Why are the mammary ducts prominent in these breasts

This 27 year old adult female had non specific pain in breast, mainly on left side. 

Ultrasound imaging showed these findings:

Normal anatomy and layers of the breast:

The adult female breast can be divided into four main layers, each with distinct sonographic characteristics:

1. Skin and subcutaneous tissue: This layer appears as a hypoechoic (dark) layer on ultrasound imaging, with the skin appearing as a thin hyperechoic (bright) line. The subcutaneous fat appears as hypoechoic lobules interspersed with hyperechoic connective tissue.

2. Mammary glandular/ fibroglandular tissue: This layer appears as hyperechoic lobules and ducts on ultrasound imaging. The glandular tissue is usually more echogenic than the surrounding adipose tissue, and the ducts may appear as hypoechoic tubules.

3. Cooper's ligaments and fibrous tissue: This layer appears as hyperechoic bands or strands on ultrasound imaging. These ligaments and fibrous tissues provide support for the breast tissue and can be visualized as thin, linear structures.

4. Retromammary space: This layer appears as a hypoechoic space between the breast tissue and the pectoralis muscle on ultrasound imaging. This space contains connective tissue and fat, and its size can vary depending on the patient's age, weight, and hormonal status.

Findings on sonography in above case:

1. Are these prominent breast mammary ducts? The patient is unmarried and non lactating. Despite this, the ducts appear mildly dilated bilaterally.

Another perspective: 

An important point to note is that this appearance could be due to high fibrous tissue in the fibroglandular layer of the breasts. 

The causes of the prominence of fibrous tissue appearing as echogenic tissue on ultrasound in the fibroglandular layer of the breast can be related to a variety of factors. Some possible causes of this include:

1. Age: Younger women often have denser breast tissue, which can appear more echogenic on ultrasound.

2. Hormonal changes: Hormonal fluctuations during the menstrual cycle, pregnancy, and menopause can affect the amount and distribution of fibrous and glandular tissue in the breast.

3. Genetics: Some women may have a genetic predisposition to denser breast tissue.

4. Obesity: Higher body fat levels can lead to less dense breast tissue.

5. Previous breast surgery or trauma: Surgery or trauma to the breast can result in the formation of scar tissue, which can appear echogenic on ultrasound.

This appearance of glandular tissue as thin hypoechoic strands on ultrasound, this can be a normal finding in young women with dense breast tissue. Glandular tissue appears hypoechoic on ultrasound because it contains more fluid and less fat than fibrous tissue. The appearance of the glandular tissue as thin hypoechoic strands can mimic breast mammary ducts, which are the structures that transport milk from the glandular tissue to the nipple. 

2. A small mildly elongated cystic lesion in left breast. 

Analysis:

The differential diagnoses for prominent mammary ducts in this case include:

In a 25-year-old unmarried adult female can include:

1. Hormonal changes: Fluctuations in hormonal levels can cause changes in the breast tissue. The menstrual cycle, pregnancy, and menopause are examples of periods when the hormone levels can change, leading to dilated mammary ducts.

2. Medications: Certain medications can cause hormonal imbalances and lead to dilated mammary ducts. Hormonal contraceptives, hormone replacement therapy, and some psychiatric medications are examples of medications that can cause this.

3. Fibrocystic breast changes: Fibrocystic breast changes can cause the breast tissue to feel lumpy or rope-like, and they can cause the ducts to become dilated.

4. Smoking: Smoking has been associated with an increased risk of breast cancer, and it can also cause changes in the breast tissue that lead to dilated mammary ducts.

5. Inflammatory breast conditions: Inflammation of the breast tissue can lead to dilated mammary ducts. Mastitis and other inflammatory breast conditions are examples of such conditions.

6. Ductal ectasia: Ductal ectasia is a benign condition where the milk ducts in the breast become dilated and may cause nipple discharge.

7. Intraductal papilloma: Intraductal papilloma is a benign growth that can occur within the milk ducts of the breast and cause the ducts to become dilated.

As the findings are bilateral, this possibility is unlikely. 

The left breast cystic lesion can have these possibilities:

Breast cyst: A breast cyst is a fluid-filled sac that can develop in the breast tissue. It is a benign condition and usually presents as a painless lump. This is the most likely diagnosis here. 

3. Fibroadenoma: This is a common benign breast tumor that can present as a painless lump in the breast tissue. It is composed of fibrous and glandular tissue and can cause the breast to feel firm or rubbery. This is not likely as the lesion is cystic. 

4. Intraductal papilloma: This is a benign growth that can occur within the milk ducts of the breast. It can cause a discharge from the nipple and may present as a palpable lump in the breast tissue. This is a possibility. However, no obvious mass is seen in the lesion. 

5. Breast cancer: While less likely in a young virgin female, breast cancer is a possibility that must be ruled out. Ultrasound findings of a cystic or solid lesion, or irregular masses with abnormal vascularity can be concerning for malignancy. Also must be considered. 

What is the management approach here?

1. Follow-up imaging: The healthcare provider may recommend follow-up imaging to monitor the dilated mammary ducts and the cystic area in the left breast to ensure they do not change over time.

2. Biopsy: of the cystic lesion must be considered to determine if it is cancerous or benign. 

3. Medications: If the dilated mammary ducts are due to hormonal changes or fibrocystic breast changes, the healthcare provider may recommend hormonal therapy or pain relief medications.

4. Lifestyle modifications: Quitting smoking, reducing caffeine intake, and wearing a well-fitting bra may alleviate symptoms of breast discomfort.

5. Surgical intervention: In rare cases where the cystic lesion causes discomfort, a surgeon may recommend surgery to remove it. 

It is important to follow the healthcare provider's recommended management plan and attend regular follow-up appointments to monitor any changes in the breast tissue.

For more on this visit:

Ultrasound imaging of breast

Chronic thrombosis femoral and popliteal veins, follow up

This patient had a thrombosis of femoral and popliteal veins of 1 month duration. He was put on anticoagulation therapy. 

Follow up ultrasound show changes of chronic thrombosis of femoral and popliteal veins. 

Chronic thrombosis is a condition characterized by thrombus of more than 1 months duration. 

Ultrasound findings in this case:

Color Doppler ultrasound imaging shows a lack or reduction of blood flow in the affected vein segment, indicating the presence of a thrombus.

2. The thrombus appears as hyperechoic or echogenic structure (depending on its age and composition) that is filling the lumen of the vein.

3. The vein wall appears thickened and irregular, and the surrounding tissue may show signs of edema or inflammation.

4. Collateral veins may be present, appearing as smaller, less well-defined vessels that run parallel to the main vein.

5. Spectral Doppler ultrasound imaging can be used to assess the velocity and direction of blood flow in the affected vein segment, which can help to determine the severity of the obstruction.

6. As the thrombus is fibrotic and echogenic, it may appear more organized and less mobile compared to a fresh thrombus.

7. The compressibility of the vein is lost.

What are the specific findings and differences between acute and chronic DVT?

Ultrasound and color Doppler findings of acute and chronic thrombosis of the femoral vein:

In acute thrombosis of the femoral vein:

- On grayscale ultrasound, acute thrombosis appears as a hypoechoic or anechoic filling defect within the lumen of the femoral vein. It may have an irregular or smooth contour and may partially or completely fill the lumen of the vein. The thrombus may also be echogenic in some cases, which may suggest the presence of red blood cell breakdown products or fibrin.

On grayscale ultrasound, acute thrombosis appears as a hypoechoic or anechoic (dark) filling defect within the lumen of the femoral vein.

- On color Doppler ultrasound, there may be absent or diminished flow within the thrombosed segment, although it is not always reliable in detecting acute thrombosis.

- Acute thrombosis may also usually causes distension of the vein above the thrombus due to a lack of compressibility

- On color Doppler ultrasound, there may be absent or diminished flow within the thrombosed segment. However, it's important to note that this finding may not always be reliable, especially in cases of partial thrombosis or small thrombi that do not completely occlude the vessel. In some cases, color Doppler may show no flow within the thrombosed segment, but spectral Doppler may detect some residual flow with a low velocity waveform pattern. This may suggest that the thrombus is still in the acute phase and has not yet fully organized.

- Acute thrombosis may cause distension of the vein above the thrombus due to a lack of compressibility. This can be appreciated by applying gentle pressure with the ultrasound transducer to the vein and observing the degree of compression. In some cases, the vein may be completely non-compressible due to the presence of the thrombus.

Chronic thrombosis of the femoral vein:

- Chronic thrombosis is characterized by recanalization and organization of the thrombus, resulting in a partially or completely occluded lumen with residual echoes and/or calcifications within the thrombus. The thrombus is more echogenic may have a tubular or layered appearance, and there may be areas of flow within the thrombus due to recanalization of the vein. This may be seen as color flow within the thrombosed segment on color Doppler.

- The vein may be reduced in diameter due to scarring or stenosis, and there may be collateral vessels seen on color Doppler. These collateral vessels may appear as hypoechoic or anechoic tubular structures adjacent to the thrombosed segment, and they may have a low velocity waveform pattern on spectral Doppler. The presence of collateral vessels suggests chronicity of the thrombosis.

- There is also a loss of normal venous phasicity, which refers to the normal variation in flow seen during respiration and changes in position. Normally, the femoral vein shows respiratory variation in flow with increased flow during inspiration and decreased flow during expiration. However, in chronic thrombosis, this phasicity may be lost or reduced due to the presence of the thrombus and the resulting changes in venous hemodynamics.

It's important to keep in mind that these ultrasound and color Doppler findings are not always specific to thrombosis and may be seen in other conditions affecting the femoral vein, such as compression by adjacent structures or intrinsic venous stenosis. Therefore, clinical correlation and additional imaging may be necessary for definitive diagnosis.

What is the further management in this patient?

In case of thrombosis of the right femoral and popliteal veins of 1 month duration, where the thrombus is fibrotic and echogenic and the patient is on anticoagulation therapy, the following management steps are recommended:

1. Continued anticoagulation therapy: If the patient is tolerating anticoagulation therapy well, the physician may continue the therapy for an additional 2-5 months or longer, depending on the severity and location of the clot. The goal of anticoagulation therapy is to prevent the clot from growing and to reduce the risk of complications, such as pulmonary embolism.

2. Compression stockings: The patient may be advised to wear compression stockings, which can help to improve blood flow and reduce the risk of post-thrombotic syndrome. Compression stockings should be worn throughout the day and removed at night.

3. Follow-up imaging: The patient may undergo follow-up imaging, such as color Doppler ultrasound or magnetic resonance venography, to assess the status of the thrombus and to monitor for any complications or residual clot.

4. Thrombolytic therapy: If the thrombus is still present after 1-2 months of anticoagulation therapy, or if the patient is at high risk for complications, the physician may consider thrombolytic therapy. This involves the use of medications to dissolve the clot, which can help to restore blood flow and prevent long-term complications.

5. Thrombectomy: In some cases, the physician may recommend thrombectomy, which involves the physical removal of the clot using a catheter or other device. This may be necessary if the clot is large or if there is a risk of complications, such as pulmonary embolism.

6. Lifestyle modifications: The patient may be advised to make lifestyle modifications to reduce the risk of recurrence, such as maintaining a healthy weight, quitting smoking, and exercising regularly.

What is the prognosis in this case?

Overall, the prognosis for chronic thrombosis depends on several factors, including the extent and severity of the clot, the presence of any underlying medical conditions, and the response to treatment. With appropriate management, most patients can expect a good outcome, but it is important to follow up with a physician regularly to monitor for any changes or complications.

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Vascular Doppler ultrasound

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Vascular Doppler ultrasound imaging

Exophytic renal cysts, what's that?

Found multiple renal cysts in this adult male patient on routine ultrasound imaging. 

In this case, there are 3 renal cortical cysts of 2 to 4 cms in left kidney and 1 simple renal cortical cyst measuring 4 cms in right kidney. No calcifications or septum are present in the cysts. The prognosis for such simple kidney cysts is generally very good.

Exophytic renal cysts:

Some of the cysts are seen bulging outward from the renal margins. These are called exophytic renal cysts. 

An exophytic renal cyst is a type of cyst that grows out of the kidney. Cortical refers to the area that is known as the cortex of the kidney. Cysts usually arise from the cortex of the kidney.

The criteria for diagnosing exophytic renal cysts are not well defined in the medical literature. However, cysts will be exophytic if at least 75 percent of its wall lies outside the kidney margins. 

Additional criteria for exophytic renal cysts:

The diagnostic criteria for exophytic renal cysts on ultrasound imaging include:

1. Location: Exophytic renal cysts are located on the periphery of the kidney and protrude from the renal parenchyma.

2. Shape: The cysts are typically round or oval in shape and have well-defined borders.

3. Size: The size of the cysts can vary, but they are typically smaller than 5 cm in diameter.

4. Wall thickness: The cyst wall is thin and smooth, and is usually less than 1 mm in thickness.

5. Internal echoes: The cyst contents are anechoic (black) and do not contain any internal echoes, which distinguishes them from solid renal masses.

6. Doppler analysis: There is no vascularity within the cyst, which is confirmed by Doppler analysis.

What is the management approach in exophytic renal cysts?

The management of an exophytic renal cyst of 4 cms size depends on several factors, including the patient's age, overall health, symptoms, and the characteristics of the cyst itself.

In general, most exophytic renal cysts that are smaller than 5 cm in diameter and asymptomatic can be managed conservatively with regular monitoring through periodic imaging studies, such as ultrasound or CT scans. However, larger cysts may require more frequent monitoring and evaluation.

If the exophytic renal cyst is causing symptoms such as pain or discomfort, or if there is a suspicion of malignancy, further evaluation and management may be necessary. In these cases, the following options may be considered:

1. Percutaneous aspiration: This is a minimally invasive procedure in which a needle is inserted into the cyst to drain the fluid. This may provide relief of symptoms, but the cyst may refill with fluid and require repeat aspiration.

2. Sclerotherapy: After aspiration, a sclerosing agent is injected into the cyst to create scarring, which may prevent the cyst from refilling with fluid.

3. Surgical excision: If the cyst is causing significant symptoms, is growing rapidly, or is suspected to be malignant, surgical excision may be necessary. This involves removing the cyst and a portion of the surrounding renal tissue.

It is important to discuss the management options with a qualified healthcare provider, who can assess the individual case and make recommendations based on the specific circumstances of the patient.

For more on this visit:

Renal ultrasound imaging

Gallbladder wall thickened, what could it be

50 years old adult male. Only positive finding is this gallbladder. 

Normal liver, gallbladder well distended. What is the cause of the gallbladder wall thickness of more than 4 mm. Also the GB wall is markedly echogenic. No GB calculus or abnormal vascularity on color Doppler ultrasound. 

Also, previous ultrasound imaging also showed the same findings. 

The patient was in a fasting state on the day of scan. 

Besides, the gallbladder is well distended. 

What are the diagnostic possibilities in this case?

 As the gallbladder wall is uniformly thickened, and there is no tenderness or pain present, the most likely diagnosis is chronic cholecystitis, which is inflammation of the gallbladder. This condition can occur without the presence of gallstones and is more common in individuals over the age of 40.

Other possible causes of a uniformly thickened gallbladder wall without tenderness or pain include:

1. Gallbladder adenomyomatosis: This is a condition where the inner wall of the gallbladder becomes thickened and forms pockets. It is usually benign, but in some cases, it can cause symptoms such as abdominal pain or discomfort.

2. Prolonged fasting: Long periods of fasting or starvation can cause gallbladder wall thickening.

3. Gallbladder polyps: These are growths on the gallbladder wall that can cause thickening.

4. Systemic diseases: Certain systemic diseases such as diabetes, lupus, or scleroderma can cause thickening of the gallbladder wall.

Some other possible differential diagnoses for gallbladder wall thickening include:

- Cholecystitis (acute, chronic, acalculous, xanthogranulomatous)

- Gallbladder empyema; excluded as there were no symptoms. 

- Postprandial physiological state (pseudothickening); here, patient was fasting since morning. 

- Secondary thickening (hepatic cirrhosis, hepatitis, congestive right heart failure, Fitz-Hugh-Curtis syndrome, hypoalbuminemia, ascites). None of these were present. 

- Other acute inflammatory processes in the right upper quadrant (acute pancreatitis, perforated duodenal ulcer, acute pyelonephritis, peritonitis). Not likely in this patient. 

- Primary sclerosing cholangitis

- Gallbladder perforation. Not likely. 

- Brucellosis

- AIDS cholangiopathy

- Severe pyelonephritis

- Renal failure

- Gallbladder carcinoma

- Diffuse adenomyomatosis of the gallbladder

- Hemophagocytic lymphohistiocytosis (HLH).

If there are no symptoms present, treatment may not be necessary, but further evaluation may be needed to rule out any underlying conditions. Follow-up ultrasound or other imaging tests may be recommended to monitor any changes in the gallbladder wall thickness.

Final diagnosis:  Possibly idiopathic thickening of gallbladder wall. 

D/d: chronic acalculous cholecystitis 

For more on this topic visit:

Ultrasound imaging of gallbladder

Also: sonography of gallbladder wall

What is idiopathic gallbladder wall thickening?

Idiopathic thickening of the gallbladder wall refers to a condition where the wall of the gallbladder becomes thicker than normal, but the underlying cause is unknown or idiopathic.

The gallbladder is a small pear-shaped organ located in the upper right quadrant of the abdomen, beneath the liver. Its main function is to store and release bile, a fluid that aids in the digestion of fats. The normal thickness of the gallbladder wall is less than 3mm.

Idiopathic thickening of the gallbladder wall is often diagnosed incidentally during an ultrasound or CT scan that was ordered for another reason. In many cases, patients may not exhibit any symptoms, and the condition is discovered accidentally during routine check-ups.

The thickening of the gallbladder wall may be due to inflammation, infection, or other underlying medical conditions such as gallstones, cholecystitis, hepatitis, or cirrhosis. However, in some cases, there may be no clear underlying cause for the thickening of the gallbladder wall, and it is classified as idiopathic.

In patients with idiopathic thickening of the gallbladder wall, doctors may monitor the condition through regular follow-up visits and imaging studies. Treatment may not be necessary unless the patient experiences symptoms or the gallbladder wall becomes excessively thick.

Symptoms of idiopathic thickening of the gallbladder wall may include pain in the upper right abdomen, nausea, vomiting, and fever. In some cases, patients may also develop jaundice.

Management: follow up ultrasound and further investigations if needed. 

Early cirrhosis, ultrasound imaging and management

This 72 year old female patient is non alcoholic and developed changes of early cirrhosis of liver. 

Ultrasound images are shown below:

The ultrasound and color Doppler findings are:

Inhomogeneous coarse echotexture of liver 

Mild splenomegaly 

Mild dilation of portal vein 14 mm

Mild dilation of splenic vein: 11 mm

No ascites 

Antegrade flow in portal vein. 

Analysis of the above imaging findings:

In the early stages of cirrhosis, ultrasound and color Doppler imaging may show the following findings:

1. Hepatic parenchymal echogenicity: In early cirrhosis, the liver parenchyma may be diffusely hyperechoic or isoechoic, reflecting early fibrosis.

2. Nodularity: Early cirrhosis may also be associated with the development of small, regenerative nodules, which can be seen as discrete, hypoechoic lesions on ultrasound.

3. Portal hypertension: Portal hypertension is a common complication of cirrhosis, and it can be detected on ultrasound by the presence of dilated portal vein and splenic vein, and splenomegaly.

4. Hepatic arterial flow: In early cirrhosis, there may be increased hepatic arterial flow, which can be detected on color Doppler imaging.

5. Portal venous flow: The presence of reversed portal venous flow, especially in the setting of a dilated portal vein, is a hallmark of advanced cirrhosis, and may not be seen in the early stages. In this case, there is antegrade forward flow. 

6. Spectral Doppler findings: Spectral Doppler imaging can detect alterations in the hepatic artery and portal venous flow patterns, including increased arterial resistive index, decreased portal venous flow velocity and reversed portal venous flow.

Analysis of portal and splenic vein Doppler:

Evidence of portal hypertension, based on the dilation of the portal and splenic veins. 

Antegrade forward flow in the portal vein indicates that blood is flowing in the normal direction, which is from the liver towards the heart. In the context of an enlarged portal vein and splenic vein, the presence of antegrade forward flow suggests that there is not a complete blockage of blood flow in the portal vein, but rather increased resistance to blood flow.

It's important to note that while antegrade flow in the portal vein is a normal finding, it doesn't rule out the possibility of portal hypertension. The severity of portal hypertension is determined by the degree of increased resistance to blood flow in the portal vein, which can be assessed using additional imaging studies such as a hepatic venous pressure gradient (HVPG) measurement.

Overall, a comprehensive evaluation of the liver function, imaging findings, and other laboratory tests are needed to accurately diagnose and manage early cirrhosis and its complications. 

What is the recommended management in this patient?

Management of early cirrhosis of the liver typically involves a combination of lifestyle modifications, medications, and monitoring for complications. Some of the common management strategies for early cirrhosis include:

1. Treating the underlying cause: The underlying cause of cirrhosis, such as hepatitis C or non-alcoholic fatty liver disease, should be identified and treated appropriately.

2. Lifestyle modifications: Individuals with cirrhosis should avoid alcohol consumption, maintain a healthy diet, and exercise regularly to improve liver function and reduce the risk of complications.

3. Medications: Medications may be prescribed to manage symptoms such as itching, fatigue, and abdominal pain. Additionally, some medications may help to slow down the progression of liver damage.

4. Monitoring for complications: Individuals with cirrhosis require regular monitoring to detect and manage complications such as portal hypertension, ascites, and hepatic encephalopathy.

5. Liver transplant: In cases of advanced cirrhosis, a liver transplant may be necessary to replace the damaged liver with a healthy liver.

What are the medications used in such cases?

Here are some medications that may be used in the management of early cirrhosis:

1. Ursodeoxycholic acid (UDCA): UDCA is a medication used to improve liver function and reduce liver inflammation. It may be prescribed for individuals with primary biliary cirrhosis, a type of autoimmune liver disease.

2. Beta-blockers: Beta-blockers, such as propranolol and nadolol, are used to reduce the risk of bleeding from esophageal varices in individuals with cirrhosis.

3. Diuretics: Diuretics, such as spironolactone and furosemide, are used to manage fluid retention and reduce the risk of developing ascites.

4. Lactulose: Lactulose is a medication used to treat hepatic encephalopathy, a neurological complication of cirrhosis.

5. Antiviral medications: Antiviral medications, such as interferon and ribavirin, are used to treat viral infections that may cause cirrhosis, such as hepatitis B and C.

6. Anti-itch medications: Anti-itch medications, such as cholestyramine and rifampin, may be prescribed to manage pruritus (itching) associated with cirrhosis.

It is important to note that these medications should only be taken under the supervision of a healthcare provider, and the individual's medication regimen should be tailored to their specific needs and circumstances.

Prognosis in this case:

It is important to note that early cirrhosis of the liver is a progressive condition, and individuals with this condition require lifelong management and monitoring to prevent complications and improve their overall quality of life. Therefore, it is essential to work closely with an expert healthcare provider.

For more on this topic visit:

Sonography of liver

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Sonography in cirrhosis of liver

Help! Leakage of fluid after surgery

This patient had an abdominal wall surgery for umbilical hernia. 

Two weeks after surgery, she developed discharge of fluid via an opening in the abdominal wall in infra umbilical region. 

Ultrasound imaging was done which revealed:

Ultrasound findings are:

1. An ultrasound imaging was conducted to assess the infra umbilical region in the peritoneal cavity after abdominal surgery.

2. The ultrasound imaging revealed the presence of a small seroma with an external sinus formation in the infra umbilical region.

This is seen as an anechoic collection just deep to the abdominal wall within the peritoneal cavity. 

3. A seroma is a collection of fluid that can occur after surgery and can be caused by the accumulation of lymphatic fluid or blood.

4. The external sinus formation is a tunnel-like structure that extends from the seroma to the skin surface.

5. The ultrasound imaging also showed the presence of a small discharge of fluid through the sinus.

6. The presence of a small seroma with an external sinus formation can be a potential complication of abdominal surgery and may require medical intervention.

Treatment options :

Treatment options for this condition include drainage of the seroma and sinus, antibiotic therapy to prevent infection, and surgical excision of the sinus if necessary.

Follow-up ultrasound imaging may be necessary to monitor the healing of the seroma and sinus and to ensure that there are no further complications.

Cautionary note:

It is important to consult with a healthcare professional if you experience any symptoms such as pain, swelling, or discharge from the surgical site after abdominal surgery.

Differential Diagnoses in this case include:

1. Abscess: An abscess is a collection of pus caused by a bacterial infection. It can also present with an external sinus and discharge of fluid, similar to a seroma.

2. Hematoma: A hematoma is a localized collection of blood outside of blood vessels, which can occur after surgery. It may also appear similar to a seroma on ultrasound imaging.

3. Fistula: A fistula is an abnormal connection between two organs or between an organ and the skin surface. In this case, it could refer to an abnormal connection between the seroma and the skin surface through the sinus.

Prognosis: in such a case depends on the size of the seroma and the presence of any infection. With appropriate treatment, such as drainage and antibiotics, most patients will recover without complications. However, without treatment, there is a risk of infection, which can lead to serious complications. It is important to follow up with a healthcare professional and adhere to their recommended treatment plan.

To know more on this topic visit:

Musculoskeletal ultrasound imaging

Video of this case: seroma, ultrasound video

Small renal calculi, all about these

Typical findings of kidney stone disease or renal calculi. 

Two small renal calculi in the left kidney. 

Ultrasound images above show characteristic findings of renal calculi, only these are very small, less than 6 mm. One of these measures only 3 mm.

With increasing resolution of ultrasound machines, a renal calculus of only 2 mm can also be picked up on sonography. 

So what are the important points to remember?

Renal calculi, commonly known as kidney stones, are solid masses formed in the kidneys due to the accumulation of minerals and salts. They can vary in size and may cause discomfort, pain, and complications if left untreated. Ultrasound imaging is a non-invasive and widely used diagnostic tool to detect renal calculi. In this blog post, we will discuss the ultrasound diagnostic features of small renal calculi and important differential diagnoses.

Ultrasound Diagnostic Features of Small Renal Calculi:

1. Hyperechoic Focus: Renal calculi appear as hyperechoic foci on ultrasound imaging. They are brighter than the surrounding tissue due to their high mineral content.

2. Acoustic Shadowing: Renal calculi cause a shadow behind them on the ultrasound image. This is due to the absorption and reflection of ultrasound waves by the stone.

3. Size: Small renal calculi are typically less than 7 mm in size, as mentioned in our case.

4. Location: Renal calculi can be located anywhere in the kidney, including the renal pelvis, calyces, or parenchyma.

5. Twinkle artefact sign on color Doppler ultrasound. This sign is sometimes seen on color Doppler ultrasound as a color artefact posterior or deep to the calculus. 

Important Differential Diagnoses:

1.Milk of calcium Renal Cysts: such renal cysts are common and can be mistaken for renal calculi on ultrasound imaging. They appear as anechoic structures with calcium mud or milk in the dependent portion of the cyst. 

2. Papillary Necrosis: Papillary necrosis is a condition where the renal papillae become necrotic and slough off into the renal pelvis, mimicking the appearance of a renal calculus on ultrasound. This condition is often associated with diabetes, sickle cell disease, and other systemic diseases.

3. Focal Cortical Necrosis: Focal cortical necrosis is a rare condition where there is ischemic necrosis of the renal cortex, leading to the formation of a hyperechoic mass that can be mistaken for a renal calculus.

4. Pyelonephritis: Pyelonephritis is a bacterial infection of the kidney that can cause inflammation and edema, leading to the appearance of hyperechoic foci on ultrasound imaging. This can be mistaken for a renal calculus.

What is the management approach in such cases of small renal calculi?

The treatment and prognosis of small renal calculi depend on several factors, including the size, location, number, and composition of the stones, as well as the presence or absence of symptoms and complications.

For small renal calculi less than 7 mm in size, the treatment options include:

1. Observation: Small renal calculi that are asymptomatic and do not cause any complications may not require any treatment and can be monitored with regular imaging and follow-up.

2. Medical Management: If the stones are composed of calcium oxalate, uric acid, or cystine, medications can be used to reduce the formation of new stones, dissolve existing stones, or prevent their growth. This may involve lifestyle modifications, such as increasing fluid intake, and medications, such as thiazide diuretics or allopurinol.

Specific medication 💊 for renal calculi:

Citralka and Cystone are both medications that are commonly used to treat small renal calculi, which are also known as kidney stones. These medications work by dissolving or preventing the formation of stones in the urinary tract.

Citralka contains potassium citrate, which is an alkalizing agent that helps to reduce the acidity of urine. This makes it less likely for stones to form in the urinary tract, and also helps to dissolve existing stones. Citralka also helps to reduce the pain and discomfort associated with kidney stones.

Cystone, on the other hand, is an ayurvedic herbal medication that contains a blend of natural ingredients, including Shilapushpa, Pasanabheda, and Gokshura. These ingredients work together to prevent the formation of stones in the urinary tract, and also help to dissolve existing stones. Cystone also helps to reduce the inflammation and pain associated with kidney stones.

In summary, the role of stone-dissolving medications like Citralka and Cystone in small renal calculi disease is to prevent the formation of new stones, and to dissolve existing stones. These medications can help to reduce the pain and discomfort associated with kidney stones, and can also prevent further complications from occurring. However, it is important to note that these medications may not be effective for all types of kidney stones, and may not be suitable for everyone. Therefore, it is important to consult with a healthcare professional before using any stone-dissolving medication.

3. Shock Wave Lithotripsy (SWL): SWL is a non-invasive procedure that uses high-energy shock waves to break the stones into smaller pieces that can be passed through the urine. It is often used for small renal calculi that are located in the upper ureter or renal pelvis and can be accessed easily by the shock wave generator.

4. Ureteroscopy: Ureteroscopy involves passing a thin, flexible scope through the urethra, bladder, and ureter to the site of the stone, where it can be removed using specialized tools. This is a minimally invasive procedure that is often used for stones that are located in the lower ureter or near the bladder.

The prognosis of small renal calculi is generally good, especially if they are asymptomatic and do not cause any complications. However, if left untreated or if complications occur, such as obstruction, infection, or bleeding, the prognosis may be less favorable. It is important to consult with a healthcare provider for appropriate diagnosis, management, and follow-up of small renal calculi to ensure the best possible outcomes.

Conclusion:

In conclusion, renal calculi are a common condition that can be detected using ultrasound imaging. Small renal calculi appear as hyperechoic foci with acoustic shadowing and are typically less than 7 mm in size. However, there are important differential diagnoses that should be considered, including renal cysts, papillary necrosis, focal cortical necrosis, and pyelonephritis. If you are experiencing symptoms or have been diagnosed with renal calculi, it is important to consult with your healthcare provider for appropriate management and follow-up.

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Sonography of renal calculi or kidney stones

Can transabdominal ultrasound reveal adenomyosis?

This 35 year old female patient had severe dysmenorrhoea or painful menses. 

Among the commonest causes of this condition are: adenomyosis and endometriosis.

Often, both conditions can coexist. 

Transabdominal ultrasound images of this case are shown below:

This case shows ultrasound signs of adenomyosis, including myometrial cysts, globular uterus, loss of interface between endometrial myometrial junction, and dirty shadows.

1. Myometrial Cysts: Myometrial cysts, or uterine cysts, are small fluid-filled sacs that develop within the myometrium, or muscular wall of the uterus. These cysts may be visible on ultrasound as small, anechoic (fluid-filled) areas within the myometrium. While myometrial cysts are generally benign and do not require treatment, they may be present in cases of adenomyosis.

Color Doppler ultrasound images above show the cystic areas in uterus are not blood vessels and confirm myometrial cysts. 

2. Globular Uterus: Adenomyosis can cause the uterus to become enlarged and globular in shape. On ultrasound, the uterus may appear round or oval-shaped with a thicker, more heterogeneous texture than normal. This can be due to the presence of the abnormal endometrial tissue within the myometrium.

3. Loss of Interface Endometrial Myometrial Junction: Adenomyosis can cause the interface between the endometrium (the inner lining of the uterus) and myometrium to become less distinct or even disappear completely. This can be seen on ultrasound as a loss of the normal "line" or "junction" between the two layers.

4. Dirty Shadows: Dirty shadows, also known as echogenic foci, are areas of increased echogenicity within the myometrium that may be visible on ultrasound in cases of adenomyosis. These shadows are thought to be caused by hemorrhage or the deposition of iron or calcium within the abnormal endometrial tissue.

What are the common symptoms in such cases of adenomyosis?

The most common symptom of adenomyosis is dysmenorrhoea, or painful periods. This pain can be severe and may interfere with daily activities. Other symptoms may include:

1. Heavy menstrual bleeding

2. Pain during sexual intercourse

3. Pelvic pain or pressure

4. Infertility

What are the various differential diagnoses in this case?

Adenomyosis is a condition where the endometrial tissue, which normally lines the inside of the uterus, grows into the uterine muscle. On ultrasound, adenomyosis can appear as diffuse or focal areas of increased echogenicity (brightness) in the myometrium, with or without cystic spaces.

Some of the important differential diagnoses that may be considered in a case of adenomyosis on ultrasound include:

1. Leiomyoma: Also known as fibroids, these are benign tumors of the uterus that can sometimes be difficult to differentiate from adenomyosis on ultrasound. Leiomyomas are typically well-circumscribed and have a whorled appearance, whereas adenomyosis is diffuse and has a more irregular appearance.

2. Endometrial hyperplasia and endometrial carcinoma: Thickening of the endometrial lining can sometimes be mistaken for adenomyosis, particularly if cystic spaces are present. However, endometrial hyperplasia or carcinoma usually presents with more focal thickening and may be associated with abnormal uterine bleeding.

3. Pelvic inflammatory disease (PID): Inflammatory changes in the uterus and surrounding tissues can sometimes mimic the appearance of adenomyosis on ultrasound. However, PID is typically associated with other signs of infection, such as fever and leukocytosis.

4. Endometriosis: This is a condition where endometrial tissue grows outside the uterus, which can sometimes involve the uterine muscle and mimic the appearance of adenomyosis on ultrasound. However, endometriosis typically presents with more focal lesions and may be associated with symptoms such as dysmenorrhea and dyspareunia. The endometriosis usually presents as focal lesions outside the uterus like endometrioma etc. Adenomyosis causes changes within the uterus. 

5. Focal myometrial hypertrophy: This refers to localized thickening of the uterine muscle and can sometimes be mistaken for adenomyosis. However, focal myometrial hypertrophy typically has a more well-defined border and is not associated with cystic spaces.

It is important to note that a definitive diagnosis of adenomyosis can only be made through histological examination of uterine tissue. Ultrasound findings can be suggestive, but they must be interpreted in the context of the patient's clinical presentation and other diagnostic tests.

Final diagnosis: adenomyosis of uterus.

What are the management options here?

1. Pain Management: Nonsteroidal anti-inflammatory drugs (NSAIDs) and hormonal medications such as oral contraceptives or progesterone may be prescribed to manage pain and heavy bleeding.

2. Hysterectomy: In severe cases of adenomyosis, a hysterectomy (removal of the uterus) may be recommended. This is typically considered a last resort, as it is a major surgery with significant risks and long-term consequences.

3. Uterine Artery Embolization (UAE): This procedure involves blocking the blood supply to the uterus to reduce the size of the adenomyosis tissue. It is less invasive than a hysterectomy but may not be suitable for all patients.

What is the prognosis for this patient? 

Adenomyosis is a chronic condition and symptoms may persist for many years. In some cases, symptoms may improve after menopause when hormone levels decrease. Adenomyosis is not typically a life-threatening condition, but it can have a significant impact on quality of life.

To answer the question we asked in the beginning: yes, though transvaginal ultrasound is superior in the diagnosis of adenomyosis, transabdominal ultrasound imaging can also be sufficient to come to a diagnosis of this condition. 

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Sonography of uterus

Just a normal anatomical variant or something ominous?

This adult male patient has a prominent column of Bertin in the left kidney. 

Can be a cause for alarm if not correctly diagnosed. 

So, what is a hypertrophied column of Bertin?

The column of Bertin is a normal anatomic structure in the kidney that separates the pyramids. It is essentially an extension of the renal cortex and can vary in size between individuals. However, in some cases, it can become hypertrophied, meaning it becomes abnormally enlarged. This can be detected using ultrasound imaging of the kidney.

Further investigations: not needed in most cases as ultrasound imaging is sufficient. 

Important points to remember:

When the column of Bertin becomes hypertrophied, it can present as a mass-like lesion within the renal cortex, which can be easily identified on ultrasound. The size, shape, and location of the hypertrophied column of Bertin can vary, but it is usually located in the middle or upper pole of the kidney.

In the case above, the middle third of the kidney is involved. 

Ultrasound findings:

On ultrasound imaging, a hypertrophied column of Bertin may appear as a well-circumscribed, hypoechoic mass with a smooth surface. It may be seen bulging into the renal pelvis or causing displacement of the renal calyces. It may also be associated with dilatation of the collecting system or renal pelvis.

Color Doppler ultrasound shows normal flow in the region. 

Important differential diagnosis:

However, it is important to differentiate a hypertrophied column of Bertin from other renal masses, such as renal cell carcinoma or oncocytoma. This can be done using additional imaging techniques such as computed tomography (CT) or magnetic resonance imaging (MRI), which can provide more detailed information about the mass, including its vascularity, internal architecture, and signal intensity.

In conclusion, ultrasound imaging can detect a hypertrophied column of Bertin in the left kidney as a mass-like lesion within the renal cortex. Although it is a benign condition, it is important to differentiate it from other renal masses using additional imaging modalities to guide proper management.

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Ultrasound imaging of kidneys