Urinary Pathology Week 10 Flashcards
Obstructive Nephropathy
Ureteral necrosis Abscess Lymphocele Fungus ball Retroperitoneal fibrosis Stricture at the ureterovesical junction Ureteral calculus Hemorrhage into the collecting system with obstruction from clots
Renovascular impedance specificity
If high renovascular impedance develops immediately after surgery, patency of the renal vein must be tested.
With the use of color and pulsed Doppler imaging, renal thrombosis displays distinctive spectral pattern with a plateaulike reversal of diastolic flow (accentuated at end diastole).
Renal artery stenosis (RAS) exhibits a high-velocity jet with distal turbulence.
Hydronephroisis
Grading system
Grade 1 hydronephrosis
Small, fluid-filled separation of the renal pelvis
Grade 2 hydronephrosis
Dilation of some but not all calyces; renal sinus orientation still concave
Grade 3 hydronephrosis
Complete pelvocaliectasis; calyx presentation is changed in convex.
Grade 4 hydronephrosis
: Prominent dilation of collecting system; thinning of renal parenchyma; no differentiation between the collecting system and renal parenchyma
With severe hydronephrosis
Parenchyma differentiaon is not seen
While scanning hdronephrosis
Post void residual and recheck the kidneys
May have effect on collecting system
Acquired causes of hydronephrosis
Bladder tumors Carcinoma of the cervix Calculi Neurogenic bladder Normal pregnancy Pelvic mass Prostatic enlargement Retroperitoneal fibrosis
Obstruction is not
Synonymous with dilation
Intrinsic causes
Calculus Stricture (Ureter) Inflammation Pyelonephritis Congenital Bladder neck obstruction Posterior urethral valves Ureterocele Ureteropelvic junction (UPJ) obstruction
Obstructive findings
Renal insufficiency
Decreased urine output
Hypertension
Obstructive hydronephrosis sono findings
Fluid filled renal collecting system
thin parenchyma
hydroureter
decreased or absent ureteral jets
twinkle can help to
Locate stones
Milly distended collecting system
Overhydration
nonobstructive hydronephrosis
Reflux Infection Large extra renal pelvis High floww tstate distended bladder Atrophy after obstruction Pregnancy dilation
Pregnancy
Uterus can compress urters, third trimester, more common on right side
False positive Hydronephrosis
Arteriovenous malformation Congenital megacalyces Extrarenal pelvis Papillary necrosis Parapelvic cysts Persistent diuresis Reflux Renal artery aneurysm
Localized hydronephrosis
Duplex
strictures
In females, may insert lower which can cause dribbling
False negative hydronephrosis
Retroperitoneal fibrosis or necrosis Distal calculi “newly” lodged Staghorn calculus PCKD and multicystic KD Parapelvic cysts
Staghorn
Fills the collecting system
Pyonephrosis
Pus within the collecting system
Severe urosepsis
Pyonephrosis is
A true urologic emergency that requires IV antibiotics
When does pyonephrosis occur
Long-standing ureteral obstruction from calculus disease, stircture or congenital anomaly
Most renal infections
Stay in the kidneys
Perirenal abscess
Direct extension
Sono findings of pyonephritis
Low level echoes with a fluid debris level
May find an anechoic dilated
Pyonephrosis Clinical
Renal insufficiency
Hematuria
Emphysemtous pyelonephritis
Occurs when air is in the parenchyma
May be caused by E-Coli
Dirty shadowing
Emphysematous is unilateral/bilateral
Unilateral
Sono findindings of emphysematous pyeloniptitus
Enlarged kidneys are hypoechoic and inflamed
Avascular
Area in the kidney that does not perfuse like the rest
Xanthogranulomatous Pyelonephritis
Uncommon renal disease associated with chronic obstruction and infection
Involves the destruction of renal parenchyma and the infiltration of lipid-laden histiocytes
Presenting symptoms include a large, nonfunctioning kidney, staghorn calculus, and multiple infections.
More common in females
Xanthogranulomatous Pyelonephritis clincial findings
Multiple infections
Nonfunctioning kidneys
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Xanthogranulomatous Pyelonephritis sono appearance
“Staghorn appearance” which can cause echogenicity
Destruction of renal parenchyma ↑ (Cystic spaces)
Echogenicity ↑
Renal size is increased
Dilated calyces
Disease may be diffuse or segmental
Renal calcifications Localized parenchymal
scar tissue by bacterial infection, abscess, infected hematoma, urinoma, lymphocele, TB, infarction, post-percutaneous procedures
Seen in cystic and solid masses
Seen in vascular components
Renal calcifications intraluminal calcifcations
Renal calculi
Milk of calcium Diveticulum
Benign renal masses
May calcify
Nephrocalcinosis
Parenchymal calcification occurs
Affects both kidneys
Diffuse foci calcium deposits are usually located in the medulla; may be seen in the renal cortex.
Cortical nephrocalcinosis
most commonly seen with chronic glomerulonephritis, chronic hypercalemic states, sickle cell disease, and rejected renal transplants.
MSK
Anatomic, causes stasis and stone formation, shadowing within them
Anatomic, not metabolic (Therefore may be unilateral or segmental)
Nephrocalinosis calcification may be
dystrophic from devitalized tissues, ischemia and/or necrosis, or from hypercalemic states, hyperparathyroidism, renal tubular acidosis, and renal failure.
sonographic findings nephrocalcinosis
Cortical nephrocalcinosis appears as increased cortical echogenicity with spared pyramids.
Medullary nephrocalcinosis pyramids become more echogenic than the adjacent cortex.
Cortical nephrocalcinosis appearance
appears as increased cortical echogenicity with spared pyramids.
Medullary nephrocalcinosis appearance
pyramids become more echogenic than the adjacent cortex.
Urolithiasis
stone in urinary system
Majority of stones formed in the kidney and course down the urinary tract
Stones
Made up of a comnination f chemical from urine
Chemicals in kidney stones
Uric acid, calcium, systene, zanthene
Kidney stone size
Most are small and can travel through the urinary system with increased hydration and without treatment.
Large stones that fill the renal collecting system, called staghorn calculi
Some kidney stones may obstruct the ureter in the constricted areas.
Where do urolithasis
Can develop anywhere in urinary tract
Kidney stones are more common in
Men
Ppl who have a hx of kidney stones
When do kidney stones form
Excessive amounts of solutes in filtrate
Insufficient fluid intake – major factor for calculi formation
Urinary tract infection
Stones are associated with
Acidosis
Stones clinically
Extreme pain, cramping on side (flank pain), may be lower in the plevis
Manifestations only occur with obstruction of urine flow
May lead to infection
Hydronephrosis with dilation of calyces
If located in kidney or ureter and atrophy
Tx of stones
Lithotripsy (breaks apart stone)
Pertucutanous nephrlithotomy
Scope removal of stone (Mid or lower urinary tract stones)
Early treatment of stones
Can reverse the damage done by stones
Sono findings of kidney stone
Very echogenic foci with posterior acoustic shadowing
Scanning is done along the lines of the renal fat; stones less than 3 mm may not shadow.
Prominent renal sinus fat, mesenteric fat, and bowel have high attenuation; they may appear as an indistinct echogenic focus with questionable posterior acoustic shadowing, making it difficult to differentiate from stones.
Blockage for long time
Thinning of parenchyma
When looking for urolithasis
Turn off compound imaging to optimize posterior acoustic shadowing
Colour and power doppler
Can cause twinkling artifact
Rapidly changing mix of colours behind the stone
Urinary bladder
US is not the imaging modality of choice
Cystoscopy
TA sonography
Bladder lesions greater than 5mm
Bladder normal
should be smooth and uniform
3-6mm
evaluate residual volume
Normal post void residual bladder
<20ml
Bladder diverticulum
Hernination/outpouching of the bladder wall
My be single or multiple
Can be acquired or congenital
Acquired
No muscle
Neck
From increased pressure
Diverticulum lacks a muscular layer and is narrow
Associated with calculi, chronic bladder outlet or neurogenic bladder
Congenital bladder diveriulum
Rare
Posterior angle of bladder trigone
All components of bladder wall
When patients empty bladder
Diverticulum may or may not empty post void
Sono finding
Fluid filled sac with neck, can still be filled after void, may lead to stone formation due to stasis of the bladder
Uterocele
Cyst like enlargemet of distal end of ureter
Usually small and aysmptomatic but may cause obstruction or bladder outlet
More often in adults
May be bilateral or unilateral
Uterocele
Cobra head appearance
May change in size with urine
Candle stick
Continuous ureteral jet
Uterocele may mimic
diverticula
Ectopic uterocele
More common in females
Extravesical (ectopic)
May be associated with hydronephrosis
Round, thin walled cystic strcuture, may cause debris protuding into bladder
Inflammation of the bladder
Cystitis is usually secondary other to satistis
Cause by a number of different causes
Sonon: early: wall may appear to be normal, as duration increases, smooth bladder wall becomes diffuse or nonfiffuse with hypoechoic thickening
As progresses: fibrosis, will get more echogenic bladder
Bladder tumors
Mostly transitional cell carcinomas
Usually not dteetced until large
Bladder tumors clinical findings
Patients typically have gross hematuria, dysuria, urinary frequency, or urinary urgency.
bladder mass may be
Secondary
Prostate, ovarian, rectum,
Bladder tumors sonographic findings
Appearance of bladder masses vary.
Commonly appear as a focal bladder wall thickness
Intravesical lesions are as small as 3 to 4 mm.
Sonography unable to detect a perivesical extension and pelvic wall involvement.
Transrectal approach can be used to detect intravesicular involvement.
Most bladder tumors
Most bladder tumors are malignant and commonly arise from transitional epithelium of the bladder.
Often develops as multiple tumors
Diagnosed by urine cytology and biopsy
Bladder tumor is
invasive through wall to adjacent structures.
Metastasizes to pelvic lymph nodes, liver, and bone
Benign bladder tumors
Hypoechoic comapred to malignant bladder tumors but may have echogenciity as maliganancy
All primary bladder tumors
tumors have the same sonographic appearance: an irregular echogenic mass that projects into the lumen of the bladder.
Any bladder mass may cause outflow obstruction; the kidneys should be evaluated for hydronephrosis.
Primary bladder tumors
squamous cell carcinoma, adenocarcinoma, and rhabdomyosarcoma in children.
If something is found in bladder
Scan the kidneys
