaneous ethanol injection still plays a role, current guidelines favor radiofrequency ablation with a higher efficacy for complete tumor destruction. Nevertheless transplantation and surgical resection remain the gold standard due to their superiority in local control and improved survival. In this manuscript we discuss the technique in detail.

Die vorliegende Arbeit erlautert Indikationen und Moglichkeiten sonografischer Interventionen in der Palliativmedizin.

Background and Objectives: Autoimmune pancreatitis (AIP) remains a difficult disease to diagnose before treatment, particularly if presenting as a focal mass lesion. The purpose of this multicenter retrospective study is to analyze imaging features of histologically confirmed AIP to determine the additional diagnostic value of contrast-enhanced ultrasound (CEUS), contrast-enhanced endoscopic ultrasound (CE-EUS), and elastography to B-mode features. Patients and Methods: We report on a retrospective data collection of 60 histologically confirmed cases of AIP in comparison to 16 patients with pancreatic adenocarcinomas (PDAC). All CE (-E) US examinations were assessed by two independent readers in consensus. The role of CEUS and CE-EUS for pancreatic evaluation was defined according to the 2011 European Federation of Societies for Ultrasound in Medicine and Biology guidelines. Results: After injection of ultrasound (US) contrast agents, most AIP lesions displayed focal or diffuse isoenhancement (86.6%) in the arterial phase, while most of the PDAC lesions (93.7%) were hypoenhancing (P < 0.01). During the late phase, most AIP lesions were hyper-(65%) or iso-enhancing (35%), while most PDAC lesions were hypoenhancing (93.7%). CE-EUS was performed in a subset of ten patients and showed hyperenhancement in all AIP cases. Most focal AIP lesions (n = 27, 79.4%) were stiffer than the surrounding pancreatic parenchyma. Conclusions: In this study, percutaneous and endoscopic contrast enhanced harmonic US techniques consistently revealed diffuse and focal types of AIP to have features consistent with vascularized lesions. Differentiation from the typically hypovascularized pancreatic adenocarcinoma was possible with CE (-E) US evaluation.

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

Intestinal ultrasonography is meanwhile an established and valid diagnostic method for inflammatory bowel disease, diverticulitis, appendicitis, bowel obstruction, perforation and intussusception. However, little is known about sonographic findings in other more rare intestinal diseases. Ultrasonography may display the transformation of the intestinal wall from normal to pathological states both in inflammatory and neoplastic disease. Besides demonstrating the transmural aspect it also shows the mesenteric reaction as well as complications such as fistula, abscesses, stenosis, or ileus. Furthermore, in some diseases intestinal ultrasonography may serve as a diagnostic clue if typical patterns of the bowel wall and impaired peristalsis can be demonstrated. This may lead to an important reduction of invasive and expensive (follow-up) procedures. The information gained by ultrasonography regarding intestinal disease, however, is as important and valid as e.g. in case of focal lesions of the liver. Serving as tertiary referral centers for a broad spectrum of intestinal diseases we therefore report some aspects of ultrasonography in patients with less often recognised diseases using ultrasound. The article is divided in two parts, the first focussing on examination techniques, infectious diseases and celiac sprue and the second on hereditary, vascular and neoplastic diseases and varia.

The sixth part of the Guidelines on Interventional Ultrasound produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for ultrasound guidance and assistance in vascular interventions. Based on convincing data, real-time sonographic guidance for central venous access is strongly recommended as a key safety measure. Systematic analysis of scientific literature shows that in difficult situations and special circumstances US guidance may also improve the efficacy and safety of peripheral venous and arterial access and endovascular interventions. Moreover, the recommendations of this guideline endorse the use of ultrasound to detect complications of vascular access and US-guided interventional treatment of arterial pseudoaneurysms.

The fourth part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound describes general aspects of endoscopic ultrasound-guided diagnostic and therapeutic interventions and assesses the evidence for endoscopic ultrasound-guided sampling. Endoscopic ultrasound combines the most advanced high-resolution ultrasound imaging of lesions within the wall and in the vicinity of the gastrointestinal tract and safe and effective fine needle-based tissue acquisition from these lesions. The guideline addresses the indications, contraindications, techniques, adverse events, training and clinical impact of EUS-guided sampling. Advantages and drawbacks are weighed in comparison with image-guided percutaneous biopsy. Based on the most current evidence, clinical practice recommendations are given for crucial preconditions and steps of EUS-guided sampling as well as for safe performance. Additionally, the guideline deals with the principles and reliability of cytopathological reporting in endoscopic ultrasound-guided sampling (short version; the long version is published online).

The fifth section of the Guidelines on Interventional Ultrasound (INVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for all the categories of endoscopic ultrasound-guided treatment reported to date. Celiac plexus neurolysis and block, vascular intervention, drainage of fluid collections, drainage of biliary and pancreatic ducts, and experimental tumor ablation techniques are discussed. For each topic, all current evidence has been extensively analyzed and summarized into major recommendations for reader consultation (short version; the long version is published online).

The third part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound (INVUS) assesses the evidence for ultrasound-guided and assisted interventions in abdominal treatment procedures. Recommendations for clinical practice are presented covering indications, contraindications, and safe and effective performance of the broad variety of these techniques. In particular, drainage of abscesses and fluid collections, interventional tumor ablation techniques, interventional treatment of symptomatic cysts and echinococcosis, percutaneous transhepatic cholangiography and drainage, percutaneous gastrostomy, urinary bladder drainage, and nephrostomy are addressed (long version).