Ultrasound Basic

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Tubo-ovarian abscess

Complex fluid next to the ovary creating what appears to be a large adnexal mass, is likely what?

The proliferative phase, because it has a trilaminar, hypoechoic appearance, making the hyperechoic polyp stand out. During the secretory phase, the endometrium is hyperechoic and may obscure a polyp.

During which phase of menses is it easiest to detect an endometrial polyp?

Posterior acoustic shadowing from the calculi. There will be no posterior shadow from a fungus ball.

How can you tell a group of bladder calculi from a fungal ball?

More. The pancreas should be brighter. Caveat = hepatic steatosis

Should the pancreas be more, or less echogenic than the liver?

Bladder paragangliomas, which are intramural lesions

What GU lesion is associated with hypotension with micturition?

Conditions characterized by the accumulation of cholesterol (and other fats) in the gallbladder. There are two main forms: 1) Adenomyomatosis: mucosal hyperplasia with growth toward the muscular layer - thickened muscular layer. Cholesterol accumulation is intraluminal (within the Rokitansky-Aschoff sinuses), therefore, lined by mucosal epithelium 2) Cholesterolosis: mucosal hyperplasia with the accumulation of cholesterol esters and triglycerides in the macrophages of the lamina propria - appearance is known as "strawberry gallbladder"

What are gallbladder cholecystoses?

Nabothian cysts are anechoic cysts within the substance of the cervix. When there are multiple nabothian cysts, they may distort the canal and mimic a multicystic mass. However the location is helpful as they are not within the endocervical canal. Avascular septations and internal debris within nabothian cysts are commonly seen and of no clinical significance.

What are nabothian cysts?

Tiny pockets within the GB wall. Cholesterol accumulates within them in gallbladder adenomyomatosis.

What are the Rokitansky-Aschoff sinuses?

Cumulus oophorus: refers to an appearance in the ovary in which multiple granulosa cells enlarge around a developing oocyte. Immediately before ovulation, 1 or more tiny peripheral curved lines may be visible within an ovarian follicle, which indicates that the ova are surrounded by cumulus oophorus within the mature follicle.

What are the curvilinear lines along the margin of the ovarian cyst?

The diagnosis of a varicocele is made when multiple dilated veins of the pampiniform plexus measuring greater than 3 mm are seen in the scrotum due to reflux in the gonadal vein. With valsalva, reflux into these veins is augmented (Valsalva during color doppler). Varicoceles are usually a left-sided process but occasionally bilateral.

What are the diagnostic findings of varicocele?

C: cortical necrosis O: oxalosis A: Alport syndrome G: (chronic) glomerulonephritis

What are the main causes of cortical nephrocalcinosis?

Potential complications of pancreatitis should be excluded, including pseudocyst and abscess formation, necrosis, pancreatic ascites, pleural effusion (usually left-sided), pseudoaneurysm formation, as well as thrombosis of the splenic, superior mesenteric and portal veins. Obstructing, intraductal stones should also be excluded as a potential cause of pancreatitis.

What are the pertinent negatives of pancreatitis?

An area of high-velocity flow between an artery and vein is usually seen as an area of aliasing on color Doppler. High-velocity, continuous, pulsatile jet on waveform.

What are the sonographic findings of a AV fistula?

Findings typical of a hemorrhagic ovarian cyst include 1) A reticular pattern 2) Retractile clot 3) Avascular 4) Circumferential flow in stretched ovarian parenchyma may be seen around the hemorrhagic cyst on color Doppler.

What are the sonographic findings of a hemorrhagic ovarian cyst?

1) Anechoic lumen 2) A well-defined back wall with posterior acoustic enhancement 3) Smooth inner contour without nodularity Color Doppler imaging should be performed to exclude vascular lesions, including aneurysms and vascular malformations. This ultrasound has all the features of a benign cyst and does not require follow-up.

What are the sonographic findings of a simple hepatic cyst?

1) Anechoic lumen 2) A well-defined back wall 3) Posterior acoustic enhancement 4) No wall irregularity. Additionally, perform color Doppler to rule out vascular lesion (e.g., pseudoaneurysm). Simple cysts do not require follow-up.

What are the sonographic findings of a simple renal cyst?

-dilatation of pampiniform plexus veins >2-3 mm in diameter 3,4 -characteristically have a serpiginous appearance -there can be flow reversal with the Valsalva maneuver 4 -Doppler ultrasound can be used to grade the degree of reflux

What are the sonographic findings of varicocele?

-Marked pancreatic duct dilation -coarse calcifications Other imaging features may include parenchymal atrophy, pseudocysts, and chronic splenic vein occlusion with gastric varices.

What are the sonographic hallmarks of chronic pancreatitis?

- Dilated ureter - Posterior acoustic shadowing - Twinkling artifact - Absence of ureteral jet

What are the sonographic signs of UVJ obstruction with a renal stone?

1) Area of focal increased echogenicity 2) Possible associated mild contour deformity 3) Decreased vascularity on doppler 4) Urothelial thickening There is overlap in the imaging appearance of renal infarction but in this case there is also urothelial thickening

What are the ultrasound findings associated with pyelonephritis?

Fluid within a simple cyst is weakly attenuating to ultrasound beams. Echoes received from areas distal to hypoattenuating material will appear more intense than other echoes from similar depths. This is known as posterior acoustic enhancement, or increased through transmission. It is one of the imaging features of a cyst on ultrasound.

What is posterior acoustic enhancement?

The resistive index (RI) is an expression of systolic/diastolic ratio. When diastolic flow is impaired, the RI goes up. Impaired diastolic flow reflects a high resistance vascular bed in the rejecting transplant kidney (or the native kidney, due to medical renal disease). Impaired diastolic flow may also be seen in renal vein thrombosis (RVT), though complete RVT will often cause reversal of diastolic flow that results in a RI > 1.0.

What is resistive index?

Reverberation artifact may make the anterior wall difficult to completely evaluate, so always scan from multiple angles to thoroughly evaluate.

What is reverberation artifact?

Failure of normal posterior anchoring of the gubernaculum, epididymis and testis is called a bell clapper deformity because it leaves the testis free to swing and rotate within the tunica vaginalis of the scrotum much like the gong (clapper) inside of a bell. Twisting of the testis on the axis of the spermatic cord is called spermatic cord torsion.

What is the "Bell-clapper" deformity?

Mobile low level internal echoes in the fluid of a spermatocele represent nonviable sperm. In real-time imaging these will move, due to the ultrasound force creating a "falling snow" or "snow globe" appearance, which can differentiate these from a simple epididymal cyst.

What is the "falling snow" or "snow globe" sign of testicular ultrasound?

The bowel wall has five layers, composed of alternating hyperechoic and hypoechoic appearances. Anatomically these layers are as follows (innermost to outermost): -superficial mucosa: echogenic -muscularis mucosa: hypoechoic -submucosa: echogenic (this is the thickest layer) -muscularis propria: hypoechoic -serosa: echogenic The gut signature can be used to differentiate benign conditions, where gut signature is preserved and long segments of bowel are involved from malignant conditions where there is destruction of gut signature usually short segments of bowel 2.

What is the "gut signature"?

Acoustic shadowing from the hyperechoic part of an ovarian dermoid cyst and/or teratoma. This may be misinterpreted as bowel gas and the lesion may be overlooked. A fat-fluid level may be present, caused by fat floating on more aqueous fluid. Multiple thin, echogenic lines or stripes may be seen, caused by hair floating in the cyst cavity. Mature cystic teratomas, even though benign, are often resected because of increased risk of ovarian torsion, the most commonly associated complication.

What is the "tip of the iceberg" sign?

MRI

What is the best modality for resolving whether an adnexal mass in ovarian or a pedunculated fibroid?

Epidermoid cysts, a benign intratesticular lesion, have a characteristic onion skin or ringed appearance

What is the characteristic appearance of an epidermoid testicular cyst?

Endometriomas typically are unilocular with diffuse internal low-level echoes and have increased through transmission

What is the characteristic ultrasound appearance of an ovarian endometrioma?

A well-defined hyperechoic mass arising from the endometrium, with a feeding vessel in the stalk on color doppler.

What is the classic sonographic appearance of an endometrial polyp?

-Unless repaired within 72 hours, salvage rate only 45% -Follow-up of conservatively treated testicular hematomas is essential due to increased risk of infection, which may result in orchiectomy -Orchiectomy (total or partial) is performed for nonviable testis in testicular rupture -Surgical exploration and drainage must be performed for large intratesticular hematomas -Tumors may be discovered after trauma, consider tumor if there is internal color flow in an intratesticular lesion

What is the clinical importance of testicular trauma?

Mild hydronephrosis is characterized by splaying of the calyces, with a continuous echogenic renal sinus outlining the calyces and normal cortical thickness

What is the definition of mild hydronephrosis in adults?

Moderate hydronephrosis refers to ballooning of the calyces, thinning of the echogenic renal sinus, and normal or thinned cortex.

What is the definition of moderate hydronephrosis in adults?

In severe hydronephrosis, there is marked dilation of the renal pelvis and calyces, loss of the echogenic renal sinus, and cortical thinning.

What is the definition of severe hydronephrosis in adults?

Duplicated collecting system. Associated with uterine Mullerian defects in women.

What is the diagnosis?

Spermatic cord hematoma

What is the diagnosis?

Testicular fracture/rupture.

What is the diagnosis?

Testicular microlithiasis. "Starry sky" appearance. 50% of testicular germ cell tumors have concominant microlithiasis, but there is no definitive evidence that microlithiasis increases risk of testicular cancer. Must have at least 5 calcifications per testicle.

What is the diagnosis?

Varicocele

What is the diagnosis?

The differential for a peritransplant fluid collection includes hematoma, seroma, urinoma, lymphocele, and abscess. The timing of the collection in relation to transplant is helpful to pinpoint the diagnosis. Hematoma and seroma are most common in the immediate post-transplant period. Urinoma usually appears within 3 weeks of transplant and is often symptomatic. Lymphoceles present 1-2 months after transplant in up to 15% of patients. Abscess can occur any time and is accompanied by fever, pain, and elevated white blood cell count.

What is the differential for post renal transplant perinephric fluid collection?

The estimated incidence is at ~15% of the general male population and ~40% of subfertile and infertile men (the most common cause of correctable male infertility). Varicoceles are rare in children under the age of ten years, however they may be seen in up to 10-15% adolescents.

What is the epidemiology of varicocele?

Most varicoceles are primary and result from incompetent or congenitally-absent valves in the testicular vein (internal spermatic vein). The left testicle is affected much more commonly (≈85%) than the right. This may be due to the shorter course of the right testicular vein and its oblique insertion into the IVC which creates less backpressure. Bilateral varicoceles are not uncommon (≈15%), but isolated right varicoceles are rare and should prompt evaluation for a secondary varicocele. Secondary varicoceles are much less common and result from increased pressure in the testicular vein due to compression (e.g. extrinsic mass), obstruction (e.g. renal vein thrombus), or splenorenal shunting (portal hypertension).

What is the etiology of varicocele?

The appendix testis (hydatid of Morgagni) is a müllerian duct remnant and is attached to the upper pole of the testis in the groove between the testis and the epididymis. If these torse, they can be a source of scrotal pain. The torsed remnant may calcify, creating a scrotal "pearl."

What is the hydatid of Morgagni?

Typical appearance of medullary nephrocalcinosis where the medulla is as echogenic as the renal sinus fat. This results in a kidney that falsely appears to have a thin renal parenchyma when in fact the hypoechoic portion of the kidney is only the renal cortex . Patients with medullary nephrocalcinosis are at increased risk of developing renal stones. Renal medullary nephrocalcinosis is the commonest form of nephrocalcinosis and refers to the deposition of calcium salts in the medulla of the kidney. Due to the concentrating effects of the loops of Henle, and the biochemical milieu of the medulla, compared to the cortex, it is 20 times more common than cortical nephrocalcinosis.

What is the likely diagnosis?

<5 cm; no follow up necessary Presumed hemorrhagic cysts > 5 cm should be described in the imaging report and short-interval follow-up (6-12 weeks) with ultrasound is recommended to ensure resolution.

What is the management of presumed hemorrhagic ovarian cysts?

Extratesticular hematocele

What is the most common finding after scrotal trauma?

90% of obstructions resulting in allograft hydronephrosis occur at the ureterovesicular junction. True obstruction results from ureteral stricture, blood clot, fungal ball, or calculus. Very rarely, a sloughed papilla or ureteric compression by perigraft fluid collections may cause ureteral obstruction. Nonobstructive causes of hydronephrosis include vesicoureteral reflux, rejection, decreased ureteral tone, or ureteral kinking.

What is the most common site of renal allograft hydronephrosis?

Seminomas are the most common type of testicular tumor, accounting for ~ 50% of all germ cell tumors. They are predominantly homogeneous in appearance.

What is the most common testicular tumor?

Fat is typically echogenic on ultrasound, and this appearance is highly suggestive of macroscopic fat within an angiomyolipoma (AML). Some renal cell carcinomas can have this appearance, especially when small; therefore, follow-up or additional imaging is often required. While benign, AMLs are at risk for hemorrhage when > 4 cm.

What is the most likely diagnosis of this lesion?

Cholesterolosis (strawberry gallbladder) Accumulation of cholesterol esters and triglycerides in the macrophages of the lamina propria