Two lesions in one ovary. A mystery?

This female young adult has severe dysmenorrhoea. 

Transabdominal and transvaginal ultrasound show a mysterious combination of two lesions in the left ovary. 

So what are the findings?

There's a small, simple cyst in the affected ovary. 

But in addition, there's an echogenic, ground glass appearance in the lateral aspect of the same ovary. 

Diagnosis: left simple cyst with endometrioma of the same ovary. Can explain the symptoms of severe pain during menses. 

More on this topic:

Ultrasound imaging is excellent in diagnosing this problem.

Endometriomas appear as dark, fluid-filled cysts with a "ground-glass" appearance on ultrasound.

Simple cysts appear as smooth, round, fluid-filled structures with well-defined borders.

The co-existence of an endometrioma with a simple cyst is a common finding on ultrasound and can be managed conservatively or surgically, depending on the patient's symptoms and desire for fertility.

Regular monitoring and follow-up with ultrasound can help detect changes in the size or appearance of the cysts and guide treatment decisions

On color Doppler ultrasound in this condition:

Endometriomas typically appear on gray-scale ultrasound as well-defined cystic masses with homogeneous low-level internal echoes, and often have a characteristic "ground-glass" appearance. On color Doppler ultrasound, they may show little to no vascularity, with blood flow detected only around the periphery or in septations.

Simple cysts of the ovary are usually anechoic (i.e. without internal echoes) and appear as well-defined, round, or oval cystic structures. On color Doppler ultrasound, they are typically avascular, with no detectable blood flow.

When an endometrioma and simple cyst coexist in the same ovary, the sonographic appearance can vary depending on the size and location of the cysts. On color Doppler ultrasound, the endometrioma may show low-level internal echoes, and the simple cyst may show no internal echoes, with no detectable vascularity in either structure.

In some cases, the coexistence of endometriomas and simple cysts may be associated with increased blood flow to the ovary on color Doppler ultrasound, which may suggest the presence of underlying inflammatory processes. However, this finding is not specific to endometriomas and simple cysts and requires further evaluation to determine its significance.

Color Doppler ultrasound can provide valuable information on the blood flow patterns within and around endometriomas and simple cysts, which can aid in the diagnosis and management of these conditions. However, the interpretation of color Doppler findings should always be considered in the context of the patient's clinical history, physical examination, and other imaging findings.

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Sonography of endometrioma

A strange looking breast mass. Diagnosis?

Ultrasound can throw up strange looking lesions, especially in the breasts. 

This lactating female patient had complex cystic lesion of the breast on ultrasound imaging. 

The key word here is lactating female. 

It looks cystic, poorly vascular on color Doppler, contains echogenic debris.

In a lactating patient, the only possibility is a galactocele or milk cyst of the breast. 

(Images courtesy of Dr Golam).

Differentiating points:

Differentiating a galactocele from other breast cystic lesions on sonographic imaging can be challenging, but there are some key features that can help. Here are some points to consider:

Galactoceles are typically located in the subareolar region of the breast.

They are often associated with lactation or recent breastfeeding.

They have a characteristic appearance on ultrasound, with a well-defined, round or oval shape and a homogeneous, anechoic,  sometimes complex, interior, as in our case above. 

Other cystic lesions, such as simple cysts or complex cysts, may have different imaging characteristics, such as internal echoes, septations, or thickened walls.

FNAC is diagnostic:

In cases of diagnostic uncertainty, ultrasound-guided aspiration can be used to confirm the cystic nature of the lesion and rule out other causes of breast masses. 

More on galactocele:

Galactocele is a milk containing cyst of the breast in lactating women. 

1. Galactoceles are usually harmless and can often be managed without surgery.
2. Symptoms may include a lump or swelling in the breast, pain, or nipple discharge.
3. Diagnosis is typically made through imaging tests, such as an ultrasound or mammogram.
4. Treatment options may include aspiration to drain the fluid, or surgery to remove the sac.
5. Breastfeeding can sometimes trigger the formation of a galactocele, but it's not a common occurrence.
6. Galactoceles are not related to breast cancer and do not increase a woman's risk of developing breast cancer.
7. In rare cases, a galactocele may become infected, which can cause more serious symptoms and require prompt medical attention.
8. Regular breast exams and mammograms are still important for women who have experienced a galactocele to ensure overall breast health.

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Galactocele ultrasound imaging

Why do a Doppler ultrasound study of portal vein?

This female has definitely signs of grade 1 or mild fatty liver. 

In addition there's a gallbladder calculus. 

Have a look:

Compare the echogenicity of the liver and right kidney. Definitely more echogenic than the right kidney. 

Portal vein at 11.5 mm. 

GB calculus 👆

I decided to study the portal vein in detail. Just to be sure. 

Centripetal flow in portal vein. Flow towards the transducer is a good sign. Rules out reverse flow. 

Normal spectral Doppler ultrasound trace.

Final diagnosis: gallbladder calculus with grade 1 fatty liver. Normal flow in portal vein. 

No evidence of portal hypertension. 

More on fatty liver and sonography:

Introduction:

• Fatty liver, also known as hepatic steatosis, is a common liver disease.
• Non-alcoholic fatty liver disease (NAFLD) is a subset or subtype of fatty liver that is not caused by excessive alcohol consumption.
• Patients with NAFLD may have complications such as portal hypertension, which can lead to serious health issues.
• Color and spectral Doppler imaging are non-invasive techniques that can help in evaluating the portal vein in these patients.

Section 1: Fatty Liver and Portal Hypertension

• Fatty liver is associated with increased incidence of portal hypertension.
• Portal hypertension occurs when there is increased pressure in the portal vein that carries blood from the digestive organs to the liver.
• Complications of portal hypertension include varices, ascites, and hepatic encephalopathy.

Section 2: Color Doppler Imaging of the Portal Vein in Fatty Liver

• Color Doppler imaging is a non-invasive technique that uses color to represent blood flow direction and velocity.
• It can help in identifying abnormal flow patterns in the portal vein, such as increased velocity or turbulence.
• This technique can also help in detecting collateral vessels or shunts, which may develop as a result of portal hypertension.

Section 3: Spectral Doppler Imaging of the Portal Vein in Fatty Liver:

• It can provide information on blood flow velocity, volume, and resistance.
• In patients with portal hypertension, spectral Doppler can help in detecting changes in flow characteristics, such as increased velocity and resistance, reversed flow etc. 

Conclusion:

• Color and spectral Doppler imaging are valuable tools in evaluating the portal vein in patients with fatty liver.
• These non-invasive techniques can provide important information on blood flow patterns, velocity, and resistance.
• Early detection of portal hypertension and related complications can help in managing the disease and improving patient outcomes.

For more on liver pathology:

Sonography in liver pathology

What's wrong with these ovaries in early pregnancy

Clearly an early intrauterine gestational sac with an embryo present. 

But those ovaries appear polycystic. 

She's a  known case of PCOD. 

PCOD in early pregnancy can increase the risk of complications, including:

1. Miscarriage
2. Gestational diabetes
3. Pre-eclampsia
4. Preterm birth
5. Cesarean delivery
6. Neonatal complications.

It's important for women with PCOD to receive early and regular prenatal care to minimize the risk of these complications and ensure a healthy pregnancy.

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Sonography of ovaries in pregnancy

Normal vs fatty pancreas, an ultrasound comparison

The normal pancreas is relatively hypoechoic to isoechoic on sonography. 

Here a case of a normal pancreas. 

The head and body are seen well. 

Now let's have a look at a case of fatty pancreas. There's also mild fatty liver in case 2:

The pancreas in the 2nd case is brightly echogenic and relatively inhomogenous. 

These are the typical findings of fatty pancreas. 

So what is fatty pancreas?

• Fatty pancreas is a condition where the pancreas has an excessive amount of fat.
• It's usually diagnosed through an ultrasound examination of the abdomen.
• Obesity, insulin resistance, metabolic syndrome, and type 2 diabetes are some of the risk factors associated with fatty pancreas.
• Fatty infiltration of the pancreas can lead to impaired pancreatic function and even chronic pancreatitis.
• The treatment of fatty pancreas involves managing the underlying risk factors and making lifestyle changes, such as exercise and a healthy diet.
• In severe cases, medications or surgery may be required.

For more on this topic visit:

Pancreatic disease, sonography

A comparison of two sapheno-femoral junctions in one patient

The above is the abnormal Rt side. 

• 
  
• In sapheno-femoral incompetence, the color Doppler ultrasound will show retrograde (backward) flow in the saphenous vein when the patient is standing.
• The retrograde flow is typically seen at the sapheno-femoral junction, where the saphenous vein empties into the deep femoral vein.
• This retrograde flow may be continuous or intermittent, depending on the severity of the incompetence.

Spectral Doppler Ultrasound Findings:

• Spectral Doppler ultrasound is used to measure the velocity and direction of blood flow in the veins.
• In sapheno-femoral incompetence, spectral Doppler ultrasound will show a reversal of flow in the saphenous vein when the patient is standing.
• The velocity of the retrograde flow is typically higher than the normal flow in the vein when the patient is supine.
• This increased velocity can be quantified and used to grade the severity of the incompetence.
• In the above right side: there's severe incompetence with a flow reversal of more than 4 seconds. 

What are the grades of reflux in SFJ?

Grading of reflux based on the duration of reflux in sapheno-femoral or venous incompetence using Doppler ultrasound:

• Grade 0: No reflux detected.
• Grade 1: Reflux lasting less than 0.5 seconds.
• Grade 2: Reflux lasting between 0.5 and 1.0 seconds.
• Grade 3: Reflux lasting longer than 1.0 seconds or continuous reflux.

In addition to the duration of reflux, other factors such as the location and extent of the reflux are also taken into account when grading venous incompetence

Let's have a look at the normal left SFJ:

The difference in the left side is obvious. No reversed flow, on color Doppler or spectral Doppler ultrasound. 

General information:

Sapheno-femoral incompetence refers to the inability of the saphenous vein to properly empty into the femoral vein. Color Doppler ultrasound is a diagnostic tool used to detect this condition. In a normal junction, blood flows unidirectionally, but in incompetent junctions, blood flow is reversed, causing reflux. Venous insufficiency, varicose veins, and chronic venous disease are common complications of this condition. Endovenous ablation and sclerotherapy are effective treatments for sapheno-femoral incompetence, and early intervention can prevent further complications. 

An interesting phenomenon, in this female

Observing the bladder and pelvic structures including uterus, I found this interesting phenomenon.

That streak of color from the posterior wall of the bladder is a ureteral jet. They come alternately from either side. 

Here are some facts about ureteral jets. 

• Ultrasound imaging of the urinary bladder may reveal a "ureteral jet".
• A ureteral jet appears as a small, pulsatile stream of urine entering the bladder.
• It indicates the presence of normal, unobstructed flow from the ureter to the bladder.
• The absence of a ureteral jet may suggest obstruction or other urinary tract abnormalities.
• Ureteral jets can be visualized using color or spectral Doppler ultrasound.

For more on this visit:

Sonography of ureteral jets in the bladder