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ISO 13485:2003 © 2014 Parker Laboratories, Inc. AD-01-6 REV 0 What’s the difference between Aquasonic® 100 and those other gels? Clarity, reliability, and economy. Aquasonic 100 Ultrasound Transmission Gel The clarity that sonographers have counted on for over fifty years. A100_The_Difference_AD-01-6_REV_0_EuroHosp_82515.qxp_European HospitaL 8/25/15 10:02 AM Page 1 www.healthcare-in-europe.com 19ULTRASOUND Ileus diagnosis is a long-running debate – perhaps without end In most cases, an ultrasound scan can confirm the presence of the three most important criteria for ileus - dilat- ed, fluid-filled intestinal loops, active peristalsis (early stage) and sudden change of the lumen (sudden change in diameter). A plain abdominal X-ray on the other hand does not help with the assessment of the peristalsis in the intestine, and other impending com- plications cannot be captured, either, Hollerweger explains. Furthermore, intestinal obstructions can be diag- nosed around 6- 12 hours earlier with ultrasound than with plain abdominal X-rays because, in the early stage, the intestinal loops are not yet strongly dilated but already filled with fluid, which can only be seen on the ultra- sound scan. Ultrasound also facilitates a more differentiated diagnosis ‘The ultrasound image also shows possible other causes of acute abdominal pain, such as renal congestion or biliary colic. The X-ray on the other hand makes no contribution to a differen- tial diagnosis,’ Hollerweger stresses. He does not accept the oft-cited argument that the abdominal X-ray visualises the fluid level in the intes- tines well. ‘This may be the case – but the level is only an indirect sign that there may be air and fluid in the intes- tines. Ultrasound allows the direct detection of the fluid.’ Hollerweger believes that the reason why so many hospitals carry out plain abdominal X-rays when an intestinal obstruction is suspected is mostly organisational: ‘A plain X-ray can be carried out at any time during the day and night without the presence of a radiologist. For smaller hospitals this is a sim- ple way of carrying out an initial, basic diagnosis outside the standard times of operation. Interestingly, the abdominal X-ray is something sur- geons still insist on, in large hospitals as well.’ Another reason for ignorance about ultrasound in the guidelines is most probably the situation in the United States, where it is not clini- cians, but members of a specifically named profession, i.e. sonographers (radiographers) who carry out ultra- sound examinations. The guidelines and ultrasound examiners agree on one thing: the follow-on examination procedure of choice to establish a diagnosis should be CT. ‘When an ultrasound scan does not deliver a result in cases where an intestinal obstruction is highly sus- pected, then the next diagnostic step should be a CT scan,’ Hollerweger emphasises. A CT scan is also indi- cated for obstructions of the large intestine, not least because the most common cause of these is cancer. In conclusion, this experienced ultrasound trainer offers some practi- cal tips. In most cases of ileus there is gas in the intestines. When the patient lies on his back this rises to the front. ‘Therefore, it’s very impor- tant to apply the transducer in the lumbar region.’ He also recommends a clear sys- tem for the examination. ‘Firstly, you should check via the side and spleen whether or not the stomach is full. Secondly, you need to check the upper small intestine via the left lum- bar region, and check whether the adjoining large intestine is contracted. ‘Finally, you must check in the right, lower abdomen whether the lower small intestine has collapsed, or whether congestion continues to the large intestine. ‘Afterwards you need to try and narrow the site of the obstruction down even more precisely.’ Hollerweger advises all colleagues to regularly update their knowledge of the gastrointestinal tract: ‘Practice makes perfect!’ Alois Hollerweger is a Consultant in the Department for Radiology and Nuclear Medicine at the Hospital of the Brothers of Mercy in Salzburg. The key focus of his work is ultrasound diagnostics, particularly ultrasound of the gastrointestinal tract. He has 44 scientific publications on this topic to his name. Born in Upper Austria, the radiologist, who read medicine in Innsbruck and specialised in Salzburg, is a much in demand instructor: Hollerweger holds ÖGUM courses and also regularly runs courses in ultrasound for the abdomen, gastrointestinal tract as well as for Small parts Controversy surrounds intestinal obstructionsThe guidelines – the Bologna Guidelines on the Diagnosis and Management of Mechanical Intestinal Obstructions as well as the respective guidelines from the American College of Radiology – recommend a plain abdominal X-ray and/or CT scan when an ileus is suspected. There is no mention at all of ultra­sound in these guidelines. However, many clinicians do not agree with this. ‘In our hospital we haven’t actually carried out plain abdominal X-rays for patients with acute abdominal pain for the last 20 years,’ emphasises Dr Alois Hollerweger, Consultant in the Department for Radiology and Nuclear Medicine at the Hospital of the Brothers of Mercy in Salzburg. ‘For us, the primary imaging modality for these cases is always ultrasound. The plain abdominal X-ray is not sensitive enough for to diagnose acute abdominal pain.’ Sample images for a mechanical obstruction of the small intestine: Fig. 1: Fluid-filled and dilated loops in the upper small intestine Fig. 2: Next to the dilated intestinal loop is the contracted colon (white arrow) Fig. 3: Coronary reconstruction. The loops in the small intestine are dilated and fluid-filled, the large intestine (white arrows) is largely contracted ferential diagnosis. ‘Physicians with adequate knowledge of sono-anato- my and sono-pathology can tell with certainty whether a patient suffering from inflammatory arthropathy is dealing with rheumatoid arthritis or psoriatic arthritis, or a crystal deposi- tion disease of the type gout or pseu- dogout,’ and,’ Tamborrini explains, inflammatory activity can be easily assessed with Doppler ultrasound. A type of exam, routinely per- formed in hospitals, is functional ultrasound of the shoulder. This highly specific imaging technique is requested by rheumatologists, inter- nal medicine specialists or shoulder surgeons when concrete questions need to be answered that MRI diag- nostics cannot resolve. ‘For example, we do a high-resolution dynamic ultrasound when complex ruptures of single tendons, or of stabilising tendons in the rotator cuff inter- val, are present. These ultrasound scans complement the MRI scan and provide the shoulder surgeon with relevant data that help him to plan surgery,’ Tamborrini explains. Shoulder ultrasound sup- ports PMR diagnosis Polymyalgia rheumatica (PMR) is another frequently occurring inflam- matory rheumatic disease where ultrasound of the shoulder supports diagnosis as well as classification of the disorder. ‘Polymyalgya is often accompanied by bursitis or inflammations in the joint,’ says Tamborrini. ‘Because the musculo- skeletal system and rheumatic dis- eases are such a complex field, over the past few years we’ve been draft- ing guidelines and recommenda- tions that are published in different journals and ultrasound text books.’ (http://dgrh.de/9399.html). With clinical and ultrasound technology being highly special- ised the European League Against Rheumatism (EULAR) launched an international training network (http://www.eular.org/musculoskel- etal_imaging_network_centres_list. cfm). Physicians from domestic and foreign hospitals can sign up for training courses in these centres. ‘In recent months we’ve had colleagues from different countries here to watch and learn,’ Tamborrini reports, ‘for example, England, Australia and Germany.’ Giorgio Tamborrini MD is Medical Director of Musculoskeletal Ultrasound und Rheumatology at the Ultrasound Center in Bethesda Hospital, Basle, Switzerland. The rheumatologist spe- cialises in general and inflammatory rheumatology as well as diagnostic and interventional ultrasound of the musculo- skeletal system, and focuses on ultrasound imaging of inflammatory conditions (e.g. peripheral spondyloarthritis, rheumatoid arthritis or crystal deposition diseases), as well as ultrasound of degenerative or trauma-related conditions, above all in the shoulder. Actively involved in several national (SGUM, Sonar) and international societies, he has also been an ultrasound trainer for many years and authored several books, web tools and scientific articles on ultrasound. A100_The_Difference_AD-01-6_REV_0_EuroHosp_82515.qxp_European HospitaL 8/25/1510:02 AM Page 1

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