The left ventricle must be depicted in the correct cross-section to assess left ventricular wall motion. Often, the apex is not a true apex, and the left ventricle size is underestimated. The long axis of the left ventricle should be enlarged as much as possible by using an echo bed or by imaging during inspiration as well as expiration. The short axis should be observed at the level of the papillary muscles to make sure that both papillary muscles are equally delineated. If they are not equal, there is a possibility of oblique swing, and wall motion evaluation cannot be done properly. Regional wall motion abnormalities and myocardial properties on short-axis and long-axis images from the apex should be evaluated. In old myocardial infarction, increased intensity and decreased wall thickness on the intimal side are also important findings. If the findings are not consistent with coronary artery supply, cardiac sarcoidosis or takotsubo cardiomyopathy should be considered. In such cases, the electrocardiogram should also be referred to. Left ventricular contractility is assessed using the method of disks (MOD). This is a method for determining the volume of the left ventricle by dividing it into 20 elliptical columns. Many people misunderstand MOD as “modify” because it is displayed on echocardiography machines, but this is a misnomer.

Purpose: Ultrasonography is effective at detecting pleural invasion in primary lung cancer, but the factors underlying discordance between findings of pleural invasion according to ultrasonography, gross assessment (PL), and pathological assessment (pl) have not been fully investigated. The aims of the present study were to compare findings from these approaches and identify factors underlying discordant findings. Subjects and Methods: Subjects were 35 patients with primary lung cancer who underwent an ultrasound-guided puncture followed by surgery between 2014 and 2017. We assessed the extent of ultrasonographic pleural invasion prior to the puncture and then evaluated ultrasonographic grading of pleural invasion (uP) by lung cancer. We compared uP, PL, and pl, and examined various factors in patients with concordant findings, overestimated pleural invasion, and underestimated pleural invasion. Results: The rates of agreement between uP and PL, uP and pl, and PL and pl were 34.3%, 28.6%, and 54.3%, respectively. In the uP and PL group, the percentage of interstitial changes significantly increased (P＝0.006) and that of emphysematous changes significantly decreased (P＝0.023) in patients with overestimated pleural invasion. The percentage of pleural irregularities around the tumor on chest CT scan tended to increase in patients with overestimated pleural invasion and interstitial changes (P＝0.066) compared to that in patients with concordant findings and interstitial changes. In the uP and pl group, the percentage of tumors in the apex of the lung significantly increased (P＝0.022) in patients with underestimated pleural invasion. In the uP2 and pl group, the percentage of tumors located near the diaphragm significantly increased (P＝0.024) in patients with overestimated pleural invasion. Conclusion: Interstitial changes, tumors in the apex of the lung, and those located near the diaphragm can affect the assessment of pleural invasion using chest ultrasound.

The patient was a Japanese male in his 70s who had previously been treated with an interferon preparation for chronic hepatitis C, but the treatment was ineffective. After edema appeared, computed tomography showed subcutaneous edema, pleural effusion, and ascites, and hepatic edema and ascites were initially suspected because of persistent hepatitis C virus (HCV) infection, thrombocytopenia, and a high FIB-4 index. Noninvasive testing (NIT), which included Mac2 binding protein glycosylation isomer (M2BPGi), ultrasound elastography, and congestion index of the portal vein, ruled out liver cirrhosis and hepatic ascites, and this case was ultimately considered to be TAFRO syndrome. The most common cause of ascites is liver cirrhosis, which is often treated by a hepatologist. Thus, it is important to objectively differentiate whether ascites is due to a hepatic cause using NIT. And since there have been no reports of HCV infection complicated by TAFRO syndrome, this case is rare and valuable.

A 20-year-old woman with a history of ulcerative colitis since 2006 presented with mild right lower abdominal pain and underwent ultrasonography for routine examination. The root of the appendix was normal with a diameter of 3 mm, but there was a 9-mm-long swollen appendage localized at the blind end. The laminar structure was clear and there was no irregularity of the mucosal surface, no brush echo, and no calcification of the lumen. No blood flow signal was detected. The isolation sign of the surrounding fatty tissue was not prominent, and ascites and enlarged lymph nodes could not be identified. CT/MRI showed similar findings, and appendiceal mucocele was suspected. Appendectomy was performed. Histologically, a xanthogranulomatous reaction consisting of foamy histiocyte aggregation and lymphocytic infiltration was found under the mucosal epithelium of the appendix, so we diagnosed xanthogranulomatous appendicitis. Although the absence of specific findings and the rarity of this condition precluded a preoperative diagnosis, it is necessary to keep in mind that this particular inflammation can occur in the appendix in addition to neoplastic lesions.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant systemic vascular disease. In this report, we present a case of HHT accompanied by focal nodular hyperplasia (FNH) with long-term follow-up. The patient was a woman in her 60s with no chief complaints, but she had recurrent nosebleeds since childhood. She was referred to our hospital in 2006 after an intrahepatic mass was suspected at another hospital. She had a family history of epistaxis. On admission, hepatitis virus and tumor markers were negative. Abdominal ultrasonography (US) revealed a prominent portal vein, dilated hepatic vein, coiled hepatic duct dilatation, multiple shunts, and multiple masses throughout the liver. Upon performing color Doppler imaging, the largest tumor (S8) showed a spoke-wheel-pattern signal. Dynamic computed tomography also revealed similar vascular abnormalities. The tumor was enhanced in the early phase, but no washout was observed. A biopsy of the tumor confirmed FNH. In 2007, Sonazoid-enhanced US of the largest mass showed enhancement in the early phase, but no defect was noted in the late phase. On annual examinations, vascular lesions remained unchanged, but the largest mass showed regression on US and gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) and disappeared in 2015. After its disappearance, EOB-MRI detected emergence and regression of other masses, but not US. However, a new mass was confirmed by US in 2022. Sonazoid contrast-enhanced US was performed using a full-focus device, and a mass that could not be observed previously on B-mode US could now be observed simultaneously. We performed long-term follow-up of HHT accompanied by multiple FNH. Sonazoid-enhanced US and EOB-MRI are useful imaging modalities for multiple evolving tumors.

The patient was a 58-year-old male. He was admitted to our hospital with anorexia, weight loss (-10 kg/2 months), and repeated vomiting after radiofrequency catheter ablation (RFCA) for atrial fibrillation. Abdominal CT showed marked gastric dilatation and partial dilatation and collapse of the third portion of the duodenum. Since a part of the third portion of the duodenum was compressed by the superior mesenteric artery (SMA) and the aorta (Ao), we diagnosed SMA syndrome. Ultrasonography utilizing positional changes revealed that the distance between the SMA and Ao varied from 6.0 mm in the supine position, 40.1 mm in the left lateral recumbent position, 30.8 mm in the right lateral recumbent position, and 7.7 mm in the sitting position, with duodenal compression being reduced most in the left lateral recumbent position. After hospitalization and instruction in mosapride citrate administration, divided meals, and left-side supine position after meals, his symptoms including vomiting resolved.The patient was discharged from the hospital without any symptoms. Recently, RFCA for atrial fibrillation has been pointed out as a cause of SMA syndrome, in which the ablation energy from RFCA is radiated outside the heart and damages the perigastric vagal plexus, resulting in gastric peristalsis, anorexia, and weight loss, which causes SMA syndrome. In the present case, the peri-SMA intestinal tract was observed with positional ultrasonography, which allowed real-time observation of the opening of the duodenal stenosis as the SMA was greatly displaced in the left lateral recumbent position. Ultrasonography utilizing positional changes is useful for diagnosis of SMA syndrome and identification of the optimal position for prevention of the onset of this syndrome.

There are limited reports on the use of laparoscopic ultrasonography in gynecological surgery. We describe a case in which intraoperative laparoscopic ultrasonography was used to identify and treat a rare paraurethral tumor. A 39-year-old woman with four previous pregnancies and one delivery had frequent urination for approximately 1 year prior to her visit to our department. Transvaginal ultrasonography and MRI showed a well-defined mass of approximately 5 cm in diameter just below the urethra in the anterior vaginal wall. The patient had frequent urination, and the tumor seemed to have increased in size. Hence, we decided to remove it. Our preoperative diagnosis was a vaginal leiomyoma in the anterior vaginal wall, which was to be removed with laparoscopic assistance due to its proximity to the bladder and urethra. Laparoscopically, the anterior vaginal wall and bladder were dissected from the vaginal wall to near the urethra. However, there was no continuity between the tumor and vaginal wall. Furthermore, intraoperative laparoscopic ultrasonography revealed that the tumor was in the dissected peri-bladder tissue. We determined that this was a paraurethral tumor, not a vaginal tumor, and switched to a transvaginal approach that allowed periurethral manipulation, which led to the removal of the tumor. Histopathological examination revealed a leiomyoma with no malignant findings. Intraoperative laparoscopic ultrasonography allowed us to diagnose the pararectal tumor. Hence, laparoscopic ultrasonography is useful for observing the intra-abdominal cavity and identifying tumors in the vaginal, paraurethral, and periurethral areas, which are considered to be relatively rare.