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CC BY-NC-ND 4.0 · Z Gastroenterol 2024; 62(06): 952-970
DOI: 10.1055/a-2145-7461
Übersicht

Kontrastverstärkte Sonografie (CEUS) zur Diagnostik fokaler Leberläsionen

Contrast-enhanced ultrasound (CEUS) for characterisation of focal liver lesions
Michael Kallenbach 
1   Department of Gastroenterology Hepatology and Infectious Diseases, University Hospital of Düsseldorf, Düsseldorf, Germany
2   Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Düsseldorf, Germany
,
Natalia Qvartskhava
1   Department of Gastroenterology Hepatology and Infectious Diseases, University Hospital of Düsseldorf, Düsseldorf, Germany
2   Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Düsseldorf, Germany
,
Christian Weigel
1   Department of Gastroenterology Hepatology and Infectious Diseases, University Hospital of Düsseldorf, Düsseldorf, Germany
2   Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Düsseldorf, Germany
,
Yvonne Dörffel
3   Medical Outpatient Department, Charité Universitätsmedizin Berlin, Berlin, Germany (Ringgold ID: RIN14903)
,
Jens Berger
4   Ernst von Bergmann Klinikum, Department of Gastroenterology, Hepatology, Infectious Diseases and Rheumatology, Potsdam, Germany
,
Georg Kunze
5   Schwarzwald-Baar Klinikum Villingen-Schwenningen GmbH, Villingen-Schwenningen, Germany (Ringgold ID: RIN39668)
,
Tom Luedde 
1   Department of Gastroenterology Hepatology and Infectious Diseases, University Hospital of Düsseldorf, Düsseldorf, Germany
2   Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Düsseldorf, Germany
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Widmung

Wir widmen diesen Artikel Herrn Professor Wolfram Wermke anlässlich seines 45-jährigen Dienstjubiläums an der Charité in Berlin-Mitte. Er hat Generationen von Sonographeuren geprägt. Ohne ihn wäre die kontrastverstärkte Sonographie nicht das, was sie heute ist. Wir danken Herrn Professor Wermke für die Ausbildung in zahlreichen Seminaren, seine Förderung und konstruktive Kritik.(MK, YD, JB, GK)

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.

Abstract

Due to the trend towards increased use of imaging and rising awareness among high-risk patients, gastroenterologists and hepatologists are more frequently confronted with patients with focal liver lesions. In the differentiation of these lesions, CT and MRI have increasingly found their way into primary diagnostic steps in everyday clinical practice. Contrast-enhanced sonography, on the other hand, is a very effective and cost-efficient method for assessing focal liver lesions. The success of the method is not only based on the visualisation of microvascularisation in real time. If sonography is performed by the treating physician, he can use the exact knowledge of history and clinical findings to specifically adapt the examination procedure and to interpret the sonographic findings with greater accuracy (“clinical sonography”). At the same time, the method enables the practitioner to combine diagnostics and management decisions in his or her own hands. To achieve excellent results with contrast-enhanced sonography—as with any other imaging method—it is necessary that the examiner is sufficiently qualified.

This article systematically presents the sonographic characteristics of the most common liver lesions and clearly shows their contrast patterns using videos (available via QR code). The article illustrates that CEUS could—and from the authors’ point of view, should—have an even greater significance in the future.

Kernaussagen

  • Die KM-Sonografie kann mit sehr hoher Treffsicherheit eine Aussage zur Dignität von Leberläsionen machen, wobei ein Kontrastverlust in der portalvenösen und späten Phase („wash-out“) als malignomsuspekt gilt.

  • Für die Artdiagnose einer Leberläsion ist das Kontrastierungsmuster in der arteriellen Phase von besonderer Bedeutung.

  • Hämangiome zeigen auch bei atypischer Erscheinung im B-Bild in der Mehrzahl der Fälle ein charakteristisches Kontrastverhalten, wodurch weitere diagnostische Maßnahmen unnötig werden.

  • Beim Vorliegen typischer Merkmale können fokal noduläre Hyperplasien ebenfalls sicher charakterisiert werden. Probleme kann die Abgrenzung zum Leberzelladenom bereiten (besonders bei FNH mit exzentrischer Gefäßverzweigung, Typ II).

  • In der Zirrhose gelingt die Charakterisierung eines HCC mit gleicher Treffsicherheit wie im MRT, sofern die Läsion im B-Bild gut darstellbar ist.

  • Um das späte Auswaschen beim HCC zu erfassen, muss die Untersuchungsdauer ggf. auf bis zu 6 Minuten p.i. ausgedehnt werden.

  • Für die Unterscheidung zwischen HCC und CCC/Metastase ist der Zeitpunkt des Beginns des wash-out in der portalvenösen/späten Phase ein wichtiges Kriterium.

  • Die KM-Sonografie kann ebenso wie CT und MRT nicht bei jeder Läsion eine ätiologische Zuordnung treffen, aber die Notwendigkeit von Biopsien reduzieren.

Schlüsselwörter

kontrastverstärkte Sonografie - Leberläsionen - Hämangiom - Adenom - FNH - HCC - cholangiozelluläres Karzinom - Bildgebung

Keywords

CEUS - liver lesion - hemangioma - adenoma - HCC - iCCA - FNH - ultrasound - imaging


Publication History

Received: 01 February 2023

Accepted after revision: 21 June 2023

Article published online:
05 October 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

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