Michael Kallenbach

Ultrasound is a widely used, non-invasive, and radiation-free imaging modality that serves as a first-line diagnostic tool in hepatology due to its accessibility and real-time imaging capabilities. Recent advancements, such as shear-wave elastography and standardized techniques like the hepatorenal index (HRI), have improved the assessment of diffuse liver diseases despite their variable sonomorphologic presentation. The HRI is a quantitative ultrasound parameter that compares the echogenicity of the liver to that of the right renal cortex and serves as a non-invasive tool for detecting and grading hepatic steatosis. It is particularly useful in routine abdominal ultrasound due to its simplicity, reproducibility, and applicability without the need for additional equipment. Normal HRI values typically range between 0.8 and 1.2, with values above 1.4–1.5 suggesting hepatic steatosis, and values exceeding 2.0 considered indicative of significant fatty infiltration. Several factors influence HRI accuracy, including image quality, region of interest (ROI) placement, and equipment settings. While software-assisted analysis can improve reproducibility, standardization across devices and protocols remains a challenge. Future developments should focus on consensus-based measurement techniques and the integration of artificial intelligence to enhance diagnostic precision and clinical applicability.

Necrotizing (abscessing) lymphadenopathy is a clinically relevant condition with a broad differential diagnosis, including acute bacterial infections, mycobacterial disease, zoonoses, fungal and parasitic infections, autoimmune disorders, and malignancies with central necrosis. Early and reliable differentiation between these causes is important to avoid misdiagnosis and to guide appropriate therapy. This review summarizes the pathophysiological mechanisms, typical imaging features, and diagnostic value of contrast-enhanced ultrasound (CEUS) in necrotizing lymphadenopathy. Representative clinical vignettes illustrate the disease spectrum and correlate CEUS patterns with underlying pathology. The literature review was narrative and based on targeted searches of PubMed/MEDLINE and Google Scholar focusing on CEUS in necrotizing lymphadenopathy. A brief literature overview highlights current evidence, limitations, and research gaps. Conventional B-mode ultrasound (BMUS) and Doppler typically demonstrate enlarged hypoechoic or heterogeneous nodes with reduced central vascularity but lack specificity for necrosis. CEUS provides real-time visualization of nodal microvascular perfusion, which may support clearer differentiation between viable tissue and necrotic or abscess cavities. Common but non-specific CEUS patterns include central non-enhancement with a peripheral hyperemic rim in abscesses, irregular avascular cores in tuberculous lymphadenopathy, patchy non-enhancing areas in autoimmune conditions, and heterogeneous enhancement with ill-defined necrosis in malignant nodes. CEUS can support biopsy targeting, facilitate drainage procedures, and enable radiation-free follow-up. CEUS may offer diagnostic and interventional advantages in the evaluation of necrotizing lymphadenopathy, offering more consistent characterization of nodal necrosis compared with conventional sonography. While most evidence focuses on tuberculosis and malignancy, growing experience with zoonotic and autoimmune diseases suggests broader utility. Most currently available evidence derives from observational studies and small case series, highlighting the need for prospective multicenter validation. Standardization of CEUS criteria, integration into multiparametric ultrasound protocols, and multicenter validation are needed to establish CEUS as a routine component in the diagnostic work-up of necrotizing lymphadenopathy.

Ultrasound diagnostics is a widely used, radiation-free, cost-effective, and bedside-applicable imaging technique. Given its numerous advantages and broad application, it appears reasonable to integrate practical use and theory into medical education at an early stage. Since the content of student ultrasound courses varies significantly on an international scale, the aim of this paper is to establish foundations for a more standardized approach to student’s ultrasound education (SUSE) especially with focus on abdominal ultrasound. This review examines to what extent measurements can be effectively incorporated into student ultrasound training and under which conditions the teaching of pathologies should be included in these courses. Additionally, the handling of false-positive and false-negative findings in student training is discussed. Considering the growing relevance of interventional ultrasound (INVUS), the paper further explores the extent to which interventional procedures should already be taught during SUSE.

Objective: To provide an overview of the technique and normal values of ultrasound studies of the bile system based on the published literature. Methods: A literature search for ultrasound studies with measurements of the bile ducts in healthy subjects was performed. Relevant data published between 1975 and end of 2024 were extracted, discussed, and complemented with the own experiences of the authors. The clinical implications are presented and discussed. Results: For the diameter of the common bile duct, reference values between 5 and 9 mm have been published. The main influencing factors are age and history of cholecystectomy, and other factors to be considered are discussed here. The cut-off for the common bile duct wall is set at 1.5 mm. The literature on measurements of intrahepatic bile ducts is scarce. A diameter of <2–3 mm can be considered normal. The method of ultrasound examination is presented here, as well as a comparison with other imaging methods and their clinical implications. Conclusions: Standardized measurement techniques and normal values in the context of influencing factors are crucial for the ultrasound examination of the bile system.

As an extension of the clinical examination and as a diagnostic and problem-solving tool, ultrasound has become an established technique for clinicians. A prerequisite for high-quality clinical ultrasound practice is adequate student ultrasound training. In light of the considerable heterogeneity of ultrasound curricula in medical studies worldwide, this review presents basic principles of modern medical student ultrasound education and advocates for the establishment of an ultrasound core curriculum embedded both horizontally and vertically in medical studies.

Zusammenfassung: Aufgrund des Trends zum vermehrten Einsatz der Bildgebung und der steigenden Awareness bei Risikopatienten werden gastroenterologisch und hepatologisch tätige Ärztinnen und Ärzte häufiger mit Patienten mit unklaren Leberläsionen konfrontiert. In der Differenzierung dieser Raumforderungen hielten CT und MRT im klinischen Alltag zunehmend Einzug in primäre Diagnostikschritte. Die kontrastverstärkte Sonografie stellt demgegenüber ein sehr effektives und kosteneffizientes Verfahren zur Beurteilung fokaler Leberläsionen dar. Der Erfolg der Methode beruht nicht nur auf der Darstellung der Mikrovaskularisation in Echtzeit. Wird die Sonografie vom Behandelnden selbst durchgeführt, kann dieser die genaue Kenntnis der Anamnese und der klinischen Befunde nutzen, um den Untersuchungsablauf gezielt anzupassen und den sonographischen Befund mit größerer Treffsicherheit zu interpretieren („klinische Sonografie“). Gleichzeitig versetzt die Methode den Behandelnden in die Lage, Diagnostik und Therapieentscheidung in den eigenen Händen zusammenzuführen. Exzellente Ergebnisse erzielt die kontrastverstärkte Sonografie – wie alle anderen bildgebenden Verfahren auch – nur bei ausreichender Qualifikation des Untersuchenden.Dieser Beitrag stellt die sonographischen Charakteristika der häufigsten Leberläsionen übersichtlich dar und zeigt deren Kontrastierungsmuster anschaulich anhand von Videos (via QR-Code abrufbar). Der Artikel verdeutlicht, dass die KM-Sonografie aus hepatologischer Sicht in Zukunft einen noch größeren Stellenwert haben könnte und aus Sicht der Autoren haben sollte.

Background: Wilson’s disease (WD) is an autosomal-recessive disorder of copper deposition caused by pathogenic variants in the copper-transporting ATP7B gene. There is not a clear correlation between genotype and phenotype in WD regarding symptom manifestations. This is supported by the presentation of genetically identical WD twins with phenotypic discordance and different response behavior to WD-specific therapy. Case Presentation: One of the female homozygous twins (age: 26 yrs) developed writing, speaking, swallowing and walking deficits which led to in-patient examination without conclusive results but recommended genetic testing. Both sisters were tested and were heterozygous for the C.2304dupC;p(Met769Hisf*26) and the C.3207C>A;p(His1069Gln) mutation. Self-medication of the affected sibling with 450 mg D-penicillamine (DPA) did not prevent further deterioration. She developed a juvenile parkinsonian syndrome and became wheelchair-bound and anarthric. A percutaneous endoscopic gastrostomy was applied. Her asymptomatic sister helped her with her daily life. Despite the immediate increase of the DPA dose (up to 1800 mg within 3 weeks) in the severely affected patient and the initiation of DPA therapy (up to 600 mg within 2 weeks) in the asymptomatic patient after the first visit in our institution, liver function tests further deteriorated in both patients. After 2 months, the parkinsonian patient started to improve and walk again, but experienced several falls, broke her right shoulder and underwent two necessary surgical interventions. With further consequent copper elimination therapy, liver dysfunction improved in both patients, without need for orthotopic liver transplantation (LTX) in the severely affected patient. Her excellent recovery of liver and brain dysfunction was only transiently interrupted by the development of a nephrotic syndrome which disappeared after switching to Cuprior^®. Unfortunately, she died from fulminant pneumonia. Conclusion: Despite identical genetic disposition, WD symptom presentations may develop differently in monozygotic twins, and they may need to be placed on a very different therapeutical regimen. The underlying gene-environment interaction is unclear so far.