GU Eval & Congenital Anomalies Flashcards
What would the indications for a renal eval be?
UTI’s – urinary tract infection
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Increased BUN and or Creatinine
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Hematuria
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Mass seen on X-ray
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Flank Pain, CVA tenderness
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Decreased urine output – Oliguria
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Azotemia - ↑ levels of nitrogen in the blood
Transducer frequency used for kideny US (adult, ped, newborn)
types.
3-5 Mhz. (adult)
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4-5 Mhz. (peds)
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6-8 Mhz. (newborn)
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Vector
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Sector
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Curved Linear
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Rib artifacts
What is renal ultrasound able to demonstrate?
The acoustic properties of a mass, delineate an abnormal lie of the kidney resulting from extrarenal mass, or determine whether hydronephrosis is secondary to renal stones
Patient postion Rt vs Lt
Right
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Supine or Lt. lateral oblique or decubitus
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Using liver as acoustic window
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Imaging through muscles
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posterior approach
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Left
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Supine or Rt. lateral oblique or decubitus
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Spleen may be used as a window, generally upper pole only
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Imaging through muscles
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posterior approach
What are the Renal contours when imaged?
Smooth outer contours surrounded by reflected echoes of Perirenal fat. Renal parenchyma surrounds the fatty central renal sinus which contains the calyces infundibula pelvis vessels and lymphatics
US Appearance (adults vs infants)
ADULTS
Cortex; homogeneous, slightly less than liver echogenicity
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Medulla-Pyramids; hypoechoic compared to cortex
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Sinus; echogenic secondary to fat and fibrous tissue
INFANTS
Cortex; more echogenic than in adults
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Medulla-Pyramids; more prominent than adults and often mistaken for cysts
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Sinus; not well developed and almost absent – lack of adipose tissue
Why is the renal sinus imaged as an area of intense echoes with variable contours?
Because of the fat interface
WHAT positon was this Td for this rt kidney?
long
What does dehydration do to the kidney?
Causes the infundibula and Renal pelvis to be collapsed making them indistinguishable from the echo dense renal sinus fat
what are the arrows pointing to?
What can you see if the bladder is hydrated?
The extrarenal pelvis medial to the kidney on transverse scans
how thick is the parenchyma? how about in the cortex?
Parenchymal thickness 1.5 cm or >
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Even thickness throughout
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Thin areas of cortex (< 1.5cm is pathologic)
What window is used to image the right kidney?
The liver
is the cortex or sinus more echogenic?
cortex
What window do you use to see the left kidney?
The liver or spleen
how much can a kidney move during inspiration?
~2.5 cm
What should the renal cortical echo amplitude be compared to with regards to amplitude and depth to set appropriate TGC and sensitivity?
Liver parenchymal echo amplitude
what poles does the kidney have?
superior and inferior.
What two parts of the kidney make up the renal Parenchyma?
The renal sinus to the outer renal surface
how can you tell this is a pediatric kidney?
the prominence of the medullary pyramids and the lack of prominence of the renal sinus as compared to the adult kidneys. (adult below)
What are the columns number Bertin?
The band of cortical tissue separating the hypo echoing medullary pyramids from the echogenic cortex
what can you see?
What normal structure could be confused for a renal artery and transverse?
The inferior vina cava. both will be tubular in transverse
what do you see?
What shape typically are renal pyramids?
Triangular
what is different about this kidney?
lack of sinus fat. prominence of medullary pyramids. *it’s an infants kidney
What vessels lie at the base of the pyramids?
The arcuate vessels
what do you see on this infant kidney
Why is it important for a sonographer to recognize variants?
So they do not suspect an abnormality when it is really a normal variation
what is this variant that is not uncommon and can be seen in some adults?
persistent fetal lobulation
What is a column Of Bertin made of ?
It is a prominent invagination of the cortex located at varying depths within the medullary substance of the kidneys
what do you see here?
Column of Bertin
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A variant, not uncommon
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Prominent cortex between the pyramids/Medulla. It is a normal variant. Can be found in either kidney.
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Important to differentiate from a mass.
what is this variant that is typically seen in the lt kidney?
dromedary hump
Upper Tract Protocol (long, trans and extras)
Renal Longitudinal
Measure in longest plane – both sup. to inf. and ant. to post.
Medial aspect
Lateral aspect
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Renal Transverse
Superior pole
Mid with measure – both med. to lat. and ant. to post.
Inferior pole
Additional images may be needed
Poles in longitudinal, if kidney is too long
Pathologies
protocol lower tracts (bladder, jets…)
Bladder Longitudinal
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Mid line
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Bladder Transverse
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Mid way between dome and bladder neck
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Additional images may be needed
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Large bladder
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Uretic Jets – Checking for urine flow into bladder
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Pathologies
what is this showing you?
where to measure length. lateral, medial
what are anterior windows generally obstructed by when taking a long image of a kidney?
bowel and gas. henceforth many renal images are taken from lateral acoustic windows.
what do you do if you can’t get the poles in their entirety?
take additional images
what planes and parts of the kidney are these images taken in?
trans –> superior, middle, inferior
what planes are these images taken in?
transverse
what is this?
bladder
what are these?
lt and right uretic jets (image of the bladder)
what plane is this image taken from?
long rt kidney
Of the congenital anamoies:
Bilateral ______ is not compatible with life
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Unilateral _______ is often an incidental finding. Pt. will have a large single kidney.
agenesis or hypoplasia
this congenital anomaly is Rare; Complete duplication of the kidney and ureter. Often duplication is within the pelvis.
supernumerary kidney
what congenital anomaly are these examples of?
Renal Ectopia – Kidney fails to rise into the normal expected location during development
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Crossed renal ectopia – Condition where both kidneys are located on the same side.
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Crossed fused ectopia – Condition where the kidneys are positioned on the same side and are fused together
malposition
what congenital anomay has –
Fusion of the upper poles or the lowers poles of the kidney. Most frequently occurs in the lower poles.
horseshoe kidney
what congenital anomaly is this?
horseshoe kidney
what is a collection system duplication (congenital anomaly)?
Dual collecting system
Two separate renal pelvi, one for upper pole and one for inferior pole
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Two ureters coming from one kidney
May be the full ureter, and enter separately in the bladder
May be a incomplete ureter, and enter into the other ureter on the way to the bladder
*Important for sonographer to image in the renal pelvis to insure there is true duplication. It is easy to miss or to incorrectly diagnose as duplicated when it is not. Because of the way we image the collecting system. Sonographer must make sure the is two distinct collection systems, separated by cortex in the area of the hilum.
what do we see here?
eg of false positive duplication of the rt kidney (duplication of collecting system)
____ is often associated w/ a duplicated collecting system
ureterocele
what does this image show?
extrarenal pelvis w/ NO dliation of collecting system
what congenital anomaliy does this image show?
peripelvic cysts
no dilation of collecting system, no communication of cysts. *cysts form in the renal sinus
What is the difference between crossed ectopia, crossed fused ectopia and an ectopic kidney?
what do these represent?
Crossed ectopia - same side of body
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Crossed fused ectopic – same side of body, fused together
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Ectopic Kidney – Kidney not located in the normal position. Often in pelvis
congenital anomalies
what is this an anomaly of? what is it?
what can happen in this site?
bladder anomaly
Diverticulum – pouch like projection from the bladder wall.
potential site for urinary stasis leading to stone formation or infections
what is exstrophy?
a bladder anomaly in which –
Failure of closer in anterior bladder wall of the urogenital sinus and genital tubercle.
Urogenital sinus
Genital tubercle
what is hypospadia?
Urethral opening on ventral side of penis
what vessels are used for anastomeses in the arterial, venous and ureter systems with regards to a renal transplant?
where do the native kidneys go?
Arterial – MRA to IIA or EIA, usually and end to end anastomosis.
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Venous – MRV to EIV, usually end to side anastomosis.
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Ureter – Implanted into the bladder, not into a ureter.
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Location: annotate on the images
Rt. lower quad
Lt. lower quad
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Native Kidneys – Typically left in place
these images represent the potential ways the kidney/vessles relationship can be due to patient’s pelvic anatomy.
what plane are these images taken from?
what quadrant of the body does this represent?
transverse
RLQ (renal transplant)
if this image was taken in the RLQ is the dot medial or lateral to the kidney?
What about if it was taken in the LLQ?
medial
lateral
what is this?
subscapular hematoma w/i the true capsule of the kidney
what is going on w/ this 3 yr post renal transplant kidney?
A large stone can be seen in the superior / mid portion of the transplant. Did you notice the small amount of fluid in the upper pole of the collecting system demonstrated on the prior images?
where has this retroperitoneal hemorrhage taken place?
how can the sonographer tell the size fo the mass when there is not a clear image?
within Gerota’a fascia
by palpating the mass and increasing the depth to the full extent of the mass.
what are sonographers often asked to rule out in the event of a retroperitoneal hemorrhage?
a ruptured AAA.
in this eg The US was done prior to the CT. US was asked to r/o a ruptured AAA. After mass of identified the sonographer was able to see an AAA at the level of the umbilicus.
what is this? what do you need to be careful to not mistake it for?
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Artificial Urinary Sphincter for bladder
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Balloon reservoir can be seen adjacent to the bladder in pt. with this type of device
where are penile implants seen?
As with the artificial sphincter the balloon reservoir will be seen adjacent to urinary bladder
what anatomy are the arrows pointing to?
what is the location of the asterisk in relation to the poles of the kidney?
what is the echogenic area inferior to the asterisk and posterior to the arrows termed?
medulla or pyramid
superior pole
renal sinus
This patient has a condition known as hydronephrosis. The anechoic area in the center of the kidney is a dilatation of what?
renal collecting system
The cortex of the kidney is measured from the true capsule to the cortico-medullary junction. Select an area where you would measure the cortical thickness.
name the areas
a. true capsule
b. column of Bertin
c. cortex
d. pyramid or medulla
e. minor calyx
f. major calyx
g. cortico-medullary junction
h. ureter
i. renal pelvis
j. hilum
name these areas
a. pyramid or medulla
b. sinus
c. column of Bertin
d. pyramid or medulla
e. rib shadows
name these
a. minor calyx
b. true capsule
c. major calyx
d. renal pelvis
e. ureter
what is notable about the echogenicity of this kidney?
Cortex is more echogenic than the liver/spleen
what can you say abou tthe cortical thickness of this kidney?
Cortex appears too thin
What is this an image of?
What plane was this image acquired in?
What can you tell about this patient?
urinary bladder
long
female patient, uterus seen posterior to bladder
what is this an image of?
what plane was it taken in?
urinary bladder
transverse
what is this an image of?
what can you say about this pt based on the image?
urinary bladder w/ lt ureteral jet. lt ureter is not totally obstructed. some uring is making it into the bladder
What is this an image of?
Can you identify the bladder wall?
Is the bladder wall thin?
What are some possible causes for this appearance of the bladder?
urinary w/ debris
yes - see image below
no. bladder wall appears thick
urinary infection of blood in bladder (causes of debris)
what can you say abou tthis kidney?
very echogenic
what does this image show?
can u identify where the transplanted kidney is located?
perfusion of the kidneys
LLQ
name each of these anatomic variables.
Column of Bertin - (appears as a mass within the normal kidney. It consists of normal tissue but can displace the pyramids and calyces.)
Dromedary hump (prominent bulge on the superolateral border of the left kidney.)
Lines a-c represent the standard protocol planes for the longitudinal images. How would letter c be annotated (labeled) on the US image?
how about letter b?
which kidney is shown in the drawing?
how do you know?
medial longitudinal
lateral long
rt kidney
the renal hilum is medial
what approach was used to image this kidney?
anterolateral
