Left ureteral calculi with hydronephrosis

This was a case of left ureteric/ ureteral calculi with resultant hydronephrosis of the left kidney. Fortunately the calculi were in the upper left ureter and hence well visible. Mid ureteral stones can often be difficult to visualize.
Left kidney and left ureter with stones visible in this ultrasound image:

Ultrasound image of the left ureter with 2 calculi seen in the upper part:

The right kidney shows cortical cysts with a calculus in this ultrasound image:

More on this topic? visit: http://www.ultrasound-images.com/ureteric-calculi.htm
Ultrasound video of this case is shown below:

A simple sonography quiz about male pelvis

Name the structure arrowed in these images of the male pelvis:
(Hint: this is a normal ultrasound scan).
Transverse section of bladder:

Sagittal section of bladder:

Transverse section of urinary bladder:

Answer: it is the rectum!

Incompetent perforators in a case of varicose veins:

A case of severe varicose veins in a 22 year old male patient:
Observe the to and fro flow of blood through incompetent perforators from the posterior tibial vein:

Some more perforators are seen lower down the leg arising from the posterior tibial vein:
The red color within the perforator suggests flow towards the probe (to the superficial veins of the saphenous system from the deep vein) which is abnormal.

The color Doppler ultrasound video of this case reveals the to and fro flow (superficial to deep veins and vise versa) across the incompetent perforator:


 Another perforator vein is seen with blood flow towards the transducer (seen in red color) in this color Doppler video:

 


For more on this topic visit:
http://www.ultrasound-images.com/vascular.htm#Color_and_Spectral_Doppler_Examination_of_the_veins_of_the_Lower_limb

Normal and enlarged lymph nodes:

This is a normal inguinal lymph node. Although a little prominent, it shows  normal vascularity and clear differentiation between the central and peripheral regions- the central region being hyperechoic whilst the periphery shows lower echogenicity.

Enlarged and inflamed lymph node:

  

This lymph node (another patient) shows a markedly enlarged inguinal lymph node (1.2 x 2.7 cms.) with remarkable increase in its vascularity- a classic picture of inguinal lymphadenitis. This patient had a large infected wound in the foot.  

Sonographic differentiation of some common renal masses:

Angiomyolioma: Among the commonest solid renal masses is angiomyolipoma. This is a benign mass and is believed to be a variant of hamartoma of the kidneys. Composed of smooth muscle, vascular tissue and above all fat (adipose tissue), an angiomyolipoma is almost invariably echogenic and usually small in size (less than 2 cms.). However, these tumors can be isoechoic to renal tissue in rare cases, where the amount of adipose tissue within the mass is smaller in amount. Visit: http://www.ultrasound-images.com/kidneys.htm#Renal_angiomyolipoma_-%28AML%29_of_right_kidney
These masses are usually benign in the vast majority of cases and rarely pose an symptomatic problems for the patient. However, it is usually in cases where the angiomyolipoma is larger than 4 cms. that, severe hematuria may be an important symptom.
Also visit: http://ultrasound-images.blogspot.com/2011/08/sonography-of-angiomyolipoma.html
  Hypertrophied column of Bertin: of Normal variants of the kidney like hypertrophic column of Bertin can also mimic a renal mass. However, careful sonography of the kidney will display the benign nature of this anatomical variant.  See the ultrasound and color Doppler images below; the column of Bertin  shows a prominent mass of renal cortical tissue extending deeper into the renal medulla separating the pyramids and also indenting the renal sinus. Color Doppler ultrasound imaging shows normal vascularity of this area, unlike the appearances of neovasculature (abnormal vessels) seen in malignant renal masses.  

See: http://www.ultrasound-images.com/kidneys.htm#Hypertrophied_column_of_Bertin_or_Junctional_parenchyma

for more on this topic.


Renal cell carcinoma: is another tumor of the kidney that may pose a diagnostic dilemma to the sonologist. This tumor is usually inhomogenous, relatively hypoechoic and does not produce posterior shadowing, so typically seen in angiomyolipoma of the kidney. Color Doppler ultrasound often helps show abnormal vasculature in the malignant tumor. Besides, follow up ultrasound will show increase in tumor size and possible metastases to adjacent organs. See:
http://www.ultrasound-images.com/kidneys.htm#Case-2_%28Renal_cell_carcinoma%29
The ultrasound image below shows a typical case of renal cell carcinoma of the right kidney. The malignant tumor is seen at the lower pole of the kidney.

Sonography of angiomyolipoma:

This middle aged female patient shows two small, echogenic, rounded lesions in the right kidney. Typical location (the right kidney is the common site for angiomyolipomas) and characteristic ultrasound features are seen in this ultrasound video of the right kidney. The images below show the twin angiomyolipomas, one in the upper pole, and barely visible, and the slightly larger lesion in the lower pole.

     

If close to the renal sinus, renal angiomyolipomas may be confused with the sinus fat echoes. Fortunately, in this patient both lesions are well within the renal cortex.
Also, regarding angiomyolipomas- it may be noted that these kidney tumors may be associated with LAM, or lymphangioleiomyomatosis. This is a progressive lung disease consistent with numerous lung cysts leading to progressive COPD. There are only 2000 known cases in the world today. It is a women's disease presumably associated with estrogen. Women with LAM may present with pneumothorax in pregnancy. Chest x-ray does not show the lung cysts, but CT scan imaging is necessary to confirm the diagnosis. When angiomyolipomas are seen a good clinical history should be taken and the possibility of LAM should be considered. There is no cure however recent research has shown promise in drugs to slow the progression of LAM. 
For more on this topic visit: http://www.ultrasound-images.com/kidneys.htm#Renal_angiomyolipoma_-%28AML%29_of_right_kidney

Congenital diaphragmatic hernia- perils and pitfalls

   It may initially appear that Congenital diaphragmatic hernia or CDH is a simple straightforward diagnosis on ultrasound imaging. But is it? I have come across many cases where the sonologist can miss this diagnosis in late 2nd trimester or early 3rd trimester fetuses. The reason is because many small diaphragmatic defects may cause only partial or intermittent fetal diaphragmatic hernia. Thus the sonographer or sonologist may not see any herniation of bowel or stomach in left sided diaphragmatic hernias or right lobe of liver in right sided hernias.                                                                                                

   

The ultrasound video clip shows one typical case of left sided congenital diaphragmatic hernia (CDH), with classic midline shift of heart to the right, literally pushed to a corner in the wrong side of the chest. In this case the ultrasound diagnosis of CDH was made late into 34 weeks of gestation.This can be a disaster for the mother, who might not have wished to continue the pregnancy.
What are the differential diagnoses of left sided congenital diaphragmatic hernia?
Almost any cystic lesion occupying the left hemithorax can be confused with CDH in fetal ultrasound. Among these conditions are- cystic adenomatoid malformation, bronchogenic cysts and pulmonary sequestration. Also, not to be ignored are intrathoracic teratomas, as the cystic components of this tumor can mimic a CDH. Even more ominously, these lesions mentioned above can co-exist with CDH, making a diagnosis of CDH even more complicated.
You may want to read more at: http://www.ultrasound-images.com/fetal-chest.htm#Congenital_diaphragmatic_hernia-_Left_%28CDH%29
What is the prognosis in such cases?
The earlier the diagnosis of congenital defects in the diaphragm are observed on ultrasound, the worse is the prognosis for the fetus. In fact, the detection of congenital hernia in 2nd trimester means that the severity of the congenital anomaly is more severe. Most cases are also associated with other fetal anomalies, notably involving the fetal heart. Also, invariably, the pressure from the herniated bowel and stomach, in this case means there would be severe hypoplasia of the lungs. In fact, despite surgery in the neonatal period, many such babies have pulmonary hypertension and respiratory difficulties. Also present in many neonates is the danger of mental retardation, trisomy 18 and trisomy 21 as well as neural tube defects. The fetus in this case showed no other major anomaly, but the severe midline shift is evidence of a large hernia with resultant pulmonary hypoplasia.