Abstracts S65

The stomach is a fascinating organ. It has the capacity to expand itsvolume substantially to receive and accommodate food after a meal,normally without any conscious notice of the expansion.It mixes and grinds the food into small particles, it separates smallparticles from large particles, and it can discriminate between solidsand liquid. After ingestion of irritant or toxic material, the stomach canreverse its normal activity to facilitate forcible ejection of gastriccontents through the mouth. How can, what appears to be a simplemuscular bag, carry out all of these functions? The answer is, of course,that the stomach is not a simple bag; it is a complex organ withdifferent compartments that acts in concert to perform a range of highlyspecialised functions.The aim of this presentation is to show how transabdominal ultrasonog-raphy can disclose the structural and functional secrets of the stomach.Ultrasound of the stomach was initially performed to detect and inves-tigate organic diseases of the gastric wall. Subsequently, differentmethods were developed to study functional aspects of gastric pathol-ogy. Ultrasound can be used to evaluate antral contractility, gastricemptying, transpyloric flow, gastric configuration, intragastric distribu-tion of meals, gastric accommodation and strain measurement of thegastric wall. Advanced methods for 3D ultrasound imaging and tissueDoppler (Strain Rate Imaging) have also been developed to studydiseases of the stomach. For symptom provocation in dyspeptic pa-tients, The Ultrasound Meal Accommodation Test (UMAT) can beapplied to distinguish and characterize patients with organic versusnon-organic dyspepsia.

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Hydrocolonic SonographyKanu Bala, University of Science & Technology Chittagong,Bangladesh

Ultrasonography of colon by conventional abdominal approach is fre-quently frustrating. Hydrocolonic sonography [HCS] is a developmentof the conventional ultrasonographic examination of abdomen that hasrecently been shown to be effective in assessing the colon wall, lumen,and surroundings.Patient is instructed to eat an exclusively low-residue diet during theprevious day of examination. On the next morning, after bowel moved,the patient comes to the centre in empty stomach. At the centre, enemasimplex with warm soap-water is given. No significant adverse effectsare noted during or after colon cleaning. The whole colon up to caecumcan be examined in most of the cases without any difficulty.Normal colon: The thickness of the colon wall is 3�1 mm. Within thecolon wall, five layers of different echogenicity are sonographicallydemonstrated. Colon polyp: Colon polyps appear sonographically asechogenic structures that project into the colon lumen and float in thelumen. Colon carcinoma: Colon carcinomas appear as rounded echo-genic structures that project into the lumen. In contrast to polyps, thesehave no observable movement in the intestinal lumen. Sometimes thewhole circumference of the colon wall is involved. In favorable exam-ination conditions, sonographic demonstration of colon wall infiltrationis detected. Crohn’s disease: In patients with active Crohn’s disease,the intestinal wall is thickened up to 10mm, as well as the loss ofhaustrations. The luminal border is less echogenic and further distinc-tion of other intestinal wall layers is no longer possible. Ulcerativecolitis: In patients with ulcerative colitis, bowel wall is thickenedapproximately 5�1mm. The five-layer structure remained intact. Colontuberculosis: Hypertrophic type of caecal tuberculosis is presented asgross thickening and total destruction of the colon wall. Lymph nodesinvolvements are present.Hydrocolonic sonography is an alternate modality of imaging thecolon. In fact, relatively less attention has been paid on this promising

method of examining colon. It is a cheap, rapid and well-tolerated

procedure. In a country like Bangladesh, this procedure can he appliedwithout involving significant amount of extra money and man-power.

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A Systematic Approach to Abnormal Uterine Bleeding. SalineInfusion Sonohysterography or Outpatient Endometrial PipelleBiopsy?Steven Goldstein, NYU Medical Center, United States

All postmenopausal women with bleeding as well as those women over35 with abnormal uterine bleeding mandate endometrial evaluation.Historically the gold standard was dilation and curettage (D&C) Latervacuum suction devices allowed for sampling in an office setting.Subsequently cheaper, smaller, less painful suction piston biopsy in-struments became popular. The best known of these, the Pipelle re-ceived widespread acceptance with very little validation. Originallydeveloped for timed endometrial biopsy as part of an infertility work-up, a subsequent paper showed 97.5% accuracy and got widespreadattention. However, other papers also studying Pipelle biopsy in pa-tients with known carcinoma revealed sensitivities as low as 67%. Inone study no endometrial cancers were missed when the pathologyoccupied more than half of the surface of the uterine cavity, but overall16% of endometrial cancers were missed. Thus they concluded “Pipelleis excellent for detecting global processes in the endometrium”.In postmenopausal patients with bleeding, transvaginal ultrasound hasa well established negative predictive value (99.9%) when the endo-metrial echo is � 4mm. Saline infusion sonohysterography is employedwhen the unenhanced TV/US is 1) not adequately thin to excludepathology or 2) inadequately imaged so as to be reliable. Salineinfusion sonohysterography will then allow triage of patients 1) noanatomic pathology, 2) global endometrial process in which case blindendometrial sampling is appropriate or 3) focal endometrial process inwhich case endometrial sampling by direct vision (hysteroscopy) isnecessary.

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Significance of Incidental Ultrasound Findings in Post-Menopausal Women, to Remove or Not to Remove?Steven Goldstein, NYU Medical Center, United States

Transvaginal ultrasound is a reliable way of excluding endometrialcarcinoma. When thin and distinct it is far superior to blind endometrialsampling whether by suction piston biopsy or actual D&C. In suchcases it can reduce the expense, discomfort, and risk of endometrialsampling. Recently The American College of Obstetricians and Gyne-cologists has endorsed endometrial thickness � 4mm as so reliable inexcluding endometrial cancer that in such patients endometrial biopsyfor tissue histology is deemed unnecessary.Unfortunately, many clinicians have assumed that because an endome-trial echo � 4-5mm in postmenopausal patients with bleeding is good,that endometrial thickness � 5mm discovered incidentally in patientswithout bleeding is abnormal and should warrant further investigation.There are fewer data on such patients. The incidence of quiescentendometrial polyps or old submucous myomas that result in endome-trial “thickening” when viewed as part of an incidental imaging study,has not established. Some data indicate that 10-17% of postmenopausalpatients have a “thickened” endometrial echo on transvaginal ultra-sound. Data exists that such endometrial thickening in non bleedingpatients will have an incidence of complex hyperplasia or endometrialcarcinoma that approaches 0%. The complications of performing op-erative hysteroscopy on such patients, has been reported as high as3.6%. Thus while TV/US � 4mm in a patient with postmenopausalbleeding reliably excludes carcinoma, the existence of an incidental

finding of endometrial thickening in postmenopausal patients without