GU DDx Flashcards
Adrenal Mass:
Adrenal Adenoma
- Circumscribed small (<2cm)oval homogenous low density mass
- < 10HU highly specific.
- Signal drop out on out of phase -> lipid rich.
- Lipid poor: absolute washout > 60%, relative washout > 40%.
Metastases (lung breast kidney melanoma)
Haemorrhage
Pheochromocytoma
- Well circumscribed 3-5cm mass
- MEN IIA or MEN IIB
- Neurofibromatosis
- VHL
- Carney syndrome
- Tuberous sclerosis
- Hyperintense T2, heterogenous bright C+
Adrenal myeloipoma
- T1 hyperintense
- Focal areas fat suppression
Adrenal TB
- Chronic: Addisons disease
- Small Ca++ glands
Adrenal carcinoma:
- non functional large lesions.
- May have necrosis, haemorrhage, Ca++
Adrenal collision tumour
Adrenal hyperplasia:
- Normal shape with increased thickness, or nodular.
Hypoechoic adrenal mass:
Adenoma Metastases Pheochromocytoma Adrenal haemorrhage Adrenal cortical carcinoma Adrenal pyogenic infection (unilateral) Granulomatous infection (bilateral)
Cystic adrenal Mass:
Simple cyst Abscess Organising haematoma Mimics: renal cyst, liver cyst, pancreatic cyst, splenic artery pseudoaneursym. Cystic adenoma Cystic neuroblastoma Cystic pheochromocytoma
Hyper echoic adrenal mass:
Adrenal haemorrhage Calcification: - Previous haemorrhage - Previous infection - Calcified neoplasm (neuroblastoma, myelolipoma, pheochromocytoma) - Wolman disease Myelolipoma Neuroblastoma Adrenal cortical carcinoma Pheochromocytoma.
Bilateral adrenal enlargement:
Adenoma Mets Haemorrhage / infarction Adrenal hyperplasia Pheochromocytoma Infection: TB, Histoplasmosis, granulomatous disease. Lymphoma
Medullary nephrocalcinosis:
"HAM HOP" H: hyperparathyroidism A: (renal tubular) acidosis M: medullary sponge kidney H: hypercalcaemia/hypercalciuria O: oxalosis P: papillary necrosis
Hyper PTH
- Clusters round Ca++ renal pyramids
Renal tubular acidosis (distal type)
Medullary sponge kidney
- Tiny calculi disapear with contrast
- Delayed CECT show renal pyramid blush
- unilateral less dense medullary nephrocalcinosis.
- Assocations: ehlers danlos, Carolis, Beckwith Weidemann.
Hyper calcaemia
Oxalosis:
- Dense Ca++ cortex +/- medulla.
- Normal sized kidneys
- Skeletal hyperdensity.
Papillary necrosis
Chronic Pyelonephritis:
- Punctate or focal Ca++ in cortex and medulla.
- Cortical thinning over dilated calyces.
- Kidneys small in size and function.
TB:
- Focal or diffuse amophous Ca++.
Child - frusemide treatment.
Cortical nephrocalcinosis: “COAG”
C: cortical necrosis
O: oxalosis
A: Alport syndrome
G: (chronic) glomerulonephritis
Acute cortical necrosis Hyperoxaluria Alport syndrome ARPCKD Transplant rejection Chronic GN
Echogenic kidneys:
Medical renal disease
- Diabetic nephropathy
- Glomerulosclerosis
- Actube tubular necrosis.
- HIV nephropathy: enlarged echogenic
Echogenic renal Mass:
Angiomyolipoma: shadowing echogenic mass specific.
Atypical malignant renal neoplasm.
Renal calculus
Intra renal gas
Milk of Calcium
Sloughed papillae due to papillary necrosis.
Renal Sinus Lesion DDX:
Sinus lipomastosis
Renal Sinus Cyst:
- Peripelvis: multiple confluent non communicating, surround and compress calyces.
- Parapelvic: solitary, spherical.
Renal Pelvis clot / haematoma
Vascular lesions:
- Aneurysm
- AVM
- Varices
TCC
Lymphoma
RCC
Gas around Kidney DDX:
Emphysematous pyelonephritis Renal abscess Emphysematous pyelitis Renal infarction Instrumentation
Radiolucent filling defect renal pelvis DDX:
Urolithiasis Blood clot Fungus ball TCC: - irregular filling defects, amputates calyces. Renal Papillary necrosis: - Sloughed papilla with cavitation of calyx. - CLub shaped calyces - Analgesic abuse.
Gas within Baldder DDX:
Iatrogenic
Bladder fistula
Cystits
Emphysematous cystitis
Filling defect in urinary bladder DDX:
Bladder carcinoma:
- mass protruding into lumen, enhances
- Cant completely exclude on imaging alone
Bladder calculi
Ureterocele:
- Orthoptopic, cobra head
Blood Clot
BPH
- J shaped ureters
Bladder fistula
Extra vesical pelvic mass.
Fungus ball: Candida.
Cystic Retroperitoneal Mass:
Retroperitoneal seroma Retroperitoneal Sarcoma: - mixoid liposarcoma can have water density Retroperitoneal lymphocele Urinoma Retroperitoneal Abscess Lymphangioma
Fat Containing Retroperitoneal Mass:
Liposarcoma:
- Large fat and soft tissue components
- Compresses and displaces retro-peritoneal organs.
- Invasion uncommmon
- Liposarcoma is less vascular than AML
Renal AML:
- Benign hamartoma of blood vessels, muscle, fat.
- AML will replace part of kidney / claw sign.
Adrenal myelolipoma:
- Fat and soft tissue components +/- Ca++
Teratomas: Met
AIDS: liodystrophy:
- Proliferation of retroperitoneal and mesenteric fat in response to AIDs medication.
Retroperitoneal lipoma:
- Less heterogenous than lipsarcoma.
Hyperechoic Renal Mass DDX:
Angiomyolipoma:
- Well defined hyperechoic mass that is equal to renal sinus
- May have posterior shadowing
- Small lesions echogenicity > RCC
- Large lesion: prominent vascularity
- May have central necrosis
- Requires CT.
RCC:
- 30% hyperechoic
- Necrosis or anechoic rim favours RCC
- Large RCC may have Ca++
- Mass with Ca++ and fat in adult = RCC
Wilms tumour:
- CHild
Fat in renal scar
Milk of Ca++ cyst:
- COmet tail artifact
Renal Calculi:
Renal Papillary Necrosis:
- Echogenic ring in medulla = Necrotic Papilla, surounded by rim of fluid.
Abscess with Gas.
Renal Mets
Renal TB:
- Papillary destruction with echogenic masses near calyces
- Ca++ granuloma or dense dystrophic Ca++ with shrunken kidney.
Renal oncocytoma
Renal Trauma.
Infiltrative Renal Lesion DDX:
Replaces renal parenchyma without distorting shape. Lacks sharp border of demarcation.
Pyelonephritis:
- Enlarged kidney, striated / wedge foci of reduced C+
TCC
Mets / lymphoma
- Multiple poorly defined renal masses
RCC:
- usually expansile, rarely diffusley infiltrative.
Renal medullary carcinoma:
- Young patient with sickle cell
HIV nephropathy
Renal TB.
Peri renal and subcapsular mass DDX:
Haemorrhage: - trauma, coagulopathic, tumour (AML / RCC), vasculitis. Renal Mets / lymphoma Abscess Xanthogranulomatous pyelonephritis urinoma Retroperitoneal fibrosis
Bilteral Renal Cysts:
ADPCKD:
- Progressively enlarged kidneys, loose function
- Cysts in liver, pancreas, seminal vesicles.
Acquired cystic disease uraemia:
- Dialysis -> increases risk of RCC.
VHL:
- cysts and tumours of kidney adrenal, pancreas, brain, spinal cord (haemangioblastomas)
Tuberous sclerosis:
- hamartomas brain, lung, heart, skin, kidneys
Medullary cystic Disease:
- Small kidneys with cysts in medulla, thinned cortex.
- Progressive renal faliure and anaemia in young patient.
Calcified small lesion in Kidney DDX:
Urolithiasis Renal artery Ca++ Nephrocalcinosis Medullary sponge kidney AIDS / opportunistic infections Renal papillary necrosis - clubbed calyces Chronic GN / pyelonephritis: - Small scared kidneys with small foci Ca++ RCC: - foci Ca++ approx 10% Renal Tb.
Renal Nuke Agent summary:
Tc-DMSA: renal structure:
- Assess for scarring and infection.
Tc- DTPA: “like CTPA hence we check eGFR”
- filtered thus givens GFR assessment.
Tc-MAG 3: “need your mag wheels to get through tight spots, like renal artery stenosis.
- Secreted
- Estimates effective renal plasma flow.
- ACE study, sick kidney will have marked tracer retention,
ACE study using DTPA, as is a GFR tracer, a sick kidney will have decreased uptake and flow, due to loss of perfusion pressure, hence worsening uptake post ACE.
Adrenal Absolute washout:
% washout = (Enhanced attenuation - delayed attenuation) / (enhanced attenuation - unenhanced attenuation)
> 60% absolute washout is diagnostic of adenoma.
Adrenal Relative Washout:
% relative washout = (enhanced attenuation - delayed attenuation) / enhanced attenuation
> 40% relative washout diagnostic adenoma.
Pheochromocytoma: 10% lesion
10% extra adrenal
10% bilateral
10% malignant
10% familial or syndromic
Pheochromocytoma associations:
MEN 2A and MEN 2B (usually bilateral intra adrenal) VHL NF1 TS Sturge weber Carney's triad: - Gastric leiomyosarcoma - Pulmonary chondroma - extra adrenal pheochromocytoma.
adrenal Ca++:
Wegner granulomatosis
TB
Histoplasmosis
Old haemorrhage
Unilateral enlarged Kidney DDx;
Pyelonephritis
Acute ureteral obstruction
Renal vein thrombosis
Compensatory hypertrophy
Striated nephrogram:
Pyelonephritis Renal Infarct Renal vein thrombosis or vasculitis Renal contusion Acute urinary obstruction Renal tumour - lymphoma Radiation nephritis
Causes of renal papillary necrosis:
POST CARD:
P: Pyleonephritis
O: Obstruction
S: Sickle Cell Disease
T: TB
C: Cirrhosis
A: Analgesics
R: Renal Vein thrombosis
D: DM
Unilateral delayed nephrogram DDx:
Acute ureteral obstruction
Renal vein thrombosis
Renal artery stenosis
Pyelonephritis
Bilateral delayed nephrogram DDx:
Bilateral obstruction
Contrast nephropathy
Systemic hypotension
Myeloma Kidney.
Ureteral filling defect DDx:
Ureteral malignancy (TCC) Ureteral calculus Blood clot Malacoplakia (multiple flat defects) Leukoplakia Infectious debris Sloughed papilla Benign ureteral mass - fibroepithelial polyp
T2 Dark Renal Cyst DDx:
Lipid poor AML - think TS Haemorrhagic Cyst (T1 bright) Papillary Subtype RCC
Renal Artery Doppler RI Values:
Normal 0.5 - 0.7
Abnormal > 0.7
Causes for elevated values: - Medical renal disease Ureteric obstruction - Hypotension - Perinephric collection / haematoma - Abdominal compartment syndrome.
Causes for elevated transplant values:
- ATN
- Rejection
- Renal vein thrombosis
- Drug toxicity
- Ureteric obstruction
- perinephric fluid collection.
Abnormally low value: down stream of renal artery stenosis
Renal artery doppler with reversed diastolic flow:
Renal vein thrombosis
“Reverse M sign”
Common within 1st week post transplant.
Post renal transplant renal artery stenosis:
within 1st year, most common vascular complication.
“Refractory HTN”
PSV > 200-300 cm/s
PSV ratio > 2.0
Tardus parvis wave form distal to level of stenosis.
Anastomotic jetting.
Lateral deviation of ureters:
Retroperitoneal adenopathy
Aortic aneursym
Psoas hypertrophy causes proximal urertic lateral deviation.
Medial deviation of Ureters:
Retroperitoneal fibrosis Retrocaval ureter - right Pelvic lipomatosis Psoas hypertrophy causes medial deviation of distal ureters. AP resection
Solid renal mass:
RCC Oncocytoma Angiomyolipoma TCC Lymphoma
Multiple bilateral renal lesions / masses:
Lymphoma Renal infection RCC AMLs Mets
Cystic renal mass:
Complex cyst Cystic neoplasm: RCC and Wilms. Multilocular cystic nephroma: - MJ lesion --> young boys middle aged women. Abscess
Perinephric fluid collection:
Perinephric Haemorrhage
Urine leak / extravasation
Pyelonephritis / perinephric infection.
Pear shaped bladder (AXR IVP):
Pelvic haematoma Lymphadenopathy Pelvic lipomatosis Psoas muscle hypertrophy Iliac artery aneursym
Bladder Wall Ca++:
TCC Schistosomiasis Cystitis TB Urachal carcinoma
Dilated Ureter:
Ureteral Obstruction
Reflux
Primary megaureter
Prune Belly syndrome.
Urethral Stricture:
Urethral trauma Post infectious / inflammatory stricture: - gonococcal - Chlamydia Urethral carcinoma
Renal artery acceleration time > 0.07
> 50% stenosis renal artery
Acceleration index < 3m/s
> 50% stenosis
Renal Resistive index:
Normally below 0.7
>0.7 implies something wrong with that kidney.
