Kidneys :( Flashcards
What are the 3 functions of the kidney?
Filtration, reabsorption, secretion
Common occurrence of a cystic disease is with adults over the age of?
50
What are the criteria that must be met for a cyst?
- Round or oval
- Thin walls
- Anechoic
- Posterior enhancement
What is an atypical cyst?
A complicated cyst that can be hemorrhagic with septations, mural nodules or calcifications, & irregular walls
All are presumed malignant until proven benign.
What is a parapelvic cyst?
A renal sinus cyst located at the hilum; can cause obstruction, pain, & hypertension
It does not connect with collecting system, normal labs, differential dx: hydronephrosis.
Which renal cysts can be acquired from being on dialysis for more than 3 years?
Acquired cystic disease
What is von Hippel-Lindau disease?
An autosomal dominant genetic disorder that is multiple cysts and tumors.
It appears in many organs; pancreas, retinal angiomas, RCC, HCC.
What is tuberous sclerosis?
Autosomal-dominant genetic multisystemic disorder that affects kidneys in 95% of adults.
Multiple renal cysts, possible neoplasms, may be seen bilateral to angiomyolipomas.
Difference between autosomal dominant vs autosomal recessive?
Autosomal dominant: one parent
Autosomal recessive: both parents
What does ARPKD stand for? What is it?
Autosomal recessive polycystic kidney disease that causes dilation of the renal collecting tubules causing renal failure.
What are the four kinds of ARPKD found?
- Perinatal
- Neonatal
- Infantile
- Juvenile
Diagnosis depends on patient age at the onset of clinical signs.
When is perinatal ARPKD found?
In utero
How does ARPKD appear sonographically in perinatal form?
Massively enlarged, echogenic kidneys
How does ARPKD appear sonographically in older children?
Enlarged, with echogenic cortex and medulla.
May also be microscopic or small cysts located in the medulla.
T/F? Liver is involved in the advanced stages of ARPKD
True
What does ADPKD stand for? What is it?
Autosomal Dominant Polycystic Kidney Disease
It is enlarged kidneys with multiple asymmetrical cysts that vary in size and located in the renal Cortex and medulla.
What are the types of ADPKD? Which is most common?
ADPKD1 (most common; affects the kidneys more severely) & ADPKD2
ADPKD is a ______ disease
Bilateral
With ADPKD, by age 60, approximately 50% of patients have?
End-stage renal disease
What are clinical symptoms of ADPKD?
- Pain
- Hypertension
- Palpable mass
- Hematuria
- Headache
- UTI
- Renal insufficiency
What are some complications of ADPKD?
- Infection
- Hemorrhage
- Stone formation
- Rupture of cyst
- Renal obstruction
What is the most common palpable abdominal mass found in neonates?
Multicystic dysplastic kidney
What is the most common form of cystic disease in neonates?
Multicystic Dysplastic Kidney (MCDK)
Multicystic dysplastic kidney disease is usually unilateral, if it’s bilateral, what does that mean?
Not compatible with life
Sonographic findings of MCDK in neonates and children:
Kidneys are multicystic, with the absence of the renal parenchyma, renal sinus, and atretic renal artery.
Sonographic findings of MCDK in adults:
Kidneys may be small (atrophic and calcified) and echogenic.
What is medullary cystic disease?
A congenital, autosomal recessive (inherited), maldevelopment of kidney, scarring of tubules resulting in tiny cysts.
A rare benign disease of both children and adults that is non-hereditary. Can be unilateral or segmental. Appears as equally spaced hyperechoic pyramids; nephrocalcinosis often present:
Medullary sponge kidney
What is nephrocalcinosis?
Calcium deposition in renal parenchyma (NOT collecting system)
What is the most common cause of nephrocalcinosis?
Hypercalcemic state associated with malignancy or due to parathyroid adenoma causing hyperthyroidism.
Most common cause of medullary nephrocalcinosis?
Medullary sponge kidney
Most common renal tumor is?
Renal cell carcinoma (85%)
Where is RCC located within the kidney?
Renal parenchymal– NOT collecting system
Renal cell carcinoma is also called?
Hypernephroma or Von Grawitz tumor
What kind of blood flow is seen with RCC?
High systolic & high diastolic arterial flow
What can RCC be mistaken as?
Column of Bertin
RCC is most common in which patients?
Patients on dialysis
RCC appears bilaterally in ____ % to ____ % of patients
0.1% to 1.5%
If patient has RCC, where else should you look in the body?
- Retroperitoneum for lymphadenopathy
- Liver for Mets
- IVC for tumor extension
RCC staging: (grade 1-4)
Grade 1: kidney only
Grade 2: within gerota’s fascia
Grade 3: to RV, IVC, nodes
Grade 4: invasion of adjacent structures; distant Mets
Where does TCC occur?
In the collecting system, renal pelvis, ureter, and bladder
TCC increases with age in males or females?
Males
Painless hematuria and hydronephrosis is associated with?
TCC
Majority of TCC arises where?
Bladder
What is squamous cell carcinoma?
Large mass evident in the renal pelvis
It is a highly invasive tumor with a poor prognosis.
Clinical findings of squamous cell carcinoma:
- History of chronic irritation and gross hematuria
- Palpable kidney secondary to severe hydronephrosis
The most common solid renal tumor in preschool children; rare in newborns is?
Wilm’s tumor
Also known as nephroblastoma.
Wilm’s tumor is also called?
Nephroblastoma
Nephroblastoma is two to eight times more common in patients with which kidney variant?
Horseshoe kidney
Signs and symptoms of Wilm’s tumor?
- Fever
- Gross hematuria
- Pain
- Palpable mass
- Nausea/vomiting
How do lymph nodes appear with infection?
oval/smooth
How do lymph nodes appear with malignancy?
irregular/round
What does elastography evaluate?
tissue stiffness
What lies anterior, medial, and superior to the kidneys?
adrenal glands
Which kidney lies more superior in the body?
left kidney
Which adrenal gland is more superior to kidney, posterior to IVC, and anterior to crus?
Right adrenal glands
What is the ultrasound appearance of adrenals?
hypoechoic
Usually not visualized sonographically unless mass; CT is better.
How big is the adrenal gland in an infant?
proportionally larger than adult (1/3 size of kidney; 1/13th in adult)
What is the outer portion of the adrenal gland and what is it responsible for?
cortex (90% gland)
-responsible for: mineralocorticoids (electrolyte metabolism), glucocorticoids (carb metabolism), & sex hormones
steroid hormones
What is the medulla (core) responsible for?
epinephrine and norepinephrine; responds to stress or pain
adrenaline, fight or flight response
Where do the right and left suprarenal veins drain?
Right: directly into IVC
Left: into LRV
What factors affect visualization of the adrenal glands?
size of patient, amount of perirenal fat surrounding adrenal area, presence of bowel gas, ability to move patient in various positions
What appearance of adrenal glands suggests a pathologic process?
rounded
Adrenal hemorrhage is very rare in which population?
adults
What usually causes adrenal hemorrhage?
severe trauma or infection
meningococcal infection & waterhouse-Friderichsen syndrome
In which patient population does adrenal hemorrhage typically occur?
neonates who experience traumatic delivery
What is Addison’s disease?
Decrease in adrenal function, increase in serum potassium; atrophy cortex, hypotension, weakness, loss of appetite and weight, bronzing of skin; has many causes
What is Waterhouse-Friderichsen syndrome?
Bilateral hemorrhage into adrenals due to acute infectious process (meningitis, sepsis) leads to insufficiency & death
What is Adrenogenital syndrome?
Increased sex hormones (congenital hyperplasia); androgens/estrogens
What is Conn’s syndrome?
Increases aldosterone, increased glucocorticoids; affects fluid balance regulation and carbohydrate metabolism
What is Cushing’s syndrome?
Hypersecretion of cortisol from cortex causing excessive glucose production (results in diabetes), decreased serum potassium
What is the acute vs chronic sonographic appearance of Addison’s disease?
Acute: diffuse enlargement
Chronic: atrophy and calcification
What syndromes can malignant adrenal tumors cause?
Cushing’s, Conn’s, or adrenogenital syndromes
Are adrenal cysts common or uncommon?
uncommon
What is the most common primary adrenal tumor?
Benign nonfunctioning adenoma
Adrenal nodules usually measure less than ____ cm
3
Which patients have a high incidence for adrenal adenoma?
older patients with diabetes or hypertension
Adrenal adenomas can be associated with what familial syndrome?
MENS (Multiple Endocrine Neoplasia Syndrome)
What are the 6 tumors associated with MENS?
-Pituitary adenoma
-Parathyroid adenoma
-Medullary thyroid carcinoma
-Pancreatic islet cell tumors
-Pheochromocytoma
ganglioneuromatosis
What is a nonfunctioning cortical adenoma?
a unilateral mass that is hypoechoic, round, and encapsulated; no history of malignancy; measures less than 3 cm
Adrenal myelolipoma are commonly seen as?
echogenic mass in the adrenal bed
-they contain both fatty and bone marrow elements
-measure less than 5 cm
What does the presence of prop speed artifact indicate?
mass containing fat tissue
Adrenal glands are the ____ most common site in the body for metastasis, after the lung, liver, and bones
4th
What are the 3 most common sources that metastasize to the adrenal glands?
-breast
-lung
-melanoma
What is pheochromocytoma?
tumor of the adrenal medulla
-causes hypertension, severe headaches, heart palpitations, tachycardia, excessive perspiration
What are the sonographic findings of pheochromocytoma?
-benign or malignant
-average size is 5-6 cm
-well encapsulated
-variable echogenicity
-highly vascular
What is the most common malignancy of the adrenal gland in childhood?
neuroblastoma
When a large, solid, upper abdominal mass is identified in an infant or young child, what should the differential diagnosis include?
-Neuroblastoma (adrenal)
-Wilms tumor (nephroblastoma, renals)
-Hepatoblastoma (liver)
What are some primary retroperitoneal tumors?
-liposarcoma (most common in retro–malignant fat cells)
-leiomyosarcoma (smooth muscles)
-fibrosarcoma (fibrous connective tissue)
-Rhabdomyosarcoma (straited muscle)
What are some retroperitoneal benign tumors?
-Fibroma
-Lipoma
-Mesothelioma
-Myxoma
-Teratoma
What is retroperitoneal fibrosis?
an idiopathic condition characterized by thick sheets of fibrous tissue in the retroperitoneal cavity; frequently pushes the aorta/IVC more anteriorly, can mimic AAA signs and symptoms
What can result from retroperitoneal fibrosis obstructing the ureters and IVC?
hydronephrosis
What is retroperitoneal fibrosis also called?
Ormond’s Disease
What is a normal variant that occurs on the left kidney as a bulge on the lateral border?
dromedary hump
What is it called when a kidney is located outside of the normal position, most often in the pelvic cavity?
ectopic kidney
What is a stone in the urinary system known as?
urolithiasis
What is the first layer adjacent to the kidney that forms a tough, fibrous covering?
renal capsule
What are bands of cortical tissue that separate the renal pyramids, which may mimic a renal mass on ultrasound?
Columns of Bertin
What is dilation of the renal collecting system known as?
hydronephrosis
What is a congenital malformation in which both kidneys are joined together by an isthmus, most commonly at the lower poles?
horseshoe kidney
What is the interruption in the normal development of the kidney resulting in absence of the kidney?
Renal agenesis
Patients with asplenia may have bilateral ____ sidedness
right
Patients with polysplenia have bilateral _____ sidedness
left
What is the most common variant of the spleen?
accessory spleen
Where is the accessory spleen most commonly located?
at the hilum
Is the texture of the spleen considered to be more or less echogenic than the liver?
more
Where in the spleen is it not considered homogeneous?
at the area of the hilum
What is congestive spleen and what is the most common cause of it?
excessive amount of blood
-most common cause is cirrhosis
What are some causes of congestive splenomegaly?
-heart failure
-portal HTN
-cirrhosis (most common)
-portal or splenic vein thrombosis
-acute splenic sequestration crisis of sickle cell disease
What is the spleen patho characterized by starch deposits?
amyloidosis
What is Gaucher’s disease?
Fat and proteins abnormally deposited in the body; jewish, enlarged spleen; auto-recessive
What is Niemann-Pick Disease?
Female infants; lipid storage disorder; rapidly fatal; splenomegaly
What is sickle cell anemia?
Hereditary; abnormal hemoglobin shape; auto splenectomy (adults); late stages – small spleen
What is polycythemia?
Excess RBCs, sometimes WBCs and platelets also; splenomegaly, firm; bone marrow
What is thalassemia?
Mediterranean and SE Asia; abnormal form of hemoglobin; fewer RBCs due to high rate of destruction; very enlarged spleen; may need blood transfusions
What is Wilson’s disease?
Build-up of copper; enlarged spleen; Kayser-Fleisher ring – copper ring around eye
What is Felty’s syndrome?
Chronic rheumatoid arthritis; enlarged spleen; autoimmune
What is infectious mononucleosis?
Kissing disease; splenomegaly
What is AIDS/HIV in relation to the spleen?
Splenomegaly; tuberculosis; Kaposi’s sarcoma; opportunistic infections due to fungus, yeast, bacterial, etc. organisms
Which form of leukemia is responsible for a more extreme splenomegaly?
chronic myelogenous leukemia
Which form of leukemia produces less severe splenomegaly?
chronic lymphocytic leukemia
What is present with splenic abscess?
-fever
-LUQ tenderness
-abdominal pain
-left shoulder pain
-flank pain
-splenomegaly
What is the most prominent feature of splenic infection?
splenomegaly
What is splenic infarction and how does it appear on ultrasound?
-occlusion of splenic arteries by embolism
-appearance depends on age; typically wedge-shaped
What is the sonographic appearance of fresh hemorrhage vs healed infarction?
fresh hemorrhage: hypoechoic
healed infarction: echogenic; peripheral wedge-shaped hypoechoic lesions
What organ is most commonly associated with trauma?
spleen
What may focal hematomas have?
intrasplenic fluid collections
Where is perisplenic fluid seen?
in patients with subscapular hematomas
Why do perisplenic or intraperitoneal hematomas occur?
due to splenic trauma where the splenic capsule ruptures
What is the parasitic infection that occurs in the spleen primarily with women?
echinococcal
What are true splenic cysts associated with?
congenital; PKD
Are primary splenic tumors common and are they always benign?
False
Primary splenic tumors are rare and can be either benign or malignant.
How do most tumors of the spleen appear compared to normal splenic parenchyma?
isoechoic
What is the most common benign tumor of the spleen?
hemangioma
type of congenital hamartoma
What is a hamartoma?
a hyperechoic, non-encapsulated, well-defined, focal-collection of lymphoid tissue
Hemangiomas are types of hamartomas.
What is a cystic lymphangioma?
a benign, epithelial lined, multiseptated cystic mass. it can occur in multiple organs
spleen is rare.
What are the two primary malignancies of the spleen?
-hemangiosarcoma (similar appearance to cavernous hemangioma)
-Lymphoma (common– focal hypoechoic)
What mass is the spleen commonly involved with?
lymphoma
What are the 4 different sonographic patterns that have been cited in patients with malignant lymphoma?
-diffuse involvement
-focal small nodular lesions (seen in low-grade lymphoma and in Hodgkin’s lymphoma)
-focal large nodular lesions
-bulky disease
What is the most common primary metastasis if spread to the spleen?
melanoma
What are the 3 compartments of retroperitoneum?
-anterior pararenal space
-perirenal space (largest)
-posterior pararenal space (smallest)
Which organs are in the anterior retroperitoneal space?
-pancreas
-ascending & transverse colon
-duodenum
Which organs are located in the perirenal space?
adrenal glands, kidneys, ureters, great vessels, renal vessels, proximal collecting systems
Which retroperitoneal space attaches to the diaphragm superiorly?
perirenal
What does Gerota’s fascia cover?
Kidney, perinephric fat, and adrenal glands
What is located in the posterior pararenal space?
blood, lymph nodes & lymph vessels, fat, vessels
What are two major lymph node bearing areas in the retroperitoneal cavity?
iliac and hypogastric nodes (within pelvis), paraaortic group (in upper retroperitoneum)
How is lymph fluid returned to the venous system?
through the thoracic duct in the chest
Patients with lymphadenopathy should be evaluated for?
splenomegaly
What do nodes surround?
aorta, IVC, anterior to spine
Nodes are sometimes termed?
“floating aorta sign”
Normal size and appearance of nodes?
1-3cm; hypoechoic or anechoic
What is the mesenteric sandwich sign?
aka mantle sign; anterior and posterior nodes surround vessels in a layered appearance
What can enlarge nodes cause?
anterior displacement of SMA and IVC
How do lymph nodes appear with infection? How do they appear with malignancy?
infection: oval/smooth; malignancy: irregular/round
Elastography evaluates?
tissue stiffness
What lies anterior, medial, and superior to the kidneys?
adrenal glands
Which kidney lies more superior in the body?
left kidney
Which adrenal gland is more superior to kidney, posterior to IVC, and anterior to crus?
Right adrenal glands
Ultrasound appearance of adrenals?
hypoechoic; usually not visualized sonographically unless mass
CT is better
How big is the adrenal gland in an infant?
proportionally larger than adult (1/3 size of kidney; 1/13th in adult)
What is the outer portion of the adrenal gland and what is it responsible for?
cortex (90% gland); responsible for: mineralocorticoids (electrolyte metabolism), glucocorticoids (carb metabolism), & sex hormones
steroid hormones
What is the medulla (core) responsible for?
epinephrine and norepinephrine; responds to stress or pain
adrenaline, fight or flight response
Where do the right and left suprarenal veins drain?
Right: directly into IVC; Left: into LRV
Visualization of the adrenal glands depends on which factors?
size of patient, amount of perirenal fat surrounding adrenal area, presence of bowel gas, ability to move patient in various positions
What appearance of adrenal glands suggests a pathologic process?
rounded
Adrenal hemorrhage is very rare in which population?
adults
Adrenal hemorrhage is usually caused by?
severe trauma or infection
meningococcal infection & waterhouse-Friderichsen syndrome
Adrenal hemorrhage typically occurs in what patient population?
neonates who experience traumatic delivery
Which adrenal gland patho? Decrease in adrenal function, increase in serum potassium; atrophy cortex, hypotension, weakness, loss of appetite and weight, bronzing of skin; has many causes
Addison’s disease
Which adrenal gland patho? Bilateral hemorrhage into adrenals due to acute infectious process (meningitis, sepsis) leads to insufficiency & death
Waterhouse-Friderichsen
Which adrenal gland patho?
Increased sex hormones (congenital hyperplasia); androgens/estrogens
Adrenogenital syndrome
Which adrenal gland patho?
Increases aldosterone, increased glucocorticoids; affects fluid balance regulation and carbohydrate metabolism
Conn’s syndrome
Which adrenal gland patho?
Hypersecretion of cortisol from cortex causing excessive glucose production (results in diabetes), decreased serum potassium
Cushing’s syndrome
Acute vs chronic sonographic appearance of Addison’s disease?
Acute: diffuse enlargement; Chronic: atrophy and calcification
Malignant adrenal tumors can cause which syndromes?
Cushing’s, Conn’s, or adrenogenital syndromes
Are adrenal cysts common or uncommon?
uncommon
What is the most common primary adrenal tumor?
Benign nonfunctioning adenoma
Adrenal nodules usually measure less than ____ cm
3
Which patients have high incidence for adrenal adenoma?
older patients with diabetes or hypertension
Adrenal adenomas can be associated with what familial syndrome?
MENS (Multiple Endocrine Neoplasia Syndrome)
6 tumors associated with MENS:
Pituitary adenoma, Parathyroid adenoma, Medullary thyroid carcinoma, Pancreatic islet cell tumors, Pheochromocytoma, ganglioneuromatosis
What is a nonfunctioning cortical adenoma?
a unilateral mass that is hypoechoic, round, and encapsulated; no history of malignancy; measures less than 3 cm
Adrenal myelolipoma are commonly seen as?
echogenic mass in the adrenal bed; they contain both fatty and bone marrow elements; measure less than 5 cm
Presence of prop speed artifact indicates what?
mass containing fat tissue
Adrenal glands are the ____ most common site in the body for metastasis, after the lung, liver, and bones
4th
3 most common sources that metastasize to the adrenal glands are?
breast, lung, melanoma
What is pheochromocytoma? What does it do?
tumor of the adrenal medulla; causes hypertension, severe headaches, heart palpitations, tachycardia, excessive perspiration
Sonographic findings of pheochromocytoma:
benign or malignant; average size is 5-6 cm; well encapsulated; variable echogenicity; highly vascular
What is the most common malignancy of adrenal gland in childhood? Also most common tumor of infancy?
neuroblastoma
When a large, solid, upper abdominal mass is identified in an infant or young child, the differential diagnosis should be?
Neuroblastoma (adrenal), Wilms tumor (nephroblastoma, renals), Hepatoblastoma (liver)
What are some primary retroperitoneal tumors?
liposarcoma (most common in retro–malignant fat cells), leiomyosarcoma (smooth muscles), fibrosarcoma (fibrous connective tissue), Rhabdomyosarcoma (straited muscle)
What are some retroperitoneal benign tumors?
Fibroma, Lipoma, Mesothelioma, Myxoma, Teratoma
What is retroperitoneal fibrosis?
an idiopathic condition characterized by thick sheets of fibrous tissue in the retroperitoneal cavity; frequently pushes the aorta/IVC more anteriorly, can mimic AAA signs and symptoms
When retroperitoneal fibrosis obstructs the ureters and IVC, what can that result in?
hydronephrosis
What is retroperitoneal fibrosis also called?
Ormond’s Disease
A normal variant that occurs on the left kidney as a bulge on the lateral border is known as:
dromedary hump
Located outside of the normal position, most often in the pelvic cavity is known as:
ectopic kidney
A stone in the urinary system is known as:
urolithiasis
First layer adjacent to the kidney that forms a tough, fibrous covering is known as:
renal capsule
Bands of cortical tissue that separate the renal pyramids, may mimic a renal mass on ultrasound is known as:
Columns of Bertin
Dilation of the renal collecting system is known as:
hydronephrosis
Congenital malformation in which both kidneys are joined together by an isthmus, most commonly at the lower poles is known as:
horseshoe kidney
Interruption in the normal development of the kidney resulting in absence of the kidney; may be unilateral or bilateral is known as:
Renal agenesis
