Thursday, December 30, 2010

Sonography of renal sinus lipomatosis

This middle aged patient presented with non specific complaints and we did a routine abdominal ultrasonography on him. This is what we found on ultrasound imaging of the kidneys:














Both kidneys showed echogenic matter within the region of the renal sinuses- and this was more prominent in the left kidney. The large echogenic mass like appearance in the lower part of the left renal sinus prompted us to think that this could be angiomyolipoma, one of the more common entities in the kidney. However, further imaging showed that this hyperechoic deposit was almost totally within the confines of the renal sinuses. Besides the lesions were bilateral.
 See ultrasound video clips below:
video 
Further observe the vessels within the renal sinus of the left kidney in this color Doppler ultrasound video clip below:
video 
The most obvious diagnosis based on these ultrasound images and video clips is renal sinus lipomatosis.
The uniformly homogenous appearance of the fatty tissue in the renal sinus suggests lipomatosis rather than any more ominous masses/ malignancies of the renal sinus. These ultrasound findings are suggestive of a grade -1 renal sinus lipomatosis of both kidneys.
References: http://www.jultrasoundmed.org/cgi/reprint/21/9/993 (free excellent article with images)
For more ultrasound/ color Doppler images of this case see:

Saturday, December 11, 2010

Subependymal cysts:

This neonate has a relatively large subependymal cyst close to the caudato-thalamic groove (ie the groove between the caudate nucleus and thalamus) of the fetal brain. Ultrasound videos taken in both the sagittal and coronal sections help confirm this diagnosis. The ultrasound video clip below shows a coronal section of the neonatal brain with the lesion displayed well.
video 
The ultrasound video clip below shows a sagittal section through the neonatal brain displaying the subependymal cyst. The video clip pans from the lateral to the medial aspect of the neonatal brain, with focus on the subependymal cyst.




video
Still ultrasound images of this same neonatal brain are shown below: (see coronal images below):


























This supendymal cyst is almost 7 to 8 mm. in dimension and needs careful follow up ultrasound imaging.
Parasagittal section image below shows another view of the subependymal cyst:













Visit:
http://www.ultrasound-images.com/pediatric.htm#Another_complication_of_subependymal_hemorrhage-_subependymal_cysts for more information and images of similar cases.

Saturday, December 4, 2010

Blunt trauma to testes with rupture:

This 25 yr. old male came to me with a history of severe blunt injury to the left scrotum. On inquiring further, he reported that the part of a heavy machine hit him squarely without causing any bleeding. However, the left scrotum was moderately swollen and markedly painful.
Ultrasound imaging of the scrotum revealed (see ultrasound video clip below):
video
 Observe the large hypoechoic (dark) inhomogenous area in the left testis. This is a typical appearance of an intratesticular hematoma. But is that all? The right half of the video shows partial rupture of the outer covering of the left testis (tunica albuginea). Do we see anything more? There is some spillage of the lateral part of the testicular parenchyma outside the confines of the testicular capsule.
See some more color Doppler ultrasound videos of this testicular trauma- below:
video
Observe normal vascularity (blood flow) of the main testicular tissue (in the above long section of the left testis). This is a good sign and shows that the injured left testis is viable and does not need to be removed surgically. However, the lower pole of the left testis does show vessels entering the tissue that has spilled out of the capsule of the testis. This confirms that seminiferous tubules from the testis have been pushed out of the rupture site (of the left testicular fibrous capsule). In addition, there is a moderately large hemorrhagic fluid collection in the left scrotum (left hematocele).
Visit this link to read more on this topic:
http://www.ultrasound-images.com/acute-scrotum.htm#Testicular_trauma_%28rupture_of_testes_or_fracture_testes%29:_
We have one more color Doppler ultrasound video (this time a transverse section of the left testis):
video 
Observe the linear strip of tissue hanging (or floating) within the hematocele in the left scrotum. This could be left testicular tissue with part of the body of the left epididymis.
Here are the ultrasound/ color Doppler images of this case of testicular trauma:















This last image is a transverse section section of the testis showing the site of rupture of the tunica albuginea, using Power Doppler imaging. The intratesticular hematoma is also seen.

Tuesday, November 23, 2010

A small vascular lesion behind the thyroid

This color Doppler ultrasound image of the left lobe of the thyroid raised more queries than answers.
The lesion only 4 mm. in size. But located in a typical location in posterior aspect of the upper pole of left lobe of thyroid.














Markedly vascular lesions in this location are usually parathyroid adenomas. The gray scale ultrasound image suggests a solid lesion, thus suggestive of an adenoma of the parathyroid gland.






























Such a highly vascular lesion can also suggest a possibility of an Arterio-venous malformation of the thyroid or the parathyroid. This is where this color Doppler ultrasound video might help (see below): this video shows a transverse section through the left lobe.
video


This color Doppler video clip below shows a long section of the left lobe of thyroid. The lesion is seen posteriorly.
video

See: http://www.ultrasound-images.com/thyroid.htm for more.
Specifically about parathyroid adenomas- visit:
http://www.ultrasound-images.com/thyroid.htm#Parathyroid_adenoma

Wednesday, November 17, 2010

Pedunculated cervical polyp- Ultrasound videos:

Polyps (small outgrowths) are known to occur in the cervical canal (the lumen of the lower third of the uterus), anytime from puberty to menopause. However, they are rare in menopausal women and even rarer in puberty. They are common in women over the age of 20 years and who have had children.
What is the cause of cervical polyps? It is believed that cervical polyps are the result of long term insult or inflammation of the lining (mucosa) of the cervical canal. Also, changes in estrogen levels can also cause polypoid growths to form in the cervical canal (endo-cervix).
What are the main symptoms of a polyp in the cervix? The common presenting symptoms are pain in the lower pelvis, vagina, discharge from the vagina- mucous or blood, irregular and painful menses etc.
What are the types of cervical polyps? The common types of polyps of the cervix are the sessile polyps (which have no stalk are seen as small projections from the endo-cervical lining). The rarer type is the pedunculated polyp of the cervix. This type of pedunculated cervical polyp has a long stalk connecting the growth to the lining  of the cervix. It may project into the vagina, and be confused with a endometrial polyp (a polyp of the body of the uterus) or small fibroid.
One the methods of diagnosing a cervical polyp is by ultrasound and color Doppler imaging of the uterus, best seen on transvaginal ultrasound (inserting the ultrasound probe via the vagina).
Present case (pedunculated polyp of the cervix):
This woman is an unusual case in that she is in the perimenopausal age (47 years) and has severe pain  in the lower pelvis with irregular menses.
This is what we saw on transvaginal ultrasound imaging (see sagittal section ultrasound video clip below):
video
 There is an elongated hyperechoic (bright) mass within the cervical canal (arrows).
video
 Power Doppler ultrasound video shows large feeder blood vessels supplying the mass (growth). This is a typical appearance. (See sagittal section Power Doppler video clip above).
Color Doppler ultrasound video clip (below) further confirms the highly vascular nature of the growth in the cervical lumen. It is elongated and fills the length of the cervix.
video
We performed a transverse section ultrasound imaging of the cervix, and this is what we saw (see the color Doppler video clip below):
video

The feeder vessels are seen entering and coursing through the entire polyp within the cervix.
Can such growths of the cervical lumen be cancerous? Generally, cervical polyps are benign (almost 99 % of polyps of the cervix are non cancerous). However, the highly vascular nature of the growth in this case, warrants further examination, at least a PAP smear and a study of the specimen after surgery is also advisable. 
 For further reading on this topic see this article on: Ultrasound imaging of Cervical polyps
For more ultrasound images of this case and more on imaging of the uterus, see:
http://www.ultrasound-images.com/uterus.htm

Tuesday, November 16, 2010

Mucosal edema of bladder following recent passage of calculus:

This patient underwent ultrasound imaging to rule out urinary stones. This is what we found in the urinary bladder:
video
The urinary bladder mucosa shows marked edema around the region of the left ureteric orifice (opening of left ureter into the urinary bladder). So could this be a malignancy or polyp of the bladder mucosa? Fortunately this patient gave a history of passing a calculus (stone) the same day. This suggests that the "mass" appearance in the left wall of the bladder is mucosal edema (mucosa is the inner lining of the urinary bladder), due to the stone being lodged in the left vesico-ureteric junction (distal end of left ureter).
Here are the ultrasound images of the same case:
The lesion is seen clearly. But the appearance is very similar to that of a bladder malignancy.
Color Doppler ultrasound image shows no significant vascularity (blood flow) within the mass (lump) (arrows). This again suggests a more benign nature of the mass.
The kidneys show small echogenic foci (one in each kidney) suggestive of renal calculi, with no backpressure  changes.
For more bladder related diseases and ultrasound study of these cases see:
http://www.ultrasound-images.com/urinary-bladder.htm

Thursday, November 11, 2010

Multiple Nabothian cysts of the cervix

video 
This middle aged woman presented with irregular menses. Transvaginal ultrasound (see video clip above) shows multiple cysts of the cervix (transverse section of the cervix). This is the typical appearance of Nabothian cysts of the cervix. Nabothian cysts are also called mucinous retention cysts or Nabothian follicles of the cervix and are usually of little clinical significance unless complicated by infection or if they become unusually large. Most such cysts usually disappear without medical treatment. 
Here is a sagittal section ultrasound video of the same cervix (transvaginal):

video
As stated above, these Nabothian cysts of the cervix do not appear ominous in any way. However, the cause of this patient's complaints appear to be due to (see ultrasound images below):


The endometrium (the inner lining of the uterus) is seen to be markedly thickened (at 13 mm.). On color Doppler imaging of the uterus (both transabdominal and transvaginal), the endometrium does not show any vascular areas or increased blood flow within any part of it. This kind of thickening of the endometrium is called endometrial hyperplasia and needs further investigation. A pap smear of the cervical fluid showed some degree of squamous metaplasia. This patient needs to be monitored and might need treatment for the hyperplastic changes in the endometrium. 
For more ultrasound and color Doppler images of uterine pathology see:

Wednesday, November 10, 2010

Unusual bilateral ectopic fused kidneys:

The left and right kidneys appear to be ectopic with some degree of fusion of both kidneys, anterior to the mid line- the right kidney being located somewhere just below the liver and anterior to the spine; the left kidney located just behind the urinary bladder.
Have a look at this ultrasound video clip, panning from the bladder to the liver showing both kidneys, in the sagittal and oblique sagittal planes.
video 


video 

Some more ultrasound videos of the bilateral ectopic kidneys follow....
The left kidney is seen below- posterior to the urinary bladder in this B-mode ultrasound video (gray scale):

video

Have a look at the ectopic right kidney, located anterior to the spine, in this right parasagittal section ultrasound video clip:
video
Note the empty right renal fossa with the right kidney in an abnormal position.
Now the transverse section through the right kidney- see below:

video
References: http://www.springerlink.com/content/92207432001l2538/
http://www.ultrasound-images.com/kidneys.htm
S-shaped fusion of kidneys
Crossed renal ectopia (good article)
Pictorial display of various kidney fusion anomalies 
It is possible that the kidneys seen above may a variant of S-shaped or L-shaped fusion anomaly of the kidneys.

Friday, November 5, 2010

Normal Gallbladder variants- Phrygian cap:

The Phrygian cap shape of the gallbladder (Gall Bladder) is a known variant. See ultrasound image below:












 

The gallbladder shows a septate appearance in this image. But is this really a septate gallbladder? See ultrasound video clip below:
video
Still not sure? See the ultrasound video clip below:
video 
The commonest cause for the"septate" appearance of the gallbladder is the Phrygian cap anatomical variant. For more on this topic see: http://www.ultrasound-images.com/gall-bladder.htm  The best method to demonstrate this variant of the GB is to unfold the gallbladder, by angling the probe to the length of the gallbladder- this displays the "cap" formed by the GB fundus. (See ultrasound picture below)-
 













The picture above shows the "unfolded" view of the gallbladder, with the Phrygian cap (arrow) clearly.

Thursday, November 4, 2010

Bowel mass- sigmoid carcinoma:

This middle aged male adult patient has a mass just above the urinary bladder. Ultrasound video clip of the mass is seen in sagittal section:
video
The mass shows an echogenic central area with hypoechoic, surrounding soft tissue area. This is called the "target sign" and is typical of colonic malignancy.
video
 Yet another sagittal ultrasound video clip shows the mass with the thickened sigmoid colon walls. Also note the absence of normal layered appearance of the normal large bowel.
video
This color Doppler ultrasound video shows the sigmoid colon mass to be poorly vascular. The mass has all the appearances of a sigmoid carcinoma.
video
 The close proximity of the mass to the urinary bladder (upper pelvis) and target sign are an indication of the mass originating from the sigmoid colon. The liver appeared normal. Close follow up and CT scan imaging are needed to rule out lymph node spread.
See more ultrasound images and description of this case at:
http://www.ultrasound-images.com/colon.htm
http://emedicine.medscape.com/article/367061-imaging

Tuesday, November 2, 2010

Double J -ureteric stent (ureteral stent):

video 

This longitudinal section ultrasound video of the right kidney shows persistent mild hydronephrosis, despite the presence of the double J stent (DJ stent or ureteral stent) in the right ureter.
video 

 The above ultrasound video shows the transverse section of the hydronephrotic right kidney with the upper end of the ureteral stent in the distended renal pelvis.
Reference: http://en.wikipedia.org/wiki/Ureteric_stent 
See the following link for article and images of ureteral stent:
See: http://cochinblogs.blogspot.com/2010/04/ultrasound-imaging-of-ureteral-stent.html 

Focal epididymitis:

This color Doppler ultrasound video shows a long section of the right testis- observe the lower pole.


video
The right tail of epididymis definitely appears inflamed. Now observe this transverse section color Doppler video clip through the right testis panning from the upper to the lower poles.


video

 There is a small right hydrocele which outlines the head and body of the right epididymis. The diagnosis in this case is focal right epididymitis involving primarily the tail.
Here is the still ultrasound image of the affected right testis:
And the color Doppler image of the same case: (right testis and epididymis):





















And the still ultrasound image of the normal left testis (above).
For more on this topic see: http://www.ultrasound-images.com/scrotal-infections.htm

Saturday, October 30, 2010

Tuberculous epididymitis/ epididymo-orchitis:

This middle aged male patient presented with a mass in the left scrotum which was mildly painful. This ultrasound video shows a transverse section through the left scrotum, with the probe panning from the lower to upper poles of the left testis.
video 
What do we see? Note the small hydrocele around the large, nodular hypoechoic mass in the lower pole of left testis. The mass originates in the tail of the left epididymis, and extends into the lower tip of the left testis.  In addition note the thickened scrotal wall. 
Have a look now, at the color Doppler and Power Doppler ultrasound videos of the left scrotum.

video
The above video clip is a color Doppler sonography study which shows marked vascularity of the "mass" in the tail of left epididymis. Note the thickened body of the left epididymis as we pan upwards.
What does this suggest? Clearly the mass is primarily a lesion involving the left epidiymis from body to the tail and the small hydrocele all point to an inflammatory pathology. The commonest cause of such an appearance is tuberculous epididymitis with orchitis (involvement of the adjacent left testis). The 2nd diagnostic possibility in such a case is pyogenic/ non tuberculous orchitis- in non tuberculous orchitis or non tuberculous epididymitis, the epididymis would be homogenously enlarged, compared to the inhomogenous mass that is seen in this case. See: Tuberculous epididymo- orchitis article(AJR)  
  video This sagittal to parasagittal section Power Doppler ultrasound video clip of the left testis further confirms the findings mentioned above.
The last video- a zoomed in view of the mass:

video