LIVER
HEPATOMEGALY.
A. LARGE TENDER HEPATOMEGALY.
1.Congestive cardiac failure.
2.Amoebic Abscess./Hepatitis.
3.Infective Hepatitis.
4.Secondaries in Liver.
5.Infected Cyst.
B. NON TENDER HEPATOMEGALY.
1.Cirrhosis of Liver
2.Fatty Infilteration/Amyoloidosis.
3.Hepatoma
4.Lymphomas( Hodgekins.non Hodgekins lymphoma)
5.kalazar
6. Malaria
7. Hydatid cyst
8. Myelofibrosis.
C.Other causes are.
1.Tuberculosis
2.Typhoid
3 Lymphosarcoma.
4 Biliary cirrhosis
5Multiple myeloma
6.Lipoid Storage diseases( Gauchers disease)
7.Polycystic Disease.
8.Diabetes Mellitus
9.Toxic Hepatitis(Anaesthetic Drugs,Gold ,Dilantin)
10.Fungal Disease( Actinomycosis,Histoplasmosis)
11. Infectious mononucleosis.
BRIGHT LIVER.
Characteristic features are.
1.Strong echoes from liver parenchyma which is equal to peri portal structures
2.Liver appears flat,ground glass texture as normal peri vascular markings are
lost, all vessels appears as wall less cleft.
3.when compared with renals,renal parenchyma appears almost echo free
while liver is highly echogenic.
4.Echogenicity of liver parenchyma and ligamentum teres is same.
Causes are.
1.Micronodular cirrhosis of liver
2.Fatty infilterations..
3 .Chronic hepatitis.
4.Granulomas.
DARK LIVER
1.Liver parenchyma is of lower echogenicity than renal cortex
2. peri portal structures echoes are exaggerated.
3.Darkness of liver is due to more fluid present in parenchyma.
Causes are.
1Congestive cardiac failure.
2Acute infective hepatitis
3 Malignancy of liver
4 Lymph reticular tumour.
FATTY INFILTRATION OF LIVER
Causes are –
Diabetes Mellitus
Glycogen storage disease (Gauchers disease)
Obesity
Starvation & kwashiorkor
Alcoholic hepatitis
Others
Pregnancy
Corticosteroid
Hallothane / Tetracycline
Ulcerative Colitis
CIRRHOSIS OF LIVER
Sonological features of cirrhosis liver are very variable.
1. Liver may be enlarged with fatty change / may be normal in size /shrunken & scarred in late stages.
2. Highly echogenic(bright liver) seen in early cases where periportal structures are in apparent & appears like hepatic veins, while in others it may be normal.
3. Liver surface smooth but large regenerating nodule could be seen in post hepatitis cases.
4. Caudate lobe often enlarged which is a good index for cirrhosis of liver. Usually caudate lobe is half of the width of right lobe.
5. Ascites is seen which is transudate, no debris seen & bowel floats normally.
6. Portal vein more than 15 mm .
7. Splenic vein more than 10 mm in inspiration.
8. Portocaval anastomosis
· Oesophageal, splenic varices appears tortuous like bag of worms.
· Umbilical appears due to canalization of ligamentum teres.
AMOEBIC ABSCESS
Early cases are hyper echoic due to solid nature of abscess & it could be confused with meta static lesion of liver.
As liquefaction starts hypo echoic area appears due to collection of puss & necrotic debris. Occasionally mass is an echoic with floating debris inside cavity of abscess.
Initially abscess wall is irregular & shaggy but later it becomes smooth & outlined.
Post acoustic shadowing(PAS) often seen depending upon attenuation of puss.
Amoebic abscess cavity usually disappears in three months but occasionally it may last for one year or even more.
Usually amoebic abscess are single.
Site of the abscess is in right lobe superiorly close to diaphragm.
PYOGENIC ABSCESS
Pyogenic abscess are usually multiple.
Echo texture is similar to amoebic abscess varying from anechoic to highly echogenic.
Usually right lobe of liver due to streaming effect of portal vein.
Size vary from 1cm to any size.
Shape rounded are ovoid.
Walls irregular.
Posterior acoustic enhancement present.
HYDATID CYST
Commonly seen in right lobe of liver & is sub-capsular.
Well circumscribed, multilocular “cysts within cyst” i.e. daughter cysts within mother cyst.
Budding of germinal inner layer forming irregularities of cystic wall.
Hydatid sand(imperfectly formed daughter cyst) & calcification observed occasionally.
Many of daughter cysts are anechoic while some may have low level echoes due to debris.
If no daughter cysts seen then difficult to diagnose from simple cyst.
HEPATIC TUBERCULOSIS
1. Hepatic texture is non-homogeneous with scattered areas of increased & decreased reflectivity.
2. Some nodules could be located.
3. Caudate lobe may be enlarged.
4. Liver is enlarged.
HAEMANGIOMA
Cavernous type(where large sinusoidal blood vessels present)
Echo free focal lesions.
Irregular or lobulated wall.
No distal enhancement.
Occasionally complex lesion due to internal echoes are fluid- fluid level.
Capillary type(numerous small vessels present)
Echogenic(homogenous echo dense) masses.
Ill defined margin / sharply marginated.
Post acoustic shadowing present in masses more than 2.5 cm
Note- Haemangioma are to be confirmed by doppler study / angiography / biopsy(often catastrophic haemorrhage).
LIVER CELL ADENOMA
Solitary, marginated, encapsulated mass.
Common in woman taking oral contraceptives.
May present as palpable mass or pain in right hypochondrium.
If bleeding occurred it appears anechoic / hypo echoic or of greater density than surrounding liver parenchyma.
HEPATOCELLULAR CARCINOMA (HCC)
Found in preexisting post necrotic or macro nodular cirrhosis who are hepatitis B positive and alpha fetoprotein is raised.
Sonological features are.
Multiple nodules through out the liver
Diffuse infiltration.
solitary massive tumour
Discrete echogenic/discrete echo free /isoechoic / mixed echo texture / hypo echoic
Hepatomegaly.
Tip.
Any macro nodular cirrhotic patient who suddenly shows progressively enlargement of liver or suddenly deteriotes & there is haemorrhagic ascites,one should suspect hcc.
METASTATIC DISEASE OF LIVER
1 Multiple echogenic mass are due to breast carcinoma
2 Cystic masses are due to ovary/pancreas/stomach/colon/Leiomyosarcoma
squamous cell carcinoma
3 Hypo echoic mass( solitary) are due to Colorectal carcinoma
“HALO”
4 Heterogenous/ coarse structure are due to Renal lesion
5 Mixed echogenic masses are due to Urogenital./GIT lesion
7 Mass with target appearance are due to any where lesion(BULLS EYE)
7 Uniformly echogenic mass are due to Any where lesion
8 Calcified focal/multiple deposit due to GUT/Ovary lesion
9 Necrotic multiple deposit are due to Any tumour
10 Generalised Involvement
Fine Texture due to Miliary Metastasis
Echo poor due to Lymph reticular tumour
Moth eaten due to Any tumour
11 Multiple echo poor deposit due to Breast. Bronchus lesion
COMMON LIVER TUMOUR PATTERN
Primary site
1 Cystic deposit Mucin secreting tumour deposit colorectal tumour
4 Echo poor deposit any tumour
HODGEKINS LYMPHOMA
1 . Hypo echoic and Diffuse pattern of liver seen.
Sunday, June 22, 2008
LIVER AND OTHER DISEASES
HEPATOCELLULAR CARCINOMA (HCC)
Found in pre existing post necrotic or macro nodular cirrhosis who are hepatitis B positive and alpha fetoprotein is raised.
Sonological features are.
Multiple nodules through out the liver
Diffuse infiltration.
solitary massive tumour
Discrete echogenic/discrete echo free /isoechoic / mixed echo texture / hypo echoic
Hepatomegaly.
Tip.
Any macro nodular cirrhotic patient who suddenly shows progressively enlargement of liver or suddenly deteriotes & there is haemorrhagic ascites,one should suspect HCC.
COMMON LIVER TUMOUR PATTERN
Primary site
1 Cystic deposit Mucin secreting tumour
2 Echogenic deposit GUT/Urogenital tract
3 Calcified deposit colorectal tumour
4 Echo poor deposit any tumour
HODGEKINS LYMPHOMA
1 . Hypo echoic and Diffuse pattern of liver seen.
NON HODGEKINS LYMPHOMA 1. Hypoechoic and diffuse pattern of liver.
2. Target and echogenic pattern also may be seen.
LEUKAEMIA
1 Multiple discrete solid/anechoic masses without PAS seen in liver.
2 Bulls eye (Target lesion) also could be seen in liver parenchyma.
ACUTE PANCREATITIS
1. Focal tenderness with normal size & echo texture of Pancreas. OR
2. Enlargement may be diffuse( more than 3.5cm for head and tail) with Hypoechoic to anechoic texture or less than liver parenchyma.
3. Margin smooth / blurred with indistinct.
4. Splenic vein distinction usually lost.
5. Focal enlargement and focal loss of echotexture
CHRONIC PANCREATITIS.
1. Normal size or less.
2. Irregular Pancreatic out line.
3. Pancreatic duct dilated more than 3mm.
4. Patchy high level echoes (Fibrosis or Calcification).
5. Calculi could be seen as dense echoes with PAS giving impression of stippled appearance of gland.
PSEUDOCYST
1. Margin initially ill defined but later clear cut as it matures.
2. Mostly seen in lesser sac anterior to tail of Pancreas, but can be seen any where in abdomen.
3. Anechoic generally, sometimes it may have internal echoes/ fluid fluid level or irregular border if infected or haemorrhagic.
CARCINOMA OF PANCREAS.
1. Pancreas may or may not be enlarged.
2. Hypoechoic mass with irregular border.
3. Pancreatic duct dilated ( Either smooth or irregular dilatation).
4. CBD,IHBR dilated.
5. Nodal metastasis.
6. Hepatic metastasis.
7. Splenic vein enlarged.
8. Portal system may be involved.
9. Ascites.
10. Splenomegaly.
GALLBLADDER
1. GB is pear shaped usually 8 cm in length and 3.5cm in diameter.
2. Wall is less than 3 mm and lumen is anechoic.
3. GB is divided in fundus body and neck.
4. various folds and kink in GB are.
· Hartman pouch. It is portion of GB between junctional fold and neck.
· Phrygian cap .Fundus of GB is separated by a junctional fold from its body. It should not be confused with stone.
5. GB may be dilated in Diabetics, prostrated bed ridden patients, Pancreatitis, patients on i/v fluids and anticholinergic drugs.
COMMON BILE DUCT ( CBD)
1. Normally less than 4 mm in adult ,I mm in neonates.
2. CBD lumen with age ie. 1mm for every 10 yrs of age, but usually it should not exceed 6 mm and occasionally 8mm in older patients.
CHOLEDOCOLITHIASIS
1. Hyper echoic stones in CBD.
2. Posterior acoustic shadow (PAS) present.
TIPS.
Exclude air, mucous plug in CBD, calcification of head of Pancreas, postoperative cholecystectomy clips, air and residues in bowel.
ACUTE CHOLECYSTITIS.
a. Wall is thick more than 4mm.
b. Sonological Murphy’s sign present.( Tenderness when transducer is applied to site of GB)
c. Pericholecystic fluid.( Peri GB discrete Fluid).
d. Usually GB filled with stones,
e. PAS seen.
f. Wall echo sign ( WES) present.
g. Gas in GB also shows PAS but not as sharp as in stone filled post. Acoustic shadowing.
h. Rounded or oval GB with transverse diameter more than 5cms.
NOTE. Acalculous cholecystitis is extremely uncommon.
GALLBLADDER FILLED WITH STONES
1 Stones moves with posture of patient.
2. WES ( Wall echo sign ) present.
3 Posterior acoustic shadowing ( PAS ) present.
SLUDGE ( VISCID BILE )
1. Low level echoes seen in dependent portion of GB.
2. No PAS .
3. Moves with posture of patient but slowly in comparison to stone.
4. Indicator abnormal biliary dynamics.
5. Precursor of Cholecystitis ( Probably).
Causes.
1. Seen occasionally in normal individual.
2. Extra hepatic obstruction
3. Acute or chronic cholecystitis.
4. Starvation/fasting
5. Hyperalimentation.
6. Sepsis.
7. Liver disease.
TIP.
Exclude.
· Blunt injury abdomen.
· Rupture of hepatic artery aneurysm.
· Hematobilia.
CONTRACTED OR NON VISUALISATION OF GALLBLADDER
1. Patient not fasting.
2. GB full of stones casting many strong echoes.
3. Obstructed biliary tract proximal to cystic duct.
4. Technical error.
5. Floating stone containing gases.
6. Congenital absence of GB.
TIP.
· If many stones are filled in GB ,see for WES ,which is 2 parallel arcuate echogenic line separated by thin anechoic space with PAS.
· Confirm cholecystectomy in the past.
MIRIZZI SYNDROME
1. Recurrent jaundice / cholangitis .
2. Partial mechanical obstruction of common hepatic duct due to inflammatory reaction of impacted stones.
3. Presence of impacted stone in cystic duct or neck of GB.
4. Two parallel tubular structure seen in the position of comm0n bile duct (CBD).
TIP.
1 Exclude GB carcinoma, Hepatoma,tumour of duct, metastatic
adenopathy in porta hepatis and focal sclerosing cholangitis.
GALL BLADDER WALL THICKENING ( More than 3.5mm)
Causes.
1. Acute Cholecystitis.
2. Ascites.
3. Hypoproteinemia.
4. Pericholecystic abscess.
5. Alcoholic hepatitis..
6. Debilitated disease.
7. Acute Hepatitis ( Type E)
8. Recent Meal.
9. Congestive cardiac failure.
10. Gall Bladder tumour.
11. Portal hypertension varices
12. Systemic Venous hypertension.
13. Adenomyomatosis.
14. Multiple myeloma.
15. Renal diseases.
16. AIDS.
17. Anti miototic drugs.
ADENOMYOMATOSIS
Type.
· Diffuse .Whole GB is involved.
· Segmental .Proximal, middle or distal portion of GB is involved in circular fashion.
· Localised. E.g. Fundus of GB is involved.
Sonological Findings.
· Multiple “comet effects” due to reverberation artifacts from multiple stones formed in GB Wall.
· Diffuse or segmental thickening of GB Wall.
· Multiple septae within the GB.
· Multiple polyps in GB seen as anechoic/echogenic foci with or without PAS depending upon what is filled in polyps ,bile, sludge or stones.
· Hyperechoic mass arising from fundus of GB..
JAUNDICE
A . Hemolytic Jaundice.
Spleen enlarged,
B . Hepatocellular Jaundice.
· Alcoholic hepatitis.
· Cirrhosis of liver.
· Intrahepatic Cholestasis.
C . Obstructive jaundice.
· Carcinoma head of pancreas.
· Carcinoma Gallbladder.
· Periampullary carcinoma.
· Benign biliary structure.
· Cholangiocarcinoma.
· Hepatic tumors.
· Gall bladder Stones.
· CBD Stones.
LOW BLOCK.
1. IHBR Dilated.
2. GB dilated.
3. CBD dilated.
Causes.
· Periampullary Carcinoma.
1 CBD dilated.
2 pancreatic duct dilated.
3 No mass in Pancreas.
· Carcinoma Head of Pancreas.
A mass in Pancreas .
MID LEVEL BLOCK.
CBD block.
HIGH LEVEL BLOCK( At Porta Hepatis)
1. IHBR dilated.
2. GB not dilated (Collapsed)
3. CBD can not be traced up to head of Pancreas.
Causes.
Carcinoma Head of Pancreas.
TIP
A. IHBR dilated but no jaundice.
Think of 1. Unilateral biliary obstruction resulting one half of biliary system dilated other half being normal.(KLATSKIN TUMOUR) Here serum bilirubin will be Normal while Alkaline Phosphatase will be raised.
.
2.Sub total biliary obstruction by a Tumour.
3. Surgical relief.
B .IHBR NOT DILATED THOUGH THERE IS OBSTRUCTION.
Causes.
1. Inexperienced sonographer
2. Sclerosing cholangitis.
3. Intermittent obstruction.
4. Early Obstruction.
HOW TO APPROACH A CASE OF BILIARY OBSTRUCTION
BILIARY OBSTRUCTION
1. Intra and extra hepatic biliary radicle dilated.
2. GB distended / collapsed.
If above present search site of obstruction it will be.
High block i.e. at porta hepatic as in Carcinoma Gall Bladder.
OR
Low Block which may be Carcinoma of Pancreas or Periampullary carcinoma.
Mid block .it will be at level of CBD.
If high block confirm Rt and left hepatic duct communicating .
If low block confirm pancreas normal or not.
Causes of Biliary obstruction could be stone ,Tumour etc.
PORTAL HYPERTENSION
Causes of PH are.
A.EXTRAHEPATIC.
1. Portal vein thrombosis
2. Compression to portal vein from out side.eg,Tumour
3. Splenic vein thrombosis.
4. splanchnic AV fistula.
5. Congenital atresia or Portal vein stenosis.
B INTRAHEPATIC.
· PRESINUSOIDAL
1. Polycystic disease.
2. Hepatic metastasis
3. Schistosomiasis (Early cases)
4. Myeloproliferative disease.
5. Early cases of Biliary cirrhosis and Idiopathic Portal hypertension
· SINUSOIDAL/POST SINUSOIDAL.
1. Portal cirrhosis
2. Idiopathic Portal hypertension (ADVANCE STAGE)
3. Acute alcoholic hepatitis
4. Congenital hepatic fibrosis
5. Advanced stage of Schistosomiasis and biliary cirrhosis.
6. Buddchiari syndrome.
C. POST HEPATIC.
1 Tricuspid regurgitation
2 Inferior Vena caval obstruction.
3 Rt sided heart failure
4 Constrictive pericarditis
5 Buddchiari syndrome.
6 Increase splenic and portal vein flow.
PORTAL HYPERTENSION
Sonological features are.
1. Portal veins are dilated. more than 15mm.
2. Splenic/superior mesenteric vein are dilated. More than 10mm in inspiration.
3. Splenic vein + Superior mesenteric vein more than 18mm in expiration.
4. Left gastric vein dilated more than 3.3mm.
5. Umbilical vein dilated more than 4mm( Bulls Eye pattern).
6. Ascites present
7. Splenomegaly.
8. Evidence of cirrhosis in liver.
9. Evidence of Intra/Extra portal vein obstruction eg Thrombosis in extra hepatic portal vein,/sclerosis of portal and splenic vein in non cirrhotic patient.
Tip.
If any doubt doppler evaluation of portal,splenic,superior mesenteric and left gastric vein could be done.
ASCITES
It is of transudate or exudate type.
Transudate Type.
· Protein less than 2.5gms.%
· Cell count less than 5 cells/cumm(Lymphocyte)
· Serum ascites albumin gradient (SAAG) more than 1.1
Causes.
· Congestive cardiac failure.
· Cirrhosis of liver with portal hypertension.
· Nephrotic syndrome.
· Anaemia with hypoproteinemia.
· Buddchiari syndrome.
Exudate Type.
· Protein more than 2.5gm %
· Cell count more than 5 cells/cu mm (Polymorph).
· Serum ascites albumin gradient (SAAG) less than 1.1.
Causes.
· Malignancy
· Tuberculosis
· Pyogenic.
· Traumatic.
· Peritonitis.
· Pancreatitis.
· Vasculitis.
SPLENOMEGALY.
Massive splenomegaly.
· Chronic malaria.
· Chronic myeloid leukaemia.
· Tropical splenomegaly.
· Ka lazar.
· Portal hypertension.
· Myelofibrosis.
Other causes.
· Typhoid.
· SABE
· Abdominal Tuberculosis
· Septicaemia.
· Splenic vein Thrombosis.
· Hodgkin’s non Hodgkin’s lymphoma..
· Leukaemia.
· Rheumatoid arthritis.
.
· Lymph sarcoma
· Sickle cell anaemia.
· Hereditary spherocytosis.
· Hemolytic Anaemia.
· Tumour and cysts of spleen.
· Disseminated lupus erythromatus.
Found in pre existing post necrotic or macro nodular cirrhosis who are hepatitis B positive and alpha fetoprotein is raised.
Sonological features are.
Multiple nodules through out the liver
Diffuse infiltration.
solitary massive tumour
Discrete echogenic/discrete echo free /isoechoic / mixed echo texture / hypo echoic
Hepatomegaly.
Tip.
Any macro nodular cirrhotic patient who suddenly shows progressively enlargement of liver or suddenly deteriotes & there is haemorrhagic ascites,one should suspect HCC.
COMMON LIVER TUMOUR PATTERN
Primary site
1 Cystic deposit Mucin secreting tumour
2 Echogenic deposit GUT/Urogenital tract
3 Calcified deposit colorectal tumour
4 Echo poor deposit any tumour
HODGEKINS LYMPHOMA
1 . Hypo echoic and Diffuse pattern of liver seen.
NON HODGEKINS LYMPHOMA 1. Hypoechoic and diffuse pattern of liver.
2. Target and echogenic pattern also may be seen.
LEUKAEMIA
1 Multiple discrete solid/anechoic masses without PAS seen in liver.
2 Bulls eye (Target lesion) also could be seen in liver parenchyma.
ACUTE PANCREATITIS
1. Focal tenderness with normal size & echo texture of Pancreas. OR
2. Enlargement may be diffuse( more than 3.5cm for head and tail) with Hypoechoic to anechoic texture or less than liver parenchyma.
3. Margin smooth / blurred with indistinct.
4. Splenic vein distinction usually lost.
5. Focal enlargement and focal loss of echotexture
CHRONIC PANCREATITIS.
1. Normal size or less.
2. Irregular Pancreatic out line.
3. Pancreatic duct dilated more than 3mm.
4. Patchy high level echoes (Fibrosis or Calcification).
5. Calculi could be seen as dense echoes with PAS giving impression of stippled appearance of gland.
PSEUDOCYST
1. Margin initially ill defined but later clear cut as it matures.
2. Mostly seen in lesser sac anterior to tail of Pancreas, but can be seen any where in abdomen.
3. Anechoic generally, sometimes it may have internal echoes/ fluid fluid level or irregular border if infected or haemorrhagic.
CARCINOMA OF PANCREAS.
1. Pancreas may or may not be enlarged.
2. Hypoechoic mass with irregular border.
3. Pancreatic duct dilated ( Either smooth or irregular dilatation).
4. CBD,IHBR dilated.
5. Nodal metastasis.
6. Hepatic metastasis.
7. Splenic vein enlarged.
8. Portal system may be involved.
9. Ascites.
10. Splenomegaly.
GALLBLADDER
1. GB is pear shaped usually 8 cm in length and 3.5cm in diameter.
2. Wall is less than 3 mm and lumen is anechoic.
3. GB is divided in fundus body and neck.
4. various folds and kink in GB are.
· Hartman pouch. It is portion of GB between junctional fold and neck.
· Phrygian cap .Fundus of GB is separated by a junctional fold from its body. It should not be confused with stone.
5. GB may be dilated in Diabetics, prostrated bed ridden patients, Pancreatitis, patients on i/v fluids and anticholinergic drugs.
COMMON BILE DUCT ( CBD)
1. Normally less than 4 mm in adult ,I mm in neonates.
2. CBD lumen with age ie. 1mm for every 10 yrs of age, but usually it should not exceed 6 mm and occasionally 8mm in older patients.
CHOLEDOCOLITHIASIS
1. Hyper echoic stones in CBD.
2. Posterior acoustic shadow (PAS) present.
TIPS.
Exclude air, mucous plug in CBD, calcification of head of Pancreas, postoperative cholecystectomy clips, air and residues in bowel.
ACUTE CHOLECYSTITIS.
a. Wall is thick more than 4mm.
b. Sonological Murphy’s sign present.( Tenderness when transducer is applied to site of GB)
c. Pericholecystic fluid.( Peri GB discrete Fluid).
d. Usually GB filled with stones,
e. PAS seen.
f. Wall echo sign ( WES) present.
g. Gas in GB also shows PAS but not as sharp as in stone filled post. Acoustic shadowing.
h. Rounded or oval GB with transverse diameter more than 5cms.
NOTE. Acalculous cholecystitis is extremely uncommon.
GALLBLADDER FILLED WITH STONES
1 Stones moves with posture of patient.
2. WES ( Wall echo sign ) present.
3 Posterior acoustic shadowing ( PAS ) present.
SLUDGE ( VISCID BILE )
1. Low level echoes seen in dependent portion of GB.
2. No PAS .
3. Moves with posture of patient but slowly in comparison to stone.
4. Indicator abnormal biliary dynamics.
5. Precursor of Cholecystitis ( Probably).
Causes.
1. Seen occasionally in normal individual.
2. Extra hepatic obstruction
3. Acute or chronic cholecystitis.
4. Starvation/fasting
5. Hyperalimentation.
6. Sepsis.
7. Liver disease.
TIP.
Exclude.
· Blunt injury abdomen.
· Rupture of hepatic artery aneurysm.
· Hematobilia.
CONTRACTED OR NON VISUALISATION OF GALLBLADDER
1. Patient not fasting.
2. GB full of stones casting many strong echoes.
3. Obstructed biliary tract proximal to cystic duct.
4. Technical error.
5. Floating stone containing gases.
6. Congenital absence of GB.
TIP.
· If many stones are filled in GB ,see for WES ,which is 2 parallel arcuate echogenic line separated by thin anechoic space with PAS.
· Confirm cholecystectomy in the past.
MIRIZZI SYNDROME
1. Recurrent jaundice / cholangitis .
2. Partial mechanical obstruction of common hepatic duct due to inflammatory reaction of impacted stones.
3. Presence of impacted stone in cystic duct or neck of GB.
4. Two parallel tubular structure seen in the position of comm0n bile duct (CBD).
TIP.
1 Exclude GB carcinoma, Hepatoma,tumour of duct, metastatic
adenopathy in porta hepatis and focal sclerosing cholangitis.
GALL BLADDER WALL THICKENING ( More than 3.5mm)
Causes.
1. Acute Cholecystitis.
2. Ascites.
3. Hypoproteinemia.
4. Pericholecystic abscess.
5. Alcoholic hepatitis..
6. Debilitated disease.
7. Acute Hepatitis ( Type E)
8. Recent Meal.
9. Congestive cardiac failure.
10. Gall Bladder tumour.
11. Portal hypertension varices
12. Systemic Venous hypertension.
13. Adenomyomatosis.
14. Multiple myeloma.
15. Renal diseases.
16. AIDS.
17. Anti miototic drugs.
ADENOMYOMATOSIS
Type.
· Diffuse .Whole GB is involved.
· Segmental .Proximal, middle or distal portion of GB is involved in circular fashion.
· Localised. E.g. Fundus of GB is involved.
Sonological Findings.
· Multiple “comet effects” due to reverberation artifacts from multiple stones formed in GB Wall.
· Diffuse or segmental thickening of GB Wall.
· Multiple septae within the GB.
· Multiple polyps in GB seen as anechoic/echogenic foci with or without PAS depending upon what is filled in polyps ,bile, sludge or stones.
· Hyperechoic mass arising from fundus of GB..
JAUNDICE
A . Hemolytic Jaundice.
Spleen enlarged,
B . Hepatocellular Jaundice.
· Alcoholic hepatitis.
· Cirrhosis of liver.
· Intrahepatic Cholestasis.
C . Obstructive jaundice.
· Carcinoma head of pancreas.
· Carcinoma Gallbladder.
· Periampullary carcinoma.
· Benign biliary structure.
· Cholangiocarcinoma.
· Hepatic tumors.
· Gall bladder Stones.
· CBD Stones.
LOW BLOCK.
1. IHBR Dilated.
2. GB dilated.
3. CBD dilated.
Causes.
· Periampullary Carcinoma.
1 CBD dilated.
2 pancreatic duct dilated.
3 No mass in Pancreas.
· Carcinoma Head of Pancreas.
A mass in Pancreas .
MID LEVEL BLOCK.
CBD block.
HIGH LEVEL BLOCK( At Porta Hepatis)
1. IHBR dilated.
2. GB not dilated (Collapsed)
3. CBD can not be traced up to head of Pancreas.
Causes.
Carcinoma Head of Pancreas.
TIP
A. IHBR dilated but no jaundice.
Think of 1. Unilateral biliary obstruction resulting one half of biliary system dilated other half being normal.(KLATSKIN TUMOUR) Here serum bilirubin will be Normal while Alkaline Phosphatase will be raised.
.
2.Sub total biliary obstruction by a Tumour.
3. Surgical relief.
B .IHBR NOT DILATED THOUGH THERE IS OBSTRUCTION.
Causes.
1. Inexperienced sonographer
2. Sclerosing cholangitis.
3. Intermittent obstruction.
4. Early Obstruction.
HOW TO APPROACH A CASE OF BILIARY OBSTRUCTION
BILIARY OBSTRUCTION
1. Intra and extra hepatic biliary radicle dilated.
2. GB distended / collapsed.
If above present search site of obstruction it will be.
High block i.e. at porta hepatic as in Carcinoma Gall Bladder.
OR
Low Block which may be Carcinoma of Pancreas or Periampullary carcinoma.
Mid block .it will be at level of CBD.
If high block confirm Rt and left hepatic duct communicating .
If low block confirm pancreas normal or not.
Causes of Biliary obstruction could be stone ,Tumour etc.
PORTAL HYPERTENSION
Causes of PH are.
A.EXTRAHEPATIC.
1. Portal vein thrombosis
2. Compression to portal vein from out side.eg,Tumour
3. Splenic vein thrombosis.
4. splanchnic AV fistula.
5. Congenital atresia or Portal vein stenosis.
B INTRAHEPATIC.
· PRESINUSOIDAL
1. Polycystic disease.
2. Hepatic metastasis
3. Schistosomiasis (Early cases)
4. Myeloproliferative disease.
5. Early cases of Biliary cirrhosis and Idiopathic Portal hypertension
· SINUSOIDAL/POST SINUSOIDAL.
1. Portal cirrhosis
2. Idiopathic Portal hypertension (ADVANCE STAGE)
3. Acute alcoholic hepatitis
4. Congenital hepatic fibrosis
5. Advanced stage of Schistosomiasis and biliary cirrhosis.
6. Buddchiari syndrome.
C. POST HEPATIC.
1 Tricuspid regurgitation
2 Inferior Vena caval obstruction.
3 Rt sided heart failure
4 Constrictive pericarditis
5 Buddchiari syndrome.
6 Increase splenic and portal vein flow.
PORTAL HYPERTENSION
Sonological features are.
1. Portal veins are dilated. more than 15mm.
2. Splenic/superior mesenteric vein are dilated. More than 10mm in inspiration.
3. Splenic vein + Superior mesenteric vein more than 18mm in expiration.
4. Left gastric vein dilated more than 3.3mm.
5. Umbilical vein dilated more than 4mm( Bulls Eye pattern).
6. Ascites present
7. Splenomegaly.
8. Evidence of cirrhosis in liver.
9. Evidence of Intra/Extra portal vein obstruction eg Thrombosis in extra hepatic portal vein,/sclerosis of portal and splenic vein in non cirrhotic patient.
Tip.
If any doubt doppler evaluation of portal,splenic,superior mesenteric and left gastric vein could be done.
ASCITES
It is of transudate or exudate type.
Transudate Type.
· Protein less than 2.5gms.%
· Cell count less than 5 cells/cumm(Lymphocyte)
· Serum ascites albumin gradient (SAAG) more than 1.1
Causes.
· Congestive cardiac failure.
· Cirrhosis of liver with portal hypertension.
· Nephrotic syndrome.
· Anaemia with hypoproteinemia.
· Buddchiari syndrome.
Exudate Type.
· Protein more than 2.5gm %
· Cell count more than 5 cells/cu mm (Polymorph).
· Serum ascites albumin gradient (SAAG) less than 1.1.
Causes.
· Malignancy
· Tuberculosis
· Pyogenic.
· Traumatic.
· Peritonitis.
· Pancreatitis.
· Vasculitis.
SPLENOMEGALY.
Massive splenomegaly.
· Chronic malaria.
· Chronic myeloid leukaemia.
· Tropical splenomegaly.
· Ka lazar.
· Portal hypertension.
· Myelofibrosis.
Other causes.
· Typhoid.
· SABE
· Abdominal Tuberculosis
· Septicaemia.
· Splenic vein Thrombosis.
· Hodgkin’s non Hodgkin’s lymphoma..
· Leukaemia.
· Rheumatoid arthritis.
.
· Lymph sarcoma
· Sickle cell anaemia.
· Hereditary spherocytosis.
· Hemolytic Anaemia.
· Tumour and cysts of spleen.
· Disseminated lupus erythromatus.
RENAL,BLADDER,APPENDIX,PROSTRATE,OTHER DISEASES
ACUTE MEDICAL RENAL DISEASE
A
1. Grade 1. Echogenicity is equal to Liver.
2. Grade 2. Echogenicity is greater than liver.
3. Grade 3. Echogenicity is equal to renal sinus echoes.
( Grade 0. Normally echogenicity of renal parenchyma is less than liver.)
B. Cortico medullary differentiation is lost.
1. C . Size of kidney is normal or large as in ACUTE TUBULAR NECROSIS OR ACUTE GLOMERILONEPHRITIS.
D Thickness of cortx is increased ( normal 2.5cm)
CHRONIC MEDICAL RENAL DISEASE
1. Size of kidney is small 5 to 8 cm ( Chronic granular contracted kidney.)
2. Renal sinus echoes is visible.
3. Renal parenchyma is shrunken with increased echogenicity.
4. If one kidney is small. And diseased suspect unilateral Pyelonephritis.
RENAL STONE
1. Highly echogenic.
2. If size more than 5-6 mm PAS is seen.
3. Calyces may be dilated.
4. Stones may be seen pyramid, calyces or pelvis of kidney..
5. Stag horn stone may be seen in pelvis with PAS.
6. If stone is seen in ureter ,upper part of ureter above the stone is dilated.
7. Only upper 1/3 and lower 1/3 of ureter could be seen as middle 1/3 part is invisible due to bowel gases.
CYSTIC STONE
1. Bladder is anechoic.
2. Stone is highly echogenic with PAS.
3. Search stone in lower 1/3 part of ureter and at ureteric orifice also.
CYSTITIS
1. Bladder is anechoic with debris/flakes floating in lumen.
2. Wall of Bladder irregular with local or generalised thickness.
ACUTE PYELONEPHRITIS
1. Kidney enlarged.
2. Hypoechoic renal parenchyma.
ACUTE FOCAL BACTERIAL NEPHRITIS
Mass is equal to or less echogenic than adjacent parenchyma.
If liquefaction started it appears anechoic or Hypoechoic with varying internal echoes.
ACUTE RENAL VEIN THROMBOSIS.
Renal size initially large but later it may decrease.
Echogenicity of cortex is decreased in beginning but later after few days to weeks
It is increased.
.Anechoic parenchyma could be seen depending upon haemorrhage or haemorrhagic infarction.
Coticomedullary differentiation is preserved in beginning but later lost.
Central sinus echoes increased.
PERI NEPHRIC ABSCESS
Peri renal fluid collection gives rise to Hypoechoic / anechoic echotexture.
Aspiration should be done to exclude urinoma /peri renal haematoma etc
HYDRONEPHROSIS
1. Calyces, infundibulum and renal pelvis dilated and renal sinus is separated with anechoic fluid.
2. Calyces and infundibulum could be traced to pelvis.
3. Renal parenchyma is thinned out ( less than 2.5cm)
4. Confirm that bladder is empty before labeling hydronephrosis.
5. In presence of calculi or dehydrated patient hydronephrosis could misse4d.
HYPERNEPHROMA.
Mass is hyper echoic/ isoechoic
Wall irregular
search for hepatic metastasis.
Para aortic group of lymph nodes enlarged.
LYMPHOMA
1. Echopenic mass.
2. renal size increased with hypoechotexture of renal parenchyma.
3. Sinus echoes lost.
4. Splenomegaly present
5. Para aortic gr of lymph nodes enlarged.
ANGIOMYOLIPOMA
Highly echogenic lesion.
Smooth border of mass.
Size may vary from 1 cm to 20 cm.
In tuberous sclerosis Angiomyolipoma is bilateral and multiple.
ADENOMA
1. Size of mass less than 1 cm.
2. Solid and highly echogenic.
3. Usually situated in renal cortex.
SIMPLE CYST
Wall of cyst smooth and sharply defined.
Anechoic , occasionally one two septa seen..
PAS present.
If cyst get infected , complex internal echoes with poorly defined thick wall.
POLYCYSTIC KIDNEY
1. Both renal are involved.
2. Renal size increased ( 15-18 cm)
3. Multiple ,with lobulated irregular margin seen all over kidney .
4. Cysts can also be located in liver, pancreas and spleen.
5. Size of cyst may vary.
6. Echotexture of parenchyma increases.
MULTIPLE CYSTS IN KIDNEY
1. Cyst are fewer in number and of equal size.
2. Smooth walled.
3. Unilateral.
4. Liver, Pancreas and spleen spared.
WILMS TUMOUR
Large , homogeneously echogenic mass ,occasionally Hypoechoic depending upon necrosis and haemorrhage.
Unilateral ( in 10 % may be Bilateral)
Found in children less than 5 yrs of age.
Highly malignant.
Search for metastasis.
TUMOUR OF URINARY BLADDER
Bladder anechoic.
Echogenic masses are seen in bladder wall.
Echogenic line of bladder wall absent if tumour has invaded the wall.
If tumour is big it may protrude in pelvis.
RENAL GRAFT REJECTION
Acute Rejection.
Renal volume increased with enlargement of pyramids.
Focal anechoic appearance of renal parenchyma.
Corticomedullary differentiation indistinct.
Increased or decreased echotexture of renal cortex.
Sub mucosal edema of collecting system.
Decreased echogenicity of renal sinus.
Confluent Hypoechoic areas seen in medulla.
Chronic Rejection.
1. Initially renal size increases but later at end stage size is much reduced.
2. Corticomedullary differentiation lost.
3. kidney is echogenic but its contour is irregular.
4. Central sinus and renal parenchymal differentiation lost.
PROSTRATE ENLARGEMENT
Benign prostratic hypertrophy.( BPH)
1. Capsular margin clear & well defined.
2. If glandular proliferation is more then gland is Hypoechoic.
3. If stromal proliferation is more ,gland is echogenic due to collagens.
4. Prostrate is spherical instead of semilunar when lateral lobe is enlarged..
5. Anteromedian diameter is increased in case of median lobe enlargement of gland.
6. Weight of gland is more than 20gms.
7. Capacity of urinary bladder ( Pre voidal) and residual urine (Post Voidal) to be calculated.
CARCINOMA OF PROSTRATE
1. Focal mass has Hypoechoic/Hyper echoic texture with irregular margin.
2. Capsular wall irregular and deformed.
3. Contour of gland is asymmetrical with elongation of antero-post diameter.
4. Prostrate is enlarged.
ADRENAL GLAND
PHAEOCHROMOCYTOMA
Solid homo / heterogenous echoes.
If necrosis , mass will be Hypoechoic
If haemorrhagic ,texture will be hyper echoic.
Patient is hypertensive.
ADENOMA OF ADRENAL GLAND.
1. Size vary 1- 5cm.
2. Poorly capsulated.
3. Hyper echoic / Hypoechoic
4. Homogenous ,smooth rounded mass.
CARCINOMA OF ADRENAL GLAND
Size of mass is large ,even up to 20 cm.
Heterogenous echotexture with irregular out line.
Invasion of IVC ,adrenal vein & lymph nodes may be present.
Metastasis to liver, Para aortic gland and lungs.etc.
GASTROINTESTINAL SYSTEM
ACUTE APPENDICITIS ( graded compression technique).
1. Due to inflammation, wall appears Hypoechoic/anechoic depending upon
Edema.
2. On transverse section it appears like Bull”s eye with total diameter 7 mm to 10mm ( Normal wall is 6 mm).
3. No peristaltic movement seen.
4. Appendix is non Compressible.
5. Tender on palpating with probe.
PERFORATED APPENDIX
1. Wall asymmetrically thick.
2. Wall hyper echoic , finger like projection.
Surrounded by hypo echoic pus.
3. Mesenteric lymph nodes enlarged.
CROHN” S DISEASE
· Intestinal wall 9mm to 16mm thick.
· Intestinal lumen narrow.
· Peristaltic movement reduced in affected part
While unaffected part shows hyper peristaltic movement.
MESENTERIC ADENITIS
· Lymph nodes vary from 3 to 20.
· Lymph nodes enlarged more than 4 mm , mostly 11 mm to 13 mm.
· Lymph nodes are spherical , Hypoechoic in periphery and hyper echoic in centre.
IN TUSSUSCEPTION
Transverse section of affected bowel shows a thick Hypoechoic ring
surrounded by a second thick Hypoechoic ring .
BLUNT INJURY ABDOMEN
· Fluid may be present at sub phrenic ,Para colic gutter , pelvis, subhepatic space, pleural space and Morrison’s pouch.
· Free fluid is anechoic while blood clot is hyper echoic.
· Patient will be hypotensive & in shock.
ABDOMINAL AORTIC ANEURISM (A A A )
1. Abdominal aorta gradually tapers but AAA distorts this tapering.
2. Diameter of AAA is more than 3 cm( Normal aorta less than 3 cm).
3. Para aortic lymph nodes may displace AAA anteriorly causing pulsatile mass .
4. AAA occurs below the origin of renal artery.
5. Patient hypertensive with c/o low back pain or pain similar to renal colic
6. AAA may rupture in retro peritoneum causing hematoma
CLINICAL PROBLEMS.
PAIN IN EPIGASTRIUM
Causes are.
1. Gastro esophageal disorders (GERD)
2. peptic ulcer.
3. Acute./Chronic Pancreatitis.
4. Inferior wall myocardial in farction.
5. Pancreatic carcinoma.
6. Pseudo cyst.
7. Liver metastasis.
8. Amoebic abscess.
9. Occasionally Acute cholecystitis or referred pain from
Acute Appendicitis /Aortic aneurysm.
PAIN IN RIGHT HYPOCHONDRIUM
1. Amoebic abscess.
2. Infective hepatitis.
3. Congestive cardiac failure.
4. Metaststasis in liver.
5. Acute cholecystitis.
MASS IN RIGHT HYPOCHONDRIUM
1. Hepatoma.
2. Cirrhosis liver.
3. Hydatid cyst.
4. Gall Bladder lump.(Cholelithiasis ,carcinoma)
5. Haemangioma.
6. Metastasis in liver.
7. Congestive cardia failure.
8. Amoebic Abscess liver.
9. Riddles lobe.
10. Adenoma of adrenal gland.
11. Focal nodular hyperplasia.
12. Adrenal gland tumour
13. Carcinoma stomach
14. Carcinoma colon
15. Renal masses ( Hydronephrosis & tumours)
MASS IN LEFT HYPOCHONDRIUM.
1. Sub phrenic abscess following stomach or spine operation.
2. Splenomegaly.
· Portal hypertension
· Malaria.
· Ka lazar
· Leukemia s.
· Metastasis.
· Myelofibrosis.
· Sub acute bacterial endocarditis ( SABE)
· Gauchers disease.
3. Hydronephrosis of left kidney.
4. Large renal cyst.
5. Adrenal cyst.
6. Pancreatic pseudo cyst.
7. Adrenal tumors ,Phaeochromocytoma/ Metastasis .
8. Retroperitoneal sarcomas.
9. Renal tumour.
10. Pancreatic Neoplasm.
UMBILICAL LUMP
1. Aortic Aneurysm
2. Lymphomas (Paraaortic,Coelic and mesenteric group lymph nodes enlarged.)
3. Gut masses ( Carcinoma of stomach, colon & Crohn s disease)
4. .Lipoma.of wall.( Echogenic structure in subcutaneous tissue.)
5. Obstruction of bowel.
6. Mesenteric cyst and lipomas.
7. Umbilical hernia.( Fluid filled bowel with PAS)
8. Rectus sheath hematoma
9. Anterior wall abscess.
10. .Retroperitoneal Tuberculosis & filariasis ( Lymph nodes enlarged).
11. Retroperitoneal sarcomas.( often fixed with post abdominal wall so not moving
with respiration. Pressure to Inferior vena cava may cause edema in lower
Limbs.)
TIPS.
1. If ascites present search for Cirrhosis liver or congestive cardiac failure ( Hypoechoic liver and dilated IVC and Hepatic veins)
2. If Para aortic /Coelic /mesenteric lymph nodes enlarged see for hepatosplenomegaly to clinch diagnosis of lymphoma.
3. If abdominal Aortic aneurysm seen trace iliac arteries for other site of aneurysm.
4. If gut mass present search for metastasis in liver (Carcinoma colon.).
5. If Mesenteric lymhnodes are enlarged search for matted intestines ,Hepatosplenomegaly & Ascites to exclude Kocks Abdomen.
PAIN AND LUMP IN LEFT ILIAC FOSSA
1 Carcinoma Sigmoid colon.
2 Diverticulitis
LUMP AND PAIN IN HYPOGASTRIUM
1. Distended urinary bladder.
2. Carcinoma urinary bladder.
3. Diseases of Uterus and its appendages.
4. Diseases of fallopian tubes and ovaries.
5. Cyst of Broad Ligament.
6. Pelvic abscess.
LUMP AND PAIN IN RIGHT ILIAC FOSSA
1. Ileocaecal mass ( Tuberculosis).
2. Carcinoma caecum.
3. Amoebic Typhilitis.
4. Impacted round worms ( Tube in Tube)
5. Crohn s Disease.
6. Appendicular mass
7. Pelvic abscess.
8. Rarely unascended kidney and undescended testis.
PYREXIA OF UNKNOWN ORIGIN ( PUO)
It is difficult problem for clinician in their clinical practice, but when sonologist is asked to help in arriving clinical diagnosis of PUO he must search evidence of following
diseases.
Sub phrenic abscess.
Sub hepatic abscess.
Hepatitis.
Cystitis.
Pyelonephritis.
Cholangitis.
Prostatitis.
Pancreatitis.
Hypernephroma.
Hepatoma.
Malaria.
Ka lazar.
SABE.
Typhoid.
Pleural effusion.
Post operative Collection of fluid pockets.( Cesarean section, hysterectomy and renal transplant)
HEMATURIA
Causes.
1 Pre renal
a. Purpura
b. Hemophilia
c. Leukemia
d. Drugs ( Salicylate, sulphonamide)
2 Disease of urinary tract.( renal ,Ureter,Bladder,Urethra)
3 Disease of Adjacent organ.
a. Carcinoma of rectum and uterus.
Infiltrating urinary bladder.
If hematuria in beginning - Urethral disease.
If hematuria at end - Bladder disease
If mixed hematuria through out the flow – it may be renal ,Pre renal or
Or Bladder disease.
If hematuria painless.
· Papilloma/ carcinoma
· Tuberculosis
If hematuria followed by Renal colic—Renal stone
If hematuria preceded by renal colic-- Tuberculosis etc.
A
1. Grade 1. Echogenicity is equal to Liver.
2. Grade 2. Echogenicity is greater than liver.
3. Grade 3. Echogenicity is equal to renal sinus echoes.
( Grade 0. Normally echogenicity of renal parenchyma is less than liver.)
B. Cortico medullary differentiation is lost.
1. C . Size of kidney is normal or large as in ACUTE TUBULAR NECROSIS OR ACUTE GLOMERILONEPHRITIS.
D Thickness of cortx is increased ( normal 2.5cm)
CHRONIC MEDICAL RENAL DISEASE
1. Size of kidney is small 5 to 8 cm ( Chronic granular contracted kidney.)
2. Renal sinus echoes is visible.
3. Renal parenchyma is shrunken with increased echogenicity.
4. If one kidney is small. And diseased suspect unilateral Pyelonephritis.
RENAL STONE
1. Highly echogenic.
2. If size more than 5-6 mm PAS is seen.
3. Calyces may be dilated.
4. Stones may be seen pyramid, calyces or pelvis of kidney..
5. Stag horn stone may be seen in pelvis with PAS.
6. If stone is seen in ureter ,upper part of ureter above the stone is dilated.
7. Only upper 1/3 and lower 1/3 of ureter could be seen as middle 1/3 part is invisible due to bowel gases.
CYSTIC STONE
1. Bladder is anechoic.
2. Stone is highly echogenic with PAS.
3. Search stone in lower 1/3 part of ureter and at ureteric orifice also.
CYSTITIS
1. Bladder is anechoic with debris/flakes floating in lumen.
2. Wall of Bladder irregular with local or generalised thickness.
ACUTE PYELONEPHRITIS
1. Kidney enlarged.
2. Hypoechoic renal parenchyma.
ACUTE FOCAL BACTERIAL NEPHRITIS
Mass is equal to or less echogenic than adjacent parenchyma.
If liquefaction started it appears anechoic or Hypoechoic with varying internal echoes.
ACUTE RENAL VEIN THROMBOSIS.
Renal size initially large but later it may decrease.
Echogenicity of cortex is decreased in beginning but later after few days to weeks
It is increased.
.Anechoic parenchyma could be seen depending upon haemorrhage or haemorrhagic infarction.
Coticomedullary differentiation is preserved in beginning but later lost.
Central sinus echoes increased.
PERI NEPHRIC ABSCESS
Peri renal fluid collection gives rise to Hypoechoic / anechoic echotexture.
Aspiration should be done to exclude urinoma /peri renal haematoma etc
HYDRONEPHROSIS
1. Calyces, infundibulum and renal pelvis dilated and renal sinus is separated with anechoic fluid.
2. Calyces and infundibulum could be traced to pelvis.
3. Renal parenchyma is thinned out ( less than 2.5cm)
4. Confirm that bladder is empty before labeling hydronephrosis.
5. In presence of calculi or dehydrated patient hydronephrosis could misse4d.
HYPERNEPHROMA.
Mass is hyper echoic/ isoechoic
Wall irregular
search for hepatic metastasis.
Para aortic group of lymph nodes enlarged.
LYMPHOMA
1. Echopenic mass.
2. renal size increased with hypoechotexture of renal parenchyma.
3. Sinus echoes lost.
4. Splenomegaly present
5. Para aortic gr of lymph nodes enlarged.
ANGIOMYOLIPOMA
Highly echogenic lesion.
Smooth border of mass.
Size may vary from 1 cm to 20 cm.
In tuberous sclerosis Angiomyolipoma is bilateral and multiple.
ADENOMA
1. Size of mass less than 1 cm.
2. Solid and highly echogenic.
3. Usually situated in renal cortex.
SIMPLE CYST
Wall of cyst smooth and sharply defined.
Anechoic , occasionally one two septa seen..
PAS present.
If cyst get infected , complex internal echoes with poorly defined thick wall.
POLYCYSTIC KIDNEY
1. Both renal are involved.
2. Renal size increased ( 15-18 cm)
3. Multiple ,with lobulated irregular margin seen all over kidney .
4. Cysts can also be located in liver, pancreas and spleen.
5. Size of cyst may vary.
6. Echotexture of parenchyma increases.
MULTIPLE CYSTS IN KIDNEY
1. Cyst are fewer in number and of equal size.
2. Smooth walled.
3. Unilateral.
4. Liver, Pancreas and spleen spared.
WILMS TUMOUR
Large , homogeneously echogenic mass ,occasionally Hypoechoic depending upon necrosis and haemorrhage.
Unilateral ( in 10 % may be Bilateral)
Found in children less than 5 yrs of age.
Highly malignant.
Search for metastasis.
TUMOUR OF URINARY BLADDER
Bladder anechoic.
Echogenic masses are seen in bladder wall.
Echogenic line of bladder wall absent if tumour has invaded the wall.
If tumour is big it may protrude in pelvis.
RENAL GRAFT REJECTION
Acute Rejection.
Renal volume increased with enlargement of pyramids.
Focal anechoic appearance of renal parenchyma.
Corticomedullary differentiation indistinct.
Increased or decreased echotexture of renal cortex.
Sub mucosal edema of collecting system.
Decreased echogenicity of renal sinus.
Confluent Hypoechoic areas seen in medulla.
Chronic Rejection.
1. Initially renal size increases but later at end stage size is much reduced.
2. Corticomedullary differentiation lost.
3. kidney is echogenic but its contour is irregular.
4. Central sinus and renal parenchymal differentiation lost.
PROSTRATE ENLARGEMENT
Benign prostratic hypertrophy.( BPH)
1. Capsular margin clear & well defined.
2. If glandular proliferation is more then gland is Hypoechoic.
3. If stromal proliferation is more ,gland is echogenic due to collagens.
4. Prostrate is spherical instead of semilunar when lateral lobe is enlarged..
5. Anteromedian diameter is increased in case of median lobe enlargement of gland.
6. Weight of gland is more than 20gms.
7. Capacity of urinary bladder ( Pre voidal) and residual urine (Post Voidal) to be calculated.
CARCINOMA OF PROSTRATE
1. Focal mass has Hypoechoic/Hyper echoic texture with irregular margin.
2. Capsular wall irregular and deformed.
3. Contour of gland is asymmetrical with elongation of antero-post diameter.
4. Prostrate is enlarged.
ADRENAL GLAND
PHAEOCHROMOCYTOMA
Solid homo / heterogenous echoes.
If necrosis , mass will be Hypoechoic
If haemorrhagic ,texture will be hyper echoic.
Patient is hypertensive.
ADENOMA OF ADRENAL GLAND.
1. Size vary 1- 5cm.
2. Poorly capsulated.
3. Hyper echoic / Hypoechoic
4. Homogenous ,smooth rounded mass.
CARCINOMA OF ADRENAL GLAND
Size of mass is large ,even up to 20 cm.
Heterogenous echotexture with irregular out line.
Invasion of IVC ,adrenal vein & lymph nodes may be present.
Metastasis to liver, Para aortic gland and lungs.etc.
GASTROINTESTINAL SYSTEM
ACUTE APPENDICITIS ( graded compression technique).
1. Due to inflammation, wall appears Hypoechoic/anechoic depending upon
Edema.
2. On transverse section it appears like Bull”s eye with total diameter 7 mm to 10mm ( Normal wall is 6 mm).
3. No peristaltic movement seen.
4. Appendix is non Compressible.
5. Tender on palpating with probe.
PERFORATED APPENDIX
1. Wall asymmetrically thick.
2. Wall hyper echoic , finger like projection.
Surrounded by hypo echoic pus.
3. Mesenteric lymph nodes enlarged.
CROHN” S DISEASE
· Intestinal wall 9mm to 16mm thick.
· Intestinal lumen narrow.
· Peristaltic movement reduced in affected part
While unaffected part shows hyper peristaltic movement.
MESENTERIC ADENITIS
· Lymph nodes vary from 3 to 20.
· Lymph nodes enlarged more than 4 mm , mostly 11 mm to 13 mm.
· Lymph nodes are spherical , Hypoechoic in periphery and hyper echoic in centre.
IN TUSSUSCEPTION
Transverse section of affected bowel shows a thick Hypoechoic ring
surrounded by a second thick Hypoechoic ring .
BLUNT INJURY ABDOMEN
· Fluid may be present at sub phrenic ,Para colic gutter , pelvis, subhepatic space, pleural space and Morrison’s pouch.
· Free fluid is anechoic while blood clot is hyper echoic.
· Patient will be hypotensive & in shock.
ABDOMINAL AORTIC ANEURISM (A A A )
1. Abdominal aorta gradually tapers but AAA distorts this tapering.
2. Diameter of AAA is more than 3 cm( Normal aorta less than 3 cm).
3. Para aortic lymph nodes may displace AAA anteriorly causing pulsatile mass .
4. AAA occurs below the origin of renal artery.
5. Patient hypertensive with c/o low back pain or pain similar to renal colic
6. AAA may rupture in retro peritoneum causing hematoma
CLINICAL PROBLEMS.
PAIN IN EPIGASTRIUM
Causes are.
1. Gastro esophageal disorders (GERD)
2. peptic ulcer.
3. Acute./Chronic Pancreatitis.
4. Inferior wall myocardial in farction.
5. Pancreatic carcinoma.
6. Pseudo cyst.
7. Liver metastasis.
8. Amoebic abscess.
9. Occasionally Acute cholecystitis or referred pain from
Acute Appendicitis /Aortic aneurysm.
PAIN IN RIGHT HYPOCHONDRIUM
1. Amoebic abscess.
2. Infective hepatitis.
3. Congestive cardiac failure.
4. Metaststasis in liver.
5. Acute cholecystitis.
MASS IN RIGHT HYPOCHONDRIUM
1. Hepatoma.
2. Cirrhosis liver.
3. Hydatid cyst.
4. Gall Bladder lump.(Cholelithiasis ,carcinoma)
5. Haemangioma.
6. Metastasis in liver.
7. Congestive cardia failure.
8. Amoebic Abscess liver.
9. Riddles lobe.
10. Adenoma of adrenal gland.
11. Focal nodular hyperplasia.
12. Adrenal gland tumour
13. Carcinoma stomach
14. Carcinoma colon
15. Renal masses ( Hydronephrosis & tumours)
MASS IN LEFT HYPOCHONDRIUM.
1. Sub phrenic abscess following stomach or spine operation.
2. Splenomegaly.
· Portal hypertension
· Malaria.
· Ka lazar
· Leukemia s.
· Metastasis.
· Myelofibrosis.
· Sub acute bacterial endocarditis ( SABE)
· Gauchers disease.
3. Hydronephrosis of left kidney.
4. Large renal cyst.
5. Adrenal cyst.
6. Pancreatic pseudo cyst.
7. Adrenal tumors ,Phaeochromocytoma/ Metastasis .
8. Retroperitoneal sarcomas.
9. Renal tumour.
10. Pancreatic Neoplasm.
UMBILICAL LUMP
1. Aortic Aneurysm
2. Lymphomas (Paraaortic,Coelic and mesenteric group lymph nodes enlarged.)
3. Gut masses ( Carcinoma of stomach, colon & Crohn s disease)
4. .Lipoma.of wall.( Echogenic structure in subcutaneous tissue.)
5. Obstruction of bowel.
6. Mesenteric cyst and lipomas.
7. Umbilical hernia.( Fluid filled bowel with PAS)
8. Rectus sheath hematoma
9. Anterior wall abscess.
10. .Retroperitoneal Tuberculosis & filariasis ( Lymph nodes enlarged).
11. Retroperitoneal sarcomas.( often fixed with post abdominal wall so not moving
with respiration. Pressure to Inferior vena cava may cause edema in lower
Limbs.)
TIPS.
1. If ascites present search for Cirrhosis liver or congestive cardiac failure ( Hypoechoic liver and dilated IVC and Hepatic veins)
2. If Para aortic /Coelic /mesenteric lymph nodes enlarged see for hepatosplenomegaly to clinch diagnosis of lymphoma.
3. If abdominal Aortic aneurysm seen trace iliac arteries for other site of aneurysm.
4. If gut mass present search for metastasis in liver (Carcinoma colon.).
5. If Mesenteric lymhnodes are enlarged search for matted intestines ,Hepatosplenomegaly & Ascites to exclude Kocks Abdomen.
PAIN AND LUMP IN LEFT ILIAC FOSSA
1 Carcinoma Sigmoid colon.
2 Diverticulitis
LUMP AND PAIN IN HYPOGASTRIUM
1. Distended urinary bladder.
2. Carcinoma urinary bladder.
3. Diseases of Uterus and its appendages.
4. Diseases of fallopian tubes and ovaries.
5. Cyst of Broad Ligament.
6. Pelvic abscess.
LUMP AND PAIN IN RIGHT ILIAC FOSSA
1. Ileocaecal mass ( Tuberculosis).
2. Carcinoma caecum.
3. Amoebic Typhilitis.
4. Impacted round worms ( Tube in Tube)
5. Crohn s Disease.
6. Appendicular mass
7. Pelvic abscess.
8. Rarely unascended kidney and undescended testis.
PYREXIA OF UNKNOWN ORIGIN ( PUO)
It is difficult problem for clinician in their clinical practice, but when sonologist is asked to help in arriving clinical diagnosis of PUO he must search evidence of following
diseases.
Sub phrenic abscess.
Sub hepatic abscess.
Hepatitis.
Cystitis.
Pyelonephritis.
Cholangitis.
Prostatitis.
Pancreatitis.
Hypernephroma.
Hepatoma.
Malaria.
Ka lazar.
SABE.
Typhoid.
Pleural effusion.
Post operative Collection of fluid pockets.( Cesarean section, hysterectomy and renal transplant)
HEMATURIA
Causes.
1 Pre renal
a. Purpura
b. Hemophilia
c. Leukemia
d. Drugs ( Salicylate, sulphonamide)
2 Disease of urinary tract.( renal ,Ureter,Bladder,Urethra)
3 Disease of Adjacent organ.
a. Carcinoma of rectum and uterus.
Infiltrating urinary bladder.
If hematuria in beginning - Urethral disease.
If hematuria at end - Bladder disease
If mixed hematuria through out the flow – it may be renal ,Pre renal or
Or Bladder disease.
If hematuria painless.
· Papilloma/ carcinoma
· Tuberculosis
If hematuria followed by Renal colic—Renal stone
If hematuria preceded by renal colic-- Tuberculosis etc.
Saturday, June 21, 2008
RENAL AND OTHER DISEASES
ACUTE MEDICAL RENAL DISEASE
A
1. Grade 1. Echogenicity is equal to Liver.
2. Grade 2. Echogenicity is greater than liver.
3. Grade 3. Echogenicity is equal to renal sinus echoes.
( Grade 0. Normally echogenicity of renal parenchyma is less than liver.)
B. Cortico medullary differentiation is lost.
1. C . Size of kidney is normal or large as in ACUTE TUBULAR NECROSIS OR ACUTE GLOMERILONEPHRITIS.
D Thickness of cortx is increased ( normal 2.5cm)
CHRONIC MEDICAL RENAL DISEASE
1. Size of kidney is small 5 to 8 cm ( Chronic granular contracted kidney.)
2. Renal sinus echoes is visible.
3. Renal parenchyma is shrunken with increased echogenicity.
4. If one kidney is small. And diseased suspect unilateral Pyelonephritis.
RENAL STONE
1. Highly echogenic.
2. If size more than 5-6 mm PAS is seen.
3. Calyces may be dilated.
4. Stones may be seen pyramid, calyces or pelvis of kidney..
5. Stag horn stone may be seen in pelvis with PAS.
6. If stone is seen in ureter ,upper part of ureter above the stone is dilated.
7. Only upper 1/3 and lower 1/3 of ureter could be seen as middle 1/3 part is invisible due to bowel gases.
CYSTIC STONE
1. Bladder is anechoic.
2. Stone is highly echogenic with PAS.
3. Search stone in lower 1/3 part of ureter and at ureteric orifice also.
CYSTITIS
1. Bladder is anechoic with debris/flakes floating in lumen.
2. Wall of Bladder irregular with local or generalised thickness.
ACUTE PYELONEPHRITIS
1. Kidney enlarged.
2. Hypoechoic renal parenchyma.
ACUTE FOCAL BACTERIAL NEPHRITIS
Mass is equal to or less echogenic than adjacent parenchyma.
If liquefaction started it appears anechoic or Hypoechoic with varying internal echoes.
ACUTE RENAL VEIN THROMBOSIS.
Renal size initially large but later it may decrease.
Echogenicity of cortex is decreased in beginning but later after few days to weeks
It is increased.
.Anechoic parenchyma could be seen depending upon haemorrhage or haemorrhagic infarction.
Coticomedullary differentiation is preserved in beginning but later lost.
Central sinus echoes increased.
PERI NEPHRIC ABSCESS
Peri renal fluid collection gives rise to Hypoechoic / anechoic echotexture.
Aspiration should be done to exclude urinoma /peri renal haematoma etc
HYDRONEPHROSIS
1. Calyces, infundibulum and renal pelvis dilated and renal sinus is separated with anechoic fluid.
2. Calyces and infundibulum could be traced to pelvis.
3. Renal parenchyma is thinned out ( less than 2.5cm)
4. Confirm that bladder is empty before labeling hydronephrosis.
5. In presence of calculi or dehydrated patient hydronephrosis could misse4d.
HYPERNEPHROMA.
Mass is hyper echoic/ isoechoic
Wall irregular
search for hepatic metastasis.
Para aortic group of lymph nodes enlarged.
LYMPHOMA
1. Echopenic mass.
2. renal size increased with hypoechotexture of renal parenchyma.
3. Sinus echoes lost.
4. Splenomegaly present
5. Para aortic gr of lymph nodes enlarged.
ANGIOMYOLIPOMA
Highly echogenic lesion.
Smooth border of mass.
Size may vary from 1 cm to 20 cm.
In tuberous sclerosis Angiomyolipoma is bilateral and multiple.
ADENOMA
1. Size of mass less than 1 cm.
2. Solid and highly echogenic.
3. Usually situated in renal cortex.
SIMPLE CYST
Wall of cyst smooth and sharply defined.
Anechoic , occasionally one two septa seen..
PAS present.
If cyst get infected , complex internal echoes with poorly defined thick wall.
POLYCYSTIC KIDNEY
1. Both renal are involved.
2. Renal size increased ( 15-18 cm)
3. Multiple ,with lobulated irregular margin seen all over kidney .
4. Cysts can also be located in liver, pancreas and spleen.
5. Size of cyst may vary.
6. Echotexture of parenchyma increases.
MULTIPLE CYSTS IN KIDNEY
1. Cyst are fewer in number and of equal size.
2. Smooth walled.
3. Unilateral.
4. Liver, Pancreas and spleen spared.
WILMS TUMOUR
Large , homogeneously echogenic mass ,occasionally Hypoechoic depending upon necrosis and haemorrhage.
Unilateral ( in 10 % may be Bilateral)
Found in children less than 5 yrs of age.
Highly malignant.
Search for metastasis.
TUMOUR OF URINARY BLADDER
Bladder anechoic.
Echogenic masses are seen in bladder wall.
Echogenic line of bladder wall absent if tumour has invaded the wall.
If tumour is big it may protrude in pelvis.
RENAL GRAFT REJECTION
Acute Rejection.
Renal volume increased with enlargement of pyramids.
Focal anechoic appearance of renal parenchyma.
Corticomedullary differentiation indistinct.
Increased or decreased echotexture of renal cortex.
Sub mucosal edema of collecting system.
Decreased echogenicity of renal sinus.
Confluent Hypoechoic areas seen in medulla.
Chronic Rejection.
1. Initially renal size increases but later at end stage size is much reduced.
2. Corticomedullary differentiation lost.
3. kidney is echogenic but its contour is irregular.
4. Central sinus and renal parenchymal differentiation lost.
PROSTRATE ENLARGEMENT
Benign prostratic hypertrophy.( BPH)
1. Capsular margin clear & well defined.
2. If glandular proliferation is more then gland is Hypoechoic.
3. If stromal proliferation is more ,gland is echogenic due to collagens.
4. Prostrate is spherical instead of semilunar when lateral lobe is enlarged..
5. Anteromedian diameter is increased in case of median lobe enlargement of gland.
6. Weight of gland is more than 20gms.
7. Capacity of urinary bladder ( Pre voidal) and residual urine (Post Voidal) to be calculated.
CARCINOMA OF PROSTRATE
1. Focal mass has Hypoechoic/Hyper echoic texture with irregular margin.
2. Capsular wall irregular and deformed.
3. Contour of gland is asymmetrical with elongation of antero-post diameter.
4. Prostrate is enlarged.
ADRENAL GLAND
PHAEOCHROMOCYTOMA
Solid homo / heterogenous echoes.
If necrosis , mass will be Hypoechoic
If haemorrhagic ,texture will be hyper echoic.
Patient is hypertensive.
ADENOMA OF ADRENAL GLAND.
1. Size vary 1- 5cm.
2. Poorly capsulated.
3. Hyper echoic / Hypoechoic
4. Homogenous ,smooth rounded mass.
CARCINOMA OF ADRENAL GLAND
Size of mass is large ,even up to 20 cm.
Heterogenous echotexture with irregular out line.
Invasion of IVC ,adrenal vein & lymph nodes may be present.
Metastasis to liver, Para aortic gland and lungs.etc.
GASTROINTESTINAL SYSTEM
ACUTE APPENDICITIS ( graded compression technique).
1. Due to inflammation, wall appears Hypoechoic/anechoic depending upon
Edema.
2. On transverse section it appears like Bull”s eye with total diameter 7 mm to 10mm ( Normal wall is 6 mm).
3. No peristaltic movement seen.
4. Appendix is non Compressible.
5. Tender on palpating with probe.
PERFORATED APPENDIX
1. Wall asymmetrically thick.
2. Wall hyper echoic , finger like projection.
Surrounded by hypo echoic pus.
3. Mesenteric lymph nodes enlarged.
CROHN” S DISEASE
· Intestinal wall 9mm to 16mm thick.
· Intestinal lumen narrow.
· Peristaltic movement reduced in affected part
While unaffected part shows hyper peristaltic movement.
MESENTERIC ADENITIS
· Lymph nodes vary from 3 to 20.
· Lymph nodes enlarged more than 4 mm , mostly 11 mm to 13 mm.
· Lymph nodes are spherical , Hypoechoic in periphery and hyper echoic in centre.
IN TUSSUSCEPTION
Transverse section of affected bowel shows a thick Hypoechoic ring
surrounded by a second thick Hypoechoic ring .
BLUNT INJURY ABDOMEN
· Fluid may be present at sub phrenic ,Para colic gutter , pelvis, subhepatic space, pleural space and Morrison’s pouch.
· Free fluid is anechoic while blood clot is hyper echoic.
· Patient will be hypotensive & in shock.
ABDOMINAL AORTIC ANEURISM (A A A )
1. Abdominal aorta gradually tapers but AAA distorts this tapering.
2. Diameter of AAA is more than 3 cm( Normal aorta less than 3 cm).
3. Para aortic lymph nodes may displace AAA anteriorly causing pulsatile mass .
4. AAA occurs below the origin of renal artery.
5. Patient hypertensive with c/o low back pain or pain similar to renal colic
6. AAA may rupture in retro peritoneum causing hematoma
CLINICAL PROBLEMS.
PAIN IN EPIGASTRIUM
Causes are.
1. Gastro esophageal disorders (GERD)
2. peptic ulcer.
3. Acute./Chronic Pancreatitis.
4. Inferior wall myocardial in farction.
5. Pancreatic carcinoma.
6. Pseudo cyst.
7. Liver metastasis.
8. Amoebic abscess.
9. Occasionally Acute cholecystitis or referred pain from
Acute Appendicitis /Aortic aneurysm.
PAIN IN RIGHT HYPOCHONDRIUM
1. Amoebic abscess.
2. Infective hepatitis.
3. Congestive cardiac failure.
4. Metaststasis in liver.
5. Acute cholecystitis.
MASS IN RIGHT HYPOCHONDRIUM
1. Hepatoma.
2. Cirrhosis liver.
3. Hydatid cyst.
4. Gall Bladder lump.(Cholelithiasis ,carcinoma)
5. Haemangioma.
6. Metastasis in liver.
7. Congestive cardia failure.
8. Amoebic Abscess liver.
9. Riddles lobe.
10. Adenoma of adrenal gland.
11. Focal nodular hyperplasia.
12. Adrenal gland tumour
13. Carcinoma stomach
14. Carcinoma colon
15. Renal masses ( Hydronephrosis & tumours)
MASS IN LEFT HYPOCHONDRIUM.
1. Sub phrenic abscess following stomach or spine operation.
2. Splenomegaly.
· Portal hypertension
· Malaria.
· Ka lazar
· Leukemia s.
· Metastasis.
· Myelofibrosis.
· Sub acute bacterial endocarditis ( SABE)
· Gauchers disease.
3. Hydronephrosis of left kidney.
4. Large renal cyst.
5. Adrenal cyst.
6. Pancreatic pseudo cyst.
7. Adrenal tumors ,Phaeochromocytoma/ Metastasis .
8. Retroperitoneal sarcomas.
9. Renal tumour.
10. Pancreatic Neoplasm.
UMBILICAL LUMP
1. Aortic Aneurysm
2. Lymphomas (Paraaortic,Coelic and mesenteric group lymph nodes enlarged.)
3. Gut masses ( Carcinoma of stomach, colon & Crohn s disease)
4. .Lipoma.of wall.( Echogenic structure in subcutaneous tissue.)
5. Obstruction of bowel.
6. Mesenteric cyst and lipomas.
7. Umbilical hernia.( Fluid filled bowel with PAS)
8. Rectus sheath hematoma
9. Anterior wall abscess.
10. .Retroperitoneal Tuberculosis & filariasis ( Lymph nodes enlarged).
11. Retroperitoneal sarcomas.( often fixed with post abdominal wall so not moving
with respiration. Pressure to Inferior vena cava may cause edema in lower
Limbs.)
TIPS.
1. If ascites present search for Cirrhosis liver or congestive cardiac failure ( Hypoechoic liver and dilated IVC and Hepatic veins)
2. If Para aortic /Coelic /mesenteric lymph nodes enlarged see for hepatosplenomegaly to clinch diagnosis of lymphoma.
3. If abdominal Aortic aneurysm seen trace iliac arteries for other site of aneurysm.
4. If gut mass present search for metastasis in liver (Carcinoma colon.).
5. If Mesenteric lymhnodes are enlarged search for matted intestines ,Hepatosplenomegaly & Ascites to exclude Kocks Abdomen.
PAIN AND LUMP IN LEFT ILIAC FOSSA
1 Carcinoma Sigmoid colon.
2 Diverticulitis
LUMP AND PAIN IN HYPOGASTRIUM
1. Distended urinary bladder.
2. Carcinoma urinary bladder.
3. Diseases of Uterus and its appendages.
4. Diseases of fallopian tubes and ovaries.
5. Cyst of Broad Ligament.
6. Pelvic abscess.
LUMP AND PAIN IN RIGHT ILIAC FOSSA
1. Ileocaecal mass ( Tuberculosis).
2. Carcinoma caecum.
3. Amoebic Typhilitis.
4. Impacted round worms ( Tube in Tube)
5. Crohn s Disease.
6. Appendicular mass
7. Pelvic abscess.
8. Rarely unascended kidney and undescended testis.
PYREXIA OF UNKNOWN ORIGIN ( PUO)
It is difficult problem for clinician in their clinical practice, but when sonologist is asked to help in arriving clinical diagnosis of PUO he must search evidence of following
diseases.
Sub phrenic abscess.
Sub hepatic abscess.
Hepatitis.
Cystitis.
Pyelonephritis.
Cholangitis.
Prostatitis.
Pancreatitis.
Hypernephroma.
Hepatoma.
Malaria.
Ka lazar.
SABE.
Typhoid.
Pleural effusion.
Post operative Collection of fluid pockets.( Cesarean section, hysterectomy and renal transplant)
HEMATURIA
Causes.
1 Pre renal
a. Purpura
b. Hemophilia
c. Leukemia
d. Drugs ( Salicylate, sulphonamide)
2 Disease of urinary tract.( renal ,Ureter,Bladder,Urethra)
3 Disease of Adjacent organ.
a. Carcinoma of rectum and uterus.
Infiltrating urinary bladder.
If hematuria in beginning - Urethral disease.
If hematuria at end - Bladder disease
If mixed hematuria through out the flow – it may be renal ,Pre renal or
Or Bladder disease.
If hematuria painless.
· Papilloma/ carcinoma
· Tuberculosis
If hematuria followed by Renal colic—Renal stone
If hematuria preceded by renal colic-- Tuberculosis etc.
A
1. Grade 1. Echogenicity is equal to Liver.
2. Grade 2. Echogenicity is greater than liver.
3. Grade 3. Echogenicity is equal to renal sinus echoes.
( Grade 0. Normally echogenicity of renal parenchyma is less than liver.)
B. Cortico medullary differentiation is lost.
1. C . Size of kidney is normal or large as in ACUTE TUBULAR NECROSIS OR ACUTE GLOMERILONEPHRITIS.
D Thickness of cortx is increased ( normal 2.5cm)
CHRONIC MEDICAL RENAL DISEASE
1. Size of kidney is small 5 to 8 cm ( Chronic granular contracted kidney.)
2. Renal sinus echoes is visible.
3. Renal parenchyma is shrunken with increased echogenicity.
4. If one kidney is small. And diseased suspect unilateral Pyelonephritis.
RENAL STONE
1. Highly echogenic.
2. If size more than 5-6 mm PAS is seen.
3. Calyces may be dilated.
4. Stones may be seen pyramid, calyces or pelvis of kidney..
5. Stag horn stone may be seen in pelvis with PAS.
6. If stone is seen in ureter ,upper part of ureter above the stone is dilated.
7. Only upper 1/3 and lower 1/3 of ureter could be seen as middle 1/3 part is invisible due to bowel gases.
CYSTIC STONE
1. Bladder is anechoic.
2. Stone is highly echogenic with PAS.
3. Search stone in lower 1/3 part of ureter and at ureteric orifice also.
CYSTITIS
1. Bladder is anechoic with debris/flakes floating in lumen.
2. Wall of Bladder irregular with local or generalised thickness.
ACUTE PYELONEPHRITIS
1. Kidney enlarged.
2. Hypoechoic renal parenchyma.
ACUTE FOCAL BACTERIAL NEPHRITIS
Mass is equal to or less echogenic than adjacent parenchyma.
If liquefaction started it appears anechoic or Hypoechoic with varying internal echoes.
ACUTE RENAL VEIN THROMBOSIS.
Renal size initially large but later it may decrease.
Echogenicity of cortex is decreased in beginning but later after few days to weeks
It is increased.
.Anechoic parenchyma could be seen depending upon haemorrhage or haemorrhagic infarction.
Coticomedullary differentiation is preserved in beginning but later lost.
Central sinus echoes increased.
PERI NEPHRIC ABSCESS
Peri renal fluid collection gives rise to Hypoechoic / anechoic echotexture.
Aspiration should be done to exclude urinoma /peri renal haematoma etc
HYDRONEPHROSIS
1. Calyces, infundibulum and renal pelvis dilated and renal sinus is separated with anechoic fluid.
2. Calyces and infundibulum could be traced to pelvis.
3. Renal parenchyma is thinned out ( less than 2.5cm)
4. Confirm that bladder is empty before labeling hydronephrosis.
5. In presence of calculi or dehydrated patient hydronephrosis could misse4d.
HYPERNEPHROMA.
Mass is hyper echoic/ isoechoic
Wall irregular
search for hepatic metastasis.
Para aortic group of lymph nodes enlarged.
LYMPHOMA
1. Echopenic mass.
2. renal size increased with hypoechotexture of renal parenchyma.
3. Sinus echoes lost.
4. Splenomegaly present
5. Para aortic gr of lymph nodes enlarged.
ANGIOMYOLIPOMA
Highly echogenic lesion.
Smooth border of mass.
Size may vary from 1 cm to 20 cm.
In tuberous sclerosis Angiomyolipoma is bilateral and multiple.
ADENOMA
1. Size of mass less than 1 cm.
2. Solid and highly echogenic.
3. Usually situated in renal cortex.
SIMPLE CYST
Wall of cyst smooth and sharply defined.
Anechoic , occasionally one two septa seen..
PAS present.
If cyst get infected , complex internal echoes with poorly defined thick wall.
POLYCYSTIC KIDNEY
1. Both renal are involved.
2. Renal size increased ( 15-18 cm)
3. Multiple ,with lobulated irregular margin seen all over kidney .
4. Cysts can also be located in liver, pancreas and spleen.
5. Size of cyst may vary.
6. Echotexture of parenchyma increases.
MULTIPLE CYSTS IN KIDNEY
1. Cyst are fewer in number and of equal size.
2. Smooth walled.
3. Unilateral.
4. Liver, Pancreas and spleen spared.
WILMS TUMOUR
Large , homogeneously echogenic mass ,occasionally Hypoechoic depending upon necrosis and haemorrhage.
Unilateral ( in 10 % may be Bilateral)
Found in children less than 5 yrs of age.
Highly malignant.
Search for metastasis.
TUMOUR OF URINARY BLADDER
Bladder anechoic.
Echogenic masses are seen in bladder wall.
Echogenic line of bladder wall absent if tumour has invaded the wall.
If tumour is big it may protrude in pelvis.
RENAL GRAFT REJECTION
Acute Rejection.
Renal volume increased with enlargement of pyramids.
Focal anechoic appearance of renal parenchyma.
Corticomedullary differentiation indistinct.
Increased or decreased echotexture of renal cortex.
Sub mucosal edema of collecting system.
Decreased echogenicity of renal sinus.
Confluent Hypoechoic areas seen in medulla.
Chronic Rejection.
1. Initially renal size increases but later at end stage size is much reduced.
2. Corticomedullary differentiation lost.
3. kidney is echogenic but its contour is irregular.
4. Central sinus and renal parenchymal differentiation lost.
PROSTRATE ENLARGEMENT
Benign prostratic hypertrophy.( BPH)
1. Capsular margin clear & well defined.
2. If glandular proliferation is more then gland is Hypoechoic.
3. If stromal proliferation is more ,gland is echogenic due to collagens.
4. Prostrate is spherical instead of semilunar when lateral lobe is enlarged..
5. Anteromedian diameter is increased in case of median lobe enlargement of gland.
6. Weight of gland is more than 20gms.
7. Capacity of urinary bladder ( Pre voidal) and residual urine (Post Voidal) to be calculated.
CARCINOMA OF PROSTRATE
1. Focal mass has Hypoechoic/Hyper echoic texture with irregular margin.
2. Capsular wall irregular and deformed.
3. Contour of gland is asymmetrical with elongation of antero-post diameter.
4. Prostrate is enlarged.
ADRENAL GLAND
PHAEOCHROMOCYTOMA
Solid homo / heterogenous echoes.
If necrosis , mass will be Hypoechoic
If haemorrhagic ,texture will be hyper echoic.
Patient is hypertensive.
ADENOMA OF ADRENAL GLAND.
1. Size vary 1- 5cm.
2. Poorly capsulated.
3. Hyper echoic / Hypoechoic
4. Homogenous ,smooth rounded mass.
CARCINOMA OF ADRENAL GLAND
Size of mass is large ,even up to 20 cm.
Heterogenous echotexture with irregular out line.
Invasion of IVC ,adrenal vein & lymph nodes may be present.
Metastasis to liver, Para aortic gland and lungs.etc.
GASTROINTESTINAL SYSTEM
ACUTE APPENDICITIS ( graded compression technique).
1. Due to inflammation, wall appears Hypoechoic/anechoic depending upon
Edema.
2. On transverse section it appears like Bull”s eye with total diameter 7 mm to 10mm ( Normal wall is 6 mm).
3. No peristaltic movement seen.
4. Appendix is non Compressible.
5. Tender on palpating with probe.
PERFORATED APPENDIX
1. Wall asymmetrically thick.
2. Wall hyper echoic , finger like projection.
Surrounded by hypo echoic pus.
3. Mesenteric lymph nodes enlarged.
CROHN” S DISEASE
· Intestinal wall 9mm to 16mm thick.
· Intestinal lumen narrow.
· Peristaltic movement reduced in affected part
While unaffected part shows hyper peristaltic movement.
MESENTERIC ADENITIS
· Lymph nodes vary from 3 to 20.
· Lymph nodes enlarged more than 4 mm , mostly 11 mm to 13 mm.
· Lymph nodes are spherical , Hypoechoic in periphery and hyper echoic in centre.
IN TUSSUSCEPTION
Transverse section of affected bowel shows a thick Hypoechoic ring
surrounded by a second thick Hypoechoic ring .
BLUNT INJURY ABDOMEN
· Fluid may be present at sub phrenic ,Para colic gutter , pelvis, subhepatic space, pleural space and Morrison’s pouch.
· Free fluid is anechoic while blood clot is hyper echoic.
· Patient will be hypotensive & in shock.
ABDOMINAL AORTIC ANEURISM (A A A )
1. Abdominal aorta gradually tapers but AAA distorts this tapering.
2. Diameter of AAA is more than 3 cm( Normal aorta less than 3 cm).
3. Para aortic lymph nodes may displace AAA anteriorly causing pulsatile mass .
4. AAA occurs below the origin of renal artery.
5. Patient hypertensive with c/o low back pain or pain similar to renal colic
6. AAA may rupture in retro peritoneum causing hematoma
CLINICAL PROBLEMS.
PAIN IN EPIGASTRIUM
Causes are.
1. Gastro esophageal disorders (GERD)
2. peptic ulcer.
3. Acute./Chronic Pancreatitis.
4. Inferior wall myocardial in farction.
5. Pancreatic carcinoma.
6. Pseudo cyst.
7. Liver metastasis.
8. Amoebic abscess.
9. Occasionally Acute cholecystitis or referred pain from
Acute Appendicitis /Aortic aneurysm.
PAIN IN RIGHT HYPOCHONDRIUM
1. Amoebic abscess.
2. Infective hepatitis.
3. Congestive cardiac failure.
4. Metaststasis in liver.
5. Acute cholecystitis.
MASS IN RIGHT HYPOCHONDRIUM
1. Hepatoma.
2. Cirrhosis liver.
3. Hydatid cyst.
4. Gall Bladder lump.(Cholelithiasis ,carcinoma)
5. Haemangioma.
6. Metastasis in liver.
7. Congestive cardia failure.
8. Amoebic Abscess liver.
9. Riddles lobe.
10. Adenoma of adrenal gland.
11. Focal nodular hyperplasia.
12. Adrenal gland tumour
13. Carcinoma stomach
14. Carcinoma colon
15. Renal masses ( Hydronephrosis & tumours)
MASS IN LEFT HYPOCHONDRIUM.
1. Sub phrenic abscess following stomach or spine operation.
2. Splenomegaly.
· Portal hypertension
· Malaria.
· Ka lazar
· Leukemia s.
· Metastasis.
· Myelofibrosis.
· Sub acute bacterial endocarditis ( SABE)
· Gauchers disease.
3. Hydronephrosis of left kidney.
4. Large renal cyst.
5. Adrenal cyst.
6. Pancreatic pseudo cyst.
7. Adrenal tumors ,Phaeochromocytoma/ Metastasis .
8. Retroperitoneal sarcomas.
9. Renal tumour.
10. Pancreatic Neoplasm.
UMBILICAL LUMP
1. Aortic Aneurysm
2. Lymphomas (Paraaortic,Coelic and mesenteric group lymph nodes enlarged.)
3. Gut masses ( Carcinoma of stomach, colon & Crohn s disease)
4. .Lipoma.of wall.( Echogenic structure in subcutaneous tissue.)
5. Obstruction of bowel.
6. Mesenteric cyst and lipomas.
7. Umbilical hernia.( Fluid filled bowel with PAS)
8. Rectus sheath hematoma
9. Anterior wall abscess.
10. .Retroperitoneal Tuberculosis & filariasis ( Lymph nodes enlarged).
11. Retroperitoneal sarcomas.( often fixed with post abdominal wall so not moving
with respiration. Pressure to Inferior vena cava may cause edema in lower
Limbs.)
TIPS.
1. If ascites present search for Cirrhosis liver or congestive cardiac failure ( Hypoechoic liver and dilated IVC and Hepatic veins)
2. If Para aortic /Coelic /mesenteric lymph nodes enlarged see for hepatosplenomegaly to clinch diagnosis of lymphoma.
3. If abdominal Aortic aneurysm seen trace iliac arteries for other site of aneurysm.
4. If gut mass present search for metastasis in liver (Carcinoma colon.).
5. If Mesenteric lymhnodes are enlarged search for matted intestines ,Hepatosplenomegaly & Ascites to exclude Kocks Abdomen.
PAIN AND LUMP IN LEFT ILIAC FOSSA
1 Carcinoma Sigmoid colon.
2 Diverticulitis
LUMP AND PAIN IN HYPOGASTRIUM
1. Distended urinary bladder.
2. Carcinoma urinary bladder.
3. Diseases of Uterus and its appendages.
4. Diseases of fallopian tubes and ovaries.
5. Cyst of Broad Ligament.
6. Pelvic abscess.
LUMP AND PAIN IN RIGHT ILIAC FOSSA
1. Ileocaecal mass ( Tuberculosis).
2. Carcinoma caecum.
3. Amoebic Typhilitis.
4. Impacted round worms ( Tube in Tube)
5. Crohn s Disease.
6. Appendicular mass
7. Pelvic abscess.
8. Rarely unascended kidney and undescended testis.
PYREXIA OF UNKNOWN ORIGIN ( PUO)
It is difficult problem for clinician in their clinical practice, but when sonologist is asked to help in arriving clinical diagnosis of PUO he must search evidence of following
diseases.
Sub phrenic abscess.
Sub hepatic abscess.
Hepatitis.
Cystitis.
Pyelonephritis.
Cholangitis.
Prostatitis.
Pancreatitis.
Hypernephroma.
Hepatoma.
Malaria.
Ka lazar.
SABE.
Typhoid.
Pleural effusion.
Post operative Collection of fluid pockets.( Cesarean section, hysterectomy and renal transplant)
HEMATURIA
Causes.
1 Pre renal
a. Purpura
b. Hemophilia
c. Leukemia
d. Drugs ( Salicylate, sulphonamide)
2 Disease of urinary tract.( renal ,Ureter,Bladder,Urethra)
3 Disease of Adjacent organ.
a. Carcinoma of rectum and uterus.
Infiltrating urinary bladder.
If hematuria in beginning - Urethral disease.
If hematuria at end - Bladder disease
If mixed hematuria through out the flow – it may be renal ,Pre renal or
Or Bladder disease.
If hematuria painless.
· Papilloma/ carcinoma
· Tuberculosis
If hematuria followed by Renal colic—Renal stone
If hematuria preceded by renal colic-- Tuberculosis etc.
Friday, June 20, 2008
AID TO ABDOMINAL ULTRASOUND
DR S.PRAKASH MD.
FOUNDER FELLOW INDIAN COLLEGE OF MEDICAL ULTRASOUND.
SENIOR CONSULTANT
TB SAPRU HOSPITAL.ALLAHABAD
UP INDIA.
INTRODUCTION
My motive of writing of this book is to give a ready hand book for sonographers and graduate students in sonology for immediate consultation at the time of doing abdominal sonography.It is not replacement of various voluminous text books of ultrasonography.
Abdominal ultrasound is used to evaluate soft tissue organs in abdomen.eg
LIVER
GALLBLADDER
SPLEEN
KIDNEY
PANCREAS
ABDOMINAL AORTA & OTHER VESSELS OF ABDOMEN
INFLAMED APPENDIX.
PREPARATION
1 For GB,LIVER,PANCREAS and AORTA fat free meal and 8 to 12 hrs fasting before test
2 For KIDNEY,URINARY BLADDER, URETER and PROSTRATE Fasting of 8 to 12 hrs done on evening before test to avoid gases.On the.day of test 1 hr before, 6 glass of water is to be taken to fill the bladder.
Abdominal ultrasound is done to solve various clinical problems as pain in abdomen,burning during micturation,hematuria, jaundice and stones in gallbladder and kidney.Beside this assessment of damages to various organs caused by diseases,blunt injury abdomen and guide lines procedure as needle biopsy and aspiration.also could be done.
Of course there is certain limitations of USG also as we can not evaluate stomach,intestine,colon and rectum as these organs are filled with gases and air which reflects the ultrasound waves. In obese persons tissues weakens the ultrasound waves creating problems when doing ultrasound,occasionly intestinal gases prevents visualization of Pancreas and Aorta.
BENEFITS.
1 Ultrasound is cheap and painless.
2 It is noninvasive.
3 No ionizing radiation.
4 Real time imaging and clear soft tissue pictures as compared to X-Ray.
5 No risk involved.
MEASUREMENTS
LIVER. .Liver is measured from mid spine to outer surface of liver in transverse scan.On longitudinal scan It can be measured in mid hepatic line from superior to inferior margins.Which should not exceed 13cm normaly,if it is more than 15.5cm, liver is said to be enlarged Between 13 cm and 15.5cm it is equivocal.
Some sinologist measures at mid clavicular line which should be less than 10.5cm +-1.5cm in longitudinal diameter and 8.1cm +-1.9 cm anteroposteriorly.if it is more than 15.5 cm hepatomegaly present.
SPLEEN. .Average adult spleen is 12 cm in length, 7 cm in breadth and 3-4cm in thickness.if it is more than 14 cm ,it is enlarged.When ever spleen is found extending below the lower pole of left kidney even then spleen could be taken enlarged..
PANCREAS. .Normal Transverse measurement is as follows
Head 2.08 cm+- 0.4cm
Body 1.16 cm+-0.29 cm
Neck 0.95 cm+-0.26 cm
Tail0.7 cm+-2.8 cm
However pancreas should not exceed following diameter anteroposteriorly
Head,Body.Tail each 3.5 cm
Neck 2.5cm
Pancreatic duct< 3mm.
Texture of Pancreas in comparison to liver is isosonic or hyperechoic.
RENALS. Normal size of kidney is 8 to 13 cm* 5cm.
Renal sinus contains major branches of renal artery ,veins and calyces,lying centrally
And is highly echogenic.
Renal cortex is normally 2.5 cm thick.
ADRENAl.GLAND. Normal size is 4 cm*2.5 cm*0.5 cm
PROSTRATE .Normal size in adult is
4 cm transversely * 2 cm Anteroposteriorly* 3 cm craniocaudaly.
Weight is 20 gms,weight can be calculated 4/3 r .( r is average of Anteroposterior+Transverse diameter.
LIVER
HEPATOMEGALY.
A. LARGE TENDER HEPATOMEGALY.
1.Congestive cardiac failure.
2.Amoebic Abscess./Hepatitis.
3.Infective Hepatitis.
4.Secondaries in Liver.
5.Infected Cyst.
B. NON TENDER HEPATOMEGALY.
1.Cirrhosis of Liver
2.Fatty Infilteration/Amyoloidosis.
3.Hepatoma
4.Lymphomas( Hodgekins.non Hodgekins lymphoma)
5.kalazar
6. Malaria
7. Hydatid cyst
8. Myelofibrosis.
C.Other causes are.
1.Tuberculosis
2.Typhoid
3 Lymphosarcoma.
4 Biliary cirrhosis
5Multiple myeloma
6.Lipoid Storage diseases( Gauchers disease)
7.Polycystic Disease.
8.Diabetes Mellitus
9.Toxic Hepatitis(Anaesthetic Drugs,Gold ,Dilantin)
10.Fungal Disease( Actinomycosis,Histoplasmosis)
11. Infectious mononucleosis.
BRIGHT LIVER.
Characteristic features are.
1.Strong echoes from liver parenchyma which is equal to peri portal structures
2.Liver appears flat,ground glass texture as normal peri vascular markings are
lost, all vessels appears as wall less cleft.
3.when compared with renals,renal parenchyma appears almost echo free
while liver is highly echogenic.
4.Echogenicity of liver parenchyma and ligamentum teres is same.
Causes are.
1.Micronodular cirrhosis of liver
2.Fatty infilterations..
3 .Chronic hepatitis.
4.Granulomas.
DARK LIVER
1.Liver parenchyma is of lower echogenicity than renal cortex
2. peri portal structures echoes are exaggerated.
3.Darkness of liver is due to more fluid present in parenchyma.
Causes are.
1Congestive cardiac failure.
2Acute infective hepatitis
3 Malignancy of liver
4 Lymph reticular tumour.
FATTY INFILTRATION OF LIVER
Causes are –
Diabetes Mellitus
Glycogen storage disease (Gauchers disease)
Obesity
Starvation & kwashiorkor
Alcoholic hepatitis
Others
Pregnancy
Corticosteroid
Hallothane / Tetracycline
Ulcerative Colitis
CIRRHOSIS OF LIVER
Sonological features of cirrhosis liver are very variable.
1. Liver may be enlarged with fatty change / may be normal in size /shrunken & scarred in late stages.
2. Highly echogenic(bright liver) seen in early cases where periportal structures are in apparent & appears like hepatic veins, while in others it may be normal.
3. Liver surface smooth but large regenerating nodule could be seen in post hepatitis cases.
4. Caudate lobe often enlarged which is a good index for cirrhosis of liver. Usually caudate lobe is half of the width of right lobe.
5. Ascites is seen which is transudate, no debris seen & bowel floats normally.
6. Portal vein more than 15 mm .
7. Splenic vein more than 10 mm in inspiration.
8. Portocaval anastomosis
· Oesophageal, splenic varices appears tortuous like bag of worms.
· Umbilical appears due to canalization of ligamentum teres.
AMOEBIC ABSCESS
Early cases are hyper echoic due to solid nature of abscess & it could be confused with meta static lesion of liver.
As liquefaction starts hypo echoic area appears due to collection of puss & necrotic debris. Occasionally mass is an echoic with floating debris inside cavity of abscess.
Initially abscess wall is irregular & shaggy but later it becomes smooth & outlined.
Post acoustic shadowing(PAS) often seen depending upon attenuation of puss.
Amoebic abscess cavity usually disappears in three months but occasionally it may last for one year or even more.
Usually amoebic abscess are single.
Site of the abscess is in right lobe superiorly close to diaphragm.
PYOGENIC ABSCESS
Pyogenic abscess are usually multiple.
Echo texture is similar to amoebic abscess varying from anechoic to highly echogenic.
Usually right lobe of liver due to streaming effect of portal vein.
Size vary from 1cm to any size.
Shape rounded are ovoid.
Walls irregular.
Posterior acoustic enhancement present.
HYDATID CYST
Commonly seen in right lobe of liver & is sub-capsular.
Well circumscribed, multilocular “cysts within cyst” i.e. daughter cysts within mother cyst.
Budding of germinal inner layer forming irregularities of cystic wall.
Hydatid sand(imperfectly formed daughter cyst) & calcification observed occasionally.
Many of daughter cysts are anechoic while some may have low level echoes due to debris.
If no daughter cysts seen then difficult to diagnose from simple cyst.
HEPATIC TUBERCULOSIS
1. Hepatic texture is non-homogeneous with scattered areas of increased & decreased reflectivity.
2. Some nodules could be located.
3. Caudate lobe may be enlarged.
4. Liver is enlarged.
HAEMANGIOMA
Cavernous type(where large sinusoidal blood vessels present)
Echo free focal lesions.
Irregular or lobulated wall.
No distal enhancement.
Occasionally complex lesion due to internal echoes are fluid- fluid level.
Capillary type(numerous small vessels present)
Echogenic(homogenous echo dense) masses.
Ill defined margin / sharply marginated.
Post acoustic shadowing present in masses more than 2.5 cm
Note- Haemangioma are to be confirmed by doppler study / angiography / biopsy(often catastrophic haemorrhage).
LIVER CELL ADENOMA
Solitary, marginated, encapsulated mass.
Common in woman taking oral contraceptives.
May present as palpable mass or pain in right hypochondrium.
If bleeding occurred it appears anechoic / hypo echoic or of greater density than surrounding liver parenchyma.
FOUNDER FELLOW INDIAN COLLEGE OF MEDICAL ULTRASOUND.
SENIOR CONSULTANT
TB SAPRU HOSPITAL.ALLAHABAD
UP INDIA.
INTRODUCTION
My motive of writing of this book is to give a ready hand book for sonographers and graduate students in sonology for immediate consultation at the time of doing abdominal sonography.It is not replacement of various voluminous text books of ultrasonography.
Abdominal ultrasound is used to evaluate soft tissue organs in abdomen.eg
LIVER
GALLBLADDER
SPLEEN
KIDNEY
PANCREAS
ABDOMINAL AORTA & OTHER VESSELS OF ABDOMEN
INFLAMED APPENDIX.
PREPARATION
1 For GB,LIVER,PANCREAS and AORTA fat free meal and 8 to 12 hrs fasting before test
2 For KIDNEY,URINARY BLADDER, URETER and PROSTRATE Fasting of 8 to 12 hrs done on evening before test to avoid gases.On the.day of test 1 hr before, 6 glass of water is to be taken to fill the bladder.
Abdominal ultrasound is done to solve various clinical problems as pain in abdomen,burning during micturation,hematuria, jaundice and stones in gallbladder and kidney.Beside this assessment of damages to various organs caused by diseases,blunt injury abdomen and guide lines procedure as needle biopsy and aspiration.also could be done.
Of course there is certain limitations of USG also as we can not evaluate stomach,intestine,colon and rectum as these organs are filled with gases and air which reflects the ultrasound waves. In obese persons tissues weakens the ultrasound waves creating problems when doing ultrasound,occasionly intestinal gases prevents visualization of Pancreas and Aorta.
BENEFITS.
1 Ultrasound is cheap and painless.
2 It is noninvasive.
3 No ionizing radiation.
4 Real time imaging and clear soft tissue pictures as compared to X-Ray.
5 No risk involved.
MEASUREMENTS
LIVER. .Liver is measured from mid spine to outer surface of liver in transverse scan.On longitudinal scan It can be measured in mid hepatic line from superior to inferior margins.Which should not exceed 13cm normaly,if it is more than 15.5cm, liver is said to be enlarged Between 13 cm and 15.5cm it is equivocal.
Some sinologist measures at mid clavicular line which should be less than 10.5cm +-1.5cm in longitudinal diameter and 8.1cm +-1.9 cm anteroposteriorly.if it is more than 15.5 cm hepatomegaly present.
SPLEEN. .Average adult spleen is 12 cm in length, 7 cm in breadth and 3-4cm in thickness.if it is more than 14 cm ,it is enlarged.When ever spleen is found extending below the lower pole of left kidney even then spleen could be taken enlarged..
PANCREAS. .Normal Transverse measurement is as follows
Head 2.08 cm+- 0.4cm
Body 1.16 cm+-0.29 cm
Neck 0.95 cm+-0.26 cm
Tail0.7 cm+-2.8 cm
However pancreas should not exceed following diameter anteroposteriorly
Head,Body.Tail each 3.5 cm
Neck 2.5cm
Pancreatic duct< 3mm.
Texture of Pancreas in comparison to liver is isosonic or hyperechoic.
RENALS. Normal size of kidney is 8 to 13 cm* 5cm.
Renal sinus contains major branches of renal artery ,veins and calyces,lying centrally
And is highly echogenic.
Renal cortex is normally 2.5 cm thick.
ADRENAl.GLAND. Normal size is 4 cm*2.5 cm*0.5 cm
PROSTRATE .Normal size in adult is
4 cm transversely * 2 cm Anteroposteriorly* 3 cm craniocaudaly.
Weight is 20 gms,weight can be calculated 4/3 r .( r is average of Anteroposterior+Transverse diameter.
LIVER
HEPATOMEGALY.
A. LARGE TENDER HEPATOMEGALY.
1.Congestive cardiac failure.
2.Amoebic Abscess./Hepatitis.
3.Infective Hepatitis.
4.Secondaries in Liver.
5.Infected Cyst.
B. NON TENDER HEPATOMEGALY.
1.Cirrhosis of Liver
2.Fatty Infilteration/Amyoloidosis.
3.Hepatoma
4.Lymphomas( Hodgekins.non Hodgekins lymphoma)
5.kalazar
6. Malaria
7. Hydatid cyst
8. Myelofibrosis.
C.Other causes are.
1.Tuberculosis
2.Typhoid
3 Lymphosarcoma.
4 Biliary cirrhosis
5Multiple myeloma
6.Lipoid Storage diseases( Gauchers disease)
7.Polycystic Disease.
8.Diabetes Mellitus
9.Toxic Hepatitis(Anaesthetic Drugs,Gold ,Dilantin)
10.Fungal Disease( Actinomycosis,Histoplasmosis)
11. Infectious mononucleosis.
BRIGHT LIVER.
Characteristic features are.
1.Strong echoes from liver parenchyma which is equal to peri portal structures
2.Liver appears flat,ground glass texture as normal peri vascular markings are
lost, all vessels appears as wall less cleft.
3.when compared with renals,renal parenchyma appears almost echo free
while liver is highly echogenic.
4.Echogenicity of liver parenchyma and ligamentum teres is same.
Causes are.
1.Micronodular cirrhosis of liver
2.Fatty infilterations..
3 .Chronic hepatitis.
4.Granulomas.
DARK LIVER
1.Liver parenchyma is of lower echogenicity than renal cortex
2. peri portal structures echoes are exaggerated.
3.Darkness of liver is due to more fluid present in parenchyma.
Causes are.
1Congestive cardiac failure.
2Acute infective hepatitis
3 Malignancy of liver
4 Lymph reticular tumour.
FATTY INFILTRATION OF LIVER
Causes are –
Diabetes Mellitus
Glycogen storage disease (Gauchers disease)
Obesity
Starvation & kwashiorkor
Alcoholic hepatitis
Others
Pregnancy
Corticosteroid
Hallothane / Tetracycline
Ulcerative Colitis
CIRRHOSIS OF LIVER
Sonological features of cirrhosis liver are very variable.
1. Liver may be enlarged with fatty change / may be normal in size /shrunken & scarred in late stages.
2. Highly echogenic(bright liver) seen in early cases where periportal structures are in apparent & appears like hepatic veins, while in others it may be normal.
3. Liver surface smooth but large regenerating nodule could be seen in post hepatitis cases.
4. Caudate lobe often enlarged which is a good index for cirrhosis of liver. Usually caudate lobe is half of the width of right lobe.
5. Ascites is seen which is transudate, no debris seen & bowel floats normally.
6. Portal vein more than 15 mm .
7. Splenic vein more than 10 mm in inspiration.
8. Portocaval anastomosis
· Oesophageal, splenic varices appears tortuous like bag of worms.
· Umbilical appears due to canalization of ligamentum teres.
AMOEBIC ABSCESS
Early cases are hyper echoic due to solid nature of abscess & it could be confused with meta static lesion of liver.
As liquefaction starts hypo echoic area appears due to collection of puss & necrotic debris. Occasionally mass is an echoic with floating debris inside cavity of abscess.
Initially abscess wall is irregular & shaggy but later it becomes smooth & outlined.
Post acoustic shadowing(PAS) often seen depending upon attenuation of puss.
Amoebic abscess cavity usually disappears in three months but occasionally it may last for one year or even more.
Usually amoebic abscess are single.
Site of the abscess is in right lobe superiorly close to diaphragm.
PYOGENIC ABSCESS
Pyogenic abscess are usually multiple.
Echo texture is similar to amoebic abscess varying from anechoic to highly echogenic.
Usually right lobe of liver due to streaming effect of portal vein.
Size vary from 1cm to any size.
Shape rounded are ovoid.
Walls irregular.
Posterior acoustic enhancement present.
HYDATID CYST
Commonly seen in right lobe of liver & is sub-capsular.
Well circumscribed, multilocular “cysts within cyst” i.e. daughter cysts within mother cyst.
Budding of germinal inner layer forming irregularities of cystic wall.
Hydatid sand(imperfectly formed daughter cyst) & calcification observed occasionally.
Many of daughter cysts are anechoic while some may have low level echoes due to debris.
If no daughter cysts seen then difficult to diagnose from simple cyst.
HEPATIC TUBERCULOSIS
1. Hepatic texture is non-homogeneous with scattered areas of increased & decreased reflectivity.
2. Some nodules could be located.
3. Caudate lobe may be enlarged.
4. Liver is enlarged.
HAEMANGIOMA
Cavernous type(where large sinusoidal blood vessels present)
Echo free focal lesions.
Irregular or lobulated wall.
No distal enhancement.
Occasionally complex lesion due to internal echoes are fluid- fluid level.
Capillary type(numerous small vessels present)
Echogenic(homogenous echo dense) masses.
Ill defined margin / sharply marginated.
Post acoustic shadowing present in masses more than 2.5 cm
Note- Haemangioma are to be confirmed by doppler study / angiography / biopsy(often catastrophic haemorrhage).
LIVER CELL ADENOMA
Solitary, marginated, encapsulated mass.
Common in woman taking oral contraceptives.
May present as palpable mass or pain in right hypochondrium.
If bleeding occurred it appears anechoic / hypo echoic or of greater density than surrounding liver parenchyma.
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