. . ""® ........ -i ;: ij "W: -m ­% !i " I \ .: ' ' injekcije im.nv., tablete, prašek za pripravo susp.zij:r antibiotik širokega spektra -rešitev problema bakterijske rezistence . ampicilin, zašciten s sulbaktamom -zato odporen proti delovanju beta laktamaz . razširja antibakterijsko delovanje ampicilina na po Gramu pozitivne bakterije, ki izlocajo penicilinazo, na po Gramu negativne in anaerobne bakterije, vkljucno Bacteroides fragilis, ter tako povecuje klinicno uporabnost in ucinkovitost ampicilina ® visoko ucinkovit v ambulantnem in bolnišnicnem zdravljenju infekcij zgornjih in spodnjih dihal, secil, rodil, kože ter mehkih tkiv ® možnost oralne in parenteralne uporabe @ ® izkljucuje potrebo po kombiniranem zdravljenju . ucinkovito preprecuje pooperativne infekcije . dobro prenašanje §3 '!mi::-............'%..%\%.."%..... Podrobnejše informacije in literaturo dobite pri proizvajalcu. ... KRK. tovarna zdravil, p.o., Novo mesto, Slovenija izdelan iz aktivnih ucinkovin firme Pfizer ====== .-=,,...'™.....%.. RADIOLOGY AND ONCOLOGY Established in 1964 as Radiologia Iugoslavica in Ljubljana, Slovenia. Radiology and Oncology is a journal devoted to publication of original contributions in diagnostic and interventional radiology, computerized tomography, ultrasound, magnetic resonance, nuclear medicine, radiotherapy, clinical and experimental oncology, radiophysics and radiation protection. Editor in chief Tomaž Benulic Ljubljana. Slovenia Associate editors Gregor Serša Ljubljana, Slovenia Viljem Kovac Ljubljana, Slovenia Editorial board Marija Auersperg Andrija Hebrang Branko Palcic Ljubljana, Slovenia Zagreb, Croatia Vancouver, Canada Matija Bistrovic Durila Horvat Jurica Papa Zagreb, Croatia Zagreb, Croatia Zagreb, Croatia Haris Boko Berta Jereb Dušan Pavcnik Zagreb, Croatia Ljubljana, Slovenia Ljubljana, Slovenia Malte Clausen Vladimir Jevtic Stojan Plesnicar Kiel, Germany Ljubljana, Slovenia Ljubljana, Slovenia Christoph Clemm H. Dieter Kogelnik Ervin B. Podgoršak Miinchen, Germany Salzburg, Austria Montreal, Canada Christian Dittrich Ivan Lovasic Miran Porenta Vienna, Austria Rijeka, Croatia Ljubljana, Slovenia Ivan Drinkovic Marijan Lovrencic Jan C. Roos Zagreb, Croatia Zagreb, Croatia Amsterdam, The Netherlands Bela Fornet Luka Milas Slavko Šimunic Budapest, Hungary Houston, USA Zagreb, Croatia Tullio Giraldi Maja Osmak Andrea Veronesi Udine, ltaly Zagreb, Croatia Gorizia, ltaly Publishers Slovenian Medica[ Society ­Section of Radiology, Croatian Medica/ Association ­Croatian Society of Radiology Correspondence acldress Radiology and Oncology Institute of Oncology Vrazov trg 4 61000 Ljubljana Slovenia Phone: + 38 61 120 068 Fax: + 38 61 114 180 Reader .for English language Olga Shrestha Design Monika Fink-Serša Key words und U DC Eva Klemencic Secretaries Milica Harisch Betka Savski Printed hy Tiskama Tone Tomšic, Ljub0ana, Slovenia Puhlished quarterly Bank account number 50101 678 48454 Foreign currency account number 50100-620-133-27620-5130/6 LB -Ljubljanska banka d.d. Ljubljana Subscription fee for institutions 100 USD, indivicluals 50 USD. Single issue for institutions 30 USD, individuals 20 USD. According to the opinion of the Slovenian O.ffice of !nformation, the journal RADIOLOGY AND ONCOLOGY is a publication of informative value, and as such subject to taxation by 5 'Ľ, sales tax. lndexed and abstractecl by: BIOMEDICINA SLOVEN!CA CHEMICAL ABSTRACTS EXCERPTA MEDICAIELECTRONIC PUBLISHING DIVISION TABLE OF CONTENTS DIAGNOSTIC RADIOLOGY AND ULTRASOUND Pncumoperitoneum of thc lcsscr sac following gastric and d11odcnal surgery Lovasi(: !, Dujmovi(: M, Uravic' M, Dimi/rovski L 85 Ascptic hip nccrosis: Early 11ltraso11nd diagnosis Babi(: M, Kozi<: S, Matovinovic D A comparativc study of ultrasonography and computed tomography in orbital discases Barla M, Rdcz P, Puskris T, Szepe !, Ferentzi J, Munktisci G, Scifrrin A 89 95 Blunt splcnic injurics: A sonographic contribution to indications for conscrvative or opcrativc trcatmcnt Miletic D, Fuc'kar Ž, Mozetic' V, ,.usti( A 99 NUCLEAR MEDICINE Quantitative analysis of blood tlow in thc cstimation of rcnal transplant function Huic D, Gro.ifeF D, Poropat M, Buhic-Filipi L, Dodig D, !vanl'evh' D, Medvedec M 105 CUNICAL AND EXPERIMENTAL ONCOLOGY Subjcctive 1>roblcms of' paticnts associatcd with trcatmcnt of maxilofacial maligmmcics Juretic' M, Car M, Žgaljardi(: Z, ,.ustic A lnvasivc cervical adcnocarcinoma: An analysis of 67 trcatcd cascs vs squamous carcinoma Stržinar V 111 115 Vira! tumor inhibition Cerar A 120 Inciclcncc of structural chromosomal abbcrations ancl sistcr chromatid cxchangcs among medica! pcrsonncl handling antincoplastic drugs Brumen V 125 EPIDEMIOLOGY Etiology and primary canccr prcvention Primic-Žakelj M 132 REPORTS The twelfth biennial meeting of the EACR Osmak M, Serša G 143 The twentyfifth annual meeting of the European Society for Radiation Biology Osmak M 147 NOTICES 150 Radio/ Oncol 1993; 27: 85-8. Pneumoperitoneum of the lesser sac following gastric and duodenal surgery Ivan Lovasic, Milivoj Dujmovic, Miljenko Uravic, Lidija Dimitrovski Clinical Hospital Center Rijeka, Clinical Department of Radiology, Surgery Clinic, Croatia Reports on inflammatory effusions in the lesser sac of various causes, and very heterogeneous, sometimes inadequate terminology, are well-known in literature. But, we have not found descriptions of pneumoperitoneum of the lesser sac following gastric and duodenal surgery. Five patients with localized effusion in the lesser sac with fluid leve! and an air vesicle above it, found 8 to 15 days postoperatively, are reported. The patients claimed no discomfort and the finding spontaneously clisappeared up to the fourth week following surgery. Key words: stomach-surgery; duodenum-surgery; pneumoperitoneum, radiology Introduction "Bursitis omentalis" implies the inflammatory effusion in the lesser sac or fluid content collec­tion of other genesis. Gas content is usually present together with the fluid giving characte­ristic radiological feature. Fluid leve! with an air bubble above it, localized behind the sto­mach, has been the typical finding. In case of effusion without the presence of gas content, radiological feature is characterized by round shadow intensity of soft particles between the lesser curvature of the stomach, !iver and diap­hragm. Inflammatory diseases of the pancreas, perforation or penetration of gastric and duode- Correspondencc to: Prof. dr. sci. Lovasic Ivan, Kli­nicki bolnicki centar Rijeka, Klinicki zavod za radio­logiju, 51000 Rijeka, Tome Strižica 3, Croatia. na! ulcus and the diseases of other adjacent organs surrounding the lesser sac (!iver, tran­sverse col on and small intestine) have been prevailing features in the aetiology. With regard to such dissimilar aetiology, various terms are found in literature concerning this state (bursitis omentalis, pneumoperitoneum of the lesser sac, empyema of the lesser sac, lesser sac abscess, 2• 3 even pancreatic pseudocyst).1• We have found only one detailed report in the literature presenting localized lesser sac effusion as an unspecific complication following gastric and duodenal surgery, without proved dehiscence of the surgical suture and without signs of the adjacent organ involvement.4 The purpose of this study was to point out this radiological entity, a thorough understan­ ding of which could be of great significance for differential diagnosis in postoperative complica­ UDC: 616.33-089-06:616.342-089-06:616.381-003.219 tions at the lesser sac area. 86 Lovasic 1 et al. Patients aud methods A smaller series of cases with the lesser sac effusions following gastric and duodenal surge­ry, verified in a long-term period, have been reportecl. Checkups covered ali the patients within 8 to 15 clays postoperatively because of unclefined discomfort and the surgical interven­tion itsel f. Ali of them unclerwent upright abodominal X-ray and classical radiological barium-enema examination. Results The first case represents a patient after Billroth I surgery. Upright abdominal X-ray showecl a large fluid leve! with an air containing bubble beneath the left and right dome of the clia­phragm on the fourth day postoperatively (Fi­gure la). Control checkup on the eighth day I1'igure la. A large fluid leve! with air collcction bcneath thc diaphragm on the fourth day postoperati­vely. following surgery showecl a great hypotonic gastric pouch full of secretion, with aggravated emptying (Figure lb). A small, well tonicized gastric pouch with regular emptying, but stili containing lesser sac fluicl leve! was revealecl on the fifteenth postoperative day (Figure le). Figure le. Thc same patient 15 days postoperatively. A small well tonicizecl gastric pouch with regular emptying. Very low fluid leve! in the lesser sac. Figure lb. The same patient 8 days after surgery. Large atonic gastric pouch (Billroth I) and the fluid Figure 2. Billroth l operatcd patient. Effusion in the leve! in the lesser sac. vestibular area of the lcsscr sac. Pneumoperitoneum of' the /esser sac following gastric umi duodenal surgay The seeond case is a patient after Billroth I surgery, with visible effusion in the vestibular area of the lesser sac (Figure 2). The third case shows a typical large postope­rative effusion in the lesser sac following Bill­roth II gastric surgery, with normal appearance of the gastric pouch and stoma on the twelfth day postoperatively (Figure 3). The fourth and the fifth patients underwent vagus-and pylorus-surgery. Routine checkup on the eighth postoperative day verified the lesser sac effusion associated with typical gastric and duodenal appearance and regular emptying (Figure 4, 5). The reported patients were not operated on urgently beeause of perforation. None of the examined patients experienced any particular postoperative discomfort. No ···signs of dehi­scence within the surgical area were found. Ali the verified effusions in the lesser sac were treated conservatively and disappeared in the course of one 111011th postoperatively. Figure 3. A largc cffusion in thc lcsscr sac following gastric Billroth II surgcry. Figure 4. Typical cffusion fcaturc in thc lcsscr sac Figure 5. Typical cffusion fcaturc in thc lcsscr sac following vagotomy ancl pyloroplasty (scc. Finncy). following vagotomy ancl pyloroplasty (scc. Finncy). Lovasic 1 et al. Discussion sary till the complete disappearance of effusion It is surprising that reports on localized effusion in the Iesser sac following gastric and duodenal surgery without proved dehiscence of the surgi­cal suture and without special clinical symptoms are so rare. We consider this state to be more frequent than it has been generally believed. The Iesser sac effusion of other genesis has been reported far more often. Pancreatitis with a formed pseudocyst or without it, perforation of gastric and duodenal ulcers, traumatic perfo­ration of the small and large intestines and !iver 1• 2• 3 abscess take the first place . Causes for this state can be of various nature. With regard to the course, the surgical trauma­tism of the adjacent structures and pneumope­ritoneum of the same origin as of subphrenic Iocalization, presumably take the first place. Taking into consideration these emergency cau­ses, the term pneumoperitoneum of the lesser sac seems the most appropriate. Localized effusion in the lesser sac following gastric and duodenal surgery need not be taken as an alarming state unless leaking of contrast medium at the site of the operative suture has been proved. Radiological follow up is neces-one to two months postoperatively. Recognition of this state as well as of other possible simul­taneous postoperative complications is of signi­ficance, in order not to overemphasize its im­portance, with respect to differential diagnosis. Together with characteristic symptoms descri­bed, which clearly define this particular radiolo­gical entity, and with proper understanding of syntopy in the region of the lesser sac, diagnosis and differential diagnosis are not hard to ob­tain. References l. Gcrth F. Zur Prage dcr sog. »Pscudozystcn« dcs Pankreas. Bursitis omentalis. Anatomische und rontgenologische Befunde. Fortschr Rontgenstr 1935; 51: 8-22. 2. Walker L, Weens S. Radiological Observations on the Lesscr Peritoncal Sac. Radiology 1963; 80: 727-37. 3. Heidenblut A, Holz K. Beitrag zur Rontgendiagno­stik der Bursitis omentalis. Fortschr Rontgenstr 1968; 108: 9-18. 4. Dujmovic M. Prilog poznavanju radiološke slike želuca i dvanaesnika poslijc vagotomije i piloropla­stike. Disertacija, Medicinski fakultet Rijeka, 1988. Radio/ Oncol 1993; 27: 89-94. Aseptic hip necrosis: Early ultrasound diagnosis Mladen Babic, Slavko Kozic, Damir Matovinovic Specialized Clinical Orthopaedic Hospital, Lovran, Croatia In its early phase aseptic hip necrosis in adults represents a diagnostic problem. Among other well established diagnostic methods we use ultrasouncl, a m.ethod that already has considerable importance in the diganosis of locomotor system cliseases. We began to use ultrasouncl in the diagnosis of aclult aseptic hip necrosis seven years ago, ancl up to now 51 patients have been examined, their age ranging between 35-55 years. The comparison groups consisted of 30 patients with normal hips ancl 30 patients with clegenerative changes in the hips. The patients were examined on Aloka SSD 500 machine with 3.5MHz and 5 MHz linear probes. Our own methocl of examination was introcluced. Ultrasound examination findings were com.parecl with findings obtainecl by other diagnostic methods such as scintigraphy, CT and tomography. In some cases, changes on femur heads were sonograp­hically determined earlier than with other diagnostic methods. Key worcls: femur head necrosis-ultrasongraphy lntroduction Diagnosis of adult aseptic hip necrosis is mostly based on X-ray methods that offer an insight into the degree of necrosis, site of necrosis and surface of affected area. However, X-ray fin­dings are negative in the early phase of the disease in which clinical findings such as pain, limping and reduced hip motions are dominant. Far early diagnosis of this disease other me­thods may be used, e.g. tomography, scintigra­phy, CT and MRI. Since some of these methods have not been available routinely, we were forced to search far new methods of imaging. 1• 2, 3 Correspondence to: Mladen Babic, MD, DSc, Specia­lized Clinical Orthopaedic Hospital Lovran, Croatia. Ultrasound plays an important role in many clinical fields, including orthopaedics. New ul­trasonic machines offer diagnostic possibilities which could not be imagined just a few years ago. Today, soft tissue changes as well as joint diseases are routinely diagnosed, especially in children. Periarticular and intraarticular patho­logic changes are also accessible to ultrasonic diagnosis. Intraosseous changes were inaccessi­ble to ultrasound owing to bone acoustic impe­dance, but with the development of ultrasonic technology it might be possible to overcome 7 this obstacle. 6• Having certain experience in bone tumour ultrasound diagnostics, we specu­lated about the possibility to visualise by ultra­sound pathological changes on the femur head in the early phase of aseptic hip necrosis.8• In the beginning we studied only the cases with X-ray findings of aseptic hip necrosis. After­ UDC: 616.718.41-021.4:534-8 ward, we have started to visualise changes Babic M et al. invisible by X-rays in the cases with suspected aseptic hip necrosis. Materials and methods In the period from 1985 to 1992, 51 patients with pain in the hip region were examined by ultrasound. The patients included in this study had a painful hip, reduced hip motions and evident or suspected X-ray changes in the ace­tabulum or femur head. The aim was to visua­lize changes characteristic for aseptic necrosis. Their age ranged between 35-55 years; there were 29 males and 22 females. The control group comprised 30 healthy persons 20-40 years of age, without a history of pain in the hip, with normal hip motions, and 30 patients with clinical symptoms and X-ray findings of degene­rative hip changes ( coxarthrosis), in the age of 50-65 years. There are no data on. this problem available in the existing literature. Therefore, we have devised our own method of ultrasonic diagnosis and assessment of the obtained results. An adult hip can be examined only under standar­dised terms, and femur head should be comple­tely visualised by ultrasound.JO, 11 We have used Aloka SSD 500 machine with 3.5 MHz and 5 MHz linear probes, and measu­rements were performed using computer calli­ pers. The aim of our preliminary work was to establish normal ultrasonic relations in the re­gion of adult hip joints, which differ greatly in comparison with neonatal and infant hips. We have established standards of examinations, since such standards do not exist in the literatu­re, and we have developed our own examina­tion methodology. It is mandatory to investigate the hip in multiple tomographic slices, which is schematically presented in Figure l. The supine position tenders the anterior and superior part of the femur head and acetabulum accessible to investigation. The probe is positioned in the horizontal plane (Figure lb), and slowly moved craniocaudally. Afterwards, the probe is turned in vertical plane to locate the great trochanter, and moved lateromedially. In this position the .if' Figure l. Schcmc of standard approaches to adult hip joint rneans of ultrasound probc (A-probc in the vertical plane, lateral to the hip joint; B-probc in thc horizontal plane, anterior to thc hip joint; C-probc in the horizontal plane, posterior to thc hip joint; D­probe in the sernioblique planeinguinurn-anterior to the joint). probe should be oriented in the semioblique position, in the direction of the inguinum (Fi­gure ld). After that, the patient should lie in decubitus position with support of the knees. The leg is thus in the horizontal plane. In this position the hip is examined in horizontal and vertical plane (Figure la). In this way, the upper and laterni joint sections as well as the great trochanter can be examined. The exami­nation is completed in prone position (Figure le), also in horizontal and vertical planes, which provides an insight into the posterior joint sec­tion. Results In healthy individuals, only the narrow bony acetabular part, adjacent to the cartilage, can be visualised. In contact with ultrasonic beam, the superficial segment is imaged on the screen as a semilunar hyperechogenic line. Identically, Aseptic hip necrosis: Early ultrasound diagnosis only superficial, intracartilaginous bony part of the femur head can be visualised as a hyperec­hogenic semilunar line (Figure 2, 2a). It is seldom possible to visualize the whole femur head, imaged as a homogeneous hypoechogenic spherical zone below the hyperechogenic line. When the patient is in supine position, and the probe in the vertical plane, the great and lesser trochanter can be visualised. In patients with coxarthrosis, a thin hyper­echogenic line visible in healthy persons is considerably wider and inhomogeneous, and hyperechogenicity is slowly replaced with normoechogenic area representing non-affected part of the femur head. The space between the acetabulum and femur head, measured sonographically, is 2-3 mm in healthy subjects. After having obtained standard images and gained certain experience with healthy hip and coxarthrotic hip examining, we started to carry out the investigations in adults with clear aseptic hip necrosis. These findings were considerably different in comparison with healthy and coxar­throtic hips. In aseptic hip necrosis, the hyper­echogenic line is clearly delineated; disrupted and inhomogeneous hyperechogenic zone can be visualised inside the femur head, represen­ting alterations of bony structure in the femur head (Figure 3, 3a, 4, 4b). It is mandatory to examine both hips, and to measure the width of the hyperechogenic zone since it represents the area of aseptic necrosis. It is also necessary to measure the joint fissure width for an indirect assessment of the cartilage condition and even­tual existence of intraarticular effusion. In addition to ultrasound examination, ali patients have been examined by other available imaging methods; scintigraphy, X-ray tomo­graphy, and in some cases also CT scan. There were 51 patients examined, and in 29 of them aseptic hip necrosis was confirmed in the course of diagnostic procedure. Aseptic hip necrosis was established by ultrasound in 21 patients. In 16 patients with pain in the hip the findings were negative, and the disease was confirmed using other imaging methods, as well as by clinical follow up. In 8 patients false-ne­ Babic M et al. Figure 3. Aseptic hip necrosis in adult-ultrasonic fin­ding. Just beneath the semilunar hyperechogenic zone there is a rhomboid zone of increased echogenicity corresponding to early aseptic necrosis of the hip. A-disrupted continuity of semilunar hyperechogenic zone. B-acetabulum, C-healthy part of the femur head, D-aseptic necrosis zone, E-skin, F-subcutaneous tissue, G-muscle. Figure 3a. Scheme of ultrasonic finding of aceptic hip Figure 4a. Scheme of ultrasonic finding of aseptic hip necrosis. The underlined parts are those visualised necrosis. The underlined parts are those visualised sonographically. sonographically. Aseptic hip necrosis: Early ultrasound diagnosis In its early stage, aseptic hip necrosis repre­sents a substantial diagnostic problem. Classical X-ray diagnosis being insufficient at this stage, we have tried to improve the diagnostic proce­dure by ultrasound imaging. In the period of 7 years we have been using probes of 3.5 MHz and 5 MHz. We believe that an 8-10 cm long 5 MHz Iinear probe is the most convenient. Using such a probe we could obtain a general insight into the analysed structures. While measuring bone structures, it should be kept in mind that ultrasound beam velocity in the bones is cca 25 % higher than soft tissue velocity. Bence, the values obtained in the bones are always somewhat Iower than in rea­lity. During the study, mathematical corrections were performed in order to obtain real va­lues.13· t 4 Altered bone structure due to aseptic necrosis enables us to visualize deeper bony structures of the hip, thus rendering pathological investi­gation of the altered structures relati vely easy. In normal bone very limited quantity of infor­mation can be obtained by means of ultra­sound,8· 15 whereas ultrasonic beam in patholo­gically altered bone has different properties, which enables us to obtain more diagnostic information.6 Alterations smaller than 1 cm can­not be visualised sonographically in bony struc­ tures with presently available ultrasonic machi­ positive findings were also obtained primarily nes.11' during the first years of our investigations. Discussion So far, etiology of ase ptic hip necrosis bas not lnterventional ultrasonography provides an opportunity for femur head biopsy in certain patients with suspected pathological alterations of the femur head, thus improving the diagno­stic procedure. been completely explained. Various pathologi­cal conditions, having nothing in common with each other, can cause aseptic hip necrosis. It is usually a consequence of a hip trauma, circula­tory disorders in the femur head, as well as of metabolic diseases.12 It is not seldom found in collagen-disorders, endocrinological disturban­ces, degenerative diseases and alcoholism. Ra­rely it can be found in septic infections and venereal diseases. Aseptic hip necrosis in in­fancy (Perthes' disease) bas different features and age of onset. Ultrasound finding in a healthy person shows a semilunar hyperechogenic line, the feature observed due to properties of ultrasonic beam in junction with healthy bone structure.7• 15 Conversely, in aseptic hip necrosis ultrasonic finding is much more prominent owing to a 7 8 large visible hyperechogenic area.• Altera­tions in the bone structure in the course of the disease enable ultrasonic beam penetration in­side the bone itself, and the reflected beam provides a substantially bigger amount of infor­mation.9 Babic M etal. A high proportion of false-positive and cer­tain proportion of false-negative findings were recorded in the begining of our study, when we were inexperienced in this imaging method, resulting in the misinterpretation of ultrasonic image. Errors were primarily due to unrecogni­sed phenomenon of reverberation in few cases, and due to misinterpetation of the superposition of shadowing caused by probe malpositioning. Large degenerative alterations of the femur head with formation of cystic zones represent a significant diagnostic problem versus aseptic hip necrosis. Hyperechogenic area in the femur head is visible in degenerative alterations as well, and special care should be taken to deli­neate a sharp border between the necrotic bone tissue in aseptic necrosis and normal bone tis­sue. Hyperechogenic area in degenerative di­sease merges gradually with the normoechoge­nic area of normal bone. This is the only difference between the two conditions. After performed sonographic examination and follow up of patients with aseptic hip necrosis in adults it is possible to draw the following conclusions: -By means of ultrasound, aseptic necrosis can be diagnosed sooner than with classical diagnostic procedures; -Examination is harmless and can be often repeated; -Dynamic visualisation form different direc­tions is possible; -Ultrasound provides a considerable contri­bution to resolving these diagnostic problems, especially in an early stage of the disease. -Ultrasonographically guided biopsy can be performed from specific sites and pathohistolo­gical diagnosis can be obtained. Our observations contribute to broadening the applicability of ultrasound diagnostics. References l. Barjaktarevic T, Hašpl M, Atias V, Orlic D, Radanovic B. Simunic S. Intraosalna flebografija u clijagnostici icliopatske nekroze glave bcclrcnc kosti. Acla Orthop !ugasi 1969; 20 (2): 48-52. 2. Matasovic T, Vrdoljak J. Ultrazvucna clijagnostika kuka i natkoljenice. In: Kurjak A, cel. Ultrazvuk u klinickoj medicini. Zagreb; Medicinska bibliote­ ka, 1989, 779-89. 3. Matasovic T. Ultra.zvucna clijagnostika sustava za kretanje. Zagreb: Skolska knjiga, 1989: 23-47. 4. Matasovic T. Rast i sustav za krctanjc. Acta Or1hop !ugasi 1989; 20 (2): 53-68. 5. Matasovic T. Dijagnosticki ultrazvuk u ortopediji. Lijec Vjesn 1991; 113 (5-6): 172-9. 6. Babic M. Mogucnost clijagnostikc hernije intcrvcr­tcbralnog diska metoclom ultrazvuka. Rijeka, Hr­vatska; Medicinski fakultet Rijeka, 1980. '18-30 p. Magistarski raci. 7. Babic M. Pokušaj clijagnostike intraosalnih tumora ultrazvukom. In: Kurjak A, Srctcnovic Z, cel. III jugoslavcnski kongres o primjeni ultrazvuka u medicini i veterini. Beograd: Sekcija za ultra­zvucnu clijagnostiku Jugoslavije i Srbije, 1989; 193-4. 8. Babic M, Matovinovic D. Mogucnost primjene ultrazvuka u clijagnostici intraosalnih tumora. Me­dicina 1990; 26: 141-7. 9. Babic M, Matovinovic D.Ultrasouncl as a racliolo­gical tool in malignant bone tumors. Aclvanccs in racliology ancl oncology. Adv Radio! On.col 1992; 102-8. lO. AnclricJ, Babic M. Pokušaj clijagnostikc migracije totalne encloproteze pomocu ultrazvuka. In: Mikic Z, cel. IX kongres ortopeda i traumatologa Jugo­slavije -JUOT 1986. Novi Sad: 1987; 459-63. 11. Hcvczi JM, Physical princi ples of cliagnostic ultra­souncl. In: Anderson E, ecl. Racliologic ancl othcr biophysical mcthocles in tumor cliagnostic. Chicago 1975, 99-l.07. 12. Baksi DP. Treatment of ostconccrosis of thc fcmo­ral heacl by clrilling ancl muscule -pecliclc bone grafting . ./ Bone .!oin.L Surg (Br) 1991; 73B: 241-5. l3. Babic M. Ultrazvuk u evaluaciji komprcsijc u lumbosakralnom segmentu. Lijec Vjesn. 1982; 104: 354-7. 14. Breyer B, Anclreic ž. Fizika ultrazvuka. In: Kur­jak A, cel.: Ultrazvuk u klinickoj medicini. Za­greb: Medicinska biblioteka, 1989; 1-3. 15. Breyer B. Fizikalne osobine ultrazvucne clijagno­stikc. In: Matasovic T, ur. Ultrazyucna clijagno­stika sustava za kretanje. Zagreb: Skolska knjiga, 1989: 9-21. Radiol Oncol 1993; 27: 95-8. A comparative study of ultrasonography and computed tomography in orbita) diseases Miklos Barta, Peter Racz, 1 Tamas Puskas, Ida Szepe, Judit Ferentzi,1 Gyorgyi Munkacsi1 and Antal Safran2 Departments of Radiology, Ophthalmolog/ and Otorhinolaryngology2 , Markusovszky Hospital, Szombathely, Hungary Examinations were performed in 121 patients suspect of orbita! disease. The sensttivtty of the echographic method was 2 mm far extraocular intraconal orbita! processes. In the majority of endocrine orbitopathies ultrasound examination yields a sufficient amount of information to confirm the clinical diagnosis. CT examination is indispensable before surgery and radiotherapy, and when the disease is extraconal or destroys the orbita! wall. Key words: orbita! diseases; ultrasonography; tomography, x-ray computed lntroduction The diagnostic use of ultrasonography (US) and computed tomography (CT) of orbita! dis­orders is dealt with by a large number of papers; L-12 however, there are only hints con­cerning comparison of the two methods. In this study we tried to establish the diagno­stic value of an excellent though not specially ophthalmological US equipment in orbita! di­seases, and to compare the efficacy of US and CT. Results obtained by Doppler-sonography are not discussed bere. We found that an overwhelming majority of orbita! processes can be diagnosed by the use of Picker LSC 7000 real-tirne equipment, espe- Correspondence to: Barta Mikl6s M. D., Markusov­szky K6rhaz, Radiol6gia, Szombathely, . POBox 143, H-9701. UDC: 617.76-073.75:534-8 cially if the pathological alteration is adjacent to the bulbus. Ali orbita! disorders are clearly discernible by CT. Computed tomography is indispensable before surgery and radiotherapy. Materials and methods Between October 1, 1988 and July 31, 1991, 121 patients with a suspected orbita! disorder were examined in Markusovszky Hospital. There were 59 US and 115 CT examinations carried out; in 26 cases both US and CT were done at the same tirne. US examinations were performed by Picker LSC real-tirne equipment, using a 5 MHz linear array transducer and a Kitecko gel-cushion pla­ced to the closed eyelids. The US diagnosis was further confirmed by CT (Somatom DRH-2 Siemens), clinical course and histology. Barta Met al. Figure l. a) Transversal sonogram of the medial rectus muscle in a patient affected by endocrine orbitopathy. b) Axial CT of medial rectus muscle in the same patient. The same finding was obtained by both met­hods. Results The evaluation of the method according to diagnosis is shown in Tables 1 and 2. Nine US and 16 CT examinations were repeated. The most frequent indications were endocrine orbi-, topathies and tumours (Figures 1-3). Endocrine orbitopathies can only be demonstrated by US if the medial rectus muscle is involved; ali intraconal processes, however, are discernible, by US. US has a restricted diagnostic value in extraconal disorders, their relationship to the osseous orbita! wall could not at ali, or only hardly, be established by the use of US. E.g., the neurofibromatosis of one of the patients could only be revealed by the positive result of the Valsalva-manoeuvre. In a false negative case an extraconal turno ur ( dermoid) was not detected by US. In another case enlargement Figure 2. a) Tarnsversal sonogram: cystic lesion in the left orbit. b) Axial CT: the cystic lesion with mural enhancement (arrow---,,) can be seen on the left of the open fronta) sinus. of the'lacrimal gland was detected but its exact nature could not be explained because no sur­gery was performed. Discussion For orbita) examinations miniaturised 8-10 MHz transducers are used. 6• 10• 13 No sufficiently exact topographic information can be obtained by orbita) US, mainly because of Jack of ima­ging in the coronary plane. Its efficacy is limited in posterior processes or disorders adjacent to the osseous orbita! wall. The anterior and mid third, however, can be sufficiently evaluated by 1• 6• 10• 13 sonography . A comparative study of ultrasonography and computed tomography in orbita/ diseases Figure 3. a) Sagittal sonogram: Cystic lesion with septal structure above the left eye. b) Sagittaly recons­tructed CT scan: Cystic stenotic process in the left half of the fronta) sinus (arrow-> ), propagating into the orbit. The eyeball is disclocated forward and downward. Diagnosis: Fronta) sinus mucocele, verified by surgery. Here we present the use of US and CT in the evaluation of orbita! diseases. Value of US in the diagnosis of orbita! processes The orbita! processes discernible acoustically from their environment can be diagnosed by US. 1• 2, 6, 10, 13• 14 The advantage of the equip­ment used by us over that intended for special ophthalmological purposes is in its lower fre­quency securing better penetration and over­view of the pathological alteration and its envi­ronment. On the other hand, the small transdu­cer with higher frequency produces a more detailed picture. The apex cannot be examined by US, but no diseases with such localisation occurred in our material. Ali intraconal processes could be detected. The use of US can be recommended in the diagnosis and follow-up as long as the medial 515 rectus muscle is involved.· This muscle is always discernible by our equipment and its width can be measured. Table l. Diagnoses based on orbital US and CT. US CT US and CT Congenital disorders (neurofibramatosis and Paget's disease) 1 2 1 Inflammation ( orbita) phlegmone) 5 Endocrine orbitopathy 11 22 11 Tomours+ 23 25 9 Injury + + - 25 Unclarified (enlargement of the lacrimal gland) 1 1 1 Negative radiological finding 18 40 4 +: lymphoma (3), neurinoma (2), glioma (1), menin­geoma (1), mucocele (1), dermoid (1), lipoma (3), haemangioma (1), metastatic neuroblastoma (2), reti­noblastoma (4), anaplastic carcinoma (3), planocellular carcinoma (3). + + : blow-out fracture (8), other orbita) fracture (13), orbita! foreign body (2), traumatic exophthalmos (2). + + +: hyperthyroidism (4), protrusion (2), orbita) injury (14), diplopia (3), papillar stasis (7), optic nerve atrophy (10). Barta Metal. The method has a restricted value in extraco­nal processes because of the shadow of the osseous orbita! margin accompanying the use of a rather big linear transducer. In some cases, the infiltrative nature of the lesion can be shown by monitoring the situation during eye movement. Dehiscences of the orbita! wall can be shown by the Valsalva manoeuvre. US fol­low-up may suffice in processes clarified earlier by other imaging or diagnostic methods. Pre­vious US may be helpful in choosing correct CT-technique ( e.g. in case of a negative sono­gram the examiner must be prepared for vie­wing the skull as well). The place of CT in the diagnosis of orbita! disorders. CT is an excellent tool in imaging the exact site and structure of orbita! processes. Administra­tion of a contrast medi um is hardly necessary, its use may be helpful in intraorbital, intracra­nial and perisellar disorders. The exact relation­ship of the lesion to bone and environment can be clarified by CT. Orbita] CT is indispensable before surgery and radiotherapy. Table 2. US and CT findings obtained by parallel examinations. Number of US CT patients positive negative positive negative Congenital disorder ( neurofibramatosis) l 1 1 Endocrine orbitopathy 8 6 5 11 Tumours + 9 8 1 9 Unclear (lacrimal gland enlargement) 1 1 1 Negative radiological finding + + 4 4 4 +: lymphoma (NHL: 2,HL: 1), neurinoma (2), optic sheet glioma (1), mucocele (1), meningeoma (1), dermoid (1). + +: diplopia (4). References 8. Hammerschlag SB, Hesselink JR, Weber AL. l. Berges O, Bilaniuk LT. Orbita! ultrasonography: Computed Tomography of the Eye and Orbit. Ocular and orbita! pathology. In: Radiology of Appleton-Century-Crofts, Norwalk, Connecticut, the Eye and Orbit. Raven Press, New York, 1983. Modem Neuroradiology; vol. 4. 1990. 7. l. 9. Lange S, Grumme T, Kluge W, Ringe! K, Meese 2. Bertenyi A. Echoophthalmography. Recent Achie­W. Orbit. In: Cerebral and Spina! Computerized vements in Ophthalmology 1985; 1: 34. Tomography. Schering, 1989; 168. 3. Char DH, Unsold R, Sobe! DF, Salvolini U, 10. Levine, RA: Orbita! Ultrasonography. Radio/. Newton TH. Computed Tomography: Ocular and Ciin. N. Amer. 1987; 25: 447. Orbita! Pathology. In: Radiology of the Eye and Orbit. Raven Press, New York, Modem Neurora­11. Rothfus WE. Differential problems in orbita! diag­diology; 1990, 4, 9. l. nosis. In: Computed Tomography of the Head, Neck and Spine. Chicago, 397, 1985. 4. Deak G, Lanyi F. Radiological diagnosis of the orbit. Szemeszet 1988; 125: 199. 12. Vargha G. Orbit, In: Computed Tomography. Medicina, Debrecen, 1990; 171. 5. Given-Wilson R, Pope R, Michell MJ, Cannon · R, Gregor AM. The use of real-tirne orbita! 13. Kolozsvari L. Echography of orbita! tumours. ultrasound in Graves' ophthalmopathy: a compa­Course of ophthalmological US diagnosis. Univer­rison with computed tomography. Brit J Radio/ sity Medica! School, 27 March 1991. 1989; 62: 705. 14. Nemeth J, Vegh M. Examination of the eyeball 6. Guthoff R. Ultraschall in der ophthalmologischen and the orbit by non-ophthalmological ultrasound Diagnostik. Ferdinand Enke Verlag, Stuttgart, equipment. Second Hungarian Medica! Ultra­Biicherei des Augenarztes; Band 116, 1988. sound Congress, August 1989, Debrecen. 7. Hajda M, Lanyi F. The role of CT examination 15. Barta M and Miletits, E. The role of computed in the diagnosis of orbita! disorder. Ujabb ered­tomography and ultrasonography in endocrine or­menyek a szemeszetben 1989; 2: 44. bitopathy. Magyar Radio/. 1990; 64: 341. Radio/ Oncol 1993; 27: 99-104. Blunt splenic injuries: A sonographic contribution to indications for conservative or operative treatment Damir Miletic, 1 Željko Fuckar ,2 Vladimir Mozetic, 3 Alan Šustic4 1 2 3 Clinical Institute of Radiology, Clinic for Surgery, Ultrasound Diagnostic Unit, 4 Department of Anesthesiology, Clinical Hospital Center Rijeka, Croatia In the presented 10 year period altogether 932 patients after blunt abdominal injury were examined, and 110 traumatic lesions of the spleen were sonographically diagnosed, from which 89 were directly visualized whereas in 21 patients only free abclominal fluid was present. We have sonographically cletected 26 (29.3 % of directly visualized lesions) subcapsular splenic hematomas, 13 (14.6 %) shallow splenic lacerations, 20 (22.5%) intraparenchymal hematomas ancl 30 (33.7%) cleep splenic ruptures. By means of ultrasouncl we have conservatively treatecl 88.5 % of subcapsular hematomas, 77 % of shallow spleenic lacerations, 80 % of intraparenchymal hematomas ancl none of cleep splenic ruptures. Ultrasouncl showed reliable results with respect to sensitivity (97 % ), specificity (100 % ) ancl accuracy (99, 7 % ) . Key words: spleen-ultrasonography; wounds, nonpenetrating lntroduction The spleen is a parenchymatous organ covered with very thin capsule which is sonographically invisible, but gives clear outline to the spleen. It is surrounded by the perisplenic and left subphrenic space which are, in normal condi­tions, only virtual peritoneal recesses. 1 The traumatic rupture of the splenic capsule results in an intraperitoneal bleeding, particu­lary in the mentioned recesses. Due to interpo­sed stomach air, left subphrenic collections cause diagnostic difficulties.2 Intracapsular (pri- Correspondence to: Mr. se. dr. Damir Miletic, Klinicki zavod za radiologiju, Klinicki bolnicki centar Rijeka, Krešimirova 42, 51000 Rijeka, Croatia. UDC: 616.411-001.42:534-8 mary) splenic rupture forms traumatic paren­chymal lesion of the spleen with intact capsule. If untouched splenic capsule ruptures under the pressure of blood collection, more severe symp­ 3 toms of bleeding appear.Namely, when an intralienal blood collection erupts into the peri­toneal cavity, a secondary bleeding from the lesion follows. A few hours or even 30 days may pass between the first, subcapsular, and the second, open bleeding. Because of a danger of the secondary splenic rupture, a patient with injury of this organ should be hospitalized at least for 3 weeks with permanent ultrasonogra­phic control. Splenic tissue have sonographically perfect homogeneity. It means that ali reflections in the splenic parenchyma should be considered abnormal, except vascular reflections at the 5 hilus leve!. 4• M iletic D et al. The most frequent mechanism of blunt sple­nic injuries is deceleration. The spleen is often injured organ in blunt abdominal trauma.6• 7• 8 Blunt splenic injuries are often concomitant with other abdominal or extraabdominal organ injuries and bone fractures. For example 20 % of injured patients with caudal rib fractures have concomitant rupture of the spleen. 9 Trau­matic effect and rupture modality are connected with the perfusion status in the moment of trauma (hydrostatic intraparenchymal pressure increase). Although sonographic appearance of a blunt splenic injury is well-known, the aim of this study was to determine the role of ultrasound in early indications for the conservative treat­ment of such injuries whenever possible. Patients and methods Between January 1982 and January 1992 alto­gether 932 patients with blunt abdominal injury were examined at the Ultrasound Diagnostic Unit of the Clinical Hospital Center Rijeka, Croatia. Left subcostal and intercostal approach were used for the sonographic examination of the spleen. We have also used right prone position of a patient with raised left hand. It is necessary Table l. Sonography of blunt splenic injuries. to mention that abdominal pansonographies were always applied due to frequent concomi­tant lesions, as well as presence of peritoneal recesses, eventually with blood collection. Ultrasound examinations were performed by means of the following equipment: Fisher Emi­sonic, Bri.iel and Kjear 1486, Aloka SSD 260 LS and Hitachi EUB 515 with sector, linear and convex transducers of 3.5 and 5 MHz. Results If blunt splenic injury was suspected, we ob­viously searched for essential sonographic signs, such as: 1) limited fluid collection (hematoma) in the splenic parenchyma, 2) splenic oedema and 3) free peritoneal ( especially perisplenic) fluid. Intralienal hematoma and/or splenic oedema was found in 89 patients after blunt abdominal trauma, which means in 32.1 % from altogether 227 sonographically detected injuries of an ab­dominal organ. Ultrasound findings of blunt splenic injuries are presented in Table l. In Table 1, sonographic appearance of parti­cular splenic injury was noted immediately after the trauma. Patients in which the ultrasound Type of injury Sonographic appearance Number % Subcapsular splenic hematoma Anechoic spindle-or sickle-like formation which elevates a thin capsule, without perisplenic extravasation, homogenous structure of the splenic parenchyma 26 29.2 Shallow splenic laceration Thin perisplenic hypoechoic liquid »halo«, the spleen sonographically appears intact 13 14.6 Intraparenchymal splenic hematoma Hypoechoic focal lesion in the splenic parenchyma without perisplenic extravasation 20 22.5 Deep splenic repture Heterogeneous echoes from the particular parenchymal segment with hypoechoic bleeding foci, perisplenic blood collection filling other peritoneal recesses 30 33.7 Tota! 89 100.0 Blunt splenic injuries: A sonographic contribution to indications far conservative ar operative treatment 101 Figure 1) were hemodinamically stable. This group of patients was_conservatively treated by sonographic follow-up of subcapsular blood re­sorption. Three patients with a concomitant hemorrhagic lesion of the !iver were, on the contrary, operated on (Table 2). In patients with presumed shallow laceration (Table 1, Figure 2) a free perisplenic fluid was Figure l. Intercostal sector scan of the subcapsular splenic hematoma (arrow). finding of blunt splenic injury was diagnostically or therapeutically equivocal were usually follo­wed-up by means of ultrasound severa! times during the first 24 hours, as well as in following days after the injury. We have also sonographi­cally checked every patient with clinical aggra­vation. After initial volume compensation ali the patients with subcapsular hematoma (Table 1, Table 2. Treatment of particular sonographic type of splenic injury. Type of injury Subcapsular hematoma No 26 Urgent laparotomy 3 (11.5 % due to concomitant injury) Secondary splenic rupture o Conservative treatment 23 (88.5 %) Shallow laceration 13 o 3 (23 %) 10(77.0%) lntraparenchymal hematoma 20 o 4 (20%) 16 (80.0%) Deep rupture Tota! 30 89 30 (100%) 33 (37 %) o 7 (8%) o 49 (55.0%) Table 3. Summarized results and parameters of the diagnostic value of ultrasound in blunt splenic injuries. Results Number Parameters % True positive 110 Sensitivity True negative 819 Specificy 100 False postivie o Accuracy 99.7 False negative 3 Positive predictive value 100 Negative predictive value 99.6 Miletic D et al. sonographically detected without presentation of the place of injury. In 11 patients (85 % of this group) a thin layer of minimal blood collec­tion was found exclusively in the perisplenic and left subphrenic space, while Morrison's and Douglas pouch were empty. In 2 patients (15 % of this group) a blood trace was found in the Morrison's pouch. In the first few hours after the injury ali the patients were hemodinamically stable, whereas 5-15 hours later hypotension and threatening hemorrhagic shock appeared. In 3 patients (23 % of this gorup) ultrasound follow-up examination evidenced an increased perisplenic collection, but no overflow to the Morrison's and Douglas pouch. Sonographical­ly, it was a secondary splenic rupture (Table 2). These 3 patients underwent explorative lapa­rotomy. The splenic salvage succeeded in two of them whereas in the remaining one splenec­tomy could not be avoided. In the conservati­vely treated patients with splenic laceration we have sonographically controled a resorption of the perisplenic blood collection. Patients with intraparenchymal hematoma (Table 1, Figure 3) were hemodinamically sta­ble at the tirne of ultrasound examination (i.e. in the first 30-60 minutes after the injury). Free intraperitoneal fluid was not found. In 8 pa- Figure 4. Subcostal sector scan of the splenic rupture. tients ( 40 % of this group) we have sonographi­cally detected an increase in the hematoma and oedema of the spleen from 12 to 24 hours after the injury. Hematomas remained stable (un­changed size) for another 2-4 days. After that, a regression untill complete resorption was ob­served. However, 4 (20 % ) patients of this group suddenly developed a hypovolemia with hypotension 3-30 hours after injury. On sono­graphy, the splenic structure became inhomoge­neous, the hematoma ruptured into the perito­neal cavity with evidence of free fluid. Secon­dary rupture of the spleen was diagnosed and splenectomy couldn's be avoided. One-third of ali sonographically determinated blunt splenic injuries were deep ruptures of the splenic parenchyma (Table 1, figure 4). Ali the patients in this group were hemodinamically unstable. Rupture of the spleen was followed by abundant endoabdominal effusion which re­quired urgent laparotomy (Table 2). Splenec­tomy was done in 26 (87 % ), and splenic salvage in 4 (13 % ) patients of this group. In 21 patients (7 .6 % of ali sonographically detected intraabdominal injuries) a splenic rup­ture was found intraoperatively, while ultra­ Blunt splenic injuries: A sonographic contribution to indications far conservative or operative treatment 103 sound detect only free abdominal fluid. It means that sonographer has diagnosed splenic injury only indirectly. Ultrasonographic detec­tion of the hematoperitoneum played an impor­tant role in the decision tor operative treatment. Blunt splenic injury was sonographically diag­nosed in 110 (39.7 % of total 277 patients with sonographically detected traumatic lesion of an abdominal organ). False negative result (Table 3) represented 3 unrecognized splenic ruptures which were surgically verified. Abdominal pansonography did not require more than 15 minutes, and it was possible to carry out the compensation of a circulating volume simultaneously. Discussion and conclusions Following our results, the spleen is absolutely the most frequently injured organ in blunt ab­dominal trauma, which corresponds to the re­sults of other authors.10 We have sonographi­cally examined 932 patients with blunt abdomi­nal injury and detected 277 traumatic intraabdo­minal organ lesions. Blunt splenic injury was tound in 110 patients (39.7 % of altogether 277 intraabdominal injuries) and was the leading cause of hematoperitoneum. In 89 patients the splenic lesion was visualized directly, whereas in 21 patients only free abdominal fluid was detected. According to our results, ali the pa­tients with indirect sonographic evidence of splenic trauma required laparotomy. Apart from therapeutic, laparotomy had even diagno­stic role in this case. Conservative treatment is possible only with direct sonographic visualiza­tion of blunt splenic injury. Such visualization have been achieved in 89 patients, i.e. in 32.1 % of ali sonographically evidenced abdominal injuries. We can correlate the sonographic ap­pearance and prognosis of the particular blunt splenic injury. Subcapsular splenic hematoma included al­most one-third, precisely 29.2% (Table 1) of all sonographically detected blunt splenic injuries. According to our experience, subcapsular sple­nic hematoma usually had a tovourable progno­sis and should be treated conservatively (Table 2) by ultrasound tollow-up of the hematoma resorption. Shallow splenic laceration (Table 1) can also be treated conservatively, although, it requires more than just sonographic tollow-up, due to possible secondary splenic rupture. In this group even 10 (77 % ) patients were conservati­vely treated despite intrapertioneal hemorrha­ge. Intraparenchymal splenic hematoma (Figure 3) was diagnosed in abouth one-tourth (Table 1) of blunt splenic injuries. If no further compli­cations exist, the treatment is conservative (Ta­ble 2). This sonographic finding on the first examination restores the diagnosis, but does not provide enough prognostic intormation. Na­mely, even 20 % of patients with intrasplenic hematoma underwent surgery due to secondary splenic rupture (Table 2). Consequently, regu­lar ultrasound tollow-up is necessary. Deep splenic rupture represented a frequent sonographic finding in blunt injuries of this organ (Table 1). They are always tollowed by abundant hematoperitoneum and are regarded as an indication tor urgent Iaparotomy. Our results point out that ultrasound, in hands of an experienced sonographer, provides a valuable intormation of posttraumatic status . of the spleen. Conseq uently, ultrasound is one of the basic diagnostic devices in the determina­tion of indications tor conservative treatment, and in tollow-up of non-surgicall treated pa­tients. The presented results were obtained by close collaboration of a surgeon, anesteziologist and sonographer. Our results Iead to the tollowing conclusions: l. Subcapsular splenic hematoma usually requi­res conservative tratment. 2. If vita! signs are stable, shallow splenic lace­rations and intralienal hematomas require also conservative approach with frequent ultrasound tollow-up examinations. 3. Deep splenic rupture as well as secondary rupture of the spleen with massive endoab­dominal effusion (Douglas, Morrison) are Miletic D et al. indications for urgent laparotomy, regardless the circulatiory condition. 4. Ultrasound is a reliable, quick, cheap and repeatable technique of great value in diag­nostics, prognosis and follow-up of a patient with blunt splenic injury. 5. Our results indicate that ultrasound in the hands of an experienced sonographer wor­king in a well organized team can be regar­ded as the first diagnostic method in ap­proach to the patient with blunt splenic injury. References · l. Križan Z. Kompendij anatomije covjeka JI/ dio: Pregled grade grudi, trbuha, zdjelice, noge i ruke. Zagreb: Školska knjiga, 1989. 2. Kassner EG. Radiologic imaging. New York. Lon­don: Gover Medica! Publishing, 1989: 524-30. 3. Streicher HJ. Chirurgie der Mi/z, Berlin, Gottin­gen, Heidelberg. 1965. 4. Weil F. L'ultrasonographie en patologie digestive. Paris. 1985. 5. Hess CF. Fokale Veranderungen der Milz, Forschr, Rontgenstr 1987; 146 (2): 178-84. 6. Pignatelli V, Palumbo A, Savino A, Kieferle M. Splenic echography in blunt abdominal trauma. Radiol-Med (Torino) 1990; 80 (5): 661-4. 7. Vollmer K, Vollmer S, Allmendiger G, Ulrich C, Schmidt E, Blunt abdominal trauma -sonographic findings. Schweiz-Rundsch-Med-Prax 1990; 79 (4): 64-6. 8. Asher WM, Parvin S, Virgilio RV, Echographic evaluation of splenic injury after blunt trauma. Radio! 1982; 118: 411-5. 9. Mills J, Ho MT, Trunkey OD. Current emergency diagnosis and treatment. Lange Medica] Publica­tions USA, 1983. 10. Wening JV. Evaluation of ultrasound and compu­ted tomography in blunt abdominal trauma. Surg Endosc 1989; 3: 152-8. Radio! Oncol 1993; 27: 105-10. Quantitative analysis of blood flow in the estimation of renal transplant function Dražen Huic,1 Darko Grošev,1 Mirjana Poropat,1 Ljubica Bubic-Filipi,2 Damir Dodig, 1 Darko Ivancevic, 1 Mario Medvedec1 Clinical Department of Nuclear Medicine and Radiation Protection, University Hospital Rebro, Medica! Faculty, Zagreb, Croatia; 2 Center far Dialysis, Clinic of Urology, University Hospital Rebro, Medica! Faculty, Zagreb, Croatia We performed 74 perfusion studies of renal transplants in 52 patients using 99 mTc-pertechnetate. Renat blood flow (RBF) was expressed as a percentage of cardiac output (CO). Mean RBF/CO in patients with creatinine serum leve! (CSL) < 150 µmolil was 13.1 % ± 5.6, and for th_ose who had CSL between 150 and 300 µmolil was 8.1 % ± 3.8. Patients with CSL between 301 and 450 µmolil had mean RBFICO 5.6 % ± 2.5, and those with CSL > 450 µmolil had mean RBFICO 3.6 % ± 1.1. Differences among ali groups and a correlation between CSL and RBFICO values were statistically significant. Patients with chronic rejection on biopsy had higher RBFICO values (mean 5.3 % ± 2.4) than those with acute rejection (mean 3. 9 % ± 0.2) and cyclosporin nephrotoxicity (mean 3.8% ± 1.6). RBFICO values are accurate in differentiation of renal transplants regarding their function and they could be helpful in the estimation of trasplant function alteration. Key words: kidney trasplantation; renal circulation; blood flow velocity Introduction Complications responsible for graft failures and finally for graft removing are: surgical complica­tions, acute tubular necrosis, cyclosporin nep­hrotoxicity ( and other complications caused by therapy) and the most often, rejection.1 Correspondence to: Dražen Huic, MD, Klinicni zavod za nuklearnu medicinu i zaštitu od zracenja Medicin­skog fakulteta, KBC Rebro, Kišpaticeva 12, 41000 Zagreb, Croatia. Fax. 38 (41) 23 57 85. Perfusion and dynamic renal scintigraphy are approved methods in evaluation of renal trans­plant function. Allograft perfusion is a qualita­tive examination. By means of that procedure it is possible to get information about the activity moving through blood vessels of the kidney, but not about the magnitude of the kidney blood flow. That is the reason why many authors have described various perfusion 5 indices, with more or less success.2­ A.M. Peters and colleagues described a me­thod for measuring renal blood flow (RBF) as a percentage of cardiac output (CO). The me­ UDC: 616.61.089 .843:616.136. 7-018.5 thod determines the count rate that would be Hui(; Det al. recorded over the organ if the tracer behaved like radiolabelled microspheres and was totaUy trapped in the vascular bed of the 01 gan on the 7 first pass. 6, We wanted to evaluate that method in our department, where we have been performing the perfusion and dynamic scintigraphy of renal transplants for more than 10 years.8 Patients and methods From October 1, 1991 to July 1, 1992, 52 patients were studied prospectively in 74 exami­nations. There were 17 females and 35 males, their age ranging from 12 to 59 (mean age 35). Forty-two cadaveric and 10 living related kid­neys were transplanted from 5 to 76 months (median 31) before examination. Ali patients were cyclosporin treated. We performed the perfusion and subsequent dynamic graft scintigraphy using 99mTc-per­technetate and iodine-131 Ortho Iodo Hippuric Acid in patients in whom worsening of trans­plant function was suspected. We chose creati­nine serum leve] (CSL) as an indicator of the renal transplant function and a relation between RBF/CO values and CSL values was obtained. ln some patients a renal biopsy was perfor­med. We presented only the biopsies done within 30 days of the study in the case of chronic rejection, and within 5 days for others diagnoses. The perfusion scintigraphy was done with 99mTc-pertechnetate (550 MBq) injected rapidly as a compact bolus. A gamrna camera with low energy parallel collimator was used for data acquisition. Flow irnages were collected at a frarne rate of 1 per sec for 60 sec, in a 64*64*16 matrix. Pre and post dose syringe counts were rnea­sured on collimated garnma carnera's face as a 10 sec static frames for the measuring of the net injected dose. Deadtime correction was rerformed as described previously.9 The distance between an anterior abdominal wall rnarker and the centre of the transplanted kidney was obtained on a laterni view for depth correction factor measuring. An irnage was made for 30 sec in a 128*128*8 matrix. The obtained distance (x) was later multiplied with a soft-tissue linear attenuation Te coefficient (µ = 0.153 cm-1). Data analysis was performed by Peters me­thod. 7 One region of interest (ROI) was positio­ned around the transplanted kidney. Three ROI-s were drawn along the course of the abdominal aorta (Figure 1). There is no need to avoid the iliac artery if there is some overlay with the transplanted kidney because the error obtained by including the artery within the graft ROI is negligible.7 ROI-s in the course of the abdominal aorta have to be very short ( one or two pixel long) because too long ROi-s produce overestimated results.7 Each aortic curve was corrected for recirculation using a gamma fit, integrated and multiplied by the ratio of the maximum upslope of the renal curve to the maximum upslope of the integrated Quantitative analysis of blood flow in the estimation of renal transplant function gamma function aortic curve. The obtained curve represents the renal curve that would have been recorded if the 99mTc pertecbnetate had an infinite transit tirne through the renal vascular bed. If the procedure is accurate, the 7 resultant curve will parallel the renal curve.6• The procedure with generated curves is presen­ted on Figure 2. RBF as a fraction of CO was finally calcula­ted from the formula: gk A . RBF/CO g. DCF . 100 (1) aD Results We compared RBF/CO values with CSL values by dividing ali patients' examinations into four groups regarding current patients' CSL (Table 1). The mean RBF/CO values of groups were progressively lower with growing CSL. The group with the Iowest CSL ( < 150 µmol/1) had Table l. RBF/CO values in comparison with creatinine serum levels. CSL (µmolil) <150 150-300 301-450 >450 N 12 39 15 8 X(%) 13.1* 8.l* 5.6* 3.6* s.d. 5.6 3.8 2.5 l.l where RBF/CO = RBF as a percentage of s.e.m. 1.6 0.6 0.6 CO; gk = maximum upsloge of renal curve; ga = maximum upslope of integrated aortic curve; A = plateau of integrated aortic curve (cts/sec); D = net patient dose (cts/sec); DCF = depth correction factor ( eµx). RBF/CO values were obtained for ali three aortic curves and the fina! result was expressed as a mean value. Statistical analysis was performed by t-test and Student's t-test. A correlation was measured by standard pro­cedure. A B CSL -creatinine serum leve!, N -number of studies, X -mean RBF/CO, s.d. -standard deviation, s.e.m. -standard error of the mean, *p < 0.01. the highest mean RBF/CO value (13 % ± 5.6) and the opposite (CSL > 450 µmol/!, mean RBF/CO = 3.6 % ± 1.1). Differences among ali four groups are statistically significant. The presumed reciprocal correlation between RBF/CO values and CSL values is presented on Figure 3. The correlation coefficient is 0.58. The coefficient square is 0.34. The correlation is statistically significant (p < 0.001). C 1800 1600 1200 DOO .. 3000 ,. 3000 2600 2000 HIOO 1000 000 6 10 15 .0 2f5 30 35 JO 16 20 26 C5 10Uli 202530 30 Figure 2. Procedure with generated curves. A) Raw renal (K) and aortic (A) curve. B) Smoothed aortic curve along with fitted gamma-variate curve. C) Integrated and fitted aortic curve (A) multiplied by gK/gA slope's ratio to obtain parallelism with upslope of kidney curve (K). o Huic Det al. 30.------------------. o 25 I o o u o 201 o o 0.001). Out of the ten exposed subjects with SCE-values beyond normal, three had accompanying aberrant findings of structural chromosomal aberration analysis. Ali the corre­sponding findings in the control group were below the laboratory normal. Even though the mean SCE value is conside­red to be representative for the results obtained by this method, it would be of relevance to present the SCE-frequency ranges for each sub­ject in both groups. Table 1 shows the upper lncidence of structural chromosomal aberrations among meclical personnel. limits of those ranges to be often far beyond the laboratory normal, while no such case has been recorded among the control subject ran­ges. Discussion Besides numerous problems connected with therapeutical application of antineoplastic drugs, the contemporary medicine is also faced with the problem of potentially noxious effects of cytostatics on the ocupationally exposed per­sonnel. One of the problems stili pending is a direct genotoxicity of cytostatic agents in medi­ca! personnel handling them. However extensi­ve, the results of cytogenetic studies are often controversial, although using the same metho­dological approaches of detection and analysis of chromosomal damages, which are still consi­dered the best bioindicator of mutagene expo­sure. Detecting changes in the peripheral blood lymphocyte celi genome of the exposed person­nel, a number of authors try either to prove or reject the suspicious genotoxic effect of cytostatic drugs. The techniques most commonly used are: conventional structural chromosomal aber­ration analysis and, more suitable stili in chemi­cal mutagen exposure, the sister chromatid ex­change (SCE) rnethod. The cytogenetic research results in the selec­ted professional groups are often controversial. A majority of authors report a significant SCE­value increase among the exposed sub­ 11• jects,2· 12 while some do not find any signifi­ cant difference in comparison to the con­14 trols. 5· 13· . However, the results of this study show the SCE-frequency to be statistically sig­nificantly higher in the exposed than in the control group (p>0.001). Severa! factors have to be taken into account in presentation and interpretation of the results obtained by the SCE-method. The common procedure is to analyse at least 50 clearly visible metaphases, and then present the SCE fre­quency per celi in form of a mean rate encoun­tered therein. The mean rate is then compared either with the normal laboratory value or with the literature normals. Hovewer, we consider such an interpretation insufficient, and believe that the SCE ranges obtained both in the expo­sed and in the control group should also be reported. Namely, our previous experience shows the highest single SCE rate obtained in the exposed subjects to be far above the normal value in a majority, or even in ali cases, even though the mean SCE frequency rate may be bellow normal.15· 16 Besides professional exposure, there is a number of interfering factors which may affect the SCE frequency. The most commonly en­countered in literature are smoking, vira! disea­ses, vaccines, oral contraceptives, radiodiagno­stics and/or radiotherapy in the referent period from 6 months up to a year before sarnpling.13 Subjects with a positive history of some of the foregoing interfering factors may either be au­tomatically excluded from the investigation, or included in the proportion which does not ex­ceed the statistically significant difference bet­ween the exposed and the control group. The latter has been applied in this paper, and con­firmed by the Chi-square test. The structural chromosomal aberration ana­lysis is the method of choice in physical rnutagen exposures, but it is also valuable in chemical mutagen exposures and particularly in simulta­ 16 neous mixed exposures. Severa! authors re­port a significant increase of the chromosomal aberration incidence among medica! personnel handling cytostatics.12· 17• 18 However, the inci­dence of structural chromosomal aberrations among our examinees was not found to be statistically singificantly higher in the exposed group (p = 0.8), though the tendency of their increase was evident, as compared with the controls. Since a number of data from literature point out a positive correlation between changes in the somatic cell genome occurring arnong per­sons exposed to cytostatic agents and neoplasia, the results of such cytogenetic studies should be considered from the carcinogenesis point of view. Establishing a teratogenic risk due to a parti­cular type of professional exposure by a direct detection of sex cells chromosornal damage is Table l. Changes in the peripheral blood lymphocyte cell genome among both medical personnel handling cytostatic drugs and control persons. EXPOSED GROUP ABERRATION YIELD Subject Age Duration Smoking Chromatid Chromo-Accentric Dicentric Tetra-Total % Mean SCE-SCE­(years) of exposure (cig Qer day) break somal ploidy of aber-rate range (years) (years) break rations l. 56 40/20 1 2 2 1 2.5 8.4 4-18 2.202 2 1 1 1.5 6.0 21 2.5 3 3 1 3.5 8.4 3-13 4. 3011 2 2 2 6.2 3-11 298 6/10 2 2 1 2.5 8.8 4-17 6.32 13 10/12 2 3 2 3.5 9,1 5-14 7. 53 15/30 5 1 2 4 9.9 5-16 8.20 1.5 20/2 1 1 1 1.5 7.7 3-12 9.32 12 15/5 2 2 6.7 4-12 ;:, 10. 28 8 10/6 2 1 1.5 8.0 4-16 11.3515 2 1 2 1 2.5 6.2 4-11 12. 21 1.5 15/3 1 1 2 1 7.4 3-13 13. 21 1.5 15/3 1 1 2 1 7.4 3-13 14. 32 13 20/13 1 1 1 1.5 11.1 6-20 15.4425 3 1 2 6.4 4-9 16. 35 14.5 1 0.5 7.6 3-10 17. 32 12.5 10/4 1 2 1 1 2 6.3 4-10 Mean value 32.2 12.5 1.6 1.1 1.1 0.3 0.4 2.1 7.8 ±SD 9.9 1.02 0.44 0.78 0.50 0.49 0.92 1.4 E_ = 0.7 p = 0.8 p = 0.001 CONTROL GROUP ABERRA TION YIELD Subject Age Smoking Chromatid Chromo-Accentric Tetraploidy Total % of Mean SCE-SCE-;i" (year) ( cig Qer day) break somal aberrations rate range (years) break ;, " l. 28 20/10 2 3 2.5 4.6 2-5 2. 30 1 2 1 2 4.8 0-5 3. 24 3 2 2.5 4.2 1-6 4. 21 10/10 2 2 1 2.5 5.8 2-6 . 30 1 0.5 6.2 1-7 c:; 6. 31 1 1 1 6.4 ;:! C "' 26 15/8 2 1 2-6 C ;:! 8. 40 1 1 1 1 1.5 4.3 2-5 ;':_ ,:::, 28 10/5 2 2 1 1 2.5 4.5 3-6 ­ " 10. 34 1 0.5 4.8 2-5 15· 11. 20 20/4 2 2 1 4.6 3-6 ;, "' 12. 42 3 1 2 4.8 2-5 ,:::, 13. 41 15/5 3 1 1 0-6 14. 29 3 2 1 1 3 4.8 0-5 ;:! C ;, "" 15. 20/5 2 1 2 2.5 4.3 1-5 16. 24 3 1 2 4.8 2-6 [ 17. 30 3 1 1 1 2.5 6.5 3-8 's:, " ;;; C Mean value 30.1 2.0 1.4 0.58 0.24 1.97 5.0 ;, ±SD 6.5 0.48 0.5 130 Brumen V a very complex and practically hardly applicable routine approach, the conclusions of which could be reached only by the follow-up of filial generations.19 Therefore, indirect approaches are used, with a great attention being paid to the history data of the examinees. Selevan and co-workers indicate the fetal loss among nurses handling cytostatics to be 2 to 3 times higher than in the general population.20 One of our examinees had a miscarriage in the first trime­ster of pregnancy, and another one reported psychosomatic abnormalities in both of her two children. Workplace conditions, exposure regimens and the use of ali the personal protective equip­ment available can considerably modify the primary noxious factor impact.21 The work place conditions of the nurses comprised by this study were extremely inadequate (no flow hood available, minimal personal protection compri­sing only masks and gloves). Cytostatics were prepared in the room also used for other daily activities, including coffee breaks. Cytostatic storage and waste disposal did not meet the regulations. Though genotoxic effect of profes­sional exposure to cytostatic drugs could not be entirely excluded in any of our previously stu­died risk groups, the results of investigation carried out in better equiped workplaces were 16 significantly less indicative.15• Conclusion The results of this study confirm the suspected genotoxic effect of the professional exposure to cytostatic agents and advocate the need of a systematic health surveillance of the exposed occupational groups, as well as a regular appli­cation of ali the safe handling practices in their workplaces. Acknowledgements The author is indebted to Professor Djurdja Horvat for her experienced guidance and help­ful suggestions throughout the study. Engage­ment of Sanja Milkovic -Kraus, M.D., Ph.D. in the health surveillance of subjects is highly appreciated. Skillful technical assistance of Mrs. Jasminka Kapetan and Mrs. Marija Milas should also be notified. The author is most obliged to Mrs. Jadranka Racic for her technical assistance and efforts engaged in the preparation of the manuscript. References l. Herrera LA, Tittelbach H, Cebhard E, Ostrosky­Wegman P. Changes in the proliferation of human lymphocytes induced by severa! cytostatics and revealed by the premature chromosome condensa­tion technique. Muta/ Res 1991; 236: 101-6. 2. Waskvik H, Klepp O, Brogger O. Chromosome analysis of nurses handling cytostatic agents. Can­cer 1981; 65: 607-10. 3. Hoover R, Fraumeni J. Drug-induced cancer. Cancer 1981; 47: 1071-80. 4. Rogers B. Health hazards to personnel handling antineoplastic agents. Occupational medicine: Stale of the Art Reviews 1987; 2 (3): 513-24. 5. Kolmodin-Hedman B, Harlving P, Sorsa M, Falck K. Occupational handling of cytostatic drugs. Arch Toxicol 1983; 54: 25-33. 6. Cloack M. Occupational exposure of nursing per­sonnel to antineoplastic agents. Oncology Nursing Forum 1985; 12: 33-9. 7. Kato H. Spontaneous sister chromatid exchanges detected by BrclU-labeling method. Nature 1974; 252: 70-2. 8. Biological dosimetry, Chromosomal aberration analysis for ·-:J >( ·­ LL (l) "'O -(l) ·-(l) C (O o CI) SIEMENS SOMATOM AR.T SIC 212 Ganzkorper-Computertomograph CT ...ll !:SANOLABOR Za..ddem Pri nas dobite vse za rentgeni O O O O KODAK AGFA GEVAERT POlAROID 3M PHILIPS 0 O O O GENERAL ELECTRIC SIEMENS TOSHIBA HIT ACHI 0 NICHOLAS O BYK GULDEN ° MAVIG ° CAWO • rentgenski filmi in kemikalije • kontrastna sredstva • rentgenska zašcitna sredstva • rentgenski aparati, aparati za ultrazvocno diagnostiko, stroji za avtomatsko razvijanje in druga oprema za rentgen !:SANOLABOR Cigaletova 9, UUBUANA it 06 l l 33 -23 l FAX: 06 l 325 -395 Navoban tropisetron ,:v·-selektivni kompetitivni antagonist 5HT3 receptorjev za preventivo emeze, ki jo povzroci kemoterapija = en -ucinkovit v preprecevanju akutne in zapoznele slabosti in bruhanja en=_ ne povzroca sedacije in estrapiramidnih sopojavov en=_ na voljo v ampulah in kapsulah c:Jj-. -odmerek Navobana za vse bolnike je 5 1ng dnevno (ff'_ cenovno najugodnejše zdravljenje s 5HT3 antagonisti Navoban tropisetron Novost iz proizvodnega programa SANDOZ ACCESS DTW-380A SSA-270A In Touch with Tomorrow TOSHIBA GLOBAL IMAGING MEDICAL SYSTEMS XPEED GCA-9300A/HG SXT-900A MGU-lOA Toshiba Medica! 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