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.