New onset of pain, swelling, and/or tenderness of intrascrotal contents is referred to as acute scrotum. Urgent surgery is indicated unless spermatic torsion is excluded because spermatic torsion is a urological emergency and requires urgent detorsion to salvage the affected testis . While the usefulness of radionuclide imaging or magnetic resonance imaging (MRI) as diagnostic modalities for acute scrotum has been reported in several articles, ultrasound is mostly indicated recently. Evaluation of blood flow in the affected testis by color Doppler ultrasonography as well as gray-scale mode is quite important in the diagnosis of testicular torsion. In our experience, one-third of the patients with acute scrotum were successfully treated with conservative management, avoiding emergent surgery, because of normal blood flow in the affected testis demonstrated by color Doppler ultrasonography. However, it was reported that blood flow in the affected testis was identified in 20-30% of patients with torsion of the spermatic cord. Therefore, detection of blood flow in the affected testis is not always a definitive finding in the diagnosis of torsion of the spermatic cord. Physical examination or the whirl pool sign on color Doppler ultrasound is also important so as not to miss torsion of the spermatic cord. Urgent surgery should not be avoided unless the diagnosis of torsion of the spermatic cord is completely ruled out. Since ultrasound is an operator-dependent modality, a skillful operator in the emergency room would be warranted to make a better management strategy for patients with acute scrotum.

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Since the second-generation ultrasound contrast agent Sonazoid^® has a stable shell, it enables visualization of the urologic vasculature for a long period of time. We therefore evaluated changes in contrast-enhanced ultrasound (CEUS) imaging of urological organs. It is used for the diagnosis of renal function by enhancing small normal blood vessels. Also, pathological changes in blood vessels are diagnosed by enhancing abnormal vessels. Furthermore, it is applied to spread of renal function and prostatic function and is used for graft function and pharmacological evaluation, respectively. The blood-flow distribution and tumor itself in the case of renal and prostatic tumors are also enhanced. It is expected that effective use of the ultrasound contrast agent will increase the diagnostic rate of renal cell carcinoma and the positive rate of prostate biopsy and lessen the number of biopsy sites.

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Recent clinical studies using color Doppler ultrasonography (CDUS) have revealed the influence of bladder ischemia caused by bladder outlet obstruction (BOO) on lower urinary tract function and lower urinary tract symptoms (LUTS). In 2003, Belenky et al. reported the increased vascular resistance of the internal iliac artery represented as the resistive index (RI) in patients with severe BOO. In 2007 and 2008, there were consecutive reports about bladder ischemia in patients with benign prostatic hyperplasia (BPH). Bladder RI was improved overall after medical therapy with alpha-blockers and surgical treatment of BPH (transurethral resection of the prostate: TURP). However, persistent detrusor overactivity after surgery was associated with persistently high bladder RI with subsequent reduced perfusion. We also studied bladder ischemia using CDUS in patients with BPH. Our studies showed that 1) bladder RI correlated with BOO grade and prostatic volume; 2) bladder RI was improved after relieving BOO by TURP or 5-alpha reductase inhibitor, but bladder RI after medical or surgical therapy was less improved in patients with persistent overactive bladder (OAB); and 3) less improvement of bladder RI after medical or surgical therapy was associated with remaining BOO or higher incidence of hypertension (an arterial sclerosis risk factor). Simple and more accurate measurement of bladder blood flow using ultrasonography would reveal the long-term impact of bladder ischemia on LUTS and the reversibility of lower urinary tract dysfunction and bladder ischemia after medical or surgical treatment.

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Facing an aging society, health care providers are seeing an increase in the number of patients with benign prostatic hyperplasia (BPH), a condition that adversely affects the quality of life (QOL). Since bladder outlet obstruction (BOO), one of the main symptoms of BPH, can lead to acute urinary retention, renal dysfunction, and urinary tract infection, and thereby influence life prognosis, BPH requires proper diagnosis and aggressive treatment. Transrectal ultrasonography (TRUS) has proven extremely useful in evaluating prostatic morphology for diagnosis of BPH. The estimated prostatic volume, presumed circle area ratio, and intravesical prostatic protrusion based on TRUS are useful parameters for predicting the severity of BOO, and recent evidence has further suggested that the resistive index (RI) in the capsular branches of the prostatic artery obtained using Doppler ultrasound correlates with the severity of BOO. While pressure-flow studies (PFS) are now generally considered the most accurate method for diagnosing BOO, their use is limited due to the invasiveness of the procedure. In the present study, RI was relatively low at 0.66 in patients diagnosed as not having BOO based on a PFS, while that in patients with BOO was relatively high at 0.75. Receiver operating characteristic analysis showed that RI was relatively high at 0.80 for the presence/absence of BOO. Consequently, in determining the severity of BOO resulting from BPH, diagnostic accuracy is expected to be further improved by combining TRUS with RI measurements.

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Purpose: The aim of this study was to clarify the relationship between the severity of aortic valve calcification (AVC) and stiffness of the proximal thoracic ascending aorta (TAA), and to examine their influence on left ventricular (LV) function and renal function. Methods: A total of 138 hypertensive patients including 32 with diabetes mellitus and 60 with dyslipidemia were divided into four groups based on the severity of AVC. We analyzed the elastic properties of the proximal TAA from the following strain-rate indices based on tissue Doppler imaging: maximum strain rate [SR(+)], minimum SR [SR(-)], and the time between the QRS peak and the peak SR(-) of the proximal TAA (SRT). Results: SR(+) and SRT were significantly greater in patients with moderate AVC than in patients with mild AVC. SRT and SR(-) were well correlated with age, peak velocity across AV, TAA wall thickness (IMC), LV diastolic function, and renal function. SRT was independently related to IMC, dyslipidemia, and LV diastolic function. Conclusion: The severity of AVC was correlated with the elastic properties of the proximal TAA. The SR indices are useful for assessing the relation of TAA stiffness to LV function and renal function in patients with AVC.

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Purpose: To determine the usefulness of contrast-enhanced ultrasonography with the contrast agent Sonazoid^® for the detection of bowel ischemia. Methods: From March 2007 to February 2009, 65 patients (35 men and 30 women, mean age 70.4±16.1 years) were enrolled. Fifty-three patients complained of acute abdominal pain with small bowel dilatation (n=40) or reduced bowel peristalsis (n=13). Twelve patients were clinically suspected of having bowel ischemia. After Sonazoid^® injection, bowel segments were scanned using harmonic imaging, and the signal intensities were classified as normalor diminished. The definitive diagnosis was confirmed by surgery in 30 patients, autopsy in 6, endoscopy in 3, angiography in 1, and clinical follow-up in 25. Results: All 50 patients with normal signal intensities were confirmed not to have bowel ischemia. In the 15patients with diminished signal intensities, 14 patients were confirmed to have bowel ischemia, resulting in an overall sensitivity of 100% [95% confidence interval (CI)80.7-100%], a specificity of 98% [95% CI 89.5-99.9%], a positive predictive value of 93% (95% CI 68.1-99.8%), and a negative predictive value of 100% (95% CI 94.1-100%). Conclusion: Contrast-enhanced ultrasonography with Sonazoid^® is a highly sensitive and specific method for the diagnosis of bowel ischemia.

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Myocardial disorder is known as a side effect during chemotherapy with trastuzumab (TRZ) for breast cancer. A 58-year-old woman was diagnosed with carcinoma of the left breast and underwent mastectomy in November 200X-2. TRZ was started as postoperative adjuvant chemotherapy from August 200X-1. In August 200X, left ventricular (LV) wall motion abnormality and ballooning in the apex were detected by echocardiography. Her LV ejection fraction decreased to 38%. After withdrawal of TRZ, the LV wall motion abnormality improved. Occurrence of symptomatic heart failure was reported in 1-4% of patients receiving TRZ, and LV ejection fraction was decreased in 10%. We report a rare case that developed takotsubo cardiomyopathy during TRZ administration.

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A 35-year-old man has been followed for suspected splenic hamartoma since 2005 in the Department of Gastroenterology. The patient complained of exacerbation of abdominal distension and oppressive sensation in January 2010. No abdominal organomegaly or tenderness were observed on physical examination. Ultrasonography (US) revealed multiple hypo-isoechoic, heterogenous nodules with unclear borders, and an increase in the number of masses was observed. Enhanced computed tomography (CT) revealed multiple nodules with heterogenous enhancement in the early phase, but no nodules were detected in the late phase. Non-enhanced magnetic resonance imaging (MRI) revealed no nodules on T1 image, but a low signal intensity mass-like image was observed on T2 image. Uptake by the tumor was observed by ferucarbotran-enhanced super paramagnetic iron oxide (SPIO) MRI, and we therefore strongly suspected multiple splenic hamartoma. Open splenectomy was performed in March 2010. because the case was symptomatic and the patient solicited its resection. The pathological diagnosis was multiple splenic hamartoma (pulposal type). Multiple splenic hamartoma is very rare, and we thus report this case with a review of the literature.

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We herein report a case of breast cholesterol granuloma that presented the twinkling artifact on color Doppler sonography. The patient was a 45-year-old woman who complained of a lump in her left breast. B-mode ultrasonography showed it to be a round, well-circumscribed hypoechoic mass. Some twinkling artifacts were seen on the surface of the tumor on color Doppler ultrasonography. Mammography showed a few tiny calcifications only. Cholesterol crystals are considered to be the cause of the twinkling artifact. A cholesterol granuloma should be considered in the differential diagnosis when encountering a breast tumor presenting the twinkling artifact.

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A 72-year-old woman with a history of urolithiasis and thoracic compression fracture was referred to our hospital for evaluation of primary hyperparathyroidism. She had osteoporosis, hypercalcemia, hypophosphatemia, and elevated intact PTH. B-mode ultrasound revealed a flat hypoechoic area adjacent to the anterior surface of the thyroid, and power Doppler imaging revealed blood flow in the same area. Three-dimensional ultrasonography revealed an oval hypoechoic area in a coronal section image, measuring 16 mm in the major axis. MIBI scintigraphy showed normal uptake in the thyroid in the acute phase, and nodular remaining uptake in the left lower pole of the thyroid in the delayed phase, whose shape was quite similar to that of the coronal section image. No other ectopic parathyroid gland was found. This hypoechoic area was revealed to be an enlarged parathyroid gland, which was confirmed by postoperative pathology. Although it is well known that the lower parathyroid gland can be found anywhere from the cervical region to the mediastinum due to its embryological procedure, a parathyroid gland on the anterior surface of the thyroid is rarely documented. Three-dimensional ultrasonography was useful for identifying the lesion.

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We report the case of a 70-year-old woman presenting with chronic vertigo and vomiting due to Meniere-like symptoms. Abdominal ultrasonography was performed, revealing an anechoic mass connected to the retrohepatic/suprarenal inferior vena cava (IVC); color Doppler imaging showed venous flow from the IVC into the mass-like space. Enhanced computed tomography (CT) demonstrated a saccular aneurysm without IVC interruption. The maximal diameter was 25 mm and the length was 45 mm. CT showed neither mural thrombus in the IVC aneurysm nor thrombus of the pulmonary artery. IVC angiography showed several compartments divided by partition walls and delayed washout of contrast agent in the aneurysm. Endoluminal observation was performed, perspectively and consecutively, with virtual vascular endoscopy (VVE) using three-dimensional ultrasonography, from inside the IVC into the intra-aneurysmal space. VVE imaging indicated the direct opening of the aneurysm orifice from the IVC and delineated the intra-aneurysmal structure, including the compartments of the inner wall of the aneurysm. In lieu of anti-coagulation therapy or surgical removal, she was started on oral anti-platelet therapy because of a lack of history of thrombosis.

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