The majority of patients with PSC also have inflammatory bowel disease (ulcerative colitis > Crohn’s disease) though the two diseases run their independent courses. As the disease progresses, patients may suffer

from repeated bouts of cholangitis, complications of end-stage liver disease or the dreaded complication of cholangiocarcinoma. Disease progression is very variable and no treatment has been found to be of benefit. Dilatation of dominant strictures may hasten progression of the disease in some. “
“A 73-year-old woman with chronic hepatitis C and hepatocellular carcinoma RO4929097 in vitro (HCC) was hospitalized for radiofrequency ablation (RFA). Laboratory test results showed the following: platelet count, 62,000/mm3; prothrombin time, 12 seconds; albumin, 4.4 g/dL; bilirubin, 0.8 mg/dL; alpha-fetoprotein, 8.5 ng/mL; and des-gamma-carboxy prothrombin, 11 mAU/mL. Gadoxetic acid–enhanced magnetic resonance imaging demonstrated a low-intensity area in the hepatobiliary phase in segment VIII. Contrast-enhanced ultrasonography (CEUS) showed hyperenhancement in the vascular phase with hypoenhancement in the postvascular phase. Aspiration biopsy CB-839 cell line revealed well-differentiated

HCC. We performed CEUS-guided RFA with a 2-cm Cool-tip RFA system (Radionics, Burlington, MA) through an intercostal space. No abnormalities in the chest wall were found before RFA and the patient had no complaints, except for mild

pain during ablation. Increased thickness of the chest wall was found during RFA. Immediately after ablation, we performed CEUS with perflubutane and identified linear extravasation of microbubbles along the needle tract in the vascular phase (Fig. 1A). After 5 and 10 minutes, we reinjected perflubutane and could find no extravasations of microbubbles (Fig. 1B). Enhanced computed tomography (CT) demonstrated a hemorrhage in the chest wall (Fig. 1C) and a small amount of intraperitoneal MCE hemorrhage on the hepatic surface (Fig. 1D), but no active bleeding. We speculated that an intercostal vessel had been injured by the electrode, with spontaneous resolution of the hemorrhage. CEUS, contrast-enhanced ultrasonography; CT, computed tomography; HCC, hepatocellular carcinoma; RFA, radiofrequency ablation. US, ultrasonic. Hemorrhages resulting from RFA occur in 0.5% of cases.1 In our case, bleeding from an intercostal vessel into the chest wall was clearly detected on CEUS. CEUS is reported to show 100% sensitivity and 100% specificity for the detection of active bleeding.2 We could repeatedly and in real time confirm continued hemorrhaging, even in the pooling of contrast agent, using high-power flashes. Briefly, a high-power flash ultrasonic (US) beam (mechanical index: 1.27) destroys the majority of microbubbles in the US plane and, consequently, allows a resetting of transient perfusion.