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.
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.

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)  
  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:

Thursday, October 28, 2010

Chronic pyelonephritis- atrophic kidney:

This adult male patient had recurrent calculi in the right kidney. Ultrasound video clip (long axis view) of the right kidney shows:
Note the small right kidney with irregular contour suggesting chronic infection/ pyelonephritis.
Color Doppler video clip of right kidney shows poor vascularity in the right kidney, again confirming atrophic changes and poor functionality in this kidney.

The normal left kidney is shown for comparison in this color Doppler ultrasound video clip. There is a certain degree of compensatory hypertrophy in this kidney.

Tuesday, October 26, 2010

Pelvic kidney- ultrasound video study

This young adult female patient presented with right hypochondrial pain. We conducted a sonography of the gall bladder and found:
There were at least 3 calculi in the gall bladder, each of 7 to 9 mm. (see ultrasound video clip above) and the image below:
But a scan of the right kidney showed an empty right renal fossa:
So are we looking at a case of agenesis (absence) of the right kidney?
We searched further below and found this reniform structure near the urinary bladder.

Here are the still ultrasound images of what we saw....

At 6.6 x 2.5 cms., this kidney shaped structure looked rather small. But ultrasound and color Doppler appearances convinced us that this is indeed an ectopic right kidney located in the right hemipelvis.

 The above color Doppler ultrasound video clip further confirms our findings- this is indeed a pelvic right kidney. See: for more on this topic.
Conclusion: the right hypochondrial pain was due to cholelithiasis with the pelvic (ectopic) right kidney an incidental finding.

Wednesday, October 20, 2010

Normal third trimester fetal anatomy -ultrasound videos: the abdomen:

This was a normal 32 week old fetus. One of the best ways to visualize the fetus is a cross sectional anatomy. But since one plane alone is not sufficient, we tried to take sections along various oblique planes.
The first ultrasound video is that of the right dome of fetal diaphragm:
The fetal diaphragm is seen as a hypoechoic curved line between the liver and the right lung. Observe the movements of the diaphragm with fetal respiratory attempts.
(abbreviations: LG= fetal right lung; H= fetal heart; LIV= fetal liver)
 Here is a still ultrasound image of the right dome of diaphragm.

Fetal Liver and Gall bladder:
Perhaps the easiest and most prominent structure in the fetal abdomen is the liver. This is seen as a large echogenic structure occupying the right hypochondrium of the fetus with a number of vessels passing through it. The fetal gall bladder is seen within this structure (the liver) as an anechoic pear shaped, elongated structure. The gall bladder is best appreciated in color Doppler imaging.
Note in the above color Doppler ultrasound video, that the gall bladder shows no flow unlike the umbilical vein and other nearby vessels.
This still ultrasound picture shows the gall bladder through the fetal liver:
 And this color Doppler image helps differentiate the gall bladder from the vessels nearby:

The fetal stomach:
Visualization of the fetal stomach is important to rule out esophageal atresia, pyloric stenosis and duodenal atresia. The fetal stomach is seen as an anechoic bubble in the left upper quadrant of the fetal abdomen.

This ultrasound video clip shows the normal fetal stomach (arrow) to the left of the spine in the left hypochondrium. Care must be taken to determine if the stomach is indeed on the left side of the abdomen and thus rule out situs anomalies (situs inversus etc).
Ultrasound image showing the normal fetal stomach- the dark "bubble" - to the left of the liver:
Fetal Kidneys:

The fetal kidneys must be visualized and measured. Aplasia, hypoplasia or absence of one or both kidneys must be ruled out. Also, the sonographer/ radiologist must look for renal masses, cysts and hydronephrosis. Pelviureteric junction obstruction and posterior urethral valve in the fetus are common findings and important causes of fetal hydronpehrosis. The above video clip shows the normal left fetal kidney, next to the spine.
Still image of the normal left kidney in fetus:

The right fetal kidney is seen in this ultrasound video clip.
Still ultrasound image of normal right kidney: (long axis view)-

See this 2nd video clip of the normal right kidney. Note the hypoechoic triangles within the kidneys- these are normal renal pyramids (part of the renal medulla). Observe how the fetal kidneys move with fetal respiratory movements. 
Both kidneys must be visualized in both long and transverse axes: this transverse section ultrasound image shows both fetal kidneys-
Fetal adrenal (suprarenal) glands:

The fetal adrenals (suprarenal glands) must be carefully visualized to rule out abnormalities including masses (neuroblastoma) and cysts. The suprarenal glands are seen as triangular caps above the upper pole of each kidney. They have an echogenic central part with a hypoechoic layer outside. The above video clip shows a transverse section through the right suprarenal gland.
A still image of the fetal right adrenal gland is seen below (this is an oblique section through the gland):
One more ultrasound image of the right suprarenal gland is shown here- ( the image below is a coronal section of the right kidney and the right suprarenal gland)

This is a longitudinal section through the right kidney and right adrenal gland. 
Visit: for more images and abnormal conditions/ images about this topic.
Umbilical vein (intra fetal part):

The umbilical vein is seen coursing through the liver (color Doppler ultrasound video clip-at right). This vein carries oxygenated blood from the placenta to the fetus.
The fetal abdominal aorta and the iliac arteries:
The normal abdominal aorta is seen in this coronal section ultrasound image, dividing near the pelvis into the common iliac arteries (arrows).

Tuesday, October 19, 2010

Unusual case of right flank pain:

This elderly male patient had right flank pain. We suspected a renal or ureteric calculus.
The ultrasound video above shows a "lump" in the right kidney in the middle third of the renal cortex. Is this a renal mass? The sonography of this case speaks in riddles- there is a vague ill-defined mass like area, but there is also a definite, but mild dilatation of the pelvicalyces. This is a case of right ureteric calculus with Bertin's column involving the right renal cortex.
Here is a still image of the same case:
Arrows point to the lesion (a normal variant). Note the dilated pelvicalyces.
The ultrasound video clip above shows the left kidney of the same patient- an obvious small cortical cyst is seen. There were no symptoms related to the left flank.
And here is the still image showing both kidneys:


Monday, October 18, 2010

Benign prostatic hypertrophy- TRUS ultrasound videos

This was a rather large hypertrophy of the prostate in an elderly male patient. Prostates can get bigger than this. This ultrasound video demo of benign hypertrophy of the prostate was obtained via the transrectal route. Often, large prostates can be difficult to image in transrectal ultrasound studies due to the sheer size of the organ. Hence it is prudent to first image huge prostates via the transabdominal route, with a full bladder before trying the endocavity method. I always prefer to image prostates first in the oblique coronal plane from apex to base (as in this ultrasound video).
This is a still image of the prostate in the same patient.
See: for more images and discussion of prostate pathology.

This color Doppler ultrasound video shows a large prostate (benign enlargement) with marked vascularity on color Doppler imaging:
This amount of hyperemia of the prostate is not normal and can't be explained by benign enlargement. The diagnosis here is benign hypertrophy with prostatitis; something that can add insult to injury with marked exacerbation of the urinary complaints.

Saturday, October 16, 2010

Transrectal ultrasound videos- seminal vesicles and vas deferens:

This video shows the left vas deferens as it merges with the left seminal vesicle to form the ejaculatory duct:
                                                                        See: for more on this topic. This includes normal sonographic anatomy during TRUS (transrectal ultrasound) imaging for the prostate, seminal vesicles, vas deferens and the ejaculatory ducts. Of these the prostate is the largest and most obvious structure seen. In the oblique coronal plane, whilst angling the transrectal/ endocavity ultrasound probe upwards, one sees the 2 seminal vesicles seen resembling a bow tie. Further tilting the probe upwards reveals the vas deferens - 2 narrow tubes joining the seminal vesicles. The ejaculatory ducts are often difficult to see unless dilated due to pathology.                   

The above endocavity (transrectal) ultrasound video shows the right vas deferens merging similarly with the right seminal vesicle.
The ultrasound video clip below visualizes the seminal vesicles and vas of both sides:

And finally, imaging the prostate from the apex (or lower tip) and sweeping upwards towards the seminal vesicles. This way one sees almost every region of interest in TRUS study.
                                                                 Another important view is the sagittal section of the prostate which shows the posterior urethra or prostatic urethra as it is known. This view is also important to show potential calculi within the prostatic urethra, as also prostatic cysts in relation to it. Pressure on this part of the urethra can cause mild to severe urinary symptoms, usually caused by either of the pathologies mentioned above.

Friday, October 15, 2010

An Unusual cortical cyst of kidney- ultrasound video:

This cortical cyst is a rather unusual location in the left kidney- it occupies a central part (the middle third) of the kidney extending from the outer cortex to the renal pelvis. This appearance can mimic a calyceal diverticulum or caliectasis.
 The ultrasound image above shows the renal cortical cyst in transverse and longitudinal axes. Read more on this at: 
And this is what a typical cortical cyst of the kidney looks like:
There is mild pelvicalyceal dilatation of the left kidney, due to pressure effect from the large left renal cortical cyst in the upper pole. I have seen renal cortical cysts from 0.5 cms. to 8 cms. in size. These cysts need to be monitored closely for signs of rupture, infection and malignancy.
 This color Doppler video clip of the same patient shows vessels curving around the rim of the cortical cyst of the left kidney.
A typical cortical cyst of the left kidney ( a very large one):

An ultrasound video clip of this large cyst in left kidney- it measures 6 to 7 cms. in diameter!
It is not unusual for renal cortical cysts to reach this size. Fortunately, there is no evidence of infection, hemorrhage or septation within this cystic lesion. But it needs to be periodically monitored for complications.

Wednesday, October 13, 2010

Complex kidney cysts (an ultrasound video study):

Case-1:Sagittal section ultrasound video clip showing the complex nature of the right renal cyst. This cyst is small and septate (fine septations). Note the presence of small calcifications in the lower part of the cyst.
Same case as above- another ultrasound video clip:
This cyst was seen in a middle aged male patient and was an incidental finding. CT scan reports suggest this is a Bosniak category 2 complex renal cyst. Indeed the ultrasound findings did not change over a period of time, nor did the cyst increase in size. This complex renal cyst measures 1.7 cms. in size.                                          
                                                                        The above ultrasound video clip shows a larger complex cyst in the left kidney of an elderly male patient. Again, the cyst might fit in with a Bosniak category-2 complex renal cyst. This renal cyst shows fine (but thicker than those in case-1 above) membranous partitions and a few calcifications along the cyst wall.                                                                                          
                                                                       This 2nd renal ultrasound video clip shows that there is a 2nd smaller cyst adjacent to the larger cyst. This one also shows few calcific lesions along the wall. These appearances suggest a benign nature of these complex cysts of the left kidney.                                                                                                                                   
 The above color Doppler video clip of the left kidney (same case-2) shows no significant vessels along the walls of the cysts or in the septae within them, again confirming the benign nature of these lesions.                    Read more at:
Also view ultrasound images of renal cysts and cystic diseases of kidneys at:

Friday, October 8, 2010

A difficult mid-ureteric calculus:

This patient had right flank pain since a few months. But was not sure if he had a renal stone (calculus). The bladder ultrasound image appears normal.

The left kidney is normal. But not the right kidney- shows moderate hydronephrosis (back-pressure changes). The stone must be lower down somewhere....A difficult job to find this calculus, somewhere in the right ureter.. in a moderately obese patient.

Persistence and dogged determination to find the culprit, works. Sustained graded compression over the right flank, shows the dilated right ureter and the 17 mm. calculus in mid ureter.

Recorded an ultrasound video clip of the right mid ureteric calculus (arrows).
  See: for more on this topic.