Medica_Montag

ULTRASOUND DEDICATED MRI HEALTHCARE IT ULTRASOUNDULTRASOUNDULTRASOUNDULTRASOUNDULTRASOUNDULTRASOUND DEDICATED MRIDEDICATED MRI HEALTHCARE IT DEDICATED MRI HEALTHCARE IT DEDICATED MRI HEALTHCARE ITHEALTHCARE ITHEALTHCARE IT www.esaote.com Quality made in Europe TODAY – DON’T MISS MEDICA EDUCATION CONFERENCE Surgery and new opera- tive techniques ROOM 15 Monday, 16 Nov 2015 • 12.45 p.m. – 02.15 p.m. SYMPOSIUM: Visceral surgery: Perspectives in hepatic surgery ROOM 15 Chairman: Prof. Dr. Robert Schwab, Koblenz • 12.45 p.m. – 01.15 p.m. Determination of the functional residual liver capacity PD Dr. Martin Stockmann, Berlin • 01.15 p.m. – 01.45 p.m. Klatskin tumour Prof. Dr. Wolf Bechstein, Frankfurt/Main • 01.45 p.m. – 02.15 p.m. Liver metastases Prof. Dr. Hans J. Schlitt, Regensburg MONDAY @ MEDICA 9 EH @ MEDICA No 1 2015 is assumed that these occur in con- nection with that systemic disease. In otherwise healthy patients, these round lesions, perhaps detected by chance, tend to be harmless. Christian Görg always advises a small diagnostic tumour staging to be on the safe side, but otherwise recommends just to wait and moni- tor the symptoms (Image 6): ‘Many colleagues find not being able to find clear answers to a diagnostic question difficult, but you have to be able to live with this. The uncertainty can be compensated for by diligence and by monitoring the patient closely with clinical procedures, including ultrasound.’ n aneurysm on the contrast enhanced ultrasound image 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 - dilated, fluid-filled intestinal loops, active peristalsis (early stage) and sudden change of the lumen (sud- den 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 complications can- not be captured, either, Hollerweger explains. Furthermore, intestinal obstructions can be diagnosed around 6- 12 hours earlier with ultra- sound 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 ultrasound scan. Ultrasound also facilitates a more differentiated diagnosis ‘The ultrasound image also shows possible other causes of acute abdominal pain, such as renal con- gestion or biliary colic. The X-ray on the other hand makes no con- tribution to a differential 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 intestines. 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 hospi- tals this is a simple way of carrying out an initial, basic diagnosis out- side the standard times of operation. Interestingly, the abdominal X-ray is something surgeons still insist on, in large hospitals as well.’ Another rea- son for ignorance about ultrasound in the guidelines is most probably the situation in the United States, where it is not clinicians, but members of a specifically named profession, i.e. sonographers (radiographers) who carry out ultrasound 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 lumbar region, and check whether the adjoining large intestine is con- tracted. ‘Finally, you must check in the right, lower abdomen whether the lower small intestine has collapsed, or whether congestion continues to the large intestine.‘ Afterward this, 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 EH @ MEDICA No 12015

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