Zusammenfassung
Die konventionelle B-Bild- und Farbdoppler-Sonographie ist nach der Anamnese, dem
körperlichen Untersuchungsbefund und im Rahmen der Interpretation von laborchemischen
Parametern das bildgebende Verfahren der ersten Wahl. Die Sonographie ist in der Hand
des Gastroenterologen zu einem ebenso wichtigen diagnostischen Werkzeug wie die Endoskopie
geworden. Die sich ständig entwickelnde Technik mit der Möglichkeit der deutlich höheren
Detailerkennung, insbesondere auch durch den Einsatz der harmonischen Bildgebung sowie
die Anwendung der Signalverstärker (Kontrastmittel), sind Veranlassung zu einer praktisch
relevanten Bestandsaufnahme. Für den vorrangigen Einsatz in der Leberdiagnostik und
am Portalsystem inklusive Milz werden praktische Hinweise gegeben. Die Bedeutung der
Sonographie zur ätiologischen Einordnung diffuser Lebererkrankungen ist insgesamt
gering. Komplikationen insbesondere der Leberzirrhose können aber sehr sensitiv detektiert
werden. Portosystemische Shunts und typische Gefäßveränderungen werden mittels Farbdoppler-Sonographie
auch als indirekte Zeichen eines fortgeschrittenen Leberparenchymschadens erkannt.
Die Sonographie zeigt darüber hinaus sensitiv eine Erweiterung der Gallenwege bzw.
kann diese ausschließen. In der Detektion und Differenzierung umschriebener Leberveränderungen
ist sie die erste Bildgebung. Die sonographische Charakterisierung von Leberläsionen
ist bei typischen Befunden ausreichend. Der Einsatz von Ultraschallkontrastmitteln
(Echosignalverstärker) erhöht die Differenzierungsrate und kann den unkritischen Einsatz
weiterer radiologischer Bildgebung (Computertomographie [CT], Magnetresonanztomographie
[MRT]) vermeiden. Bei Zweifeln an der Dignität bleibt die histologische Sicherung
allerdings unabdingbar. Die Beurteilung der Milz und der versorgenden Gefäße erfolgt
regelhaft bei diffusen Leberparenchymschäden unter der Frage einer portalen Hypertension.
Fokale Milzläsionen sind insbesondere im Zusammenhang mit Lymphomerkrankungen (Lymphominfiltrate)
und anderen Knochenmarkserkrankungen zu beobachten. Durch die Anwendung der Kontrastmittelsonographie
werden auch die Vaskularisationsstörungen (Infarkte) sichtbar und traumatische Läsionen
sind besser diagnostizierbar.
Abstract
Conventional B-mode and colour duplex imaging is the first choice imaging technique
after history taking and physical examination and for the interpretation of laboratory
parameters. In the hands of a gastroenterologist ultrasound has become an equally
important diagnostic tool as endoscopy. The constantly evolving technique with its
possibility of higher resolution by use of “harmonic imaging” and signal enhancement
with contrast medium is the reason for a practically relevant review of the situation.
Practical references will be given for diagnostics of the liver and portal system
including the spleen. The significance of the sonographic diagnosis of “fatty liver”
is critically discussed. The overall importance of ultrasound to distinguish different
aetiologies of diffuse liver diseases is relatively low. Nevertheless, it is a very
sensitive means to detect complications of liver cirrhosis. Portosystemic shunts and
typical changes in blood vessel morphology can be diagnosed by colour duplex sonography
and used as indirect signs of advanced damage to liver parenchyma. In addition, ultrasound
has its value in the confirmation or exclusion of dilated bile ducts as well as in
the detection and differentiation of circumscribed liver lesions. The characterisation
of focal liver lesions by ultrasound is sufficient in typical cases. The use of ultrasound
contrast media (signal enhancers) raises the rate of differentiation and can avoid
the uncritical and sequential application of radiological imaging (computed tomography
[CT] or magnetic resonance imaging [MRI]). If in doubt about the nature of a lesion,
a histological diagnosis remains indispensable. The examination of the spleen and
its feeding vessels is regularly done in cases of diffuse parenchymal liver disease
when searching for its complications, e. g., portal hypertension. Focal spleen lesions
can be observed especially in the context of lymphoma (infiltration) and other bone
marrow diseases. Through the application of contrast media, changes of vascularisation
(e. g., infarcts) can be visualised and traumatic lesions can be diagnosed more precisely.
Schlüsselwörter
Ultraschall - Lebertumoren - Hepatitis - Fettleber - Milztumoren - Kontrastmittelsonographie
Key words
Ultrasound - liver tumours - hepatitis - fatty liver - spleen tumours - contrast enhancement
Literatur
- 1
Sporea I, Popescu A, Stirli R. et al .
Ultrasound assisted liver biopsy for the staging of diffuse chronic hepatopathies.
Rom J Gastroenterol.
2004;
13 (4)
287-290
- 2
Poynard T, Ratziu V, Bedossa P.
Appropriateness of liver biopsy.
Can J Gastroenterol.
2000;
14 (6)
543-548
- 3
Farrell R J, Smiddy P F, Pilkington R M. et al .
Guided versus blind liver biopsy for chronic hepatitis C: clinical benefits and costs.
J Hepatol.
1999;
30 (4)
580-587
- 4
Pasha T, Gabriel S, Therneau T. et al .
Cost-effectiveness of ultrasound-guided liver biopsy.
Hepatology.
1998;
27 (5)
1220-1226
- 5
Weickert U, Jakobs R, Siegel E. et al .
Complications of diagnostic laparoscopy.
Dtsch Med Wochenschr.
2005;
130 (1/2)
16-20
- 6
Helmreich-Becker I, Meyer zum Buschenfelde M H, Lohse A W.
Safety and feasibility of a new minimally invasive diagnostic laparoscopy technique.
Endoscopy.
1998;
30 (9)
756-762
- 7
Helmreich-Becker I, Schirmacher P, Denzer U. et al .
Minilaparoscopy in the diagnosis of cirrhosis: superiority in patients with Child-Pugh
A and macronodular disease.
Endoscopy.
2003;
35 (1)
55-60
- 8
Denzer U, Helmreich-Becker I, Galle P R. et al .
Safety and value of minilaparoscopy in high risk patients.
Z Gastroenterol.
2001;
39 (Suppl 1)
11-14
- 9
Dietrich C F, Chichakli M, Hirche T O. et al .
Sonographic findings of the hepatobiliary-pancreatic system in adult patients with
cystic fibrosis.
J Ultrasound Med.
2002;
21 (4)
409-416
- 10
Dietrich C F, Wehrmann T, Zeuzem S. et al .
Analysis of hepatic echo patterns in chronic hepatitis C.
Ultraschall Med.
1999;
20 (1)
9-14
- 11
Bonhof J A, Linhart P.
Quality of sonography in internal medicine.
Dtsch Med Wochenschr.
1986;
111 (33)
1227-1229
- 12
Zwiebel W J, Mountford R A, Halliwell M J. et al .
Splanchnic blood flow in patients with cirrhosis and portal hypertension: investigation
with duplex Doppler US.
Radiology.
1995;
194 (3)
807-812
- 13
Joseph A E, Saverymuttu S H, al S am S. et al .
Comparison of liver histology with ultrasonography in assessing diffuse parenchymal
liver disease.
Clin Radiol.
1991;
43 (1)
26-31
- 14
Joseph A E, Dewbury K C, McGuire P G.
Ultrasound in the detection of chronic liver disease (the „bright liver”).
Br J Radiol.
1979;
52 (615)
184-188
- 15
Foster K J, Dewbury K C, Griffith A H. et al .
The accuracy of ultrasound in the detection of fatty infiltration of the liver.
Br J Radiol.
1980;
53 (629)
440-442
- 16
Dietrich C F, Lee J H, Gottschalk R. et al .
Hepatic and portal vein flow pattern in correlation with intrahepatic fat deposition
and liver histology in patients with chronic hepatitis C.
Am J Roentgenolog.
1998;
171 (2)
437-443
- 17
Siegelman E S, Rosen M A.
Imaging of hepatic steatosis.
Semin Liver Dis.
2001;
21 (1)
71-80
- 18
Schlottmann K, Baer A, Lock G. et al .
The sonographic picture of an echogenic liver is an indicator of pathologic glucose
tolerance.
Dtsch Med Wochenschr.
2000;
125 (17)
517-522
- 19
Wanless I R, Lentz J S.
Fatty liver hepatitis (steatohepatitis) and obesity: an autopsy study with analysis
of risk factors.
Hepatology.
1990;
12 (5)
1106-1110
- 20
Wanless I R, Bargman J M, Oreopoulos D G. et al .
Subcapsular steatonecrosis in response to peritoneal insulin delivery: a clue to the
pathogenesis of steatonecrosis in obesity.
Mod Pathol.
1989;
2 (2)
69-74
- 21
Wanless I R, Shiota K.
The pathogenesis of nonalcoholic steatohepatitis and other fatty liver diseases: a
four-step model including the role of lipid release and hepatic venular obstruction
in the progression to cirrhosis.
Semin Liver Dis.
2004;
24 (1)
99-106
- 22
Celle G, Savarino V, Picciotto A. et al .
Is hepatic ultrasonography a valid alternative tool to liver biopsy? Report on 507
cases studied with both techniques.
Dig Dis Sci.
1988;
33 (4)
467-471
- 23
Rinella M E, Alonso E, Rao S. et al .
Body mass index as a predictor of hepatic steatosis in living liver donors.
Liver Transpl.
2001;
7 (5)
409-414
- 24
Bleck J S, Gebel M, Hebel R. et al .
Tissue characterization using intelligent adaptive filter in the diagnosis of diffuse
and focal liver disease.
Ultrasound Med Biol.
1994;
20 (6)
521-528
- 25
Dietrich C F, Schall H, Kirchner J. et al .
Sonographic detection of focal changes in the liver hilus in patients receiving corticosteroid
therapy.
Z Gastroenterol.
1997;
35 (12)
1051-1057
- 26
Dietrich C F, Gottschalk R, Herrmann G. et al .
Sonographic detection of lymph nodes in the hepatoduodenal ligament.
Dtsch Med Wochenschr.
1997;
122 (42)
1269-1274
- 27
Zwiebel W J.
Sonographic diagnosis of diffuse liver disease.
Semin Ultrasound CT MR.
1995;
16 (1)
8-15
- 28
Pozzato C, Curti A, Radaelli G. et al .
Abdominal ultrasonography in inheredited diseases of carbohydrate metabolism.
Radiol Med.
2005;
109 (1/2)
139-147
- 29
Lefkowitch J H, Grossman M E.
Hepatic pathology in porphyria cutanea tarda.
Liver.
1983;
3 (1)
19-29
- 30
Salata H, Cortes J M, Enriquez D S. et al .
Porphyria cutanea tarda and hepatocellular carcinoma. Frequency of occurrence and
related factors.
J Hepatol.
1985;
1 (5)
477-487
- 31
Dietrich C F, Lee J H, Herrmann G. et al .
Enlargement of perihepatic lymph nodes in relation to liver histology and viremia
in patients with chronic hepatitis C.
Hepatology.
1997;
26 (2)
467-472
- 32 Dietrich C F. Ultraschalllehrbuch. Deutscher Ärzteverlag 2006
- 33
Seitz K, Wermke W.
Portal hypertension - current status of ultrasound diagnosis.
Z Gastroenterol.
1995;
33 (6)
349-361
- 34
Bodner G, Peer S, Kreczy A. et al .
Results of doppler sonography in normally functioning transjugular portosystemic shunts.
Ultraschall Med.
2000;
21 (4)
160-164
- 35
Abu-Yousef M M.
Duplex Doppler sonography of the hepatic vein in tricuspid regurgitation.
Am J Roentgenolog.
1991;
156 (1)
79-83
- 36
Abu-Yousef M M, Milam S G, Farner R M.
Pulsatile portal vein flow: a sign of tricuspid regurgitation on duplex Doppler sonography.
Am J Roentgenolog.
1990;
155 (4)
785-788
- 37
Wang J T, Zhao H Y, Liu Y L.
Portal vein thrombosis.
Hepatobiliary Pancreat Dis Int.
2005;
4 (4)
515-518
- 38
Lassau N, Auperin A, Leclere J. et al .
Prognostic value of doppler-ultrasonography in hepatic veno-occlusive disease.
Transplantation.
2002;
74 (1)
60-66
- 39
Clement T, Swars H, Boerner N. et al .
Venous occlusive disease of the liver - a rare pregnancy complication.
Internist.
1990;
31 (4)
297-300
- 40
Zwiebel W J.
Sonographic diagnosis of hepatic vascular disorders.
Semin Ultrasound CT MR.
1995;
16 (1)
34-48
- 41
Siegelman E S, Outwater E, Hanau C A. et al .
Abdominal iron distribution in sickle cell disease: MR findings in transfusion and
nontransfusion dependent patients.
J Comput Assist Tomogr.
1994;
18 (1)
63-67
- 42
Ocran K, Rickes S, Heukamp I. et al .
Sonographic findings in hepatic involvement of hereditary haemorrhagic telangiectasia.
Ultraschall Med.
2004;
25 (3)
191-194
- 43
Wermke W.
Ultrasonic diagnosis of bile duct calculi. A prospective study regarding the effects
and the objective and subjective factors on accuracy in choledocholithiasis.
Ultraschall Med.
1992;
13 (6)
246-254
- 44
Pai S S, Bude R O.
Sonographic appearance of extensive hepatic arterial calcification mimicking pneumobilia.
J Clin Ultrasound.
2002;
30 (1)
38-41
- 45
Schuessler G, Ignee A, Hirche T. et al .
Improved detection and characterisation of liver tumors with echo-enhanced ultrasound.
Z Gastroenterol.
2003;
41 (12)
1167-1176
- 46
Gossmann J, Scheuermann E H, Frilling A. et al .
Multiple adenomas and hepatocellular carcinoma in a renal transplant patient with
glycogen storage disease type 1a (von Gierke disease).
Transplantation.
2001;
72 (2)
343-344
- 47
Pozzato C, Botta A, Melgara C. et al .
Sonographic findings in type I glycogen storage disease.
J Clin Ultrasound.
2001;
29 (8)
456-461
- 48
Dietrich C F, Schuessler G, Trojan J. et al .
Differentiation of focal nodular hyperplasia and hepatocellular adenoma by contrast-enhanced
ultrasound.
Br J Radiol.
2005;
78 (932)
704-707
- 49
Bergert H, Kersting S, Pyrc J. et al .
Therapeutic options in the treatment of pyogenic liver abscess.
Ultraschall Med.
2004;
25 (5)
356-362
- 50
Ignee A, Weiper D, Schuessler G. et al .
Sonographic characterisation of hepatocellular carcinoma at time of diagnosis.
Z Gastroenterol.
2005;
43 (3)
289-294
- 51
Strobel D, Kleinecke C, Hansler J. et al .
Contrast-enhanced sonography for the characterisation of hepatocellular carcinomas
- correlation with histological differentiation.
Ultraschall Med.
2005;
26 (4)
270-276
- 52
MS, Tosti M E, Mele A.
Screening for hepatocellular carcinoma.
Dig Liver Dis.
2005;
37 (4)
260-268
- 53
Bunk A, Stoelben E, Konopke R. et al .
Color Doppler sonography in liver surgery. Status of perioperative monitoring.
Ultraschall Med.
1998;
19 (5)
202-212
- 54
Dietrich C F, Ignee A, Trojan J. et al .
Improved characterisation of histologically proven liver tumours by contrast enhanced
ultrasonography during the portal venous and specific late phase of SHU 508A.
Gut.
2004;
53 (3)
401-405
- 55
Konopke R, Kersting S, Saeger H D. et al .
Detection of liver lesions by contrast-enhanced ultrasound - comparison to intraoperative
findings.
Ultraschall Med.
2005;
26 (2)
107-113
- 56
von Herbay A, Vogt C, Willers R. et al .
Real-time imaging with the sonographic contrast agent SonoVue: differentiation between
benign and malignant hepatic lesions.
J Ultrasound Med.
2004;
23 (12)
1557-1568
- 57
Albrecht T, Oldenburg A, Hohmann J. et al .
Imaging of liver metastases with contrast-specific low-MI real-time ultrasound and
SonoVue.
Eur Radiol.
2003;
13 (Suppl 3)
N79-N86
- 58
Schlottmann K.
Reader’s letter concerning the article by H. Strunk et al. (Fortschr Röntgenstr 2005,
177: 900 - 904). Erroneous diagnosis of liver metastasis as benign tumor in the contrast
media aided „Low-MI-Real-Time” sonography with SonoVue.
Fortschr Röntgenstr.
2005;
177 (12)
1722-1723
- 59
Dietrich C F, Kratzer W, Strobel D. et al .
Assessment of metastatic liver disease in patients with primary extrahepatic tumors
by contrast-enhanced sonography versus CT and MRI.
World J Gastroenterol.
2006;
12 (11)
1699-1705
- 60
Schlottmann K, Klebl F, Zorger N. et al .
Contrast-enhanced ultrasound allows for interventions of hepatic lesions which are
invisible on convential B-mode.
Z Gastroenterol.
2004;
42 (4)
303-310
- 61
Leen E, Ceccotti P, Moug S J. et al .
Potential value of contrast-enhanced intraoperative ultrasonography during partial
hepatectomy for metastases: an essential investigation before resection?.
Ann Surg.
2006;
243 (2)
236-240
- 62
Oldenburg A, Hohmann J, Foert E. et al .
Detection of hepatic metastases with low MI real time contrast enhanced sonography
and SonoVue.
Ultraschall Med.
2005;
26 (4)
277-284
- 63
Albrecht T, Hohmann J, Oldenburg A. et al .
Detection and characterisation of liver metastases.
Eur Radiol.
2004;
14 (Suppl 8)
25-33
- 64
Albrecht T.
Contrast medium-supported sonography of the liver-a challenge to German radiology.
Fortschr Röntgenstr.
2003;
175 (7)
889-891
- 65
Dietrich C F, Ignee A, Frey H.
Contrast-enhanced endoscopic ultrasound with low mechanical index: a new technique.
Z Gastroenterol.
2005;
43 (11)
1219-1223
- 66
Zhou X, Strobel D, Haensler J. et al .
Hepatic transit time: indicator of the therapeutic response to radiofrequency ablation
of liver tumours.
Br J Radiol.
2005;
78 (929)
433-436
- 67
Yan K, Chen M H, Dai Y. et al .
Results of enhanced ultrasonography in assessing hepatoma treated with radiofrequency
ablation.
Zhonghua Zhong Liu Za Zhi.
2005;
27 (1)
41-44
- 68
Buscarini E, Savoia A, Brambilla G. et al .
Radiofrequency thermal ablation of liver tumors.
Eur Radiol.
2005;
15 (5)
884-894
- 69
Solbiati L, Ierace T, Tonolini M. et al .
Guidance and monitoring of radiofrequency liver tumor ablation with contrast-enhanced
ultrasound.
Eur J Radiol.
2004;
51 (Suppl 1)
S19-S23
- 70
Hansler J, Frieser M, Schaber S. et al .
Radiofrequency ablation of hepatocellular carcinoma with a saline solution perfusion
device: a pilot study.
J Vasc Interv Radiol.
2003;
14 (5)
575-580
- 71
Kormann J, Ockert D, Bunk A.
Radiofrequency ablation of liver tumours.
Zentralbl Chir.
2001;
126 (8)
576-585
- 72
Dietrich C F, Zeuzem S, Caspary W F. et al .
Ultrasound lymph node imaging in the abdomen and retroperitoneum of healthy probands.
Ultraschall Med.
1998;
19 (6)
265-269
- 73
Hosey R G, Mattacola C G, Kriss V. et al .
Ultrasound assessment of spleen size in collegiate athletes.
Br J Sports Med.
2006;
40 (3)
251-254
- 74
Frank K, Thelen M, Linhart P.
Splenomegaly.
Dtsch Med Wochenschr.
1986;
111 (40)
1541-1542
- 75
Frank K, Linhart P, Kortsik C. et al .
Sonographic determination of spleen size: normal dimensions in adults with a healthy
spleen.
Ultraschall Med.
1986;
7 (3)
134-137
- 76
Wedemeyer J, Gratz K F, Soudah B. et al .
Splenosis - important differential diagnosis in splenectomized patients presenting
with abdominal masses of unknown origin.
Z Gastroenterol.
2005;
43 (11)
1225-1229
- 77
Rettenmaier G.
The spleen in ultrasound of the abdomen.
Ultraschall Med.
1995;
16 (3)
103
- 78
Dietrich C F, Brunner V, Seifert H. et al .
Intestinal B-mode sonography in patients with endemic sprue. Intestinal sonography
in endemic sprue.
Ultraschall Med.
1999;
20 (6)
242-247
- 79
Bachmann C.
Color Doppler sonographic findings in focal spleen lesions.
Eur J Radiol.
2005;
56 (3)
386-390
- 80
Gorg C, Bert T.
Second-generation sonographic contrast agent for differential diagnosis of perisplenic
lesions.
Am J Roentgenolog.
2006;
186 (3)
621-626
- 81
Gorg C, Bert T.
Contrast enhanced sonography of focal splenic lesions with a second-generation contrast
agent.
Ultraschall Med.
2005;
26 (6)
470-477
- 82
Gorg C, Seifart U, Gorg K.
Acute, complete splenic infarction in cancer patient is associated with a fatal outcome.
Abdom Imaging.
2004;
29 (2)
224-227
- 83
Gorg C, Riera-Knorrenschild J, Gorg K. et al .
Focal splenic lesions in myeloproliferative disease: association with fatal outcome.
Ann Hematol.
2004;
83 (1)
14-17
- 84
Dietrich C F.
3D real time contrast enhanced ultrasonography, a new technique.
Fortschr Röntgenstr.
2002;
174 (2)
160-163
- 85
Goerg C, Schwerk W B, Goerg K.
Splenic lesions: sonographic patterns, follow-up, differential diagnosis.
Eur J Radiol.
1991;
13 (1)
59-66
- 86
Goerg C, Schwerk W B, Goerg K.
Sonography of focal lesions of the spleen.
Am J Roentgenolog.
1991;
156 (5)
949-953
- 87
Goerg C, Schwerk W B, Goerg K. et al .
Sonographic patterns of the affected spleen in malignant lymphoma.
J Clin Ultrasound.
1990;
18 (7)
569-574
- 88
Goerg C, Schwerk W B.
Splenic infarction: sonographic patterns, diagnosis, follow-up, and complications.
Radiology.
1990;
174 (3 Pt 1)
803-807
- 89
Gorg C, Gorg K, Bert T. et al .
Colour Doppler ultrasound patterns and clinical follow-up of incidentally found hypoechoic,
vascular tumours of the spleen: evidence for a benign tumour.
Br J Radiol.
2006;
79 (940)
319-325
- 90
Gorg C, Zugmaier G.
Chronic recurring infarction of the spleen: sonographic patterns and complications.
Ultraschall Med.
2003;
24 (4)
245-249
- 91
Gorg C, Colle J, Gorg K. et al .
Spontaneous rupture of the spleen: ultrasound patterns, diagnosis and follow-up.
Br J Radiol.
2003;
76 (910)
704-711
- 92
Gorg C, Eichkorn M, Zugmaier G.
The small spleen: sonographic patterns of functional hyposplenia or asplenia.
J Clin Ultrasound.
2003;
31 (3)
152-155
Prof. Dr. Christoph F. Dietrich
Innere Medizin 2, Caritas Krankenhaus Bad Mergentheim
Uhlandstr. 7
97980 Bad Mergentheim
Phone: ++49/79 31/58 22 01
Fax: ++49/79 31/58 22 90
Email: christoph.dietrich@ckbm.de
