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The transjugular intrahepatic stent-shunt (TIPSS) is a well accepted minimal invasive therapy for complications of portal hypertension: recurrent variceal bleeding, refractory ascites and liver failure due to the Budd-Chiari syndrome. The high frequency of shunt stenoses and occlusions makes regular follow up examinations essential. Despite modern non invasive imaging methods direct portography still is the gold standard for shunt surveillance in TIPSS. Ultrasound is helpful to detect shunt dysfunction, but nevertheless its failure rate is considerable despite the use of contrast enhancers such as Levovist because of anatomic and physical limitations, particularly when TIPSS-tracts deep in the liver are present. Reintervention rates approach 90-100% after 24 months, with 100% in child's A patients with comparatively good liver function. However, a strict shunt surveillance program with early portography and reintervention when necessary guarantees high clinical success rates associated with very low rebleeding rates below 10%. Overall the secondary success rate is 80%. Secondary failures are mainly caused by lack of patient compliance during follow-up. In a subgroup of patients no shunt maturation is observed, requiring multiple shunt revisions. In cases of recurrent shunt occlusions an association with bile leaks is presumed. In selected cases patients with chronically recurrent shunt stenosis or occlusions may benefit from placement of TIPSS stent grafts.

Imaging Diagnostics of Colonic Diverticulosis and Its Complications Radiodiagnostic imaging modalities in diverticulosis and diverticulitis for visualization of complications include supine radiograph of the abdomen, ultrasonography, barium studies of the colon, in case of diverticulitis and suspicion of penetration only water-soluble contrast medium studies, spiral-CT and magnetic resonance imaging (MRI). In cases of endoscopic failure to localize diverticular bleedings because of massive intraluminal blood clots, selective and superselective angiography is indicated for localization of the bleeding source and, if necessary, transcatheter embolization or vasopressin infusion to stop the bleeding. In endoscopical failure to pass the stenosis of inflammatory origin because of diverticulitis, only water-soluble contrast medium studies are indicated, mainly to visualize the post-stenotic areas of the colon orally to the stenosis. In cases of penetration or suspected perforation, fistulas in surrounding organ structures like adjacent bowel loops, urinary bladder or muscle tissue, ultrasound or spiral-CT are the favorite imaging modalities. Up to now, MRI does not play the role as ultrasound or spiral-CT do.

Fragestellung: Vergleich zwischen Farbdopplersonographie und Portographie zur Nachsorge von TIPSS-Patienten. Material und Methoden: In einer prospektiven Studie wurde bei 40 konsekutiven TIPSS-Patienten im Rahmen der Nachsorge eine venose Portographie und am selben Tag eine Farbdopplersonographie durchgefuhrt. Innerhalb des TIPSS wurden Fluswerte am Einflustrakt (portales Segment) und Ausflustrakt (Lebervenensegment) gemessen. Ergebnisse: Bei 28 Patienten mit unauffalligem Shunt lag die Flusgeschwindigkeit im Einflustrakt zwischen 30–120 cm/s (Median 60 cm/s), im Ausflustrakt zwischen 60–155 cm/s (Median 82 cm/s). Im Ausflustrakt war die Flusgeschwindigkeit signifikant hoher als im Einflustrakt (p

INTRODUCTION A study was carried out to determine whether an improvement in the detection of vascular signals in patients after orthotopic liver transplantation can be achieved by the use of ultrasound contrast medium in colour Doppler sonography. MATERIAL AND METHODS In the early postoperative follow-up of liver transplant recipients, 31 colour Doppler sonograms were obtained in 21 patients before and after intravenous injection of the ultrasound contrast agent Levovist (Schering, Berlin). A grading score with four categories was used to evaluate the sonograms with special regard to the visibility of colour and flow signals in the hepatic artery and also in the portal vein and the hepatic veins. The arterial and portal venous signals were evaluated in the hepatic portal and in the left and right lobe. RESULTS With contrast enhancement significantly better arterial signals were seen in 20 of 31 sonograms for the hepatic portal, in 22 for the right lobe and in 26 for the left lobe. Better portal vein signals were obtained in 17 of 31 examinations for the right lobe and in 16 for the left lobe; only little improvement was obtained for the main stem of the portal vein. For the hepatic veins there was no significant improvement. CONCLUSIONS Early vascular complications after liver transplantation usually occur in the hepatic arteries. With the use of contrast-enhanced colour Doppler sonography, better detection of arterial and peripheral portal signals can be achieved; peripheral portal vein branches can be helpful in finding small arteries.

Klinische Untersuchung: stark reduzierter AZ und EZ, Gewichtsabnahme von mehr als 10 kg wahrend der letzten 3 Wochen (Grose 164 cm, Gewicht 48 kg). Abdomen wirkt eingefallen, epigastrisch sind hochgestellte Darmgerausche mit stenosetypischer Peristaltik auskultierbar. Bei klinischem Verdacht auf eine adhasionsbedingte Symptomatik im oberen Dunndarm wird der orale Kostaufbau gestoppt und eine weiterfuhrende Diagnostik eingeleitet. In der Abdomenubersichtsaufnahme Luft in Projektion auf das Duodenum, im ubrigen Abdomen nur wenig Luft nachweisbar. Zur weiteren Abklarung Magen-Darm-Passage nach oraler Gabe von wasserloslichem jodhaltigem Kontrastmittel (Abb. 1). Zusatzlich wurde eine Abdomen-CT durchgefuhrt. Eine den Darm komprimierende Raumforderung last sich nicht nachweisen (Abb. 2).

Klinisch zeigte sich eine deutliche Weichteilschwellung am linken Ellenbogen. Die periphere Durchblutung und Motorik waren unauffallig, die Sensibilitat war lediglich an D IV und D V leicht eingeschrankt Zur weiteren diagnostischen Abklarung wurde eine konventionelle Rontgenaufnahme des linken Ellenbogens in zwei Ebenen angefertigt (Abb. 1a und b). In der AP-Aufnahme sieht man bei noch offenen Epiphysenfugen des Epicondylus ulnaris und radialis humeri eine erhohte Transparenz des distalen Humerus radialseitig. Die Ausenkontur des distalen Humerus erscheint intakt, jedoch erkennt man eine zweite Kontur proximal des hemero-radialen Gelenks. In der Seitenaufnahme sieht man eine halbmondformige Struktur ventral in der Ellenbeuge sowie eine Verlagerung der Fettlamelle ventral und dorsal als Hinweis auf einen Gelenkergus. Ihre Diagnose ?

A study was performed to determine the visualization of the transjugular intrahepatic portosystemic stent shunt (TIPSS) and the detection of stenosis by the use of a capillary transversing signal enhancer. In 37 patients 37 colour-coded duplex sonographies were performed before and after intravenous injection of the ultrasound signal enhancer Levovist (Schering, Berlin). The examinations were evaluated using a four-category score. Special attention was paid to the detection of stenoses in the TIPSS. Transjugular portal venograms of the same day were used as gold standard. The use of Levovist provided better colour and flow signals for the portal vein end of the shunt in only 9 of 37 sonograms and for the hepatic vein end of the shunt in 37 of 39 sonograms. Eleven of 13 stenoses requiring reintervention in portal venography could be correctly identified with signal enhancer. Eleven of these 13 stenoses were located in the hepatic vein end of the shunt. Ultrasound signal enhancer can significantly improve the sonomorphological visualization especially of the hepatic vein end of TIPSS in colour-coded duplex sonography. Stenoses which usually occur in the hepatic vein end of the shunt may be better detected.

A study was carried out to determine whether an improvement in the detection of vascular signals in patients after orthotopic liver transplantation can be achieved by the use of ultrasound contrast medium in colour Doppler sonography.In the early postoperative follow-up of liver transplant recipients, 31 colour Doppler sonograms were obtained in 21 patients before and after intravenous injection of the ultrasound contrast agent Levovist (Schering, Berlin). A grading score with four categories was used to evaluate the sonograms with special regard to the visibility of colour and flow signals in the hepatic artery and also in the portal vein and the hepatic veins. The arterial and portal venous signals were evaluated in the hepatic portal and in the left and right lobe.With contrast enhancement significantly better arterial signals were seen in 20 of 31 sonograms for the hepatic portal, in 22 for the right lobe and in 26 for the left lobe. Better portal vein signals were obtained in 17 of 31 examinations for the right lobe and in 16 for the left lobe; only little improvement was obtained for the main stem of the portal vein. For the hepatic veins there was no significant improvement.Early vascular complications after liver transplantation usually occur in the hepatic arteries. With the use of contrast-enhanced colour Doppler sonography, better detection of arterial and peripheral portal signals can be achieved; peripheral portal vein branches can be helpful in finding small arteries.