Three Dimensional Ultrasonography in the

Hepatogastroenterology.
BY Dr. Gamal Esmat
Assistant Professor of hepatogastroenterology,
Kasr El Aini School of Medicine, Cairo University.

Three-dimensional ultrasonography represents a development of

non- invasive diagnostic imaging real-time two-dimensional
ultrasonography. The use of transparent rotating scans, comparable to a
block of glass, generates a three-dimensional effect (1). The clinical use
of 3D-US in the hepatogastroenterology system revealed its possible
applications (2,3,4).

Although the risks associated with X-ray carcinogenesis are

relatively low at diagnostic dose levels, concerns remain for individuals
in high-risk categories. In addition, cost and portability of CT and MRI
machines can be prohibitive. In comparison, ultrasound can provide
portable, low-cost, non-ionizing imaging (5).

The major advantage of 3D is the ability to obtain ultrasound

sections which are impossible to see on a routine scan and the ability to
perform accurate volume measurements, in addition to interactive
manipulation of volume data using rendering, rotation and zooming on
localized features which means clinically that images of anatomy and
organs can be displayed in a straight forward manner (6).
 But the real problem with three-dimensional sonography is not its
efficiency but rather its efficacy, that is which actual role this technique
can play in diagnosis and which information it can add to two-
dimensional imaging (7).

Liver:

Ultrasound plays an extremely important role in evaluating liver

diseases worldwide. In developed countries computed tomography (CT)
magnetic resonance imaging (MRI) and ultrasound all have both
complementary and competing roles in assessing the liver (8,9). The
limitations of 2D-US include a lesser ability to give an overall panoramic
view of large structures, such as the liver, and a sensitivity to artifacts,
because of degradation by gas, bone and to a lesser extent, fat (10).

It is necessary to image the patient in different positions at

different phases of respiration. Typically, one must scan from at least
three different scanning positions to obtain an adequate examination,
because the liver is too large to be seen from any single perspective. The
examiner must visualize exactly which portions of the liver have been
imaged from each transducer location to be sure the entire organ has been
evaluated. This can be challenging. A good 3D-US system should
document exactly, which portions of the liver were evaluated and
therefore facilitate a more thorough examination (11).

Liver volume:
 In a clinical context, measurements of organ volume are often
performed in the diagnosis and follow-up of patients with a variety of
diseases. Ultrasonography is a cheap, widely available and non-hazardous
imaging modality to use for estimation of volumes. Using two-
dimensional (2D) ultrasound, the simplest method of calculating the
volume of an organ is based on the multiplication of three diameters
perpendicular to each other. These 2D methods are often based on
geometrical assumptions, which may introduce significant errors in
volume estimation. Therefore volume estimation based on three-
dimensional (3D) ultrasound has been developed to increase accuracy and
percision (12).

Knowing the true volume of the entire liver is clinically important

sometimes, both native and transplant liver tissue have the ability to
regenerate, and imaging often is used to monitor this regeneration process
following surgery (13).

To date, MRI and volumetric CT are the modalities most

frequently employed for these assessments (13,14). 3D-US has the
potential to replace CT and MRI in this role, if the technical problems in
acquiring high-quality data sets can be overcomed. This would be
desirable, as assessment could be done more frequently, since ultrasound
is more readily available, uses non ionizing radiation, and is less
expensive (15).

 Diffuse liver disease:

Wagner et al studied 93 patients with chronic liver disease and
compared the 3D-US with the conventional 2D-US. They found that
3D imaging is superior to routine sonography in the anatomical
assignment in complex vascular and biliary duct alterations. Three-
 dimensional ultrasonography was found better in the diagnosis of
Budd-Chiari syndrome, primary sclerosing cholangitis. However, 3D
imaging did not add important information in diffuse liver disease (11).

In our personal experience, 3D-US was very valuable in

demonstrating the irregular surface of the liver cirrhosis and rounded
edges in a view very similar to the laparoscopic view. Visualization of the
falciform ligament (Fig.1) and the omentum (Fig 4) could also be
demonstrated.

 Hepatic focal lesions:

Liess and his colleagues showed that 3D-US provided more
accurate and repeatable measurements of focal liver lesions than either
2D-US or CT in sequential studies (16).

This is an extremely important information, as it is crucial to have

an accurate measurement of the volume of liver lesions that are to be
treated with minimally invasive therapies. The amount of therapy given
to the patient is usually directly proportional to the volume of the lesion.
For example, with alcohol ablation of hepatocellular carcinoma in
cirrhotic patients, the dose of alcohol injected into the lesion is directly
proportional to the volume of the tumor (17).

As regards the accuracy of volume measurement, 3D-US is

comparable to 3D-CT but more precise than 2D-US. This indicates that
3D-US may be applied in the follow up of tumor patients as an alternative
diagnostic procedure to CT. In addition, 3D-US might be useful in
planning liver resections by virtue of better evaluation of the volume of
the liver tissue remaining after resection and better visualization of the
topography of liver tumors and major hepatic vessels (18).
 Lang and his colleague showed that the volume measurement using
3D-US provide comparable results to 3D-CT. Clinically, 3D-US could be
helpful in the follow up in patients with non resectable tumors or
planning for liver resection by assessing the volume of the liver tissue
remaining after resection or by a better visualization of the topography of
the liver tumor or the major hepatic structures (19).

Three-dimensional ultrasonography was found to be a helpful

imaging technique in the detection of hepatic hydatid cyst (Fig.3) and in
the measurements of its volume. The effect of alcohol injection by
Percutaneous-Aspiration-Injection and Reaspiration (PAIR) technique
could be demonstrated in the form of detachment of the membrane.

Four-dimensional ultrasonography (upgraded 3D) is very useful in

providing the guidance for interventional procedures from the liver
including taking biopsies, aspirations or injection of therapeutic
materials.

 Hepatic vasculature:
Three-dimensional ultrasonography power Doppler of the portal
vein produces relatively clear images of the portal venous system when
viewed in volume – rendered mode. In addition, assessing the patency of
the portal systemic shunts and Transjugular–Intrahepatic– Portosystemic
shunt (TIPS) procedures may be more elegantly displayed in three
dimensions, essentially with 3D-US power rendering. The role of contrast
enhancement of liver tumors using three dimensions holds tremendous
promise, although this is still untested (20).
 Doppler 3D was a useful addition in diagnosing the cause of
chronic liver disease in patients with ascites due to veno-occlusive
disease, where the hepatic veins were occluded with minimal irregular
blood flow (21).

Spleen:
Diffuse splenomegaly is the most commonly diagnosed abnormality
within the spleen. Focal splenic abnormalities including cysts (Fig ),
benign and malignant tumors are easily demonstrated (22).
Splenic volumes can be were calculated automatically after serial
slices each has a manually drawn region of interest assigned around the
spleen.
Three-dimension ultrasonography is potentially superior to 2D-US
for evaluation of irregularly shaped objects, such as the spleen and can
provide improved accuracy over that of traditional technique (23).

High quality 3D-US power Doppler images of the spleare relatively

obtained and this type of evaluation may assess in evaluating splenic
infarctions and trauma (20).

Pancreas:
Sackmann et al used 3D-US to visualize pancreatic lesions and
stones and they concluded that this imaging procedure could be helpful in
identification of the extension of tumors and in the invasion of the
surrounding tissues (Fig 5). Stone and stone fragments in the pancreas
were also visualized (24).
 Three dimensional US may also be helpful in deciding, the extent of
peri-pancreatic cystic diseases due to either pseudocyst formation or
tumors and may help in measuring intra-pancreatic lesions more
accurately, which may be clinically useful in following the pseudocyst
(book).

Selner et al commented on the importance of tumor volume in the

prognosis of radically periampullary cancer. They found that the larger
the cancer, the worse the prognosis (25). Whether 3D-US will provide
more accurate measurements than CT or EUS is currently unknown (25).

Gall bladder & biliary tract:

Knowing the exact location of the gall bladder is important prior to
surgery or radiological intervention (Fig10). Although extremely rare,
anomalies in gallbladder location such as a left-sided gallbladder or
intrahepatic gall bladder may make laporoscopic cholecystectomy and
other procedures extremely challenging. These anomalies might be better
appreciated in 3D-US examination, when a more panoramic view of the
gall bladder and the surrounding structures is present. Getting a clear
perspective of the pericholecystic region may also be desirable in trying
to assess the appropriate surgical approach for gall bladder masses, either
carcinoma or metastatic disease (22).

Three-dimensional ultrasonography accurately measures gall bladder

volume and emptying and was characterized by a significantly smaller
systematic bias and closer limits of agreement with the true volume (26).

Sackmann et al demonstrated the use of 3D US in evaluating the gall

bladder wall and gall bladder stones (24).
 In our experience, in case of portal hypertension, porto-systemic
collaterals can be visualized surrounding the wall of the gall bladder
(Fig11).

Wagner et al evaluated the role of 3D-US in detecting the extent of

biliary tract alterations in primary sclerosing cholangitis (11).

Dilated CBD and its relation to the gall bladder, portal vein, hepatic
artery and IVC are visualized in (Fig 14).
Gastrointestinal tract:
Recent studies illustrated that; Endoluminal US allowed detailed
imaging of the gastrointestinal wall and adjacent structures. Three-
dimensional imaging may improve visualization of topographic relations
and the nature of pathologic lesions.

Trans-cutaneous sonography has been reported to be clinically

useful in assessing focal mass lesions, diffuse lesions of the bowel wall
and intra-luminal pathologies (22).

Hydrosonography using 3D US can be performed in diagnosis of

hollow organ pathology, which was found to be more accurate than 2D
US because of the multiple cuts that can be done and also due to more
accurate orientation (21).

3D-US can be extremely helpful in assessing overall tumor volume

and for measuring some distances (e.g. the distance from a rectal tumor to
the external sphincter, which may dictate how and when surgery is
planned)(22).
 The utility of 3D-US in the esophagus showed that it was technically
possible and that it adds good potential to improve cancer-staging (27).
Molin evaluated the usefulness of 3D reconstration for interpretation
and quantitative analysis during stent deployment in cancer esophagus
(28).

In assessment of intragastric distribution and gastric emptying, 3D-

US magnetic scanhead tracking showed excellent in vitro accuracy,
calculating emptying rates more precisely than by 2D-US, and enable
estimating the intragastric distribution of soap meal (28).

3D hydrosonography of the stomach demonstrated a malignant ulcer

on the greater curvature of the stomach with nodal involvement (Fig17),
and by this technique a mass in the caecum and the ascending colon was
demonstrated by 3D-US (Fig16) and it was proved by colonoscopy and
histopathology to be of tuberculous etiology (21).

The loops of the small bowel, visceral peritoneum, greater as well as

lesser omentum can be visualized in ascitic patients (Fig5).

Hunerbein and Schlag assessed the role of three-dimensional

endosonography in examining 100 patients with rectal cancer. They
concluded that the technique allowed visualization of the lesions in
different planes, which would be impossible with conventional 2D-US
imaging (30).
Ascites:
 The best 3D-US images were obtained from anatomical and
pathological conditions with a liquid content and structures surrounded
by liquid (e.g. hydrocele and ascites) (31).

Gamal and El Raziky studied 39 ascitic patients. Ascites was found

beneficial in 3D-US examination because it facilitate the visualization of
the intestinal surface as well as the parietal peritoneum. They evaluated
the role of 3D-US in etiological diagnosis of ascites. Peritoneal nodules
were seen in most of ascitic cases due to local causes.
They found that 3D-US was helpful in the differentiation between
tuberculous nodules (Fig 7,8) and malignant nodules (Fig9) in 80% of the
cases and a typical pattern was prescribed for tuberculous ascites (Fig6)
(21).
 REFRENCES.
(1) Zoller W, Liess H, Roth C, Umgelter A (1993):
Clinical application of three-dimensional sonography in internal
medicine.
Clin Investig, 71(3): 220-32.
(2) Liess H, Roth C, Umgelter A, et al (1994):
Improvements in volumetric quantification of circumscribed hepatic
lesions by three-dimensional sonography.
Z Gastroenterol, 39:488-92.
(3) Pauctelzki J, Sackmann M, HII J, et al (1996):
Evaluation of gall bladder volume and emptying with a novel three
dimensional ultrasound system: comparison with the sum of cylinders
and the ellipsoid methods.
J Clin Ultrasound, 24:277-85.
(4) Wolf G, Lang H, Prokop M, Schreiber M, Zoller W (1998):
Volume measurements of localized hepatic lesions using three-
dimensional sonography in comparison with three-dimensional computed
tomography.
Eur J Med Res, 3 (3): 157-64.
(5) Morimoto A, Krumm J, Kozlowski D, Kuhlmann J, Wilson C, Little
C, Dickey F, Kwok K, Rogers B, Walsh N (1997):
High definition 3D ultrasound imaging.
Stud Health Technol Inform, 39:90-8.
(6)Thomas R and Dolores H (1997):
Interactive acquisition, analysis and visualization of sonographioc
volume data.
Inter J of imaging and technology, 35:40-7.
(7) Riccabona M, Nelson T, Pretorius D, Davidson T (1995):
Distance and volume measurement using three-dimensional
ultrasonography.
J Ultrasound Med, 14 (12): 881-6.
(8) Ferrucci J (1990):
Liver tumor imaging: current concepts.
AJR, 155:473-84.
(9) Ohahsi I, Ina H, Okada Y, et al (1996):
Segmental anatomy of the liver under the right diaphragmatic dome:
evaluation with axial CT.
Radiology, 200: 779-83.
(10) Cosgrove D (1996):
Why do we need contrast agents for ultrasound?
Clin Radiol, 51(suppl) 1:1-4.
(11) Wagner S, Gebel M, Bleck J, Manns M (1994):
Clinical application of three-dimensional sonography in hepatobiliary
diseases.
Bildgebung, 61(2): 104-109.
(12) Gilja O, Hausken T, Perstand A, Odegaard S (1999):
Measurements of organ volumes by ultrasonography.
Proc Inst Mech Eng, 213(3): 247-59.
(13) Chari R, Baker M, Sue S, Meyers W (1996):
Regeneration of a transplanted liver after right hepatic lobectomy.
Liver Transpl Surg, 2:233-234.
(14) Caldwell S, de Lange E, Gaffey M, et al. (1996):
Accuracy and significance of pretransplant liver volume measured by
magnetic resonance energy.
Liver Transpl Surg, 2:438-42.
(15) Henderson J, Macky G, Kutner M, Noe B (1993):
Volumetric and functional liver blood flow are both increased in the
human transplanted liver.
J Hepatol, 17: 204-8.
(16) Liess H, Roth C, Umgelter A, Zoller W (1994):
Improvements in volumetric quantification of circumscribed hepatic
lesions by 3D-US.
Z Gastroenerol, 32: 488-92.
(17) Alexander D, Unger E, Seeger S, Karmann S et al (1996):
Estimation of volumes of distribution and intra-tumoral ethanol
concentrations by CT scanning after percutaneous ethanol injection.
Acad Radiol, 3:49-56.
(18) Lang H, Wolf G, Prokop M, Nuber B, Weimann A (1999):
3 –D sonography for volume determination of liver tumor – report of
initial experiences.
Chirurg, 70(3): 246-50.
(19) Lang H, Wolf G, Prokop M, Nuber B, Weimann A (1998):
Volumetry of circumscribed liver changes with 3D US in comparison
with 3D CT.
Langenbecks Arch Chir Suppl Kongressbd, 115:1478-80.
(20) Downey D, Fenster A (1995):
Vascular imaging with a 3 D power Doppler system.
AJR, 156: 665-8.

(21) Esmat G and El Raziky M (2000):

Medical Imaging International (in press)
(22) Nelson T, Downey D, Pretorius D, Fenester A (1999):
In: Three-dimensional ultrasonography.
Lippincott Williams and Wilkins publications.
 (23) De Odoricio I, Spaulding K, Pretorius D, Lev-Toaff A, et al
(1999):
Normal splenic volumes estimated using THREE-D ultrasonography.
J Ultrasound Med, 18: 231-6.

(24) Sackmann M, Pauletzki J, Zwiebel F, Holl J (1994):

Three-dimensional ultrasonography in hepatobiliary and pancreatic
diseases.
Bildgebung, 61(2): 100-3.
(25) Sellner F, Machacek E (1993):
The importance of tumor volume in the prognosis of radically treated
periampullary carcinomas.
Eur J Surg, 159:95-100.
(26) Pauletzki J, Sackmann M, Holl J, Paumgartner G (1996):
Evaluation of gall bladder volume and emptying with a novel three-
dimensional ultrasound system: comparison with the sum-of-cylinders
and the ellipsoid methods.
J Clin Ultrasound, 24:277-85.
(27) Kallimanis G, Garra B, Tio T, et al (1995):
The feasibility of three-dimensional endoscopic ultrasonography: a
preliminary report.
Gastrointest Endosc, 41:235-9.
(28) Molin S (1999):
Abstract book of 8th International Congress on Interventional Ultrasound.
(29) Gilja O, Detmer P, Jong J, Leotta D, et al (1997):
Intragastric distribution and gastric emptying assessed by three-
dimensional ultrasonography.
Gastroenterology, 113:38-49.
(30) Hunerbein N, Dohmoto M, Haensch W, Schlag P (1996):
Evaluation and biopsy of recurrent rectal cancer using 3D
endosonography.
Dis Colon Rectum, 39:1373-8.

(31) Cesarani F, Isolato G, Capello S, Pianchi S (1999):

Tridimesional ultrasonography. First clinical experience with dedicated
devices and review of the literature.
Radiol Med (Torino), 97:256-64.