Advantages of the CEUS examination
\\n\\n
Dr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\\n\\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\\n\\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\\n\\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\\n\\nThank you all for being part of the journey. 5,000 times thank you!
\\n\\nNow with 5,000 titles available Open Access, which one will you read next?
\\n\\nRead, share and download for free: https://www.intechopen.com/books
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Preparation of Space Experiments edited by international leading expert Dr. Vladimir Pletser, Director of Space Training Operations at Blue Abyss is the 5,000th Open Access book published by IntechOpen and our milestone publication!
\n\n"This book presents some of the current trends in space microgravity research. The eleven chapters introduce various facets of space research in physical sciences, human physiology and technology developed using the microgravity environment not only to improve our fundamental understanding in these domains but also to adapt this new knowledge for application on earth." says the editor. Listen what else Dr. Pletser has to say...
\n\n\n\nDr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\n\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\n\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\n\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\n\nThank you all for being part of the journey. 5,000 times thank you!
\n\nNow with 5,000 titles available Open Access, which one will you read next?
\n\nRead, share and download for free: https://www.intechopen.com/books
\n\n\n\n
\n'}],latestNews:[{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"},{slug:"oiv-awards-recognizes-intechopen-s-editors-20201127",title:"OIV Awards Recognizes IntechOpen's Editors"},{slug:"intechopen-joins-crossref-s-initiative-for-open-abstracts-i4oa-to-boost-the-discovery-of-research-20201005",title:"IntechOpen joins Crossref's Initiative for Open Abstracts (I4OA) to Boost the Discovery of Research"},{slug:"intechopen-hits-milestone-5-000-open-access-books-published-20200908",title:"IntechOpen hits milestone: 5,000 Open Access books published!"},{slug:"intechopen-books-hosted-on-the-mathworks-book-program-20200819",title:"IntechOpen Books Hosted on the MathWorks Book Program"},{slug:"intechopen-s-chapter-awarded-the-guenther-von-pannewitz-preis-2020-20200715",title:"IntechOpen's Chapter Awarded the Günther-von-Pannewitz-Preis 2020"},{slug:"suf-and-intechopen-announce-collaboration-20200331",title:"SUF and IntechOpen Announce Collaboration"}]},book:{item:{type:"book",id:"1533",leadTitle:null,fullTitle:"Nd YAG Laser",title:"Nd YAG Laser",subtitle:null,reviewType:"peer-reviewed",abstract:"Discovered almost fifty years ago at Bell Labs (1964), the Nd:YAG laser has undergone an enormous evolution in the years, being now widely used in both basic research and technological applications. 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\r\n\tElectromagnetic imaging is an emerging biomedical imaging modality, which when matured, might present an effective supplement to current imaging technologies for non-invasive assessment of functional and pathological conditions of tissues. This book aims to provide a state-of-art for the most relevant advancements in the development of electromagnetic sensing and imaging for non-invasive detection, by covering all aspects related to the design, modeling, and experimentation. The authors are welcome to submit original research and review articles reporting recent advances in the application of electromagnetic waves technologies in industry and bioengineering.
\r\n\r\n\tThe scope of this book will be the collection of new and/or review results exploring the use of electromagnetic waves for industrial and biomedical applications with particular focus on inclusion detection and medical treatment as well as a diagnostic tool for disease detection. Potential topics include but are not limited to the following: Electromagnetic sensing and imaging for industry applications, Electromagnetic sensing and imaging for biomedical applications, Microwave sensing and imaging , Non-invasive electromagnetic diagnostic tools, Usage of electromagnetic waves for probing organs and advanced MRI techniques, Theoretical modeling of electromagnetic wave propagation, Application of electromagnetic waves in advanced MRI techniques, RF sensors and coils, Biomaterials for wearable sensors, In vitro and in vivo testing.
",isbn:"978-1-83968-582-8",printIsbn:"978-1-83968-581-1",pdfIsbn:"978-1-83968-583-5",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"e57ef4b5bada0d966637cd303d76278f",bookSignature:"Distinguished Prof. Lulu Wang",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/9878.jpg",keywords:"Electromagnetic Sensing, Imaging, Biomedical Applications, Electromagnetic Measurements, Conductivity, Electromagnetic Induction Tomography, Electric Impedance Imaging, Microwave Imaging, Biomaterials, RF Coils, Electromagnetic Scattering Problems, Integral Equations",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"August 26th 2020",dateEndSecondStepPublish:"November 3rd 2020",dateEndThirdStepPublish:"January 2nd 2021",dateEndFourthStepPublish:"March 23rd 2021",dateEndFifthStepPublish:"May 22nd 2021",remainingDaysToSecondStep:"3 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"With an M.E. (Hons.) and a Ph.D. degree from the Auckland University of Technology, New Zealand, Dr. Wang is the first author of over 60 peer-reviewed publications, received multiple national and international awards from various professional societies and organizations she is a member of (ASME, IEEE, AAAS, PSNZ, and IPENZ ).",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"257388",title:"Distinguished Prof.",name:"Lulu",middleName:null,surname:"Wang",slug:"lulu-wang",fullName:"Lulu Wang",profilePictureURL:"https://mts.intechopen.com/storage/users/257388/images/system/257388.jpg",biography:"Lulu Wang is a Full Professor of Biomedical Engineering at Shenzhen Technology University in China. She received the M.E. (First class Hons.) and Ph.D. degrees from the Auckland University of Technology, New Zealand, in 2009 and 2013, respectively. From 2013 to 2015, she was a Research Fellow with the Institute of Biomedical Technologies, Auckland University of Technology, New Zealand. In 2015, Dr. Wang became an Associate Professor of biomedical engineering with the Hefei University of Technology. In 2019, she became a Full Professor of biomedical engineering with the College of Health Science and Environmental Engineering, Shenzhen Technology University. Her research interests include medical devices, electromagnetic sensing and imaging, and computational mechanics. Over the past five years, Dr. Wang is the first author of 60 peer-reviewed publications, 2 ASME books, 7 book chapters, and 12 innovation patents. She has edited three books and two special issues of international journals. Dr. Wang is a member of ASME, IEEE, AAAS, PSNZ, and IPENZ. She has been an active scientific reviewer for numerous journals and international conferences. She received multiple National and International Awards from various professional societies and organizations.",institutionString:"Shenzhen Technology University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Shenzhen Technology University",institutionURL:null,country:{name:"China"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"20",title:"Physics",slug:"physics"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"259492",firstName:"Sara",lastName:"Gojević-Zrnić",middleName:null,title:"Mrs.",imageUrl:"https://mts.intechopen.com/storage/users/259492/images/7469_n.png",email:"sara.p@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"44097",title:"Contrast-Enhanced Ultrasonography (CEUS) of Liver Masses — Principles, Clinical Applications, Drawbacks",doi:"10.5772/55500",slug:"contrast-enhanced-ultrasonography-ceus-of-liver-masses-principles-clinical-applications-drawbacks",body:'Ultrasonography (US) is one of the most widely used imaging procedures. The main advantages of this investigation over others include it being non-invasive and safe, with no radiation exposure. In addition, its images are provided in “real time”, delivering dynamic images with both anatomical and functional information. The images acquired by ultrasonography are sectional and easy to understand. The method is accurate, without distortion. The major disadvantage of ultrasonography is that it is operator dependent, requiring a large number of examinations performed personally in order to reach a high level of proficiency [1]. Additional issues include poorer performance if gas, adipose tissue or bony structures come between the transducer and the region of interest. A number of artifacts, such as reverberations and false reflections, may interfere with the acquisition of the ultrasound image, and need to be recognized and avoided.
Ultrasonography is practiced on a daily basis, both by physicians and specialized personal. Now it is widely accepted that a good correlation of the ultrasonographic data with clinical information is necessary in order to achieve an optimal performance [2]. The proposal that access to US should become generalized and be practiced by every physician within their specialty as a way of completing the clinical examination is increasingly voiced [3]. Liver ultrasonography has been recognized for a long time as an application of US efficient in detecting diffuse liver conditions, hepatic tumors, vascular abnormalities, post-traumatic lesions as well as in guiding interventional procedures [4, 5, 6, 7, 8, 9].
Ultrasonography is a multimodal examination, meaning that the final report and basis for the diagnosis, is a complex one, obtained through multiple procedures. Each procedure brings specific data in relation to the underlying principle of operation. The main US component is bidimensional ultrasonography (“grey scale” ultrasound). It consists of sectional images, presented on a grey scale, with each shade of grey representing a density (in fact, an acoustic impedance). “Grey scale” ultrasonography is a dynamic examination that allows the overall evaluation of the liver, with measurements of the hepatic lobes, identification of liver segments, as well as characterization of texture and echogenicity (in relation with the degree of fat infiltration and fibrosis). Grey scale US also enables the detection and evaluation of normal anatomical structures (bile ducts, vessels) and of pathological elements (mainly liver masses). Elastography, an additional component, realizes a quantitative and qualitative (using color coding) characterization of the elasticity of the liver parenchyma [10, 11, 12]. The Doppler procedure represents the basis for evaluating the flow within liver vessels. There is also the spectral version of this application which provides quantitative data (direction of flow, flow velocities, debits, etc) and a color coded version that gives information regarding the presence and the direction of blood flow in the region of interest [13, 14]. Ultrasonography using intravenous (i.v.) contrast agents (CEUS) is a procedure that observes the blood flow in a reference region by revealing the harmonic echoes [15]. Recently, a number of other applications have been developed, many of them based on the mathematical processing of the image. These are meant to optimize the information, enabling quantification, for example, and even allow an automatization of the US diagnosis [16]. Generally speaking, ultrasonography is often the first imaging exploration performed after the clinical exam. As a method, it has proven its value in many respects, including in the detection of liver tumors. In its standard form, however, it is not sensitive enough to characterize and establish the nature of these lesions, despite the many technical advances that have been made [17].
The use of contrast in ultrasonography represents a huge advance for this investigation. Even though Doppler ultrasound has a certified role and is the recognized technique for detecting vascular abnormalities in large vessels, it is only after the introduction of contrast agents that we can talk about an exact and reproducible evaluation of microcirculation with the help of ultrasound.
Contrast enhanced ultrasonography (CEUS) consists of injecting gas ‘microbubbles’ into the systemic circulation. The contrast agent (CA) used is made of small bubbles close in size to red blood cell. These microbubbles contain low soluble gases encapsulated into a biocompatible membrane which may have variable composition – lipids, proteins or biopolymers. The membrane can be either rigid or flexible with a thickness between10-200 nm [18]. Basically, like in any other contrast based imaging procedure, the CEUS exam consists of a “bolus” administration of the contrast media through a superficial peripheral vein. Due to their extremely small size, the microbubbles pass through the pulmonary circulation and then disseminate into the systemic circulation through the arterial blood stream. The contrast agent remains in the blood stream for about 4-5 minutes. There is also a parenchymal phase at the level of the liver and spleen because the contrast agent is captured by the reticuloendothelial system and/or it becomes adherent to the hepatic sinusoids [19]. Unlike the contrast agents used for CT or MRI, the gas used for CEUS is eliminated through the air-ways 10-15 minutes after administration, while the substances that make up the membrane are eliminated through the kidney or metabolized by the liver. The contrast media used in ultrasonography have no toxicity and the technique is less harmful to patients when compared with other investigations.
The contrast enhanced examination is based on the emission of harmonic echoes by the CA when this passes through an ultrasound beam that has a mechanical index of 0.09 – 0.11. The mechanical index (MI) represents a value that is directly correlated with the biological effect of the ultrasounds upon the tissues. This index is variable depending on the ultrasound machine, but it is basically conditioned by the acoustic power of the ultrasounds beam. The acoustic power (AP), measured in Pascals, represents the energy of the sound beam acting on a target, for example a group of red cells or the contrast agent inside the blood stream. Usually, at high values of the AP, up to MegaPa, the micro bubbles are “broken” and an irregular, non-linear signal is generated. At low values of the AP (30-70 kPa) the microbubbles vibrate in a particular, non-linear manner, producing alternating contractions and relaxations, thus generating harmonic echoes.
The ultrasound equipment produces a separation of the harmonic echoes generated by the CA within the blood stream from the echoes generated by the surrounding tissues. This separation may be realized by modulating the phase and the amplitude of the US beam. There are multiple US generating techniques within the transducer that generate harmonic echoes within the CA. Techniques of pulse inversion (“Pulse Inversion”, “Power Pulse Inversion”, “Cadence Contrast Pulse Sequencing”) perform a “subtraction” of the tissue echoes by alternative emission of pulses found in an inversed phase. A “Vascular Recognition Imaging” technique introduces the Doppler principle in the analysis of the returned signals, allowing a color coding of the red cells in relation to their direction of flow.
Practically, CEUS consists of an injection of a contrast agent, prepared at the time of use, into a cubital vein. This is followed by a bolus of 10 cc saline solution. The region of interest, previously identified during the “grey scale” exam, is continuously observed on the monitor. The monitor may be divided into two identical, real-time images, one using fundamental, “grey scale”, echoes and the other one using harmonic echoes obtained by exposure to a sound beam with a low mechanical index (0.09 – 0.11). The examination continues for 90 seconds. After this time the exploration may be intermittent. CEUS is focused on a single region of interest, usually a mass. The exploration of another mass requires either a “breaking” of the bubbles inside the mass, performed with special software or using the CFM technique, or a repetition of the CEUS exam after another contrast administration focused on the second lesion. There are no risks for the patient, so the injection of the CA can be repeated as often as needed.
Using CEUS in the exploration of the liver has special features that arise from the double vascularity of this organ – through the portal vein (two thirds) and through the arterial system (one third). The sequence of blood entering the liver is first arterial (up to 30 seconds) and then portal (30 to 90 seconds, with little variation). This vascular discrimination (similar to the one obtained by contrast CT or MRI) allows for gathering information regarding the circulatory bed (types of feeding vessels, tumor circulatory volume) of a tumor. The presence of arteriovenous communications is characteristic for the neoplastic circulation and in CEUS is expressed by the “wash-out” process. This phenomenon begins at the end of the arterial phase and/or during the venous phase, is persistent and is characteristic for neoplastic processes in 90 % of cases [20]. There are studies that correlate the wash-out speed of the tumor with its aggressiveness, attributing CEUS a prognostic value.
An important component of the CEUS exam is represented by the quantitative analysis of the data. This consists of a representation in time of the acoustic impedance variation in one or more predetermined regions of interest. A graphic is obtained that can be correlated with hemodynamic parameters, like the time of maximum systolic ascent in the region of interest, the volume of the circulatory bed, presence and scale of the arteriovenous shunts, etc. All these elements are indicators for the quality of a specific circulatory bed [21].
The advantages of the CEUS technique are summarized in Table 1 and include the lack of ionizing radiation exposure, the non invasive character of the method, as well as very good spatial and temporal resolution [22]. The method is safe for patients, with very few cases of anaphylaxis having been reported (about 0.001% of the total number of investigations). It is therefore recommended in some centres as the firstline procedure for assessment of liver nodules. Contrast CT not only exposes the patient to ionizing radiation, but iodine based contrast agents can be toxic and produce allergic reactions. CT scan imaging may also be less sensitive, “losing” or failing to capture the early arterial phase in highly vascular tumors.
• very good spatial resolution; | \n\t\t
• high temporal resolution – it is a “real time” examination; | \n\t\t
• it reveals very slow blood flow or stagnant blood streams; | \n\t\t
• non-ionizing examination; | \n\t\t
• lack of anaphylaxis; | \n\t\t
• the contrast agent is eliminated through the air-ways; • can be repeated as often as needed | \n\t\t
Advantages of the CEUS examination
It should also be recognized that CEUS exploration has a number of limitations, as summarized in Table 2. It is dependent on expensive and sophisticated equipment that raises the cost of the investigation. The harmonic image is depending on good quality 2D image. Deeper lesions are harder to visualize and attenuation may represent a limit in detecting tumors located further from the transducer. Last, but not least the investigation is operator dependent and often the information that is obtained must be correlated with the clinical data and biochemical functional information.
• expensive and sophisticated equipment; | \n\t\t
• high cost of the exploration compared with the standard investigation; | \n\t\t
• operator dependent; | \n\t\t
• it depends on a good quality 2D image; | \n\t\t
• low quality information in case of attenuation like in liver steatosis; | \n\t\t
• it investigates a single region of interest; | \n\t\t
Limitations of CEUS examination
The imaging/ultrasonographic contribution to the detection of benign liver tumors is not insignificant. Benign lesions are numerous, affecting about 20% of the population [23]. They are frequently detected following ultrasonography, which is widely available and represents a common investigation in any abdominal complaint. CEUS exploration can distinguish between benign and malignant tumors and consequently can halt the diagnostic algorithm when a mass detected by 2D ultrasonography is characterized by CEUS as being benign. In this way the numbers of investigations is optimal and the patient\'s discomfort is significantly reduced. There a multiple benign liver masses, however, and not all of them have CEUS characteristic features. Their ultrasonographic aspect is often similar and their discrimination may require additional criteria [24]. Among the lesions that present specific circulation patterns which can be defined when analyzed by CEUS are cysts, hemangiomas, adenoma and benign focal hyperplasia (table 3).
\n\t\t\t\tTumor\n\t\t\t | \n\t\t\t\n\t\t\t\tArterial phase\n\t\t\t | \n\t\t\t\n\t\t\t\tPortal phase\n\t\t\t | \n\t\t\t\n\t\t\t\tDelayed phase\n\t\t\t | \n\t\t\t\n\t\t\t\t2D feature\n\t\t\t | \n\t\t
Cyst | \n\t\t\tNo uptake | \n\t\t\tNo uptake | \n\t\t\tNo uptake | \n\t\t\tTranssonic | \n\t\t
Hemangioma | \n\t\t\t“Ring-like” peripheral uptake | \n\t\t\tCentripetal enhancement resembling “buds” | \n\t\t\tComplete uptake | \n\t\t\tHyperechoic Well-defined Compressibility “Mirror” effect | \n\t\t
Focal nodular hyperplasia | \n\t\t\tCentral enhancement with a “spoked wheel” distribution of the CA | \n\t\t\tComplete enhancement with an isoechoic appearance compared with liver parenchyma | \n\t\t\tIsoechoic aspect when compared with the liver parenchyma | \n\t\t\tEchoic scar in the centre of the lesion Arterial signal in the centre of the tumor | \n\t\t
Adenoma | \n\t\t\tInhomogeneous uptake | \n\t\t\tDiscrete wash-out Iso or hypoechoic aspect compared to liver parenchyma | \n\t\t\tDiscrete wash-out, Iso or hypoechoic aspect compared to liver parenchyma | \n\t\t\tHypoechoic nodule Non-cirrhotic liver | \n\t\t
CEUS and 2D ultrasonographic features in cases of benign liver lesions. (*)
(*) The information presented in the table is referring to typical situations. In practice, there are variations of the 2D or CEUS aspects that require further investigations
Liver hemangioma. It is the most frequently encountered benign tumor of the liver. It is most often found in women and has a prevalence of about 0.4 – 7.4 % in the population [25]. The mass consists of a vascular, capillary or venous, bundle, rich in fibrotic bands and with no capsule. It may be frequently associated with other benign tumors like cysts or adenomas. Hemangiomas are usually asymptomatic (in very rare cases, when extremely large they may cause a distension of the liver capsule and thrombocytopenia) and have a slow, self-limiting development. In most cases there is just one lesion, but there is also a multicentric type. The grey scale US appearance of hemangiomas is fairly characteristic: a well circumscribed, hyperechoic liver mass, with a slightly hypoechoic centre or periphery (figure 1).
Liver hemangioma. The lesion is found within the left lobe (asterisk) and has a characteristic appearance on “grey scale” ultrasound: well circumscribed, hypoechoic nodule with irregular margins.
Hemangiomas do not cause vascular or biliary ducts invasion. But they may produce an effect of posterior acoustic enhancement. On closer inspection the operator can observe this effect by changing the aspect of the transducer in combination with profound compression. When the hemangioma is located in contact with the diaphragm it can generate a “mirror” effect that leads to a reproduction of the image in the lung parenchyma. Hemangiomas do not usually show signal on the Doppler investigation as flow velocities inside them are very low. Additionally, in many cases intratumoral ischemia or fibrotic scars will develop. Often, the ultrasonographic diagnostic criteria are clear enough and in most situations the conventional ultrasound which first detects the nodule, is sufficient to characterize the lesion. But there are circumstances when 2D ultrasound is not sufficient for tumor characterization and thus CEUS is needed. In the presence of severe steatosis as well as in patients undergoing chemotherapy for various neoplastic conditions, the appearance of a hemangioma may alter and become “atypical”. Also in patients with liver cirrhosis, a hemangioma may be misinterpreted for a hepatocellular carcinoma or a large regeneration nodule. Extremely large hemangiomas may have a heterogeneous structure due to possible hemorrhage or ischemia developed inside the lesion, which can alter their appearance. Last but not least, CEUS can be very useful in reassuring both operator and patient that a nodule accidentally found during an ultrasound exam is benign.
The appearance of a hemangioma on CEUS is characterized by a peripheral, ring-like, clear enhancement during the arterial phase (figure 2a). This process is continuous and slow and is followed the appearance of contrast “buds” inwardly oriented (figure 2b). In the end, after several minutes of observation, a complete enhancement of the hemangioma is observed (figure 2c). Therefore a pattern of progressive and centripetal enhancement of a nodule is the characteristic feature for the diagnosis of hemangioma [26].
Liver hemangioma. a. CEUS performed during the arterial phase (18 seconds since contrast media injection) shows a well defined “ring” around the nodule. b. The appearance of the contrast “buds” suggests the centripetal character of CA progression. c. At the end of the arterial phase there is complete enhancement of the lesion with contrast agent.
The uptake may take variable amounts of time, from tens of seconds to several minutes (even tens of minutes), depending on the size of the lesion and the type of circulatory bed (figure 3a; figure 3b; figure 3c).
A particular type of hemangioma is the arterialized type. It is characterized by accelerated, complete uptake during the arterial phase. It corresponds to circulatory alterations characterized by an important arterial flow. In this situations a differential diagnosis with hypervascular metastases or HCC is difficult and thus a correlation with other imaging techniques is mandatory [27].
a. “Atypical” liver hemangioma. This is the case of a female patient undergoing chemotherapy for breast cancer. There is increased echogenicity of the liver suggesting therapy induced dystrophy. In the middle of the right lobe there is a hypoechoic, solid lesion that raises the possibility of a liver metastasis. b. CEUS exam shows a “ring” enhancement of the lesion during the arterial phase (16th second). c. CEUS exam reveals a complete enhancement of the nodule at the end of the portal phase (70th second). The enhancement process was centripetal (from periphery towards the centre). The diagnosis is certainly of hemangioma. The case demonstrates the role of the CEUS in patients undergoing oncologic treatments who present liver nodules.
Liver cysts. Liver cysts are serous collection circumscribed by cuboidal epithelium. They are frequently encountered during 2D ultrasound, especially in women. Usually they measure less than 20 mm and can present as single or multiple lesions. An involvement of the entire liver is rare. The grey scale US aspect of cysts is that of a well defined, transsonic lesion with posterior acoustic enhancement. The walls of a cyst are very thin and often difficult to distinguish. Inside the cyst there may be thin septa and sometimes deposits. Cysts show no signal on the CFM (color flow mode) interrogation. A hydatid cyst additionally presents daughter cysts and abundant deposits inside. The size of a hydatid cyst is usually larger and the 2D pattern may present in one of several ways, including organization as a solid mass. In such cases the differential diagnosis includes a malignant tumor. In addition to these cases, a CEUS examination is indicated in cases of hypoechoic cysts identified in patients with liver steatosis or cirrhosis, when identifying a vascular signal inside the lesion is determinant in establishing the differential diagnosis (figure 4a; figure 4b). During the arterial phase cysts are highlighted even at sizes of 2 mm, due to their transsonic appearance that contrasts the arterialized surrounding parenchyma.
a. Inactive, solid, organized hydatid cyst of the liver (Gharbi classification, 1981). b. Organized hydatid cyst. CEUS exam demonstrates the lack of vascularity within the tumor and thus contributes to the decisive exclusion of a malignant liver tumor.
Focal nodular hyperplasia (FNH). FNH is a pseudotumor characterized by an area of normal liver cells proliferated around an arterialized scar. Focal nodular hyperplasia has an abundant portal circulatory bed. It is more frequent in women and its development may be linked with the use of oral contraceptives [28]. There is no risk of malignant transformation or spontaneous rupture. The lesion may be unique or there can be multiple lesions. The grey scale ultrasonographic aspect is that of a solid lesion with no capsule of its own (figure 5).
Focal nodular hyperplasia. “Grey scale” ultrasound examination. Perpendicular view through the left lobe. The lesion is solid and well-defined. In the centre of the lesion there is a linear structure that belongs to the typical, central scar (asterisk).
The central scar is more obvious in larger lesions and it presents as a linear, echoic structure. The CFM examination reveals a vascular signal in this area, while pulsed Doppler ultrasound detects arterial flow (figure 6a; figure 6b).
Focal nodular hyperplasia. a. CFM examination. The lesion has a high vascular signal. The vessels have “spoked wheel” spatial distribution. b. “Power mode” exam. “Spoked wheel” vascular pattern.
The CEUS behavior of FNH is characterized by an accelerated uptake in the centre of the lesion during the arterial phase, with a radial distribution, creating a “spoked wheel” appearance (figure 7a). The use of image post-processing procedures allows the identification of the vessels that make up the lesion, as well as their spatial distribution (figure 7b).
a. Focal nodular hyperplasia. CEUS exam during arterial phase. In the 13th second after contrast administration there is complete enhancement of the lesion. In the centre of the lesion there is a hypoechoic structure (the tumoral scar). The tumor pedicle can also be visualized. b. Focal nodular hyperplasia. Combined CEUS examination, using image post-processing techniques, that allows visualization of the spatial distribution of the vessels, which present a radiant orientation. c. Focal nodular hyperplasia (same case as figures 5, 6a, 6b). The CEUS examination performed after 160 seconds from contrast media injection reveals a similar aspect of the lesion. There is no contrast wash-out, thus excluding malignancy.
Liver adenoma. A liver adenoma is an accumulation of hepatic cells, with no biliary structures or Kupffer cells. Its development can be induced by the use of oral contraceptives. Adenomas may also arise in patients with metabolic diseases such as type I glycogen storage disease, as well as in long term administration of anabolic androgenic hormones. Adenomas are arterialized but they do not contain portal vessels. They may be very large in size and thus become symptomatic through pain and intratumoral bleeding. In 5% of the cases adenomas may undergo malignant transformation [30]. Risk of malignant transformation as well as the risk of rupture within the peritoneal cavity can make detected and characterized adenomas indications for surgery. The grey scale ultrasound aspect is that of a well-circumscribed, hypoechoic, solid tumor. The vascular signal evaluated by CFM is non characteristic. After contrast media administration, during the arterial phase there is an irregular enhancement (due to intratumoral bleeding) (figure 8a,\n\t\t\t\tfigure 8b). During the portal venous phase there is moderate wash-out which makes the tumor look iso or hypoechoic compared with the surrounding liver parenchyma. This behavior is seen in the delayed phase as well. The slow wash-out, the hypoechoic aspect during the portal and delayed phases as well as the moderate and inhomogeneous uptake in the arterial phase are elements that may cause misinterpretation of adenomas for malignant tumors.
Liver adenoma, CEUS examination. a. during the arterial phase the tumor presents inhomogeneous uptake. b. CEUS shows moderate contrast wash-out at the end of the arterial phase.
The discrimination of adenomas from HCC is often based on the appearance of the liver on which it developed being normal or dystrophic. As HCC can arise in the absence of chronic liver disease, if there is any cause for doubt additional imaging techniques and/or liver biopsy should be considered. Similarly, distinguishing an adenoma from a metastasis is difficult and the lesion may need additional investigation to complete the diagnosis.
Malignant tumors of the liver represent the main application of ultrasonography. The method can detect these masses within an evocative clinical context (a typical example is that of an oncologic patient who presents with liver nodules or that of a patient with cirrhosis that during follow-up develops a liver nodule) or by chance, during a routine ultrasound examination. The spatial resolution of ultrasonography is sufficient to allow the detection of nodules as small as 10 mm (table 4).
The CEUS examination has a high, but not absolute, specificity! The method contributes to the consolidation of the clinical and grey scale ultrasonographic diagnosis of malignant tumor. The final diagnosis (tumor characterization) is based on an accumulation of criteria, among which is the character of the liver on which a nodule develops (cirrhotic or non-cirrhotic liver), the clinical presentation and the biochemical and functional data of the patient. The intensity of intratumoral echogenicity as the CA crosses the nodule is compared with that of the neighboring liver parenchyma during the same vascular phase.
\n\t\t\t\tTumor\n\t\t\t | \n\t\t\t\n\t\t\t\tArterial phase\n\t\t\t | \n\t\t\t\n\t\t\t\tPortal venous phase\n\t\t\t | \n\t\t\t\n\t\t\t\tDelayed phase\n\t\t\t | \n\t\t\t\n\t\t\t\t“Grey scale” ultrasound (2D)\n\t\t\t | \n\t\t
Hepatocellular carcinoma | \n\t\t\tIntense enhancement Hyperechoic aspect | \n\t\t\tModerate/Intense wash-out Hypoechoic or isoechoic aspect | \n\t\t\tModerate/Intense wash-out Hypoechoic aspect | \n\t\t\tSolid tumor Inhomogeneous structure “Basket-like” appearance of the CFM vascular pattern Arterialized circulation Portal invasion | \n\t\t
Cholangiocarcinoma | \n\t\t\tModerate, inhomogeneous uptake Hyperechoic /Isoechoic aspect | \n\t\t\tModerate wash-out Hypoechoic aspect | \n\t\t\tModerate or intense wash-out Hypoechic aspect | \n\t\t\tSolid tumor located in the hilum or subcapsulary Bile ducts dilations oriented towards the tumor | \n\t\t
Hypovascular metastases | \n\t\t\tPeripheral uptake Hypoechoic aspect | \n\t\t\tPeripheral wash-out Hypoechoic aspect | \n\t\t\tIntense wash-out Hypoechoic aspect | \n\t\t\tMultiple, solid masses Involvement of all liver lobes | \n\t\t
Hypervascular metastases | \n\t\t\tIntense uptake Hyperechoic aspect | \n\t\t\tModerate wash-out Hypoechoic aspect | \n\t\t\tIntense wash-out Hypoechoic aspect | \n\t\t
CEUS and 2D ultrasonographic features of malignant liver masses
Hepatocellular carcinoma is the most frequent primary tumor of the liver [31]. In the vast majority of the cases (over 80%) HCC develops on a liver already affected by cirrhosis. Liver cirrhosis is defined in morphological terms as a process of fibrosis and reorganization. The reorganization of the liver parenchyma leads to the development of variable size, even millimetric, nodules with an ubiquitous distribution involving the entire liver and representing the origin of hepatocellular carcinoma. HCC develops from one or more cirrhosis nodules. Many prospective and retrospective studies have demonstrated this continuity. The development of high resolution imaging techniques that can reliably distinguish between regenerative and cancerous nodules necessitates the accomplishment of practical systematic and validated approaches for their clinically relevant application. In addition to a role in the characterization of such nodules in the diagnosis of cancer, some US characteristics are thought to identify individuals at high risk of developing a cancer. The ultrasonographic pattern of a “restless liver”, for example, is recognized as a “risk” model for the development of hepatocellular carcinoma [32].
The work group of the World Gastroenterology Congress in 1994 agreed upon an anatomical and clinical systematization of the nodules that considers both the presence of the nodules (at the moment of their imaging detection) as well as the dynamics of their development. Regeneration nodules, low dysplastic nodules, high dysplastic nodules with outbreaks of hepatocelllular carcinoma, incipient hepatocellular carcinoma (< 2 cm) and typical hepatocarcinoma can be identified in the cirrhotic liver [33]. This systematization also considers the existence of a vascular dynamics inside the nodules which is considered a key element of carcinogenesis [34, 35]. Inside the dysplastic nodules there is a progressive reduction – until disappearance – of the portal vessels and a proportional growth of the arterial vessels during the multiplication process of the neoplastic cells. The tumoral circulatory bed is made of arterial vessels with a disorganized, chaotic spatial distribution, arteriovenous shunts and the precapillary sphincter of the arterioles is missing. The vascular characteristics of the neoplastic nodules are considered to be determinant for their echogenicity in contrast with that of the surrounding liver parenchyma. In conclusion, high dysplastic nodules are usually hypoechoic, while incipient nodules of highly differentiated hepatocellular carcinoma are usually isoechoic [36].
The Liver Cancer Study Group of Japan defined the following types of nodules:
a small nodule with ill defined margins, size under 20 mm, consisting of well differentiated cells and portal vessels (about 85% of the cases). It may contain areas of low differentiated cells with a different potential of multiplication, realizing a “nodule in nodule” pattern;
a small nodule with ill defined margins, round shape and non-tumoral capsule. In most situations it is made of well differentiated cells (about 75%) and sometimes (about 20% of cases) it may present histological signs of portal invasion;
a tumor nodule with extratumoral buds consisting in most cases of low differentiated cells;
a multinodular pattern made of several nodules in contact with each other, realizing an irregular delineation. They consist of moderate or low differentiated cells;
an infiltrative pattern characterized by a vague, irregular delineation. In most situations it is made of low differentiated cells and/or transitional hepatocytes and cholangiocytes, generating a mixed tumor between the two cellular types.
On the “grey scale” ultrasound exploration a 10 – 20 mm incipient HCC has the aspect of a heterogenous nodule with hypoechoic and hyperechoic areas inside, an appearance that is influenced by the fat content and the degree of cellular differentiation [37]. The Doppler exploration shows a continuous, portal vascular signal oriented towards the tumor [38]. The undulating character of the flow draws attention to a more significant arterial component, which often correlates with poorly differentiated tumors.
The advanced form of HCC may have the following characteristics: demarcation by a halo and lateral shadow (produced by the fibrous capsule of the tumor); inhomogeneous structure (generated by fibrotic and vascular bands which alternate with areas of intact and necrotic tumoral tissue); irregular, ill defined margins (suggesting an invasion of the surrounding liver parenchyma and of the portal vascular bed); posterior acoustic shadowing (generated by the softer consistency of the tumor compared with the normal liver parenchyma). The distinctive vascular aspect, obtained by using the color coded technique of the blood flow (CFM), is that of a basket pattern, characterized by the presence of arterial vessels that circumscribe the tumor and feed it from outside [39]. The spectral exploration demonstrates accelerated flow velocities and altered impedance indexes, since the vascular resistance of the circulatory bed is lower in the absence of precapillary sphincters. On CEUS the aspect of the HCC is typical and is the consequence of its vascular features described earlier (Figure 9). It is characterized by accelerated uptake during the arterial phase, contrast wash-out during the portal venous phase and a hypoechoic appearance in the delayed phase. The wash-out speed is conditioned by the degree of cellular differentiation of the tumor, the lower the differentiation the faster the wash-out (figure 10a; figure 10b;).
Multicentric, large hepatocellular carcinoma. Two large lesions are visualized during the arterial phase. One of the lesions presents an important feeding artery.
Multicentric, large hepatocellular carcinoma. a. CEUS examination (arterial phase) demonstrates the presence of highly enhancing, numerous nodules. b. The hypoechoic appearance of the lesions can be visualized (34th second), suggesting their malignant nature and the low differentiating grade of the tumor.
The exploration allows the discrimination of a malignant invasion of the portal vein from thrombosis based on the behavior during the arterial phase: in case of tumor invasion, the signal is simultaneous with the one inside the hepatic artery, while during the portal phase it loses its signal and becomes obvious (Figure 11) [40].
Tumor invasion of the portal vein. Dual harmonics examination with i.v. contrast, that shows a filling with echoes of the right portal vein on the left and contrast media uptake within the portal lumen during the arterial phase (15th second).
Cholangiocarcinoma is a rare primary malignancy (3 – 7 % of all malignant liver tumors) which usually develops in a histologically normal liver [41]. There are conditions, however, that present higher risks for developing CCC. These included primary sclerosing cholangitis, choledochal cysts, Caroli disease or intrahepatic biliary lithiasis [30]. The origin of CCC is in the small biliary ducts and tumour development is frequently associated with an early appearance of jaundice. The tumor may present a nodular pattern (most cases), an intraductal circumscribed pattern, or a periductal infiltrative type. The nodular type is well-circumscribed, with a fibrotic structure and moderate or poorly differentiated cells. It is frequently associated with metastases in the surrounding parenchyma (developed by contiguity as well as through portal veins) as well as lymph nodes in the hepatic hilum [42]. On the grey scale ultrasound examination, an early CCC is undetectable. In this situation the diagnosis is based on indirect signs, the main one being the dilatation of the intrahepatic bile ducts. Biochemical serum tests, especially those elevated and reflecting abnormal biliary function such as CA 19 – 9 and CEA, may be useful for diagnosis [28]. When the tumor is advanced stage the diagnosis is based on the presence of a solid mass, well delineated, but without a capsule, adjacent to the bile ducts (often in the hilum). The bile ducts may be well dilated. The vascular signal detected upon CFM exploration is weaker than that detected in HCC. The vessels are arterial and have a chaotic spatial distribution. The tumor may be unique or multicentric and it may have a subcapsular localization. An indirect element that sustains the diagnosis is the development of the tumor in a normal liver. The CEUS exam may present an inhomogeneous uptake during the arterial phase, the behavior being uncharacteristic. During the portal venous phase the appearance is hypoechoic and it persists this way in the delayed phase [43].
The liver represents the second site for malignant secondary tumors in oncology. There are usually multiple lesions and rarely single. The common sites of origin are mainly represented by the digestive tract, lungs, breast and pancreatic head [44]. They have fewer vessels than primary malignancies of the liver. During their evolution they may develop hemorrhage, areas of ischemia and necrosis, as well as areas of fibrosis and calcifications. These features contribute to imaging appearances that are extremely diverse and uncharacteristic for their origin when assessed by US. In essence, in a patient with a known neoplastic condition, or in the situation of weight loss in the context of a malignancy, the presence of multiple nodules, measuring more than 10 mm, involving the whole liver, is suggestive for the presence of liver metastases. The CFM exploration does not bring significant information. The CEUS exam is based on demonstrating a hypoechoic aspect during the portal venous phase and delayed phase, which is highly suspicious for malignancy. During the arterial phase metastases may present either a hypo or a hypervascular pattern (figure 12; figure 13a,\n\t\t\t\tfigure 13b).
Liver metastasis (breast neoplasm). CEUS exploration shows a vascular mass 23 seconds after contrast media injection.
a. Liver metastasis (colon neoplasm). CEUS examination reveals a hypoechoic mass 28 seconds after injection. b. Liver metastasis (colon neoplasm). CEUS examination shows multiple hypoechoic masses at 52 seconds after injection (portal venous phase). Typical appearance.
Hypervascular mets may be associated to carcinoid tumors, melanomas, sarcomas and thyroid or renal tumors. The role of CEUS in the evaluation of liver metastases is focused on at least two applications: a. detection of metastases smaller than 10 mm and counting them. The method significantly increases the sensitivity of ultrasound and gets it closer to that of i.v. contrast-enhanced CT [45]. b. assessment of therapy efficiency (chemotherapy and chemoembolization). In this regard the method can document the disappearance of the circulatory bed and suggests an efficient treatment.
This category includes non neoplastic liver masses that are quiet frequently encountered. Ultrasonography often detects such lesions. The US exam must clarify whether there are evolving features or not and if there are special risks for the patient (table 5).
\n\t\t\t\tLiver mass\n\t\t\t | \n\t\t\t\n\t\t\t\tArterial phase\n\t\t\t | \n\t\t\t\n\t\t\t\tPortal venous phase\n\t\t\t | \n\t\t\t\n\t\t\t\tDelayed phase\n\t\t\t | \n\t\t\t\n\t\t\t\t“Grey scale” US\n\t\t\t | \n\t\t
Liver abscess | \n\t\t\tPeripheral uptake and liver parenchyma uptake Hypoechoic/Transsonic aspect | \n\t\t\tEchoic appearance of the liver parenchyma Hypoechoic aspect | \n\t\t\tEchoic appearance of the liver parenchyma Hypoechoic aspect | \n\t\t\tHypoechoic or transsonic lesion Semifluid content Intratumoral gas | \n\t\t
Focal liver steatosis | \n\t\t\tSimultaneous uptake with the liver parenchyma | \n\t\t\tIsoechoic aspect | \n\t\t\tIsoechoic aspect | \n\t\t\tHypoechoic area “Shining” appearance of the liver parenchyma | \n\t\t
Regeneration nodule | \n\t\t\tWeak uptake Hypoechoic aspect | \n\t\t\tIsoechoic aspect | \n\t\t\tIsoechoic aspect | \n\t\t\tSolid nodule, d = 10 – 20 mm Inhomogeneous liver | \n\t\t
CEUS and “grey scale” US criteria for the diagnosis of non neoplastic masses of the liver.
Liver abscess. Liver abscesses may arise in various circumstances: primary abscesses (in immune deficiency cases) or secondary abscesses in postoperative patients, or associated with sepsis, abdominal abscesses, post traumatic conditions, acute angiocholitis or acute pancreatitis etc. The “grey scale” ultrasound aspect is variable in relation to the number and size of the lesions (figure 14). In general it presents itself as a unique, large mass, well circumscribed, but irregular, with a semi-fluid content and with echoic tissue elements and air inside. It can also present as multiple, smaller size lesions, a situation when their texture may mimic liver metastases. The CFM exploration reveals that the vessels are displaced by the mass and that the abscess has no vascular signal inside.
Liver abscess. Hypoechoic mass, with semifluid features, visualized in the right lobe of the liver. There is also right pleural fluid collection.
The CEUS exam shows a progressive uptake in the periphery of the abscess during the arterial phase. This enhancement happens simultaneously with that of the surrounding liver parenchyma which is congested (figure 15a). This aspect is persistent during the portal venous phase as well. During the delayed phase the fluid areas inside the abscess/abscesses are highlighted due to the enhancement of the liver sinusoids and the reticuloendothelial system of the liver (figure 15b) [46].
Liver abscess (same case as figure 14). a. Dual image showing on the left an increased echogenicity of the liver parenchyma during arterial phase. The aspect suggests liver congestion and represents an indirect sign that supports the diagnosis of a liver abscess. b. Portal-venous phase. A decrease of liver echogenicity is noted while the infected collection is emphasized.
Focal liver steatosis. Focal steatosis develops in the context of metabolic conditions, chemotherapy or excessive alcohol consumption. The liver is intensely echoic and presents hypoechoic, rather well circumscribed “islands” or “areas” inside. The Doppler exploration does not reveal additional vessels. The CEUS exam reveals an isoechoic aspect of the liver during the arterial phase. During the portal venous phase and the delayed phase the region of interest is identical with the surrounding liver and thus excludes the presence of a mass.
Regeneration nodules. Regeneration nodules appear as nodular, well circumscribed, hypoechoic masses, usually measuring less than 20 mm. They are often numerous and have a uniform, ubiquitous distribution, involving all the segments of the liver. They may come together as a cluster and form large pseudotumors. This aspect is characteristic for viral liver cirrhosis. These nodules do not present Doppler signals. CEUS exploration is indicated when a certain nodule is larger than the majority of the liver nodules. An increase in size, demonstrated by measurements performed at 6 – 8 weeks, represents an additional indication. Characteristically, the vascular signal is weak or absent during the arterial phase, while in the portal and delayed phases the lesion is persistently isoechoic (figure 16). CEUS is useful in order to exclude an active lesion at the moment of the examination, but it has no prognosis value and that is why the patient must be reexamined at short time intervals [8]. A correlation with the clinical findings and with the values of AFP is mandatory.
Regeneration nodule. CEUS reveals low irrigation during the arterial phase (23th second) and lack of contrast wash-out during the portal venous phase (52th second).
Contrast-enhanced ultrasonography is a noninvasive imaging procedure that allows the gathering of information regarding the dynamics of circulation and the features of the circulatory bed in the region of interest [47]. The investigation is based on the identification of the circulatory phases within the liver – arterial, portal and delayed phase – which are overlapping those identified at contrast CT or MRI. The dynamic analysis of the image in relation with these phases allows the detection and characterization of tumors with similar accuracy to that of CT and MRI [48, 49]. The risks and side effects of the method are insignificant and that is why CEUS must be considered a safe procedure for the patient. This investigation should be commonly used for the characterization of liver nodules developed on liver cirrhosis and suspicion of HCC, regardless of the stage, as well as for the detection of small size metastases. Low price of the procedure, large accessibility and lack of the radiation, are among the most prominent advantages of CEUS that should be taken into consideration. Real time information and clinical character are among them also. These characteristics make CEUS a good and reliable procedure for the detection of liver tumors and follow–up under treatment. However, CEUS is restricted and with low performance in every case where 2D is limited e.g. attenuation, intense liver steatosis, deep region of interest. The procedure is limited to a single lesion and should be repeated to each other one when multiple tumors are detected. Finally, CEUS is operator and equipment dependent. These are reasons because CEUS cannot replace CT or MRI. In every case when the investigation is considered inconclusive, which happens in about 10 % of the cases, other sectional explorations must be considered, like the CT or MRI, and/or liver biopsy [48].
US = ultrasonography; CEUS = contrast-enhanced ultrasonography; CA = contrast agent; HCC = hepatocellular carcinoma; CCC = cholangiocarcinoma; AP = accustic power;
The data presented into this chapter belong to the Research Program CEEX 138/2006 - Angiotumor financed by the Minister of Education & Research in România.
The universal aging of the population is a global concern because of its association with degenerative diseases, which can cause disabilities in humans, limit their productivity in society, and negatively affect their quality of life [1, 2, 3, 4, 5].
In all societies, blindness has profound human and socioeconomic consequences. The costs of loss of productivity, rehabilitation, and education for the blind constitute a significant economic burden for the individual, the family, and society [6].
Thus, it is interesting to know that total or partial opacification of the lens is the main cause of bilateral blindness and severe visual impairment represents about 48% of cases of visual impairment in the world and is known to have a multifactorial cause. In addition, it incapacitates the individual and increases their dependence and early retirement from life [7].
According to the WHO, visual function is subdivided into four levels: normal vision, moderate visual impairment, severe visual impairment, and blindness. Visual disability includes moderate and severe visual impairment and blindness [8, 9], see Table 1.
Category | Visual acuity |
---|---|
Normal vision | 20/20–20/60 |
Moderate visual impairment | 20/60–20/200 |
Severe visual disability | 20/200–20/400 |
Blindness | ≥20/400 |
Count the fingers at 1, 2, 3 m | |
HM | |
PL | |
DNPL |
Classification of visual function according to the WHO.
Symbology: Hand movement (HM), perceive light (PL), do not perceive light (DNPL), meter (m).
The International Classification of Diseases (WHO ICD-10) contains the following definitions:
Blindness: visual acuity (AV) less than 20/400 in the best eye with the available correction (AVCD), with the best possible correction AVMC or with pinhole hole (AVAE)
Severe visual impairment (DVG): AV 20/200–20/400 in the best eye with the AVCD, AVMC, or AVAE
Moderate visual impairment (MVD): AV 20/60–20/200 in the best eye with AVCD, AVMC, or AVAE [7, 10, 11]
Low vision: alteration of visual function, even after treatment and/or standard correction of refraction and an AV less than 20/60 to perception of light but useful for planning or executing a task [7, 8, 10, 11]
According to the WHO data, it is estimated that, worldwide, approximately 1300 million people live with some form of visual impairment. More than 314 million have a severe visual impairment. Of these, 37 million are blind and 124 million suffer from low vision. Eighty percent of all these cases are considered avoidable [12, 13].
According to WHO estimates, of the more than 26 million people with visual disorders in the Region of the Americas in 2010, more than 3 million were blind, and most of them were 50 years of age or older [12].
Most of the national and local surveys were published and published in Latin America, and refractive errors were not corrected in the main cause of visual impairment, both severe (19.7%) and moderate (58.6%) [14, 15, 16].
Between 1990 and 2010, the prevalences normalized according to the age of blindness, and moderate and severe visual impairment decreased in Latin America and the Caribbean [17].
The WHO estimated the prevalence of blindness in 2002 in people over 50 years by subregions [18], see Table 2. In Latin America, the prevalence of blindness in people over 50 responds between 1% in urban areas with good socioeconomic development and more than 4% in rural and marginal areas [19]. In Central America, the prevalence of blindness is 2.1% (95% CI: 1.7–2.7) [17], and in countries such as Panama, it is 3.0% (95% CI: 2.3–3.6) [20], Costa Rica 1.7% (2.1%, IC95%: 1.7–2.7) [21], and Honduras 1.9% (95% CI: 1.4–2.4%) [22].
WHO subregion | Country | Prevalence of blindness in people aged 50+ (%) |
---|---|---|
Amr-A | Canada, Cuba, USA | 0.4 |
Amr-B | Argentina, Bahamas, Belize, Brazil, Chile, Colombia, Costa Rica, Dominica, Dominican Republic, El Salvador, Grenada, Guyana, Honduras, Jamaica, Mexico, Panama, Paraguay, Suriname, Uruguay, Venezuela | 1.3 |
Amr-C | Bolivia, Ecuador, Guatemala, Haiti, Nicaragua, Peru | 2.6 |
Estimates of the prevalence of blindness in 2002 in people over 50 years of age by subregion of the WHO.
Source: Silva [18].
In Latin America, cataract without correction represents by far the main cause of blindness in adults over 50 years, followed by glaucoma, diabetic retinopathy (DR), age-related macular degeneration, and uncorrected refractive errors [23], see Table 3.
Country | Uncorrected refractive error (%) | Uncorrected cataract (%) | Non-trachomatous corneal opacity (%) | Glaucoma (%) | Diabetic retinopathy (%) | Age-related macular degeneration (%) |
---|---|---|---|---|---|---|
Argentina | 8.0 | 44.0 | 0.0 | 8.0 | 16.0 | 4.0 |
El Salvador | 4.0 | 68.7 | 7.1 | 5.1 | 5.1 | 4.0 |
Honduras | 3.0 | 59.2 | 2.6 | 21.1 | 0.0 | 3.9 |
Panamá | 0.1 | 66.4 | 2.2 | 10.2 | 1.5 | 5.1 |
Paraguay | 3.1 | 43.8 | 9.4 | 15.6 | 6.3 | 9.4 |
Peru | 1.5 | 58.0 | 5.3 | 13.7 | 0.8 | 11.5 |
Uruguay | 2.9 | 48.6 | 0.0 | 14.3 | 5.7 | 8.6 |
Main reported causes of blindness adults over 50 years, Latin America, 2011–2013.
Source: Silva [23].
The causes from one country to another. The visual impairment attributable to cataract is greater in low- and middle-income countries than in high-income countries. In high-income countries, diseases such as diabetic retinopathy, glaucoma, and macular degeneration are related to the most frequent age [24].
Johns Hopkins University has found that the main cause of blindness in white people is macular degeneration associated with age, while in the black population, it is due to glaucoma or cataract. In addition, in the elderly, blindness is three times more frequent in blacks than in whites [25].
The main causes of blindness in order of frequency are cataract (39%), uncorrected refractive errors (18%), glaucoma (10%), macular degeneration related to age (7%), corneal opacities (4%), diabetic retinopathy (4%), trachoma (3%), childhood eye diseases (3%), and onchocerciasis (0.7%). Cataract is the leading cause of easily curable blindness [7, 26].
For this reason, a description of the main causes is made, see Table 4.
Causes | Definition |
---|---|
Cataract | It is the opacity of the lens, which is understood as the passage of light to the retina, causes a slow and progressive loss of vision, and can appear at any stage of life, from birth to older age than being human [27, 28, 29, 30] |
Glaucoma | It is an optic neuropathy that presents with a characteristic structural damage, associated with the progressive death of retinal ganglion cells, loss of nerve fibers, and loss of pathognomonic visual field [31, 32, 33, 34] |
Uncorrected refraction | In myopia, the point of focus is in front of the retina, because the cornea has too much curvature or the axial length of the eye is excessive In hyperopia, the focus point is behind the retina because the cornea has too flat a curvature or the axial length is too short Astigmatism, a non-spherical (variable) curvature of the cornea or lens, causes light rays of different orientations (e.g., vertical, oblique, horizontal) to focus on different points [35] Presbyopia is a clinical loss of the amplitude of accommodation or, in other words, the loss of the ability to change the shape of the lens to focus on nearby objects [35, 36] |
The most common causes of visual disability and blindness.
The different etiologies are known to have multifactorial causes; in cataract modifiable risk factors are identified as exposure to ultraviolet rays, mainly UV-B, deficiency in the diet of antioxidants and proteins, smoking, diabetes mellitus, the use of corticosteroids, and severe dehydration. And non-modifiable risk factors are genetic, with a probability three times higher in relatives of people with the disease [37, 38, 39, 40, 41].
In glaucoma it is said that age increases the probability of suffering ocular hypertension. A glaucoma can evolve of various etiologies. The prevalence increases from 4 to 10 times in people older than 60 years [42]. Other risk factors are myopia, inheritance, African-American race, exfoliation, and pigmentary dispersion [43].
Refractive errors are associated with racial factors, the myopia and astigmatism are more prevalent in the Chinese population and hyperopia is the most common in the Hispanic population [44].
Regarding diabetic retinopathy (DR), it corresponds to one of the microvascular complications of diabetes mellitus.
The risk factors are the time of evolution of DM and poor glycemic control, glycosylated hemoglobin (HbA1c) level greater than 6.9% [45], associated arterial hypertension [46, 47], juvenile type 2 DM of early onset [48], and genetic susceptibility (the haptoglobin genotype 1-1) [49].
In Figure 1, the relationship between glycemic control and the duration of diabetes with diabetic retinopathy is shown as a function of the time of follow-up, with different curves for the different HbA1C values [50].
The relationship between glycemic control and duration of diabetes with diabetic retinopathy. Source: Longo et al. [50].
Between 80 and 95% corresponds to simple or nonproliferative DR and the remaining 5–10% to proliferative DR [51].
Basic knowledge of ocular symptoms is required to perform an adequate ophthalmological evaluation. It is always necessary to completely define the characteristics of the symptoms and discomforts.
The ocular symptoms can be classified in the fundamental categories: abnormalities of the eyes, anomalies of the ocular aspect and abnormalities of the sensations, pains, and ocular discomforts.
Therefore, it can be useful to make one order and ask the following questions:
Has the disorder started gradually, quickly, or asymptomatically? For example, was blurred vision in one eye discovered until the other eye was inadvertently covered?
Was the duration of the problem brief, or did the symptom persist until the current consultation? If the symptom has been intermittent, how has been its frequency?
Is the location of the disorder focal or diffuse, and is it a unilateral or bilateral condition? Finally, does the patient rate the degree of the disorder as mild, moderate, or severe?
In Table 5, some of the main characteristics of the most common pathologies associated with preventable blindness are observed.
Of all the organs of the body, the eye is the most accessible to direct examination. The visual function can be evaluated by means of simple subjective tests. The same can be taken care of from an adequate primary care service.
The clinic plays a decisive role in the initial evaluation of any patient, so the correct approach orderly and systematic is essential in the sequence of subsequent processes for the consolidation of a presumptive diagnosis and complementary tests and to achieve an accurate diagnosis and therapeutic approach suitable.
Therefore, an adequate anamnesis that includes general, sociodemographic data, personal and family pathological history, and ocular and non-ocular as well as traumatic surgical history is imperative and invariably its symptomatology.
The external anatomy of the eye is visible and can be examined with the naked eye or with simple instruments.
The eye is the only part of the body where you have direct vision to blood vessels and tissues of the central nervous system (retina and optic nerve). Thanks to this it is possible to identify, by ocular examination, important systemic effects of infectious, autoimmune, neoplastic, and vascular diseases.
And so, a basic physical examination aimed at the search of suspected abnormalities that merit its timely reference to a higher level of specialty is essential in the primary care physician, see Figure 2.
Basic ophthalmologic exploration.
And it is in this sense that it can describe certain characteristic findings of these pathologies, the same ones that can guide our mental scheme to achieve a presumptive diagnosis; some of them are described in Table 6.
Clinic of the main causes of visual disability and blindness.
Physical examination | |
---|---|
Cataract [56] | Opacification of the lens Pupillary reflexes may be slowed down, but they do not disappear |
Uncorrected refraction [52] | Improvement of the AV with the pinhole hole test |
Glaucoma [54, 55] | Closed-angle glaucoma
|
Diabetic retinopathy [57] | Vascular microaneurysms, hemorrhage, cotton-wool exudates, vein caliber alterations, neovascularizations |
Findings of the physical examination in the main causes of visual disability and blindness.
The Latin America and the Caribbean region are considered one of the most inequitable in the world in terms of the distribution of goods and services, social determinants, and health.
Using a standard methodology for international use [58], it has been possible to determine the prevalence of blindness and visual impairment, coverage, and the quality of cataract services and barriers to access them in several countries [56].
The Vision 2020 program in Latin America, with the participation of PAHO/WHO, the Christian Blind Mission, and the International Agency for the Prevention of Blindness, has proposed to document the problem of blindness and visual impairment in people over 50 years of age and designed a statistical instrument called “rapid assessment of avoidable blindness” (ERCE). To date, ERCE activities have been conducted to determine the prevalence of blindness [16, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63].
And it is through this instrument that in nine countries of Latin America, the following barriers have been determined for cataract surgery: lack of knowledge about the existence of a treatment, it is thought to be the destination, there is no availability of surgery services or very distant, fear of the operation or loss of vision, cannot pay for the operation, indication of waiting until it “matures” (possible waiting list), no one can accompany to the ophthalmological care, and other diseases and contraindications for surgery [64, 65, 66].
All are surmountable through information and education campaigns.
To control blindness and visual impairment, it is essential to implement plans to (a) detect cases of low vision and operate cataract cases, (b) detect and give optical correction to cases with refractive errors and presbyopia, and (c) integrate eye care in primary health care. These three interventions could solve around 67% of cases of blindness and could help detect people with glaucoma, in order to treat them in early stages.
Eighty percent of all these cases are considered avoidable. Therefore, the exhaustive evaluation in the patient with determining risks plays a key role, together with the fact that the visual function can be evaluated by means of simple subjective tests and be attended to by an adequate primary care service.
The difficulties in the supply of surgeries vary according to the country, being very available for most of the population in developed countries and becoming the most performed surgery in the elderly. In developing countries, the situation varies according to the regions or countries.
Visual disability and blindness correspond to one of the microvascular complications of diabetes mellitus, where the relationship that keeps the glycemic control in function of the time of presenting the disease is widely demonstrated. Between 80 and 95% corresponds to nonproliferative DR and the remaining 5–10% to proliferative DR. Here is the need for a holistic approach to the patient aimed at prevention and proper medical management.
IntechOpen implements a robust policy to minimize and deal with instances of fraud or misconduct. As part of our general commitment to transparency and openness, and in order to maintain high scientific standards, we have a well-defined editorial policy regarding Retractions and Corrections.
",metaTitle:"Retraction and Correction Policy",metaDescription:"Retraction and Correction Policy",metaKeywords:null,canonicalURL:"/page/retraction-and-correction-policy",contentRaw:'[{"type":"htmlEditorComponent","content":"IntechOpen’s Retraction and Correction Policy has been developed in accordance with the Committee on Publication Ethics (COPE) publication guidelines relating to scientific misconduct and research ethics:
\\n\\n1. RETRACTIONS
\\n\\nA Retraction of a Chapter will be issued by the Academic Editor, either following an Author’s request to do so or when there is a 3rd party report of scientific misconduct. Upon receipt of a report by a 3rd party, the Academic Editor will investigate any allegations of scientific misconduct, working in cooperation with the Author(s) and their institution(s).
\\n\\nA formal Retraction will be issued when there is clear and conclusive evidence of any of the following:
\\n\\nPublishing of a Retraction Notice will adhere to the following guidelines:
\\n\\n1.2. REMOVALS AND CANCELLATIONS
\\n\\n2. STATEMENTS OF CONCERN
\\n\\nA Statement of Concern detailing alleged misconduct will be issued by the Academic Editor or publisher following a 3rd party report of scientific misconduct when:
\\n\\nIntechOpen believes that the number of occasions on which a Statement of Concern is issued will be very few in number. In all cases when such a decision has been taken by the Academic Editor the decision will be reviewed by another editor to whom the author can make representations.
\\n\\n3. CORRECTIONS
\\n\\nA Correction will be issued by the Academic Editor when:
\\n\\n3.1. ERRATUM
\\n\\nAn Erratum will be issued by the Academic Editor when it is determined that a mistake in a Chapter originates from the production process handled by the publisher.
\\n\\nA published Erratum will adhere to the Retraction Notice publishing guidelines outlined above.
\\n\\n3.2. CORRIGENDUM
\\n\\nA Corrigendum will be issued by the Academic Editor when it is determined that a mistake in a Chapter is a result of an Author’s miscalculation or oversight. A published Corrigendum will adhere to the Retraction Notice publishing guidelines outlined above.
\\n\\n4. FINAL REMARKS
\\n\\nIntechOpen wishes to emphasize that the final decision on whether a Retraction, Statement of Concern, or a Correction will be issued rests with the Academic Editor. The publisher is obliged to act upon any reports of scientific misconduct in its publications and to make a reasonable effort to facilitate any subsequent investigation of such claims.
\\n\\nIn the case of Retraction or removal of the Work, the publisher will be under no obligation to refund the APC.
\\n\\nThe general principles set out above apply to Retractions and Corrections issued in all IntechOpen publications.
\\n\\nAny suggestions or comments on this Policy are welcome and may be sent to permissions@intechopen.com.
\\n\\nPolicy last updated: 2017-09-11
\\n"}]'},components:[{type:"htmlEditorComponent",content:'IntechOpen’s Retraction and Correction Policy has been developed in accordance with the Committee on Publication Ethics (COPE) publication guidelines relating to scientific misconduct and research ethics:
\n\n1. RETRACTIONS
\n\nA Retraction of a Chapter will be issued by the Academic Editor, either following an Author’s request to do so or when there is a 3rd party report of scientific misconduct. Upon receipt of a report by a 3rd party, the Academic Editor will investigate any allegations of scientific misconduct, working in cooperation with the Author(s) and their institution(s).
\n\nA formal Retraction will be issued when there is clear and conclusive evidence of any of the following:
\n\nPublishing of a Retraction Notice will adhere to the following guidelines:
\n\n1.2. REMOVALS AND CANCELLATIONS
\n\n2. STATEMENTS OF CONCERN
\n\nA Statement of Concern detailing alleged misconduct will be issued by the Academic Editor or publisher following a 3rd party report of scientific misconduct when:
\n\nIntechOpen believes that the number of occasions on which a Statement of Concern is issued will be very few in number. In all cases when such a decision has been taken by the Academic Editor the decision will be reviewed by another editor to whom the author can make representations.
\n\n3. CORRECTIONS
\n\nA Correction will be issued by the Academic Editor when:
\n\n3.1. ERRATUM
\n\nAn Erratum will be issued by the Academic Editor when it is determined that a mistake in a Chapter originates from the production process handled by the publisher.
\n\nA published Erratum will adhere to the Retraction Notice publishing guidelines outlined above.
\n\n3.2. CORRIGENDUM
\n\nA Corrigendum will be issued by the Academic Editor when it is determined that a mistake in a Chapter is a result of an Author’s miscalculation or oversight. A published Corrigendum will adhere to the Retraction Notice publishing guidelines outlined above.
\n\n4. FINAL REMARKS
\n\nIntechOpen wishes to emphasize that the final decision on whether a Retraction, Statement of Concern, or a Correction will be issued rests with the Academic Editor. The publisher is obliged to act upon any reports of scientific misconduct in its publications and to make a reasonable effort to facilitate any subsequent investigation of such claims.
\n\nIn the case of Retraction or removal of the Work, the publisher will be under no obligation to refund the APC.
\n\nThe general principles set out above apply to Retractions and Corrections issued in all IntechOpen publications.
\n\nAny suggestions or comments on this Policy are welcome and may be sent to permissions@intechopen.com.
\n\nPolicy last updated: 2017-09-11
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She performed (inter)national tasks as vice-president of the Concilium Anaesthesia and related committees. \nShe performed research in several fields, with over 100 publications in (inter)national journals and numerous papers on scientific conferences. \nShe received several awards and is a member of Honour of the Dutch Society of Anaesthesia.",institutionString:null,institution:{name:"Albert Schweitzer Hospital",country:{name:"Gabon"}}},{id:"83089",title:"Prof.",name:"Aaron",middleName:null,surname:"Ojule",slug:"aaron-ojule",fullName:"Aaron Ojule",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Port Harcourt",country:{name:"Nigeria"}}},{id:"295748",title:"Mr.",name:"Abayomi",middleName:null,surname:"Modupe",slug:"abayomi-modupe",fullName:"Abayomi Modupe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:null,institution:{name:"Landmark University",country:{name:"Nigeria"}}},{id:"94191",title:"Prof.",name:"Abbas",middleName:null,surname:"Moustafa",slug:"abbas-moustafa",fullName:"Abbas Moustafa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94191/images/96_n.jpg",biography:"Prof. Moustafa got his doctoral degree in earthquake engineering and structural safety from Indian Institute of Science in 2002. 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His research interest includes earthquake engineering, seismic design, nonlinear dynamics, random vibration, structural reliability, structural health monitoring and uncertainty modeling.",institutionString:null,institution:{name:"Minia University",country:{name:"Egypt"}}},{id:"84562",title:"Dr.",name:"Abbyssinia",middleName:null,surname:"Mushunje",slug:"abbyssinia-mushunje",fullName:"Abbyssinia Mushunje",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Fort Hare",country:{name:"South Africa"}}},{id:"202206",title:"Associate Prof.",name:"Abd Elmoniem",middleName:"Ahmed",surname:"Elzain",slug:"abd-elmoniem-elzain",fullName:"Abd Elmoniem Elzain",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Kassala University",country:{name:"Sudan"}}},{id:"98127",title:"Dr.",name:"Abdallah",middleName:null,surname:"Handoura",slug:"abdallah-handoura",fullName:"Abdallah Handoura",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Supérieure des Télécommunications",country:{name:"Morocco"}}},{id:"91404",title:"Prof.",name:"Abdecharif",middleName:null,surname:"Boumaza",slug:"abdecharif-boumaza",fullName:"Abdecharif Boumaza",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Abbès Laghrour University of Khenchela",country:{name:"Algeria"}}},{id:"105795",title:"Prof.",name:"Abdel Ghani",middleName:null,surname:"Aissaoui",slug:"abdel-ghani-aissaoui",fullName:"Abdel Ghani Aissaoui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/105795/images/system/105795.jpeg",biography:"Abdel Ghani AISSAOUI is a Full Professor of electrical engineering at University of Bechar (ALGERIA). 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El-Hemaly\nProfessor OB/GYN & Urogynecology\nFaculty of medicine, Al-Azhar University \nPersonal Information: \nMarried with two children\nWife: Professor Laila A. Moussa MD.\nSons: Mohamad A. M. El-Hemaly Jr. MD. Died March 25-2007\nMostafa A. M. El-Hemaly, Computer Scientist working at Microsoft Seatle, USA. \nQualifications: \n1.\tM.B.-Bch Cairo Univ. June 1963. \n2.\tDiploma Ob./Gyn. Cairo Univ. April 1966. \n3.\tDiploma Surgery Cairo Univ. Oct. 1966. \n4.\tMRCOG London Feb. 1975. \n5.\tF.R.C.S. Glasgow June 1976. \n6.\tPopulation Study Johns Hopkins 1981. \n7.\tGyn. Oncology Johns Hopkins 1983. \n8.\tAdvanced Laparoscopic Surgery, with Prof. Paulson, Alexandria, Virginia USA 1993. \nSocieties & Associations: \n1.\t Member of the Royal College of Ob./Gyn. London. \n2.\tFellow of the Royal College of Surgeons Glasgow UK. \n3.\tMember of the advisory board on urogyn. FIGO. \n4.\tMember of the New York Academy of Sciences. \n5.\tMember of the American Association for the Advancement of Science. \n6.\tFeatured in �Who is Who in the World� from the 16th edition to the 20th edition. \n7.\tFeatured in �Who is Who in Science and Engineering� in the 7th edition. \n8.\tMember of the Egyptian Fertility & Sterility Society. \n9.\tMember of the Egyptian Society of Ob./Gyn. \n10.\tMember of the Egyptian Society of Urogyn. \n\nScientific Publications & Communications:\n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Asim Kurjak, Ahmad G. Serour, Laila A. S. Mousa, Amr M. Zaied, Khalid Z. El Sheikha. \nImaging the Internal Urethral Sphincter and the Vagina in Normal Women and Women Suffering from Stress Urinary Incontinence and Vaginal Prolapse. Gynaecologia Et Perinatologia, Vol18, No 4; 169-286 October-December 2009.\n2- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nFecal Incontinence, A Novel Concept: The Role of the internal Anal sphincter (IAS) in defecation and fecal incontinence. Gynaecologia Et Perinatologia, Vol19, No 2; 79-85 April -June 2010.\n3- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nSurgical Treatment of Stress Urinary Incontinence, Fecal Incontinence and Vaginal Prolapse By A Novel Operation \n"Urethro-Ano-Vaginoplasty"\n Gynaecologia Et Perinatologia, Vol19, No 3; 129-188 July-September 2010.\n4- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n5- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n6- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n7-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n8-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n9-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n10-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n11-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n12- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n13-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n14- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n15-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n\n16-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n17- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis\n\n18-Maternal Mortality in Egypt, a cry for help and attention. The Second International Conference of the African Society of Organization & Gestosis, 1998, 3rd Annual International Conference of Ob/Gyn Department � Sohag Faculty of Medicine University. Feb. 11-13. Luxor, Egypt. \n19-Postmenopausal Osteprosis. The 2nd annual conference of Health Insurance Organization on Family Planning and its role in primary health care. Zagaziz, Egypt, February 26-27, 1997, Center of Complementary Services for Maternity and childhood care. \n20-Laparoscopic Assisted vaginal hysterectomy. 10th International Annual Congress Modern Trends in Reproductive Techniques 23-24 March 1995. Alexandria, Egypt. \n21-Immunological Studies in Pre-eclamptic Toxaemia. Proceedings of 10th Annual Ain Shams Medical Congress. Cairo, Egypt, March 6-10, 1987. \n22-Socio-demographic factorse affecting acceptability of the long-acting contraceptive injections in a rural Egyptian community. Journal of Biosocial Science 29:305, 1987. \n23-Plasma fibronectin levels hypertension during pregnancy. The Journal of the Egypt. Soc. of Ob./Gyn. 13:1, 17-21, Jan. 1987. \n24-Effect of smoking on pregnancy. Journal of Egypt. Soc. of Ob./Gyn. 12:3, 111-121, Sept 1986. \n25-Socio-demographic aspects of nausea and vomiting in early pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 35-42, Sept. 1986. \n26-Effect of intrapartum oxygen inhalation on maternofetal blood gases and pH. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 57-64, Sept. 1986. \n27-The effect of severe pre-eclampsia on serum transaminases. The Egypt. J. Med. Sci. 7(2): 479-485, 1986. \n28-A study of placental immunoreceptors in pre-eclampsia. The Egypt. J. Med. Sci. 7(2): 211-216, 1986. \n29-Serum human placental lactogen (hpl) in normal, toxaemic and diabetic pregnant women, during pregnancy and its relation to the outcome of pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:2, 11-23, May 1986. \n30-Pregnancy specific B1 Glycoprotein and free estriol in the serum of normal, toxaemic and diabetic pregnant women during pregnancy and after delivery. Journal of the Egypt. Soc. of Ob./Gyn. 12:1, 63-70, Jan. 1986. Also was accepted and presented at Xith World Congress of Gynecology and Obstetrics, Berlin (West), September 15-20, 1985. \n31-Pregnancy and labor in women over the age of forty years. Accepted and presented at Al-Azhar International Medical Conference, Cairo 28-31 Dec. 1985. \n32-Effect of Copper T intra-uterine device on cervico-vaginal flora. Int. J. Gynaecol. Obstet. 23:2, 153-156, April 1985. \n33-Factors affecting the occurrence of post-Caesarean section febrile morbidity. Population Sciences, 6, 139-149, 1985. \n34-Pre-eclamptic toxaemia and its relation to H.L.A. system. Population Sciences, 6, 131-139, 1985. \n35-The menstrual pattern and occurrence of pregnancy one year after discontinuation of Depo-medroxy progesterone acetate as a postpartum contraceptive. Population Sciences, 6, 105-111, 1985. \n36-The menstrual pattern and side effects of Depo-medroxy progesterone acetate as postpartum contraceptive. Population Sciences, 6, 97-105, 1985. \n37-Actinomyces in the vaginas of women with and without intrauterine contraceptive devices. Population Sciences, 6, 77-85, 1985. \n38-Comparative efficacy of ibuprofen and etamsylate in the treatment of I.U.D. menorrhagia. Population Sciences, 6, 63-77, 1985. \n39-Changes in cervical mucus copper and zinc in women using I.U.D.�s. Population Sciences, 6, 35-41, 1985. \n40-Histochemical study of the endometrium of infertile women. Egypt. J. Histol. 8(1) 63-66, 1985. \n41-Genital flora in pre- and post-menopausal women. Egypt. J. Med. Sci. 4(2), 165-172, 1983. \n42-Evaluation of the vaginal rugae and thickness in 8 different groups. Journal of the Egypt. Soc. of Ob./Gyn. 9:2, 101-114, May 1983. \n43-The effect of menopausal status and conjugated oestrogen therapy on serum cholesterol, triglycerides and electrophoretic lipoprotein patterns. Al-Azhar Medical Journal, 12:2, 113-119, April 1983. \n44-Laparoscopic ventrosuspension: A New Technique. Int. J. Gynaecol. Obstet., 20, 129-31, 1982. \n45-The laparoscope: A useful diagnostic tool in general surgery. Al-Azhar Medical Journal, 11:4, 397-401, Oct. 1982. \n46-The value of the laparoscope in the diagnosis of polycystic ovary. Al-Azhar Medical Journal, 11:2, 153-159, April 1982. \n47-An anaesthetic approach to the management of eclampsia. Ain Shams Medical Journal, accepted for publication 1981. \n48-Laparoscopy on patients with previous lower abdominal surgery. Fertility management edited by E. Osman and M. Wahba 1981. \n49-Heart diseases with pregnancy. Population Sciences, 11, 121-130, 1981. \n50-A study of the biosocial factors affecting perinatal mortality in an Egyptian maternity hospital. Population Sciences, 6, 71-90, 1981. \n51-Pregnancy Wastage. Journal of the Egypt. Soc. of Ob./Gyn. 11:3, 57-67, Sept. 1980. \n52-Analysis of maternal deaths in Egyptian maternity hospitals. Population Sciences, 1, 59-65, 1979. \nArticles published on OBGYN.net: \n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n2- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n3- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n4-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n5-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n6-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n7-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n8-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n9- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n10-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n11- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n12-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n13-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n14- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis",institutionString:null,institution:{name:"Al Azhar University",country:{name:"Egypt"}}},{id:"113313",title:"Dr.",name:"Abdel-Aal",middleName:null,surname:"Mantawy",slug:"abdel-aal-mantawy",fullName:"Abdel-Aal Mantawy",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ain Shams University",country:{name:"Egypt"}}}],filtersByRegion:[{group:"region",caption:"North America",value:1,count:5681},{group:"region",caption:"Middle and South America",value:2,count:5161},{group:"region",caption:"Africa",value:3,count:1683},{group:"region",caption:"Asia",value:4,count:10200},{group:"region",caption:"Australia and Oceania",value:5,count:886},{group:"region",caption:"Europe",value:6,count:15610}],offset:12,limit:12,total:1683},chapterEmbeded:{data:{}},editorApplication:{success:null,errors:{}},ofsBooks:{filterParams:{sort:"qngrRaqGuveqFgrcChoyvfu"},books:[],filtersByTopic:[{group:"topic",caption:"Agricultural and Biological Sciences",value:5,count:9},{group:"topic",caption:"Biochemistry, Genetics and Molecular Biology",value:6,count:18},{group:"topic",caption:"Business, Management and Economics",value:7,count:2},{group:"topic",caption:"Chemistry",value:8,count:7},{group:"topic",caption:"Computer and Information Science",value:9,count:10},{group:"topic",caption:"Earth and Planetary Sciences",value:10,count:5},{group:"topic",caption:"Engineering",value:11,count:14},{group:"topic",caption:"Environmental Sciences",value:12,count:2},{group:"topic",caption:"Immunology and Microbiology",value:13,count:5},{group:"topic",caption:"Materials Science",value:14,count:4},{group:"topic",caption:"Mathematics",value:15,count:1},{group:"topic",caption:"Medicine",value:16,count:63},{group:"topic",caption:"Nanotechnology and Nanomaterials",value:17,count:1},{group:"topic",caption:"Neuroscience",value:18,count:1},{group:"topic",caption:"Pharmacology, Toxicology and Pharmaceutical Science",value:19,count:6},{group:"topic",caption:"Physics",value:20,count:2},{group:"topic",caption:"Psychology",value:21,count:3},{group:"topic",caption:"Robotics",value:22,count:1},{group:"topic",caption:"Social Sciences",value:23,count:3},{group:"topic",caption:"Technology",value:24,count:1},{group:"topic",caption:"Veterinary Medicine and Science",value:25,count:2}],offset:0,limit:12,total:null},popularBooks:{featuredBooks:[{type:"book",id:"9208",title:"Welding",subtitle:"Modern Topics",isOpenForSubmission:!1,hash:"7d6be076ccf3a3f8bd2ca52d86d4506b",slug:"welding-modern-topics",bookSignature:"Sadek Crisóstomo Absi Alfaro, Wojciech Borek and Błażej Tomiczek",coverURL:"https://cdn.intechopen.com/books/images_new/9208.jpg",editors:[{id:"65292",title:"Prof.",name:"Sadek Crisostomo Absi",middleName:"C. 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