Aktueller Stand der Sonographie in der Gastroenterologie - Leber und Milz

Zusammenfassung

Die konventionelle B-Bild- und Farbdoppler-Sonographie ist nach der Anamnese, dem körperlichen Untersuchungsbefund und im Rahmen der Interpretation von laborchemischen Parametern das bildgebende Verfahren der ersten Wahl. Die Sonographie ist in der Hand des Gastroenterologen zu einem ebenso wichtigen diagnostischen Werkzeug wie die Endoskopie geworden. Die sich ständig entwickelnde Technik mit der Möglichkeit der deutlich höheren Detailerkennung, insbesondere auch durch den Einsatz der harmonischen Bildgebung sowie die Anwendung der Signalverstärker (Kontrastmittel), sind Veranlassung zu einer praktisch relevanten Bestandsaufnahme. Für den vorrangigen Einsatz in der Leberdiagnostik und am Portalsystem inklusive Milz werden praktische Hinweise gegeben. Die Bedeutung der Sonographie zur ätiologischen Einordnung diffuser Lebererkrankungen ist insgesamt gering. Komplikationen insbesondere der Leberzirrhose können aber sehr sensitiv detektiert werden. Portosystemische Shunts und typische Gefäßveränderungen werden mittels Farbdoppler-Sonographie auch als indirekte Zeichen eines fortgeschrittenen Leberparenchymschadens erkannt. Die Sonographie zeigt darüber hinaus sensitiv eine Erweiterung der Gallenwege bzw. kann diese ausschließen. In der Detektion und Differenzierung umschriebener Leberveränderungen ist sie die erste Bildgebung. Die sonographische Charakterisierung von Leberläsionen ist bei typischen Befunden ausreichend. Der Einsatz von Ultraschallkontrastmitteln (Echosignalverstärker) erhöht die Differenzierungsrate und kann den unkritischen Einsatz weiterer radiologischer Bildgebung (Computertomographie [CT], Magnetresonanztomographie [MRT]) vermeiden. Bei Zweifeln an der Dignität bleibt die histologische Sicherung allerdings unabdingbar. Die Beurteilung der Milz und der versorgenden Gefäße erfolgt regelhaft bei diffusen Leberparenchymschäden unter der Frage einer portalen Hypertension. Fokale Milzläsionen sind insbesondere im Zusammenhang mit Lymphomerkrankungen (Lymphominfiltrate) und anderen Knochenmarkserkrankungen zu beobachten. Durch die Anwendung der Kontrastmittelsonographie werden auch die Vaskularisationsstörungen (Infarkte) sichtbar und traumatische Läsionen sind besser diagnostizierbar.

Abstract

Conventional B-mode and colour duplex imaging is the first choice imaging technique after history taking and physical examination and for the interpretation of laboratory parameters. In the hands of a gastroenterologist ultrasound has become an equally important diagnostic tool as endoscopy. The constantly evolving technique with its possibility of higher resolution by use of “harmonic imaging” and signal enhancement with contrast medium is the reason for a practically relevant review of the situation. Practical references will be given for diagnostics of the liver and portal system including the spleen. The significance of the sonographic diagnosis of “fatty liver” is critically discussed. The overall importance of ultrasound to distinguish different aetiologies of diffuse liver diseases is relatively low. Nevertheless, it is a very sensitive means to detect complications of liver cirrhosis. Portosystemic shunts and typical changes in blood vessel morphology can be diagnosed by colour duplex sonography and used as indirect signs of advanced damage to liver parenchyma. In addition, ultrasound has its value in the confirmation or exclusion of dilated bile ducts as well as in the detection and differentiation of circumscribed liver lesions. The characterisation of focal liver lesions by ultrasound is sufficient in typical cases. The use of ultrasound contrast media (signal enhancers) raises the rate of differentiation and can avoid the uncritical and sequential application of radiological imaging (computed tomography [CT] or magnetic resonance imaging [MRI]). If in doubt about the nature of a lesion, a histological diagnosis remains indispensable. The examination of the spleen and its feeding vessels is regularly done in cases of diffuse parenchymal liver disease when searching for its complications, e. g., portal hypertension. Focal spleen lesions can be observed especially in the context of lymphoma (infiltration) and other bone marrow diseases. Through the application of contrast media, changes of vascularisation (e. g., infarcts) can be visualised and traumatic lesions can be diagnosed more precisely.

Schlüsselwörter

Ultraschall - Lebertumoren - Hepatitis - Fettleber - Milztumoren - Kontrastmittelsonographie

Key words

Ultrasound - liver tumours - hepatitis - fatty liver - spleen tumours - contrast enhancement

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