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수의학석사학위논문
PercutaneousUltrasound-guided
CholecystographywithUltrasound
ContrastAgentinDogs
개에서 초음파 조영제를 이용한
초음파 유도하의 경피적 담낭조영술
2015년 2월
서울대학교 대학원
수의학과 임상수의학(수의방사선과학)전공
지서연
-
수의학석사학위논문
PercutaneousUltrasound-guided
CholecystographywithUltrasound
ContrastAgentinDogs
개에서 초음파 조영제를 이용한
초음파 유도하의 경피적 담낭조영술
2015년 2월
서울대학교 대학원
수의학과 임상수의학(수의방사선과학)전공
지서연
-
Percutaneousultrasound-guided
cholecystographywithUltrasound
ContrastAgentindogs
Director:ProfessorMincheolchoi
SeoyeounJi
MajorinClinicalVeterinaryMedicine(VeterinaryRadiology)
DepartmentofVeterinaryMedicine
TheGraduateSchool
SeoulNationalUniversity
Abstract
Differentiating hepatocellular disease versus biliary obstruction can be
-
challengingindogspresentedforicterus.Thepurposeofthisprospectivestudy
was to determine the feasibility ofpercutaneous contrastultrasound-guided
cholecystographyindogs.Tennormaldogsweighing7.6-13.0kg(median9.8
kg)wererecruited.Alldogswereconsiderednormalbasedoncompleteblood
count, serum chemistry profile, ultrasound examination, and percutaneous
radiographic cholecystography. Percutaneous contrast ultrasound-guided
cholecystographywasperformedusing0.5mlofcommerciallyavailablecontrast
agentandtwoconventionalultrasoundmachinesforsimultaneousscanningat
twodifferentlocations.Twoobserversindependentlyevaluatedthetimetoinitial
detection ofcontrastin the proximalduodenum and duration ofcontrast
enhancement via visual monitoring. Dynamic contrast enhancement was
calculatedusingtime-intensitycurves.Mean(±SD)andmedian(range)oftime
toinitialdetectionwere8.60sec(±3.35)and8.0sec(2.0-11.0),respectively,
andmeanandmediandurationwere50.45sec(±23.24)and53.0sec(20.0-
70.0),respectively.Mean,medianandrangeofpeakintensitywere114.1mean
pixelvalue(MPV)(SD ±30.7),109.2MPV and79.7-166.7,respectively,and
mean,median,andrangeoftimetopeakintensitywere26.1sec(SD±7.1sec),
24.0secand19.0-41.0sec,respectively. Findingsindicatedthatpercutaneous
contrastultrasound-guidedcholecystographyisafeasibletechniquefordetecting
andquantifying patencyofthebileductinnormaldogs.Futurestudiesare
-
neededtoassessthediagnosticutilityofthistechniquefordogswithbiliary
obstruction.
Keywords: Percutaneous ultrasound-guided cholecystography, Ultrasound
contrastagent,SonoVue
Studentnumber:2011-21675
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CONTENTS
INTRODUCTION......................................................................................1
MATERIALSAND METHODS.........................................................2
1.Experimentalanimals.......................................................................2
2.Percutaneousradiographiccholecystography..................................3
3.Percutaneousultrasound-guidedcholecystography........................4
4.Imageassessment............................................................................7
5.Statisticalanalysis............................................................................8
RESULTS.....................................................................................................8
DISCUSSION............................................................................................15
REFERENCES..........................................................................................17
ABSTRACT IN KOREAN..................................................................21
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INTRODUCTION
Common causes oficterus in dogs include intravascular hemolysis,
hepatocellulardiseaseandbiliaryobstruction.Hemolysiscanbediagnosedby
evaluating completeblood counts foranemia and urinalysis forhemoglobin.
However,differentiatinghepatocellulardiseasefrom biliaryobstructionisusually
more difficult(1,2).Conventionalultrasonography has proven beneficialin
evaluatingbiliarydisease(3-5).However,thismodalityhasdiagnosticlimitsfor
biliaryobstructionbecauseductaldilationalonemaynotbeareliableindicator
ofexistingbiliaryobstruction(6-9),andobstructivediseasemayoccurwithout
ductaldilatation (10-12).Both radiographic cholecystography and endoscopic
retrogradecholangiography arefeasiblemethodsforopacifying bileductsand
evaluating biliary patency (13-15).However,radiographic cholecystography
requiresfluoroscopy forrealtimemonitoring and requiresradiation exposure.
Endoscopicretrogradecholangiographyalsorequiresaskilledoperator,especially
fortheratherdifficultcanulationoftheduodenalpapillainsmall-sizeddogs
(16-17).
Ultrasoundcontrastagentsconsistofmicrobubblesthatcontainagas
stabilizedbyashell.Theuseofsuchagentshasimprovedthesensitivityof
ultrasoundduetohighacousticimpedanceattheinterfacebetweenthebubble
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andthesurroundingmedium.Inhumans,ultrasoundcontrastagentshavebeen
used for intravenous and intra-cavitary applications (18,19).Intra-biliary
contrast-enhanced ultrasound has been reported as highly effective in the
diagnosis ofobstructive biliary disease in humans (20,21).An important
limitationofcontrast-enhancedultrasonographyisthenecessityforspecialized
contrast-specificultrasoundtechniques,butsomeintra-biliaryprocedureshave
demonstrated that biliary leakage can be evaluated using conventional
ultrasonographywithalow-mechanicalindexmode(22,23).
The purpose of the current study was to determine whether
percutaneouscontrastultrasound-guidedcholecystographyisafeasibletechnique
fordetectingandquantifyingbiliarypatencyattheleveloftheduodenalpapilla
indogs.
MATERIALSAND METHODS
1.Experimentalanimals
AllproceduresinvolvingdogswereapprovedbytheGuidefortheCare
andUseofLaboratoryAnimalsofSeoulNationalUniversity,Korea.Tenadult
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beaglesweighing7.6to13.0kg(median:9.8kg)andranginginagefrom 3to
7years(median:5.1years)wererecruited.Normalstatusofeachdog was
assessed based on history,physicalexamination,complete blood cellcount,
serum chemistryprofileandultrasoundexamination.
2.Percutaneousradiographiccholecystography
To prove biliary tract patency, all dogs underwent percutaneous
radiographic cholecystography based on a modified version ofa previously
publishedstudyprotocol(14).Foodwaswithheldfor12-18hoursbeforethe
investigation.Aftersedationwithacepromazineandatropine,generalanesthesia
wasinducedwithpropofolandwasmaintainedwithisoflurane/oxygeninhalation.
Alldogsreceivedbroad-spectrum antibioticsandcefazolinsodium (20mg/kg
bodyweight(BW),intravenous)tominimizesepticcomplications.Thehairover
theabdomenwasclipped,andtheskinsurfacewascleanedwith70% isopropyl
alcohol.Thegallbladderwasscannedbyconventionalultrasonography(Sonoace
9900®,Medison,Korea) usingalineartransducer(5-12MHz)witheachdogin
leftlateralrecumbency.Underultrasoundguidance,a23G chibaneedlewas
passedthroughtheventralabdominalwallslightlytotherightofthemidlineat
thecaudalborderofthexiphoid,andthegallbladderwaspunctured.Following
styletremoval,theneedlewasconnectedbymeansofanextensiontubetoa
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three-way stopcock with an empty 10 mlsyringe and a second syringe
containing20mlofcontrastmedium mixedwitha1:1ratioof300mgI/ml
iohexol(Omnipaque300®,GEHealthcare,Co.Cork,Ireland)injectionandsterile
salinesolution.Fiveto10mlofthebilewasaspiratedalongthetube,and20
mlofthecontrastmedium wasinjectedslowlyunderfluoroscopy(DXG-525RF,
Dong-AX-rayco.Ltd.,Korea) monitoring.
3.Percutaneousultrasound-guidedcholecystography
Percutaneous ultrasound-guided cholecystography was performed on
average4.5days(4-5)afterradiographiccholecystographyforalldogs.This
procedurerequiredtwoultrasoundmachinesforsimultaneousscanningattwo
different locations. We additionally used a portable ultrasound machine
(Sonovet®,Medison,Korea).Tobereadyforuse,5mLof0.9% sodium chloride
solution was injected into a bottle ofultrasound contrastagent(SonoVue,
Bracco Imaging,Milan,Italy) for dispersion.Patient preparation,including
generalanesthesiaandtheapproachforthepercutaneouspunctureofthegall
bladder,werethesameasforthepercutaneousradiographiccholecystography.
Initially,thebilewasremovedfrom thegallbladderasfollows:a23G chiba
needlepuncturedthegallbladderundertheguidanceofaportableultrasound
withacurvedarraytransducer(4-9MHz).Followingstyletremoval,theneedle
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wasconnectedbymeansofanextensiontubetoathree-waystopcockwithan
empty10mlsyringeandasecond10mlsyringecontaining10mlof0.9%
sodium chloridesolution.Tenmlofthebilewasaspiratedalongthetube,and
10mlof0.9% sodium chloridesolutionwasinjected(FIG.1A).Thisprocedure
wasrepeatedthreetimestocompletelywashthebileoutofthegallbladder.
Then,0.5mlofthecontrastagentwasmixedwith10mL of0.9% sodium
chloridesolutionina10mLinjectionsyringe.Beforeinjectionofthecontrast
agentintothegallbladder,ascanoftheproximalduodenum wasperformed
using conventional ultrasound with a 5-12 MHz linear transducer.The
transducerwasplacedattherightlateralninthtotwelfthintercostalspaces
neartheventralmidline.Theproximalduodenum wasscannedinalongitudinal
section,andthetransducerwasnotsubsequentlymoved.TheMI(Mechanical
Index)valuewasswitchedtolessthan0.2.Thegainsettingwasregulatedto
obtainananechoicbowellumenorthecentralhyperechoiclinearisingfrom the
bowellumen.Thecontrastagentdispersion wasslowly injected through an
extensiontubeforapproximately30secunderultrasoundguidance(FIG.1B).
Simultaneously,ascanoftheproximalduodenum wasperformedfor90sec.All
theimageswererecordedandsavedtotheharddisk forlaterreview and
documentation.Inalldogs,completebloodcellcounts,serum chemistryprofiles
and abdominal ultrasound examinations were performed 7 days after
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percutaneous ultrasound-guided cholecystography to assess possible
complicationsofthestudy.
FIG.1.Biledrainagefrom gallbladderandinjectionofultrasoundcontrast
agentintothegallbladderinadog.(A)Identificationofthegallbladderand
insertion ofneedleareperformedunderultrasoundguidancetodrainagebile
from thegallbladder.(B)Theprobewaspositionedontheintercostralspace
and the proximalduodenum underwent carefulgrey-scale imaging.After
identification oftheproximalduodenum,Theultrasound contrastagentwas
slowlyinjectedthroughaextensiontube.
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4.Imageassessment
Imagemediasoftware(Gomplayer2.2,gretechco.,Korea)wasusedto
view theimagesandtoexportselectedframesforanalysis.Twoexperienced
veterinaryradiologists(S.J.andB.K.)inourdepartmentsubjectivelyevaluated
contrastenhancementin the proximalduodenallumen.The two observers
independently measured the time to initialdetection following injection and
durationbyviewingtheimages.Thetimetoinitialdetectionfollowinginjection
wasdefinedasthetimewhencontrastenhancementintheproximalduodenum
wasfirstdetected.Thedurationwasdefinedastheperiodoftimeinwhich
contrastenhancementwas observed in the proximalduodenum.The visual
patternofcontrastenhancementwasalsodescribed.Forquantitativeanalysis,
individualultrasound images were acquired by a video frame grabberand
capturedatarateofoneframepersecfor90sec.Consecutivemeanpixel
value(MPV)measurementswereobtained using imagesoftware(NIH 1,43,
NationalInstitutesofHealth,USA)byasingleobserver(S.J.).A regionof
interest(ROI)wasdrawninthemoststronglyechogenicareaoftheduodenal
papillaafterinjectionofthecontrastagent.Standardizedtime-intensitycurves
depictingthesignalintensityplottedagainsttimewerecreatedbasedonselected
ROI,andpeakintensityandtimetopeakintensityafterinjectionwererecorded.
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5.Statisticalanalysis
Statisticalanalysiswasperformedwithastandardcomputersoftware
program (SPSS 21.0.0.2,SPSS Inc.,Chicago,USA)by theobserver(S.J.).
Intra-observerrepeatabilitywasevaluatedbymeansofanintraclasscorrelation
coefficient(ICC).
RESULTS
Duringpercutaneousradiographiccholecystography,thecontrastmedium
wasobservedtoemptyintotheduodenum inthirtyminutesinalldogs(FIG2).
Beforetheinjection ofthecontrastagentinto thegallbladder,the
sonographic appearance ofthe proximalduodenum wasnormalin alldogs.
There were centralhyperechoic lines arising from the bowellumen and
intermittentsmallamountsofechogenic materialswithin the lumen due to
mucusorfoodremnants.
Duringtheinjectionofthecontrastagent,theechogenicsignalinthe
gallbladderwasimmediatelyvisible(FIG.3).Echogenicfluidbegantogradually
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andnon-homogeneouslydispersewithinthelumenoftheproximalduodenum.
Then,echogenicfluid with athin and strong stream wasidentified overa
periodofsecondsatthelevelofthepresumedduodenalpapilla(FIG.4)and
wasfollowed by a progressively decreasing enhancement.Thispattern was
repeatableandirregular.
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FIG.2.Radiographicimagesofthepercutaneousradiographiccholecystography.
During percutaneousradiographiccholecystography,thecontrastmedium was
observedtoemptyintotheduodenum intendogs.
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FIG.3.Ultrasoundimagesofthegallbladderandcomparisonsoftheechogenic
signalbefore(A)andafter(B)percutaneousinjection ofultrasoundcontrast
agent.Afterinjectionofthecontrastagent,anechogenicsignalwasimmediately
visible.
FIG. 4.Longitudinalultrasound images of the proximalduodenum after
percutaneousinjectionofultrasoundcontrastagent.Markedechogenicfluidwith
athinandstrongstream (arrows)wasidentifiedatthelevelofthepresumed
duodenalpapilla.
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Parameters Mean±SD ICC
TTI(s)
Observer1 8.60(±3.06)0.981
Observer2 8.60(±3.78)
8.60(±3.35)
Duration(s)
Observer1 54.10(±20.53)0.876
Observer2 46.80(±26.26)
50.45(±23.24)
The mean (±SD)and median (range)time to the initialdetection
followinginjectionwere8.60sec(±3.35)and8.0sec(2.0-11.0),respectively,
andthemeanandmediandurationwere50.45sec(±23.24)and53.0sec(20.0-
70.0), respectively. Intra-observer repeatability was excellent for both
measurements(intraclasscorrelationcoefficientfortimetoinitialdetection:0.981,
intraclasscorrelationcoefficientforduration:0.876)(Table1).
Table 1.Intraobserver Correlations for VisualMeasurements of Contrast
Enhancement of the Proximal Duodenal Lumen Following Percutaneous
Ultrasound-GuidedCholecystographyinTenHealthyDogs
TTI,timetoinitialdetectionafterinjection;ICC,intraclasscorrelationcoefficient
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A regionofinterestwasdrawnintheregionofafocal,thin,highly
echogenicareaofthepresumedduodenalpapilla.Theareawas30mm2and
wasmaintainedin thesameposition.Time-intensity curvesoftheareaare
depicted in FIG.3.Therewereinconsistentincreasesand decreasesin the
intensity,andpatternsofirregularintensity fluctuation wereobservedin all
dogs.
FIG.3.Time-intensitycurvesofaregionofinterest(ROI)forthreedogs.The
ROIwasdrawninthemoststronglyechogenicareaofthepresumedduodenal
papillaafterinjectionof ultrasoundcontrastagent.Thecurvesshowedirregular
fluctuationsanddifferentpatternsforeachdog.
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Parameters Mean±SD Range
PI(MPV) 114.1±30.7 79.7– 166.7
TTP 26.1±7.1 19.0– 41.0
Themean,medianandrangeofpeakintensitywere114.1MPV (SD ±
30.7),109.2MPVand79.7-166.7,respectively,andthemean,medianandrange
oftimetopeakintensitywere26.1sec(SD±7.1sec),24.0secand19.0-41.0
sec,respectively(Table2).
Complete blood cellcounts,serum chemistry profiles and abdominal
ultrasound examinations performed 7 days after the percutaneous
ultrasound-guidedcholecystographyrevealednosignificantabnormalitiesinany
dog.
Table2.QuantitativeContrastEnhancementoftheDuodenalPapillainTen
HealthyDogsFollowingPercutaneousUltrasoundGuidedCholecystography
PI,peakintensity;TTP,timetopeakfrom injection;MPV,meanpixelvalue
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DISCUSSION
Inthisstudy,wewereabletoobservenotonlycontrastenhancementin
theduodenallumenbutalsothelocationofthepresumedduodenalpapillainall
dogs.Thesuccessinidentifyingechogenicflow withintheproximalduodenum
indicatesthatthetechniquecanbeusedfortheevaluationofbiliarypatency.
Unlikethehumanstudies,wechosetoevaluatecontrastenhancementinthe
proximalduodenum insteadofthebileductsbecauseultrasoundscansofbile
ducts in healthy dogs are limited by underlying gastricand duodenalgas,
respiratorymotionandthesmallsizeofthebiliarystructures.Weusedtwo
ultrasoundmachinesbecauseultrasound-guidedinjectionofthecontrastagent
intothegallbladderandultrasoundexaminationoftheproximalduodenum were
performedsimultaneously.Despiteartifactsduetomucus,foodremnantsandthe
echogeniccentrallinefrom theduodenum,highlyechogenicfluidwasclearly
identifiedwithin theduodenum inalldogsafterthecontrastagentinfusion.
Additionally,thelocationofthepresumedduodenalpapillawasidentifiedasthe
contrastagentpassedthroughtheduodenalpapillawithafocal,thin,andstrong
echogenic stream.The time-intensity curve ofthe duodenalpapilla showed
inconsistentfluctuations.Theintensity fluctuationsmostlikely resulted from
contractionandrelaxationofthesphincterofOddiinthegallbladdertocontrol
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the excessive pressure induced by the injection ofcontrastagent.Authors
proposethattheinconsistencypatternineachdogmayhavebeenassociated
with pressure-related factors,such as variable volume ofthe gallbladder,
gallbladderdistensibility,intrahepaticreflux,resistanceofthesphincterofOddi
andvariabledistributionofcontrastagentinthefluid.
Onelimitationofthestudyreportedherewasthechoicetouseasingle
doseof0.5mlofcontrastagent.Thischoicewasmadebecause0.1-1mL of
contrastagentdilutedin0.9% salinehasbeenrecommendedforextravascular
contrast-enhancedultrasonographyinhumans(24).Theoptimalcontrastagent
doseand concentration wasnottested in thecurrentstudy and should be
optimizedinfuturestudies.Anotherlimitationwasthatonlynormaldogswere
evaluated.Itremainsunknownwhetherthetechniquewouldbefeasibleandsafe
indogswithbiliaryobstructivediseases.
In conclusion, findings from the current study indicated that
percutaneousultrasound-guidedcholecystography using anultrasoundcontrast
agentisfeasibleandsafeforevaluationofbiliarypatencyandlocalizationofthe
duodenalpapillainnormaldogs.Futurestudiesareneededtodeterminethe
utilityofthistechniquefordiagnosingobstructivebiliarydiseaseindogs.
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국문초록
개에서 초음파 조영제를 이용한
초음파 유도하의 경피적 담낭조영술
서울대학교 대학원
수의학과 임상수의학 (수의방사선과학)전공
지서연
황달이 있는 개에서 간세포성 질환과 담도폐색을 구분하여 진단하는 것은
어려운 문제이다.본 연구의 목적은 담도폐색을 평가하기 위하여 지금까지 소동물
에서 적용해본 적이 없는 초음파 조영제를 이용한 초음파 유도하의 경피적 담낭조
영술을 실시하고 그 유용성을 확인하고자 하는 것이다.
본 연구에는 체중이 7.6-13.0kg(중간값 9.8kg)이며 건강에 문제가 없
는 열 마리의 개가 사용되었다.모든 개들은 연구에 앞서 건강상태를 확인하기 위
하여 전혈검사,혈청검사,흉복부 방사선 및 복부초음파 검사를 실시하였고 담도개
-
- 22 -
통상태를 평가하기 위하여 기존의 담도폐색 유무를 확인하기 위한 일반적인 진단방
법인 방사선 조영제를 이용한 경피적 담낭조영술을 실시하였다.건강 및 담도개통
상태에 이상이 없음을 확인한 개들에 대해 0.5ml의 초음파 조영제를 이용하여 초
음파 유도하의 경피적 담낭조영술을 실시하였다.초음파상에서 근위 십이지장에서
의 초음파 조영제에 의한 조영증강 과정을 기록하고 이를 두명의 관찰자가 각각 조
영제 주입후 조영증강이 발생하는 시간과 조영증강이 유지되는 기간을 측정하였다.
또한 근위 십이지장내 조영증강이 발생하는 관심영역에 대하여 시간-강도 곡선을
그렸다.
본 실험 결과,초음파 조영제 주입후 조영증강이 발생하는 시간의 평균,중
간값,범위는 각각 8.60sec(±3.35)과 8.0sec,2.0-11.0sec였고 조영증강이 유
지되는 기간의 평균,중간값,기간은 각각 50.45sec(±23.24),53.0sec,20.0-70.0
sec였으며 두 관찰자간의 유의적인 차이는 확인되지 않았다.또한 근위 십이지장
내 조영증강이 발생하는 관심영역의 최대 신호강도의 평균,중간값,범위는 각각
114.1MPV (SD±30.7),109.2MPV,79.7-166.7MPV 였고 최대 신호강도가 확
인되는 시간의 평균,중간값,범위는 각각 26.1sec(SD±7.1sec),24.0sec,19.0-
41.0sec였다.
본 실험을 통해 초음파 조영제를 이용한 초음파 유도하의 경피적 담낭조영
술이 정상개의 담도개통성을 보여줄 수 있음을 확인하였고 추후 폐쇄성 담도계 질
환에 대한 진단적 도구를 연구하는데 이용될 수 있을 것으로 사료된다.
INTRODUCTIONMATERIALS AND METHODS1.Experimental animals2.Percutaneous radiographic cholecystography3. Percutaneous ultrasound-guided cholecystography4. Image assessment5. Statistical analysis
RESULTSDISCUSSIONREFERENCESABSTRACT IN KOREAN
9INTRODUCTION 1MATERIALS AND METHODS 2 1.Experimental animals 2 2.Percutaneous radiographic cholecystography 3 3. Percutaneous ultrasound-guided cholecystography 4 4. Image assessment 7 5. Statistical analysis 8RESULTS 8DISCUSSION 15REFERENCES 17ABSTRACT IN KOREAN 21