Abstracts S51

proved specific for the diagnosis of midgut volvulus, it has not com-pletely replaced the UGI diagnosis. The purpose of this presentation isto present various sonographic findings in addition to whirlpool sign.Materials and Methods: For 7 year period, ten children were diag-nosed as midgut volvulus on US and confirmed surgically. We retro-spectively reviewed the sonographic findings of these children. Theages were from 2 days to 81 days. The male to female ration was 6:4.Results: Whirlpool sign was seen in 8 babies. Beaking of the duode-num (beak sign) was seen in 7 babies. Convergence of vessel on colorDoppler sonography (converging vessel sign) was seen in 8 babies.Whirling mass sign was seen in all babies.Conclusion: In addition to classic whirlpool sign in the sonographicdiagnosis of midgut volvulus, whirling mass sign, converging vesselsign and beak sign were also very helpful. Among these, the whirlingmass sign, especially on real time image was more helpful than whirl-pool sign.Understanding of above mentioned sonographic signs will make rapidand precise preoperative diagnosis possible and could replace UGIevaluation of midgut volvulus.

0370

Live Scanning Workshop: Leg Arteries/BypassDebbie Coghlan, Queensland Vascular Diagnosis, Australia

Vascular surgeons are able to perform an extensive range of arterialbypass procedures to restore circulation to the lower extremity. Bypassgrafts can be made of synthetic materials such as polytetrafluoroeth-ylene (PTFE), however autogenous grafts are the best conduits cur-rently in use as they offer the best long term patency rates.Approximately 15 to 20% of vein grafts fail within the first 5 years ofimplantation. Identification of vein defects prior to thrombus formationin the graft is critical, as meaningful long-term graft salvage is often notpossible when thrombosis occurs. The surveillance of synthetic graftsremains debatable, however these grafts are more likely to becomeinfected, and may lead to serious complications and graft failure.Duplex surveillance of infrainguinal arterial bypass grafts, has emergedas the technique of choice for evaluating bypass grafts, and coupledwith ankle-brachial indices (ABIs) provides a crucial element to thevascular surgeon’s clinical evaluation.The first evaluation of the graft should be performed within the firstmonth of graft implantation. Subsequent examinations are carried out at3, 6, 12 and 18 months after implantation, then if no abnormality isdetected annually thereafter. An initial baseline examination includesthe native inflow vessel, proximal and distal anastomosis sites, the bodyof the graft and native outflow vessel. Doppler provides hemodynamicinformation, while colour and b-mode imaging provide morphologyand structural detail.During this workshop I will provide participants with a practicalprotocol that is used at Queensland Vascular Diagnostics. Hints, tips,criteria, pitfalls and accurate analysis will all be discussed, and detailedhandouts will be available on request.

0371

Live Scanning Workshop: Forefoot Pain AssessmentStephen Bird, Benson Radiology, Australia

Forefoot pain is a common clinical presentation which is often debil-itating for the patient. Chronic forefoot pain often impacts upon thepatient’s ability to participate in paid employment. Enjoyment of sim-ple life pleasures is also compromised as forefoot pain makes walkinga dog or playing with children / grandchildren unpleasant. This paperwill demonstrate a systematic approach to sonographic assessment offorefoot pain considering a wide range of differential pathologies. In

particular the sonographic technique for plantar plate assessment will

be demonstrated. A dynamic method for identification and differenti-ation of Morton’s neuroma and intermetatarsal bursitis will also bedemonstrated.

0372

Live Scanning Workshop: Shoulder Ultrasound Traps andTricksAndrew Wilmot, Dr Jones and Partners, Australia

The standard technique for scanning the shoulder and the rotator cufftendons is well established. Some sonographers go so far as to considerit a simple examination and use the same technique for almost everypatient. The shoulder ultrasound and the art of achieving adequatevisualisation of the rotator cuff tendons can be a challenging exami-nation. In certain clinical situations the protocol must be tailored to suitthe patient’s specific anatomy or pathology.This presentation and workshop will aim to highlight some of thecommon traps that a sonographer may encounter in the “routine”shoulder ultrasound - identification of the rotator cable, the differenttypes of tendinopathy, appearance of post-surgical changes, full versuspartial thickness tears and pathology outside of the rotator cuff.The second part of the workshop will be used to discuss and demon-strate some of the tricks and techniques that can be used to improve thequality of the images produced when performing a thorough andcomplete examination of the rotator cuff tendons and the shouldergirdle.

(Tuesday, 1 September 2009)

0401

Ultrasound of Neck Masses (Non-Thyroid)Norbert Gritzmann, President of EFSUMB, Austria

In many clinical conditions high resolution sonography proved to be afirst line modality is evaluation of cervical soft tissue lesions. Cervicalcysts, lipoma, paraganglioma, neurogenic tumors, haemangiomas orlymphangiomas most times reveal a typical sonographic morphology.Sonography can be used for cervical lymph node assessment. Most ofthe salivary gland diseases can be diagnosed sonographically. Sonog-raphy can be used for guiding biopsy of lymph nodes, cervical softtissue tumors or salivary gland lesions. The relationship of tumors orlymph nodes to the great cervical vessels can be evaluated. ColorDoppler can visualize the vascularisation of cervical soft tissue lesions,often narrowing the differential diagnoses.

0402

Sonography of Thyroid NodulesAnil Ahuja, The Chinese University of Hong Kong, Hong Kong

Patients with thyroid disease may present systemically with disturbanceof thyroid function and/or locally as diffuse goiter or a focal thyroidnodule. While the physiological derangement can be assessed by clin-ical examination and biochemical tests, high resolution sonography isan ideal and non-invasive imaging modality for evaluation of thyroidnodules.The spectrum of thyroid nodules ranges from the common multinodularchange to malignant thyroid tumours. The main aim of imaging is toidentify patients with malignant thyroid disease so that prompt andappropriate treatment can be instituted; and to ascertain benignity ofother thyroid nodules so that patients can be reassured and managedconservatively.The major indications for ultrasound of the thyroid gland include:

(1) Characterize nature of thyroid nodule;

S52 Ultrasound in Medicine and Biology Volume 35, Number 8S, 2009

(2) Provide real time imaging guidance for fine needle aspirationcytology (FNAC) / biopsy;(3) Follow-up patients post-operatively to exclude local or regionaltumor recurrence;(4) Evaluate nodal status to accurately stage thyroid cancerThis presentation will review the ultrasound features of the commonlyencountered thyroid lesions.

0403

3D in Small Parts: Thyroid, Parathyroid and ParotidsLeandro Fernandez, Instituto Medico La Floresta, Venezuela

3DUS can be used in ultrasonography for Small Parts, among othermedical areas. The assessment of the parotid, thyroid and parathyroidglands is properly achieved. The Multiplanar presentation and NicheMode are quite useful to determine the extension -inside or outside theorgans-, of nodules, cysts or tumors. The VOCAL® makes it possibleto obtain a proper after-treatment follow-up of focal disorders in thesesmall organs. Neovascularization is clearly viewed with 3DUS andprobably can suggest malignant origin of a neoplasm. 3DUS offers amore comprehensive image of anatomical structures and pathologicalconditions and also permits to observe the exact spatial relationships.According our previous published results, 3DUS in Small Parts has anexcellent conspicuity in 86.4%, moderate in 9.8% and poor in 3.8%.The feasibility was very easy in 65.2%, easy in 32.8% and difficult in2% of the cases.We are very aware more studies are needed to demonstrate specificityand sensibility of 3DUS in particular clinical conditions, not only insmall parts but also in some other non-Ob/Gyn applications.

0404

Sonography of Neck NodesAnil Ahuja, The Chinese University of Hong Kong, Hong Kong

Lymph node enlargement is the commonest cause of a neck lump.High-resolution ultrasound (US) combined with fine needle aspirationcytology (FNAC) has a high sensitivity & specificity in the assessmentof cervical lymph nodes. Grey scale sonography helps to evaluate themorphology of cervical nodes, whereas power Doppler sonographyassesses nodal vasculature. Grey scale sonographic features such asinternal architecture, presence of intranodal necrosis, echogenic hilus,and calcification help to distinguish between the various causes ofcervical lymphadenopathy. The presence of adjacent soft tissue edemaand matting of nodes are additional useful features to identify tuber-culous lymphadenitis. Power Doppler sonography evaluates the vascu-lar pattern of the lymph nodes and further improves the diagnosticaccuracy of sonography in differentiating benign from malignantnodes. Metastatic nodes exhibit disorganized peripheral vessels, lym-phomatous nodes are invariably hypervascular with chaotic internalvascularity while tuberculous nodes are avascular or hypovascular withdisplaced hilar vessels.Apart from the role in diagnosis, ultrasound helps in the surveillance ofthe post-treatment neck for presence of nodal recurrence and to monitortreatment response in patients undergoing chemotherapy or radiother-apy. The increasing use of ultrasound contrast further enhances the roleof sonography in these areas.This presentation aims to provide an overview of sonographic evalua-tion of cervical lymph nodes and its use in the post-treatment neck.

0406

Blood Flow in the LiverDavid Cosgrove, Imperial College, Hammersmith Hospital, United

Kingdom

The double vascular supply to the liver means that special care must betaken when scanning patients with vascular liver problems. Both supplyvessels as well as the hepatic veins and sites for porto-systemic shuntsmust be scrutinised.Arterial abnormalities are rare, though variants such as a dual supplyare very common and important in liver surgery, especially for partiallive-related transplantation. Occlusion is only encountered after livertransplantation. The anatomy of the portal vein is very constant butanomalies of the hepatic veins are common, especially accessory veinsdraining the right liver (segments 7 and sometimes 6) as well as thecaudate lobe (segment 1). They are important in liver surgery and needto be mapped out as part of surgical planning using CT or ultrasound.Portal hypertension can be caused by narrowings at different levels, thecommonest being intrahepatic and resulting from cirrhosis. Pre-hepaticportal hypertension results from stenosis of the main portal vein or itstributaries and is a complication of carcinoma of the head of thepancreas and of splenectomy. Post-hepatic hypertension is seen in theBudd Chiari syndrome. Each produces different patterns of abnormalDoppler changes which are characteristic, with reduced or reversedflow in the main portal vein and marked increases in hepatic arterialflow, which eventually becomes the sole supply to the liver. In alltypes, extra hepatic porto-systemic shunts may form and the typicalsites (gall bladder bed, retroperitoneum at the head of the pancreas,spleno-renal and spleno-gastric) need to be examined systematicallywith a view to understanding the altered haemodynamics. Except in thepre-hepatic types, the fetal umbilical vein may recanalise and decom-press the portal system; it is seen as a channel in the position of theligamentum teres and can be traced away from the liver passinginferiorly in the direction of the umbilicus. Here, varices may emptyinto subcutaneous veins that either take flow superiorly to anastomosewith the superior epigastric veins or, more commonly, pass inferiorlyinto the pelvis and empty into retroperitoneal veins. In this situation,portal vein flow is faster than normal and there may be reversed flowin the right portal branch. If the portal vein occludes, flow may berestored via recanalisation or new vessels that open around the originalportal vein, so-called cavernous transformation. The Doppler findingsare complex, with numerous tortuous vascular channels in the portahepatis.The intrahepatic arterio-venous shunts that are so important in cirrhosisare usually microscopic and cannot be imaged with ultrasound. How-ever, the rapid transit of blood from the hepatic artery to the hepaticveins can be tracked by using a bolus of a microbubble contrast agentas a tracer. In the normal, there is a substantial delay (� 12 secs) butthis is much shorter in cirrhosis. This non-invasive test separates mildfrom severe chronic hepatitis and from frank cirrhosis and can be usedto monitor these patients. Metastases produce a similar shift of theliver’s blood supply in favour of the artery.Surgical stents to shunt the blood from the portal to the systemiccirculation may be inserted, the usual version being the transjugularintrahepatic porto-systemic shunt, which is highly echogenic on ultra-sound. This may make Doppler evaluation difficult and there is alwayssome degree of flow disturbance at the portal end of the shunt. UsuallyDoppler can be used to establish that the shunt is patent, but assessingrestenosis is difficult because the flow may accelerate (across a steno-sis) or slow (if the stenosis becomes haemodynamically significant).This confusing situation has led to angiography with pressure measure-ments being used instead of ultrasound.Pathology of the hepatic veins is relatively uncommon, but occlusionoccurs in the Budd-Chiari syndrome, which may be caused by mem-branous flaps in the upper IVC or occur in hypercoagulable states.Occasionally a tumour, such as a metastasis compresses one of theveins, leading to occlusion. If the occlusion is complete and of rapidonset, acute liver failure ensues and is usually rapidly fatal. Partial or

incomplete forms lead to portal hypertension and Doppler can be used