CEUS in the Abdomen - HD

Introduction

My name is Hans Peter Vesco.
I'm a physician from Germany.
I'm actually an internist,
and I'm head
of the ultrasound central ultrasound department in the
clinical that's part of the clinical renova in Germany.
In my department, we perform round about 80
ultrasonic examinations on a daily basis.
And within one year we do about 20,000 examinations.
And nowadays we have 12%
of all our studies are contrast studies.
And of course, the main indications are diseases in the
abdominal organs and vessels.
I've collected some interesting cases,
hopefully interesting cases for you that I have
the pleasure to present to you in the upcoming lecture.

Use of Contrast Agents in the Abdomen

Now I'm going to talk about the use
of contrast agents in the abdomen,
as we have contrast agents available in Europe since 1996.
We have now a huge experience in this field,
and it is just like as if you would ask a radiologist
to talk about in, let's say half an hour
or one hour about the benefit of using CT in the abdomen.
So I concentrated on a couple of cases
and I hope you find it interesting.
So we think yes,
ultrasound contrast agents are a new wonder weapon,
and I hope I can convince you with that statement.

Aorta and Hepatic Vessels

So first of all, I'm going to deal with the aorta
and hepatic vessels.
What you can see here is the aorta. I can show it.
Here's the aorta and the vena cava,
and you can see the gastroduodenal artery quite nicely
branching from the hepatic common hepatic artery
and the hepatic artery as well.

Clinical Case: Aortic Perforation

So on the next is a clinical case of a patient,
70 years old.
He had a sudden onset of back pain about four hours ago.
And then he came to us.
He was quite an obese patient, so we were not very happy
with the image quality, but that was due to the pain
of the patient and that the patient was really a big one.
So we then decided to give contrast,
and this is definitely the aorta.
So we are now looking at the contrast arrival.
And here you can see the contrast coming up.
And you can see also that there is now a perforation
of the aorta.
And this is the reason
for his back pain that he had.
And then the surgeon asked us, okay, can you really say
that the renal arteries are patent?
And we said, well, we do not dare to press harder,
and the image quality is not as good
as we could really say something about the
renal arteries.
So then the surgeon wanted to have a CT,
and he had the CT, of course, the CT confirmed our finding,
and then he went to the operating theater.
And on the way there, he came into a sudden shock.
And unfortunately he didn't survive.

Clinical Case: Aortic Stenosis

So the next case is a patient who had pain
by walking in both legs.
So the clinical diagnosis was peripheral artery
disease of both legs.
So but the reason for that,
you can see on already on the gray scale image,
there is a severe stenosis of the aorta.
And when we add contrast,
then you can see very nicely that we have a high degree
aortic stenosis with a jet
behind the stenosis.
And when we look at the still frame,
so then we measure the degree of stenosis as
well definitely 90%.
And the diameter is three millimeters,
and the velocity is about five meters.

Clinical Case: Thoracic Aorta Endoleak

So the next case is a patient who was 80 years old
and he couldn't remember about his the surgeries
that he had in the abdomen and in his chest,
but we've figured out it was definitely a
coronary heart disease.
So there was a bypass operation that he underwent,
but the reason for his referral
to our lab was a malignant melanoma.
But when we looked at his aorta, we found
that the thoracic aorta was
measured round about nine centimeters in diameter.
And you can see a stent here.
So this is the color Doppler image
that you can see on the left side.
And when we add now contrast, then you can see very nicely,
I think that we see an endoleak with a pulsating
blood flow into these endoleak.
And second scan plane shows also quite
nicely where we are.

Arterial Tree of the Liver

So let me switch now to the arterial tree of the liver.
So we gave contrast
and during the arterial filling,
we performed the sweep starting at the dome of the liver
and then going downwards.
And then you can see here all the artery tree quite nicely
displayed here in this image.
And what is the clinical value of that?
Well, we can image early enhancement of tumors, of course,
and we can also image the liver cirrhosis,
like in this case on the right side that you can see,
you can see these tortuous arteries coming from the
right liver artery here
and branching into the segments of the liver.
Another patient who had an anal carcinoma
with liver metastasis.
You can see multiple liver metas on the
gray scale image here.
And then you can see the portal vein branching to segment eight.
And you can see it doesn't look really clear.
So we decided to do a contrast study,
and this is what you can see on the right side here.
And look at the clock
that is indicating the arrival time of the
contrast agent.
And it comes rather late after 21 seconds.
So this also is a sign for a heart problem
or a cardiopulmonary problem of the patient.
But what you can see also is that
after the enhancement of the arteries,
you can see an enhancement of course, of the portal vein,
and you can see very nicely the clot within the right
portal venous branch.
You can see the extent of the clot,
and you can see that there is an
enhancement around the clot.

Clinical Case: Portal Venous Occlusion

Another patient you can see here is a peripheral artery,
a portal venous occlusion also by in a patient
with liver metastasis.
You can see some liver metastasis here and here.
And what you can see is a hyper enhancement
of a triangular that's triangular shaped in the segment six.
And you can see when you watch very closely that both arteries going to this subsegment are patent,
but the portal vein in the middle is not completely open.
And this is why we have a hyper enhancement of this segment.
And when we look more closely to what was happening here
is this is 19 seconds,
you can see only the arteries supplying the subsegment.
And when we wait a little bit
after 22 seconds, then you can see very nicely,
this is the patent part of this portal venous branch.
And here it is occluded, and this is even later.
And you can still see the liver metastasis
close to the occlusion of the portal vein.

Clinical Case: Post-Hepatectomy Perfusion Problem

So this is a patient coming,
or is she's in the intensive care unit,
and she had multiple liver metastasis
in the right liver lobe.
And this is the day
after the hemihepatectomy on the right
of the right liver lobe.
And the liver tests were extremely elevated.
So this is why the surgeon called us
through the intensive care unit to ask us
what is wrong with this patient.
So we were looking at grayscale
and grayscale of course didn't tell us any
or didn't make any clues for that.
And when you add contrast,
you can see what was happening.
You can see after, let's say 15,
16 seconds an enhancement of a part
of the liver.
But the greatest part,
segment two is nearly completely not vascularized anymore
because of the occlusion of the portal vein
and partly also sinusoids
or not completely open arteries.
So this is a severe perfusion problem of the
segment two of the left liver lobe,
another patient with a vascular problem.

Clinical Case: Tumor Invasion of Portal Vein

So this is a patient who had some liver metastasis in the left liver lobe.
And then you can see a tumor
or a clot in the left portal venous branch.
And if you now look at the contrast examination,
you can see that this clot is not clot, but it is tumor.
So the tumor invaded the portal vein,
and you can see during the arterial phase an enhancement
of this tumor in the left portal vein.
And of course, as it is a tumor, malignant tumor,
it is washing out during the late phase,
as you can see here on the right.

Contrast Agents in Liver Disease

So seals and the liver.
So what is the job of contrast agents and liver disease?
Number one, of course, it's detection
of focal liver lesions.
So during the arterial phase, we very much like
to characterize FNHs or hemangiomas
because we have typical findings and the portal
and the late phase,
we then detect best the malignant liver lesions.
But again, the FNHs
and hemangiomas are best detected
and characterized during the arterial phase.
So characterization of focal liver lesions is being done
during the arterial phase.
And this is where ultrasound has a big advantage over other
imaging modalities, because we, number one,
have very high spatial resolution.
And number two, we have a very high frame rate.
So as things are happening very quickly,
so we then depend also on a high temporal resolution.
And third big interest
that we have is monitoring interventions
and follow up for patients, especially with malignant tumors, primary tumor or secondary tumors of the liver.

Detection of Liver Lesions

So detection of liver lesions.
It's important to detect the small ones, of course,
so don't wait too long.
So this is a tree on my way to my hospital.
And you can see it during summertime.
During summertime, you don't see what is happening in these tree.
But during winter, when all leaves have gone,
you can see these lesions of the tree.
Okay, so this is a review paper published
by Nico in Radiology 2010.
It's a review paper on more than 3000 patients.
And the question is detection of liver metastases
with MRI and CT.
And the reference standard was intraoperative findings
and follow up, and you can see the mean sensitivity
in percent,
and when we look at the small ones
and small is here defined
as lesions smaller than 10 millimeters.
MRI has its sensitivity of 60% and CT of 75,
and it of course goes up in metastasis
that exceeding 10 millimeters in size to 90% or
close to 90% on CT.
Of course there are a lot of studies
that have been performed during recent years to compare the findings of CEUS with CT.
And you can see that there is over the years, no statistically significant differences
between the performance of CEUS and CT.
We know that the CEUS is doing not that well in patients
that are big and have severe fatty liver disease.
So this is definitely a shortcoming of the technique.
And CT may not have this problem in the same way.
And of course, we benefit in characterizing lesions from our high temporal resolution.
You can see here that it really is sometimes only a matter
of a couple of seconds
that we see a lesion lighting up in the liver.
So when you come later, a couple of seconds later,
it may already be partly or completely washed out.
So this is the advantage
of a contrast agent in not only detecting
but also characterizing lesions.
There's a paper published by Sharmi
and Lasso in 2008,
and they were looking for 82 patients with liver metastasis, all from GI tumors,
all histologically intraoperatively proven,
and the gold standard was segmental or liver lobe resection.
So when we look at these statistics, then we can see
that B-mode is not performing very well.
CEUS is performing much better, of course,
with nearly 70% of correctly
detected lesions.
And CT MRI and PET was not doing very much better
or not performing better.
And the intraoperative ultrasound using also contrast agent
was the best performance imaging technique.
When we look more closely to the results published
by this group, we see that 34%
of all detected metastases were below one centimeter,
but the vast majority of nearly two thirds
of all missed metastasis were also below one centimeter.
So of course, it is important
to really concentrate on the tiny lesions,
and this is, again, a big advantage of CEUS.

Clinical Case: Urothelial Cancer Metastases

So this is a patient with a urothelial cancer and metastasis.
You can see during the arterial phase that they are hyper vascularized.
And during the end of the arterial phase at 27 seconds starting,
you can see that they're washing out.
Okay? And then you can see these two are not the only ones.
And when we perform a sweep, like here,
then you can see we have multiple metastasis.
And the tiniest metastasis that we can detect
with this technique measures three millimeters in size.

Clinical Case: Breast Cancer Metastases

Okay? So this is an example of a patient
with breast cancer metastasis,
and we found out that breast cancer metastasis have the
smallest metastasis of all tumors.
So two thirds of all these metastasis measure
below one centimeter.
So this is our finding.
So this was a little bit below five millimeters,
so characterizing focal liver lesions, okay?

Characterization of Focal Liver Lesions

You can see here the an Irish setter.
And when you look at the Irish setter, it is difficult
to tell if the dog is happy, depressed,
or even suicidal.
So it always looks the same.
But this is maybe also the problem
for grayscale ultrasound, mean grayscale ultrasound,
most lesions look the same, and of course, they're not.
I'm going to give you some examples of that.
So number one of course, how can we differentiate between benign
and malignant focal liver lesions?
What are the serious criteria?
So benign focal liver lesions hyper to iso enhancing,
lasting beyond the portal venous phase into the late phase.
And that means beyond two minutes.
So this is a characteristic for benign focal liver lesions
and benign focal liver lesions are
therefore detected best on B-mode
or during the arterial phase, like FNH
and hemangioma, as I told you before.
So what are the characteristics
for malignant focal liver lesions?
So the washout starts at the end of the arterial phase,
or early portal venous phase with one exclusion,
and that our HCCs may wash out rather late.
So it is very important for HCCs that you detect them
during the arterial phase,
and that you then carefully follow these lesions during the very late arterial phase.

Diagnostic Confidence in Hemangiomas

So diagnostic confidence of B-mode
and imaging liver hemangiomas, when we started to use contrast in characterizing liver hemangiomas other colleagues told me, we don't need contrasts for that
because it's an easy job to do that,
that is right in a healthy population.
So in a healthy population, this study by life in radiology, 2000 said yes.
Out of 213 patients with characteristic signs
of hepatic hemangiomas 212 were correctly
diagnosed on gray scale.
So but these patients have no complaints,
have no elevated liver tests, healthy population.
If you look at the hemangioma looking lesions in the
population at risk, meaning these are patients
with chronic hepatitis liver cirrhosis,
or having malignant diseases, underlying diseases,
so then the specificity goes down to 50%.
So this is the reason why we should, in these patients,
be careful with the diagnosing hemangiomas.

Clinical Case: Typical Hemangioma

So this is an intercostal scan plane of a patient
with a typical hemangioma presenting at gray scale.
If we now look during the arterial phase, then you can see
during the arterial phase, the hemangiomas are supplied
or push the blood via the arteries into tiny racemose.
And from these lacunae, these contrast agent is then slowly moving centripetal
to the center of the hemangiomas.
So after a short while, like here, you can see the hemangiomas are completely more or less completely filled.
Of course, some of the hemangiomas,
especially when they are bigger, are maybe thrombosed in the center.
So in this case, of course, they cannot be filled
correctly completely.
So this is another story.

Clinical Case: Carcinoid Metastasis Mimicking Hemangioma

So this is a patient with a lesion
that really is looking like a hemangioma,
but you can see it is completely immediately
filled with contrast.
And if you wait a bit,
and now we are at 23 24 seconds,
it now starting to wash out.
So this is not a hemangioma.
This was a carcinoid metastasis from a carcinoid.

Clinical Case: Breast Cancer Lesion

Okay? This is a patient with breast cancer,
and 45 years old has this echo poor lesion
in the left liver lobe.
And when we give contrast,
you can easily make the diagnosis.
You don't need any biopsy or any other imaging
modality to tell.
Yes, this is definitely a hemangioma.
And again, it starts at the periphery.
We have these peripheral globular enhancement,
and you can see the enhancement is growing towards the center.
So we have a centripetal filling,
and if you look at the late portal venous phase,
it is nearly completely filled now with contrast.
So this is a definite diagnosis.
You don't need to do anything more.

Clinical Case: FNH

And this is another case of a male, 39-year-old male
with a iso echoic lesion in segment four five.
And you can see even in the color Doppler,
this looks typical for an FNH.
And when you look at scan capture mode, accumulation mode,
with a contrast, you can see very nicely the supplying artery, the feeding artery.
You can see that the FNH starts
to enhance in the center.
And then you can see tiny branches of arteries going radially to the periphery of the tumor.
And these arteries measure
around about one millimeter in size.
And this is the late phase.
And the late phase, you can see nicely the central scar.

Clinical Case: Colon Cancer Metastasis

Another patient with colon cancer metastasis.
So you can see it here in segment six.
And on contrast, you can see nicely how this lesion is being filled with contrast from the artery.
Here's the artery, and you can see adjacent to the artery.
Now the portal vein is filling,
and you can see that the center
of the metastasis is probably,
or definitely is ischemic, if not necrotic.

Clinical Case: Malignant Melanoma Follow-Up

And this is a patient follow up
of malignant melanoma.
And the question was, is this cyst?
And well, we had some doubts,
so this is why I changed the probe.
So I used a linear probe with a linear probe that you see
that the margins is not that sharply delineated to the
surrounding liver tissue.
So that is the indication that for giving contrast.
And on the contrast image, you can see these are,
this is not cyst
and is not only one metastasis, three metastasis.
The metastasis subcapsular metastasis
that you can see here measures seven millimeters times three millimeters.
So it's really a tiny one that we could not detect with the
abdominal probe.
And of course, it was not detected on CT.

Clinical Case: Calcified Colon Cancer Metastases

So the next patient is a patient with colon cancer metastasis and the liver,
and you can see they are they look completely calcified.
So resolution matters,
and that means when we give contrast, we would like
to see is there tumor tissue surrounding this calcification?
And the answer, of course, is yes.
And you can see that very nicely on the contrast
enhanced images on the right, you can see that
around the calcifications we see a layer of tumor
tissue that is enhanced during the arterial phase.
So yes, these are metastasis.

Clinical Case: Malignant Melanoma Perfusion

Another patient in which we can already see on gray scale,
that there are metastasis in the right lobe of also a patient with malignant melanoma, 43 years old.
And when you give contrast, we do not want to prove
that these are metastasis.
I think that's rather clear from grayscale image,
but we would like to characterize them.
We would like to know what is the degree of perfusion
of these metastasis.
So this is important for the follow up of patients
because we would like to see on the chemotherapy that the
vascular status is changing afterwards.
So this is the contrast study,
and you can see that the arteries are being filled now and
before the portal veins are filling up, you can see lots of
the metastases that are all hyper vascularized,
but this is only for a couple of seconds.
Now you can see that they are iso enhancing
with the surrounding liver tissue.
So that is important finding, I think for the follow up.

Clinical Case: HCC

HCC, not difficult to diagnose.
And here you can see the performance on the CEUS.
You can see the supplying and feeding artery.
You can see the hyper enhancement during the arterial phase.
And later you can see that the liver tissue is enhancing as well.
Of course.

Clinical Case: Prostate Cancer Follow-Up Lesion

The next patient.
I would like to explain a little bit the history
of the patient, because that was a little bit irritating.
So it is a 73-year-old male who diagnosed prostate cancer and treated four years ago.
At that time, he had only a local disease, no metastasis,
no lymph node metastasis, no liver metastasis
or pulmonary metastasis, no bone metastasis.
So the patient thought that he's completely free
of disease at that time.
But then in spring 2012, the urologist who had the follow up,
saw a lesion in segment five and sent the patient to the CT.
CT said it's an unclear lesion,
but most probably benign lesion.
So he recommended a follow up.
So the follow up was performed with MRI in 2013.
So it looked like a little, it is,
the lesion is a little bit bigger,
but again, also MRI had no clue for the diagnosis.
So this is why the patient was sent to our lab.
And this is the grayscale image subcostal scan plane.
You can see a nearly seven centimeter
measuring poor lesion.
And from the intercostal plane,
you can see the lesion here.
And it already looks like that there are vessels running
through this lesion.
So when we look at contrast, this is the contrast mode
and 1.5 ml of SonoVue.
And you can see very nicely the two arteries.
You can see the tiny branches from the arteries,
and you can see in the center of the portal vein,
and you can see it's hyper vascularized.
And now the enhancement of the normal liver tissue starts.
And when it starts, you see
that the lesion itself is washing out.
And when we wait a little bit, so this is
after one minute, 15, you can see,
see it's nearly completely washed out the lesion.
So this is a typical finding,
and I show you the it's typical for non-Hodgkin lymphoma infiltration
because the vessels are respected by the tumor.
And this is the biopsy
because of this was the first diagnosis,
it is in the extra nodal hepatic non-Hodgkin lymphoma.
You can see it here. And this is the staining.
This is the CD20 stain indicating active B lymphocytes.
And this is the HE stain.

Non-Hodgkin Lymphoma Cases

Clinical Case: Pancreas Involvement

So this is another patient coming, he's a German,
but was giving lectures for in a music Conservatorium in Cairo.
And then he felt rather ill, he was short of breath,
went to an x-ray examination,
and then they found out that there was a big
pleural effusion on the left side.
And he was punctured without any clue.
And as he got worse and worse, he came back to Germany.
And was then sent my department
because we should have a look at the pulmonary status of the patient.
But we also looked at the abdominal organs
and found out that there is a big lesion in the tail of the pancreas.
So we gave contrast,
and again, similar to what you have seen in the liver,
you can see that all the big
and smaller arteries are being preserved.
So there's no destruction of vessels,
there's not a neovascularization.
And all vessels are being respected by the tumor.
And this, after 40 seconds, still the same,
but after time, it has been washed out.
So now we have three minutes,
and you can see, still see some
of the vessels running through the tumor.
So the diagnosis comes from a core biopsy of the pancreas.
And it was a B-cell non-Hodgkin lymphoma of the lung,
the pancreas, and the spleen.
And you can see now the spleen in the portal venous phase, you can see the infiltration of the spleen quite nicely.

Clinical Case: Renal Involvement

Okay, and again, another patient, renal lesions.
Now you can see we have some renal poor lesions,
and you see also that close to the capsule
and it looks like a bleeding.
And this is also typical finding for non-Hodgkin lymphomas.
It's of course not a bleeding,
but it's an infiltration of the fatty tissue that looks like
blood or fluid.
So we have to confirm that, of course, with contrast.
And this is the first contrast
that we did on this patient.
You can see here is the non-Hodgkin
infiltration.
And of course, we can also see now the vasculature
of these well maybe misleading fluid looking like area
around the capsule of the right kidney.
And that is look with another technique,
the same patient.
And you can see again, all the
tiny vessels are being respected again.
And the so-called bleeding is infiltration
of the non-Hodgkin lymphoma.
So we biopsied this renal lesion.
And this is again, still frame from the loop
that you have just seen with the nicely the tiny
vessels can nicely be seen here.
And this is the diagnosis from our pathologist.
It's a T cell non-Hodgkin lymphoma.
And the reason for washing out is just like on the pancreas case, densely packed tumor cells.
This is the reason because they're compressing the tiny veins, mainly the tiny veins leading to a high flow resistance.

Renal Applications

Complicated Cysts

Okay, another nice indication of course, are
for the renals are the complicated cysts.
And everybody who's performing these CEUS in complicated cyst is convinced
that this is the gold standard
to characterize complicated cysts.
So this is maybe not that difficult job.
So we can now add contrast.
And you can see now that all these septa,
these thick septa are tumors what is
tumor from a clear cell renal cell carcinoma.
Okay? So this is if you like,
a Bosniak three or four.

Clinical Case: Inconclusive Prior Imaging

Another case.
This is a patient coming from another city center,
my department, because they were inconclusive, two CT
and one MRI study.
And this 40-year-old woman wants to know
what really is wrong with her kidney because all these imaging modalities
that have been performed previously came not
to the same conclusion.
So we were looking at this cyst of the
left kidney with contrast.
And then you can see it is not a cyst,
it is a tiny one centimeter measuring renal cell carcinoma.

Pyelonephritis

Okay, indication for imaging in pyelonephritis.
So what can we do?
We can say that pyelonephritis is
of course a clinical diagnosis, number one.
Number two, CEUS
or any other imaging modality is indicated in unexpected
course of disease, and
that means fever more than 72 hours under treatment and or
persisting pain.
And of course, we believe that CEUS is the method of choice
because all other imaging modalities use contrast
that may also be of danger for the kidney.
And other indication is recurrent urinary tract infections.
The pathophysiology is that toxins of E. coli,
which is the most common cause for pyelonephritis,
they cause a reduction of the muscle tonus
of the ureter, thus favoring the ascension
of bacteria up to the renal pelvis.
And the inflammation coming from the renal pelvis causes a thickening of the wall
of the collecting system and a global
or global cortical vasoconstriction
and perirenal hyper vascularization.
So B-mode will often detect the perirenal fluid,
what we named renal sweating.
So this is what you can see here
with a linear high frequency probe.
You can see quite nicely that we have this renal sweating
that you can see on the left image
and on the right you can see the renal pelvis is thickened.
And when we give contrast in this case, you can see
that this patient who still has pain on the right flank suffers under an ischemia of these lobules in the right kidney.
And the arrow points to these lobular ischemia.

Clinical Case: Perirenal Abscess

Perirenal abscess is of course also easy
to detect in gray scale mostly.
And this is the CEUS study of the same patient.
You can see that there's a hyper enhancement
around the abscess.
Okay? And you can see the extent of the abscess quite nicely in contrast.

Clinical Case: Acute Pyelonephritis Misdiagnosed as RCC

Okay? And this is a patient sent to our urology department
because MRI diagnosed a renal cell carcinoma
of the left kidney.
And you can you have an idea
because when you look at the right image, you can see
that there is a mass, looks like a mass in the left kidney
that is hypoechoic.
And when we looked at it with contrast, then we saw
that it is not a tumor, but it's acute pyelonephritis.
And that is a known cause for misdiagnosing renal cell carcinoma.
And we then treated this patient with antibiotics.
The patient actually had a fever for only one or two days,
and received for a short term antibiotics
and was well afterwards.
And then she had back pain.
And because of back pain, she had this CT
that was suggested for RCC two weeks later and
after restarting antibiotic therapy, everything was gone.
So the renal then looked very normal again.

Gallbladder

Gallbladder Polyp

So the gallbladder polyp that you can see here
can also be imaged with contrast.
And you can see it here, you can see now the arteries of the segment five coming up.
You can see the portal vein filling,
and you can see very nicely the artery of the gallbladder wall, the cystic artery,
the major cystic artery supplying this tiny polyp.

Off-Label Use Note

So maybe I should at this point also say that the contrast agent SonoVue that is used
for all these examination is not approved for kidney diseases or gallbladder diseases.
So it's an off-label use, but it's very, very helpful.
And those who have patients with renal diseases they nearly always perform
also contrast on these patients, especially
as I just told you in patients with complicated cysts.

Clinical Case: Gallbladder Perforation

So this is another patient who had right upper quadrant pain a couple of days ago,
and then went to his doctor
and his doctor gave him antibiotics
and said, yes, this probably a cholecystitis.
So take antibiotics
and you will feel better, but please come back.
So this patient came back
and said, you were completely right.
I have no complaints anymore,
and I don't want to go into hospital as you suggested last time because I'm now okay again.
And then the doctor was very happy with that,
but then he also said, let's have a second look.
And then he found this situation
and sent the patient to my lab
and the patient entered the examination room
and said, I'm not going to stay in your hospital.
Please just tell me that everything is okay.
But we couldn't do that. And it is
of course very convincing when you can show patients images and explain these images.
And you can see this is a rupture, the perforation
of the gallbladder into the liver.
And the patient saw that and was very impressed
and stayed in the hospital and was operated,
and of course, finding was confirmed.

Intestinal Cases

Clinical Case: Intestinal Infarction

Okay, let's switch now to the intestine.
So this intestinal thickening caused problems
of these 82 year patient in the left mid abdomen since two weeks,
but now it's increasing.
So the question was why does this patient has an
increasing pain in his left mid abdomen?
So we gave contrast,
and you can see now with contrast that the wall
of the descending colon was taken out of contrast.
Yes. Now I'm going upwards to the left flexure
and then down again.
And when I'm going down, so this is live scanning,
you can see this is an infarction,
clearly an infarction.
So we did it again to assure that
because we would like to know if there was the extent of the infarction.
And you can see very nicely again that these a part of the descending colon is completely infarcted.
And that was confirmed on surgery
that was performed on the very same day.

Clinical Case: Crohn's Disease Fistula

This is a patient with a Crohn's disease
and a cutaneous fistula.
And we fill this fistula with contrast.
It is 10 ml
and we only added one drop of contrast agent.
And you can see very nicely, not only the connection to the first loop of the bowel, but also to other loops.
So it's a very complicated situation
and the patient refused any surgical treatment.

Conclusion

So I thank you very much for your attention
and I hope you benefit from that for your daily practice.
Thank you very much.