Ultrasonography – At A Glance (BMRC – CMU Exam Preparation)

Ultrasound 

It is a name given to high frequency sound waves over 20kHz, which are inaudible to humans and can be transmitted in beams to scan the soft tissues of the body. 



Ultrasound waves are generated by a piezoelectric transducer, which are directed towards the body tissues, where some reflect directly and some scatter before returning to the same transducer as echoes 


Different Modes Of Ultrasound 

  1. A mode
    • Echoes are measured in peaks 
    • Distance between various structures can be measured
  2. B mode
    • Shows a two dimensional images in gray scale 
    • Displays an image in varying brightness or intensity depending upon the reflected signals of varying amplitude 
  3. Real time
    • When B mode images are watched in a rapid sequence, it becomes a real time image 
  4. M mode
    • It is method of displaying motion, resulting in a wavy line
    • Used commonly in cardiac ultrasound to see the cardiac valves, cardiac chambers, vessel wall and fetal cardiac activity  
 
 
Different Types / Routes Of Ultrasound
  1. Abdominal ultrasound imaging
  2. Transvaginal imaging
  3. Transrectal imaging
  4. Obstetric ultrasound imaging
  5. Carotid and abdominal aorta ultrasound imaging



Types Of Transducers

  1. Linear array transducer
    • Useful in obstetrics and scanning of breast and thyroid
  2. Phased array sector transducer 
    • Used in upper abdomen and for gynaecological and cardiological examination 
  3. Convex transducer
    • Can be used to examine all parts of the body except echocardiography
  4. Mechanical transducers  
 
Fig : Types of tranducers



Choosing The Appropriate Transducer 

  1. Obstetric ultrasound 
    • Linear or convex – 3.5 / 5 MHz
  2. General purpose ultrasound 
    • Sector or convex – 3.5 MHz
  3. Paediatric ultrasound
    • Linear – 5 MHz or sector – 7.5 MHz 
 



Preparation Of A Patient For Ultrasound Of Whole Abdomen
  1. For adults – Nothing by mouth for at least 8 hours
    For infants – Nothing by mouth for at least 3 hours
  2. Water can only be taken 
  3. For renal ultrasound or during pregnancy, it is required to have a full bladder
    • 1L of water one hour prior to scan 

* If the symptoms are acute, examination can be conducted immediately without preparation

 
 
Problems Face, If Patient Isn’t Prepared Properly
  1. Undigested food can block the imaging or create false images 
  2. Ingestion of fatty food can cause, contraction of the gallbladder leading to false diagnoses
  3. Difficulty to calculate MCC and PVR due to unfilled bladder 
  4. Inability to see the reproductive organs properly
 
 
Acoustic Coupling Agent 

The fluid medium that provide the link between the transducer and surface of the patient is called as a acoustic coupling agent 

Best coupling agent is water soluble gel


Function Of Coupling Agent
  1. To prevent air from trapping between the transducer and skin of the patient
  2. To reduce the friction between the transducer and skin surface 


Advantages Of Ultrasonography

  1. Uses non ionizing radiation, so it won’t damage or mutate the cells as in X-ray 
  2. Safe to use during pregnancy
  3. Non invasive technique
  4. Cost effective
  5. Provides real time images 
  6. Excellent in scanning soft tissues  


 

LIVER
 

Indications Of Ultrasonography Of Liver 

  1. Enlarged liver/ hepatomegaly
  2. Suspected liver abscess
  3. Jaundice 
  4. Abdominal trauma
  5. Ascites
  6. Suspected liver mass or metastasis
  7. Right upper abdominal pain



Points To Assess In Liver
  1. Position
  2. Size 
  3. Outline
  4. Echogenicity
  5. Vascularity
  6. Surrounding structures 
  7. Other lesions 
 
 
Normal Size Of Liver
 
Less than 15cm 
Hepatomegaly is present when it exceeding 20cm

 Fig : Normal Liver (Longitudinal Scan)
 
 Fig : Normal Liver (Longitudinal Scan)
 
Fig : Oblique and Transverse Scan Of Liver



Causes Of Hypoechoic Liver

  1. Acute hepatitis
  2. Diffuse malignant infiltration (Lymphoma)


Causes Of Hyperechoic Liver

  1. Chronic liver diseases
  2. Fatty liver
  3. Hepatic haemangioma
  4. Malignancy
 
 

Acute Hepatitis

Inflammation of the liver

Presentation
  1. Fever
  2. Jaundice
  3. Abdominal pain
  4. Nausea, vomiting, diarrhoea
  5. Tender hepatomegaly
 
Sonographic findings
  1. Pain while probing
  2. Increased vascularity
  3. Hepatomegaly
  4. Echogenicity is reduced – More hypoechoeic 
  5. Thick wall or oedema of the wall of gallbladder
  6. In very acute cases echogenicity and size will be normal 
 
Fig : Acute Hepatitis



Chronic Hepatitis / Cirrhosis


Presentation

  1. History – Stigamata of CLD
 
Sonographic findings
  1. Small liver
  2. Coarse parenchyma
  3. Hyperechoic nodules / Surface nodularity
  4. Gallbladder is small
  5. Ascites
  6. Splenomegaly
  7. Enormous caudate lobe
  8. Varices – Recanalization of paraumbilical vein 
 
Fig : Chronic Hepatis

 

 
Sonographic Difference Between Acute And Chronic Hepatitis

Traits
Acute Hepatitis
Chronic Hepatitis
1. Pain while probing Present Absent
2. Size Enlarged
Reduced

Enormous caudate lobe

3. Echogenicity More hypoechoeic
Coarse parenchyma
Hyperechoeic nodules

Surface nodularity

4. Vascularity Increased Normal
5. Gallbladder Oedema of the wall of the gb Small
6. Splenomegaly Absent Present
7. Ascites Absent Present
8. Varies Absent Recanalization of paraumbilical vein



Difference Between Acute Hepatitis And Fatty Liver


Traits
Acute Hepatitis
Fatty Liver
1. Echogenicity Hypoechoic Hyperechoic
2. Size of liver Normal or increased Normal or increased
3. Pain during probing Present Absent
4. Increased vascularity Present Absent
5. Gallbladder Thick walled Normal



Hepatic Cyst

  1. Well rounded, sharp margin
  2. Purely anechoic 
  3. Post acoustic enhancement
  4. May present without symptoms 
  5. Liver maybe normal / enlarged 
 
 Fig : Hepatic Cyst
 
 
Hepatic Abscess
  1. Maybe single or multiple 
  2. Anechoic area with internal echoes 
  3. Irregular and thick walled
  4. Internal debris
  5. Gas maybe present 
  6. Turbulence can be seen 
 
Fig : Hepatic Abscess 



Sonographic Difference Between Hepatic Cyst And Abscess

 

Trait
Cyst
Abscess
1. Echogenicity Purely anechoic Anechoic area with internal echoes
2. Margin Sharp Irregular and thick margin
3. Post. Acoustic enhancement Present Absent
4. Presentation Can be silent for years Acute in onset
5. Turbulance Absent Present
6. Definition A pathological fluid filled sac, lined by an epithelium or any other wall is called a cyst It is a localized collection of pus walled off by an area of inflammation



Hydatid Disease


Hydatid disease is a parasitic infestation caused by Echinococcus granulosus


Common Sites Of Hydatid Disease

  1. Liver
  2. Lungs
  3. Abdominal cavity 
  4. Kidney 
  5. CNS
  6. Bones
 
Presentation
  1. Painless lump in the right hypochondriac region
 
Sonographic features 
  1. Honeycomb appearance 
  2. Cyst within a cyst
  3. Water lily appearance 
  4. Cartwheel appearance 
  5. Nodule in cyst
  6. Detachment in cyst
  7. Membrane floating within a cyst
  8. Nothing but a clean cyst 
 



Fatty Liver 


Fatty liver is a reversible condition wherein large vacuoles of triglyceride fat accumulate in liver cells via the process of steatosis

Causes

  1. Obesity
  2. Insulin resistance
  3. Hypertriglyceraemia
  4. Hyperglycemia 
  5. Hypothyroidism
  6. PCOD

Presentation
  1. Usually asymptomatic
  2. Fatigue
  3. Pain in upper right quadrant of the abdomen
  4. Liver maybe enlarged   


Sonographic findings

  1. Size – Normal or increased
  2. Hyperechoic 
  3. Portal vein marking become indistinct 
  4. Diaphragm cannot be differentiated from liver
 
Grading
 
Traits
Grade 1
Grade 2
Grade 3
1. Echogenicity Hyperechoic Hyperechoic Hyperechoic
2. Portal vein marking Visible Hazy Hazy
3. Diaphragm Visible Visible Obscured and cannot be differentiated from liver
 
Fig : Fatty Liver

 

Hepatocellular Carcinoma


Presentation

  1. Weight loss
  2. Anaemic
  3. Jaundice
  4. Mass in right hypochondriac region
  5. Regional lymph node enlargement 
 
Sonographic findings
  1. Outline maybe irregular / regular / spiculated
  2. Surrounding hypoechoice halo
  3. Mixed echogenicity
  4. Coarse echotexture
  5. Increased vascularity
 



Ascites


Ascites is an accumulation of fluid in the peritoneal cavity


Causes Of Ascites

  • Common
    1. Hepatic cirrhosis with portal hypertension
    2. Intra-abdominal malignancy with peritoneal spread
    3. Congestive heart failure
  •  Uncommon
    1. Hepatic or portal vein occlusion
    2. Constrictive pericarditis
    3. Hypoproteinaemia (Nephrotic syndrome, protein-losing enteropathy)
    4. Peritonitis (Tuberculosis, pancreatitis)
 
Sonographic findings
  1. Anechoic area
  2. Found adjacent to the diaphragm or anterior margin of liver
  3. Internal echoes maybe present due to hemorrhage or neoplasm 
  4. Septations can be seen in case of inflammation or neoplasm 




GALLBLADDER And BILIARY TREE


Indications Of Ultragonography Of GB And biliary tree

  1. Pain in the upper right abdomen 
  2. Jaundice 
  3. Palpable right upper abdominal mass
  4. PUO

Gallbladder is a pear shaped anechoic structure 


Points To Examine In Gallbladder
  1. Site
  2. Size and shape including wall thickness
  3. Margin (Regular or irregular)
  4. Echogenicity
  5. Other structures 
    • Polyp
    • Stone
    • Slough
  6. Surrounding tissue
    • Pericholecystic collection of fluid
 
 Fig : Longitudinal Scan Of Gallbladder
 
Fig : Transverse Scan Of Gallbladder
 
Fig : Oblique Scan Of Gallbladder
 
 

Normal Parameters Of GB And Biliary Tree

Length : 8 – 12 cm 

Width : < 4 cm
Wall thickness : In fasting : 3 mm or less ; When distended 1 mm
CBD : 6 mm ; should not exceed 9 mm 
Shape : Pear shaped 

Causes Of Absence Of Gallbladder

  1. Congenital absence 
  2. Surgical removal of gallbladder 


Causes Of Enlarged Gallbladder

  1. Gallstones 
  2. Obstruction at cystic duct (Due to mass or lymph node)
  3. Stone in CBD
  4. Biliary ascariasis
  5. Mucocele of gallbladder 
  6. Empyema of gallbladder



Causes Of Small Gallbladder

  1. Examination after a meal of fatty food
  2. Chronic cholecystitis
 
 

Causes Of Gallbladder Wall Thickening

  • Generalized thickening
    1. Acute cholecystitis
    2. Chronic cholecystits
    3. Acute hepatitis
    4. CKD
    5. CCF
    6. CLD 
  • Localized thickening 
    1. Polyp
    2. Mucosal fold
    3. Carcinoma of gallbladder


Acute Cholecystitis


Acute cholecystitis is an inflammation of the gallbladder


Causes

  1. Gall stone
  2. Mucus
  3. Pancreatic worms
  4. Tumour


Presentation

  1. Abdominal pain
    • Pain in the right upper quadrant of the abdomen 
    • May also involve the epigastrium
    • Radiation to the right shoulder tip or interscapular region
  2. Nausea, vomiting 
  3. Fever 
  4. Tenderness & rigidity of right hypochondriac region
  5. Murphy’s sign is positive
 
Sonographic findings
  1. Pain during probing, in right hypochondriac region
  2. Distended gallbladder
  3. Increase thickness of the gallbladder wall 
  4. Oedema of the gallbladder wall – Multiple layers of oedematous folding of the gallbladder wall 
  5. Pericholecystic collection of fluid
  6. Gallstones maybe present – Echogenic round mass with posterior acoustic shadowing 
 
Fig : Acute Cholecystitis
 
 
Chronic Cholecystitis
 
Presentation
  1. Previous history of acute cholecystitis
  2. Abdominal pain
    • Pain in the right upper quadrant of the abdomen 
    • May also involve the epigastrium
    • Radiation to the right shoulder tip or interscapular region
  3. Fatty food intolerance 
  4. Dyspepsia
  5. Nausea, vomiting
  6. Tenderness in right hypochondriac region
 
Sonographic findings
  1. Gallstone maybe present
  2. Increased wall thickness of the gallbladder
  3. Gallbladder maybe contracted or distended
  4. No pericholecystic collection of fluid
 

 

Fig : Chronic Cholecystitis (Contracted GB)



Cholelithiasis


Stone in gallbladder is called as cholelithiasis


Presentation

  1. Asymptomatic
  2. May present with features of acute / chronic cholecystitis 
  3. May present with complications
 
Sonographic findings
  1. Echo bright structures with posterior acoustic shadowing
  2. Structures move with change of posture 
  3. Single or multiple
  4. Small or large
  5. Calcified or non calcified

 

Fig : Cholelithiasis


Complications Of Gallstones

  • Within the gallbladder
    1. Biliary colic 
    2. Acute cholecystitis 
    3. Chronic cholecystitis 
    4. Empyema 
    5. Mucocele 
    6. Gangrene
    7. Perforation 
  • Within the CBD
    1. Biliary obstruction 
    2. Acute cholangitis
    3. Acute pancreatitis
  • Within the intestine 
    1. Intestinal obstruction (gallstone ileus)



Biliary Ascariasis


Caused by Ascaris lumbricoids


Presentation

  1. Due to migration to lung
    • Cough
    • Dyspnea
    • Wheezing 
    • Chest pain
  2. Abdominal pain& distension
  3. Nausea & intermittent diarrhea


Sonographic findings

  1. Tubular structure
  2. Target sign – A tube within a tube 
  3. Mobile, if alive 
  4. If dead, may become calcified 
 
Fig : Biliary Ascariasis
 
Fig : Biliary Ascariasis (Target Sign)
 
 
Thickened Sludge Within Gallbladder
  1. Distended gallbladder
  2. Seen as a fine dependent hypoechoic area within the gallbladder
  3. Sand clock appearance is seen with the change of posture (Moves quickly than gallstones)
* Pus will not show sand clock appearance 
* Blood will show a non homogeneous, irregular, hypoechoic area 
 
Fig : Sludge Within Gallbladder
 
 
Gallbladder Polyp
  1. Pedunculated or broad based
  2. Echo bright structures
  3. Does not move with posture 
  4. No posterior acoustic shadowing 
 
Fig : Gallbladder Polyp
 
 
 
PANCREAS
 
Indications Of Ultrasonography Of Pancreas

  1. Midline upper abdominal pain 
  2. Jaundice 
  3. Upper abdominal mass
  4. Persistent fever with upper abdominal tenderness
  5. Suspected malignant disease
  6. Recurrent chronic pancreatitis
  7. Complications of pancreatitis (Pancreatic pseudocyst, pancreatic abscess)


Normal Parameters Of Pancreas


Head – 2.8 cm 

Body – 2.3 cm
Tail – 2.8 cm
Internal diameter of pancreatic duct should be  2 mm 

Fig : Transverse Scan Of Pancreas
 
Fig : Transverse Scan Of Pancreas (Body and Tail Of Pancreas)
 
 Fig : Transverse Scan Of Pancreas (Pancreatic Duct)
 
Fig : Longitudinal Scan Of Pancreas (Head Of Pancreas)
 
Fig : Longitudinal Scan Of Pancreas (Body Of Pancreas)


Anatomical Landmarks Of Pancreas

  1. Aorta 
  2. IVC
  3. Superior mesenteric artery 
  4. Splenic vein 
  5. Superior mesenteric vein 
  6. Wall of stomach 
  7. Common bile duct 
 



Acute Pancreatitis


It is an acute abdominal condition presenting with abdominal pain and usually associated with raised pancreatic enzymes levels in the blood or urine as a result of inflammatory disease of the pancreas 


Causes

  1. Idiopathic
  2. Alcohol
  3. Gallstones
  4. Post ERCP
  5. Abdominal trauma
  6. Surgery – Biliary, upper GI, cardiothoracic surgery
 
Presentation
  1. Severe upper abdominal pain, radiating to the back and relieved by leaning forward
  2. Nausea, vomiting
  3. Fever
  4. Hiccups 
  5. Investigations – Serum amylase and urinary amylase is elevated

Sonographic findings
  1. Tenderness on probing 
  2. Diffusely enlarged pancreas
  3. Echogenicity – Normal or hypoechoic
  4. May have a heterogenous parenchyma 
  5. Peripancreatic collection of fluid
  6. Pancreatic duct is not dilated
 
Fig : Acute Pancreatitis


Chronic Pancreatitis
 
Chronic pancreatitis is a progressive inflammatory disease in which there is irreversible destruction of pancreatic tissue, characterized by severe pain & later pancreatic insufficiency
 
Presentation
  • May be asymptomatic
  • Abdominal pain
  • Diarrhoea
  • Malabsorption – Steatorrhoea
  • Weight loss
  • Features of diabetes


Sonographic findings

  1. Small sized pancreas
    • Can’t comment on it as we don’t know the previous size of the pancreas
    • If we know the previous size, can comment on it
  2. Hyperechoic, irregular 
  3. Heterogenous parenchyma
  4. Dilated pancreatic duct
  5. No peripancreatic collection 
  6. Calcification maybe present 


* Irregular hyperechoic and diffusely enlarged pancreas is suggestive of an acute pancreatitis superimposed on chronic pancreatitis


Pancreatic Pseudocyst


It is a collection of amylase rich fluid enclosed by a wall of fibrous or granulation tissue  


Presentation 

  1. History of acute pancreatitis (Usually 4 weeks back)
  2. Low grade fever
  3. Lump in upper abdomen
 
Sonographic findings
  1. Single or multiple
  2. Lesions are present surroundings the pancreas
  3. In early stage
    • Complex with internal echoes 
    • Ill defined walls
  4. In later stage 
    1. Echo free
    2. Smooth walled 
 
* Usually resolves spontaneously, if not resolved surgical interventions are done 
 
Sonographic followup after 6 – 8 weeks

Fig : Pancreatic pseudocyst


Carcinoma Of Head Of The Pancreas 
 
Presentation
  1. Upper abdomen pain 
  2. Progressive jaundice 
  3. Itching 
  4. Weight loss
  5. Anaemia 
  6. Regional lymph nodes are enlarged 
  7. Ascites 
 
Sonographic findings
  1. Head is enlarged 
  2. Irregular, spiculated margins
  3. Heterogenous parenchyma 
  4. Increased vascularity 
  5. Double duct sign 
    • It is the simultaneous presence of dilated CBD and pancreatic duct
  6. Compress the surrounding structures
 
 
Pancreatic Cyst
  1. Rare
  2. Usually single / small multiple cysts – Maybe congenital 
  3. Anechoic 
  4. Well defined margins
  5. Arises from the parenchyma of the pancreas
 
 
Pancreatic Abscess 
  1. Mostly associated with severe pancreatitis
  2. Anechoic area with internal echoes
  3. Margin is irregular and thick
 
 
Pancreatic Calcification
  1. Echogenic masses with posterior acoustic shadowing
  2. If very small may only be seen as a echo bright structure without shadowing 
  3. May occur in chronic pancreatitis 
 
Fig : Pancreatic Calcification
 
 
Pancreatic Calculi
  • Echogenic masses / mass with posterior acoustic shadowing
  • Found within the pancreatic duct / follows the anatomical pattern of the duct

 

Fig : Pancreatic Calculi



Causes Of Dilatation Of Pancreatic Duct 
    1. Tumor of the head of the pancreas or ampulla of Vater
  1. Stone in the CBD
  2. Stone in intrapancreatic duct
  3. Chronic pancreatitis
  4. Postoperative stricture following Whipples operation or partial pancreatectomy 
 

Dilatation Of Pancreatic Duct

 
Walls of the pancreatic duct is smooth and lumen is clear
It should be less than 2 mm
When dilatation occurs the wall become irregular and diameter exceeds 2 mm 

Fig : Pancreatic Duct


Structures Identified While Scanning For Spleen
  • Left hemidiaphragm
  • Splenic hilus
  • Splenic veins and relationship to pancreas
  • Left kidney
  • Left edge of liver
  • Pancreas

 

 
Normal Parameters Of Spleen

Normal : Up to 11 cm 
≥ 12 cm in female, ≥ 13 cm in males – Considered as splenomegaly


Splenomegaly

Abnormal enlargement of the spleen is called as splenomegaly


Grading Of Splenomegaly
 
Mild : >11 cm (> 500 g)
Moderate :13 – 17 cm (500 – 800 g)
Severe : ≥ 18 cm (> 800 g)
 
 
Causes Of Splenomegaly
  • Mild splenomegaly 
    1. Bacterial infection 
    2. Myocardial insufficiency 
    3. Infectious mononucleosis
    4. Febrile infections
  • Moderate splenomegaly 
    1. Portal hypotension 
    2. Thalassemia major 
    3. Leukamia
    4. Amyloidosis
    5. Sarcoidosis
  • Severe splenomegaly
    1. Chronic myeloproliferative diseases
    2. Chronic lymphatic leukaemia
    3. Lymphoma 
    4. Malaria




Kidney, Ureter, Bladder (KUB)
 
Indications Of Ultrasonography Of KUB Region
  1. Renal or ureteric pain 
  2. Suspected renal mass
  3. Non functioning kidney on IVU
  4. Haematuria
  5. Recurrent UTI
  6. Trauma 
  7. Suspected CKD
  8. Suspected PKD
  9. Features of LUTS

 

 
Normal Parameters Of The KUB
 
Length : 9 – 12 cm  
Width : 4 – 6 cm 
Renal sinus : Usually about 1/3rd of the kidney 
Renal pelvis : < 1 cm

Full bladder, lateral wall thickness : Up to 4 mm


In new borne : 4 cm in length and 2 cm in width



Points To Examine In Kidney And Ureter

  1. Position 
    • If absent, look for pelvic region of ectopic kidney
  2. Renal capsule
    • Bright, smooth, echogenic line around the kidney
  3. Renal cortex
    • Hypoechoic than liver 
    • Hyperechoic than adjacent renal pyramid 
  4. Renal medulla 
    • Hypoechoic renal pyramids are present 
  5. Renal sinus
    • Innermost part of the kidney
    • Echogenic
    • Contains fat, collecting system and vessels at the hilus 
  6. Ureter
    • Cannot be seen unless it is dilated 
  7. Renal artery & vein 
    • Best seen at the hilus 

 

 Fig : Longitudinal Scan of Kidney
 
Fig : Transverse Scan of Kidney


Renal Cyst
 
Always seen in the cortex ; Never in the medulla
 
Types
  1. Simple cyst
  2. Complex cyst
 
 
Simple Renal Cyst
  1. Single / Multiple
  2. Rounded
  3. Smooth and thin walled
  4. Purely anechoic 
  5. Posterior enhancement 
 

 

Fig : Renal Cyst



Complex cyst
 
Any deviation from a simple cyst is considered as a complex cyst
  1. Thick walled
  2. Internal echoes due to debris, haemorrhage, slough
  3. Mucosal fold 



Renal Stone 


Seen in the renal collecting system ; Always in medulla and sinus

  1. Hyperechoic or echogenic lesions
  2. Posterior acoustic shadowing 
Correct localization and measurement is obtained by taking images in two imaging planes 
 
5MHz transducer is required to see small stones

Fig : Renal Calculi


Renal Mass 
 
Ultrasound scans cannot reliably differentiate between benign and malignant renal tumors
  1. Well circumscribed or irregular
  2. May alter the shape of the kidney
  3. Increased or decreased echogenicity
  4. Homogeneous (Majority of malignant tumors) or non homogeneous
  5. Internal echoes due to central necrosis
  6. Prominent column of Bertin
  7. Invasion of IVC (Confirmatory sign of malignancy)
  8. Calcifications may be present  
 
Fig : Renal Tumor


EXCEPTION – Angiomyolipoma
  1. Well circumscribed
  2. Hyperechogenic
  3. Homogeneous mass
  4. As it grows – Back wall attenuation 
  5. Back wall echoes due to central necrosis 
 
Fig : Angiomyolipoma of Kidney


Renal Abscess
  1. Rough, irregular walled
  2. Anechoic mass
  3. Internal echoes 
 
Fig : Renal Abscess
 
 
Chronic Kidney Disease

CKD is defined as structural or functional abnormalities of the kidney for > 3 months with or without a decrease in GFR, or GFR < 60mL/min/1.73m2 for > 3 months with or without evidence of kidney damage 

Causes

  • Renal 
    1. Glomerulonephritis 
    2. Diabetic nephropathy
    3. Interstitial nephritis 
    4. Pyelonephritis
    5. Analgesic nephropathy
    6. Hypertension 
  • Metabolic
    1. Cystenosis
    2. Oxalosis 
    3. Gout 
  • Vascular
    1. Renal artery stenosis 
    2. Scleroderma 
    3. Haemolytic uremic syndrome 
  • Vasculitis disease
    1. SLE
    2. Wegner’s granulomatosis 
  • Dysproteinaemia 
    1. Amyloidosis 
    2. Myeloma 
  • Hereditary 
    1. Alport’s disease
    2. Fabry’s disease 
  • Malignancy 
    1. RCC
    2. Lymphoma 
  • Structural abnormalities 
 
Presentation
  • H/O long standing hypertension or diabetes mellitus
  • Chronic ill health (More than 3 months)
  • Anorexia, Nausea, Vomiting
  • Ankle swelling
  • Breathlessness
  • Inability to concentrate
  • Fetid (Uremic) smell
  • Flapping tremor
  • Pallor
  • Pigmentation
  • Pruritis
  • Purpura
  • Oedema (face, sacrum, ankles)
  • Excoriation of skin
  • Easy bruising
  • Brown nail
  • Fundoscopy – Haemorrhagic exudates
  • Displaced apex beat
  • Pericardial rub
  • Basal crepitations
 
Sonographic findings
  1. Small sized kidney
  2. Both sides are usually affected 
  3. Reduced cortical thickness
 
Fig : Chronic Kidney Disease


Pyelonephritis 

Presentation 

  1. Fever with chills and rigor
  2. Loin pain 
  3. Nausea, vomiting
  4. Renal angle tenderness
 
Sonographic findings 
  • Acute
    1. Bilateral enlarged kidneys (Severe)
    2. Normal in shape
    3. Homogeneous (But can be increased or decreased)
  • Chronic 
    1. Bilateral small kidneys
    2. Hyperechoic 
    3. Irregular, rough kidney outline 
    4. Variable thickness of cortex 
 
 
Renal Trauma
  • Acute
    1. Intrarenal or perirenal echo free (Anechoic) areas
      • Due to presence of blood or urine
  • Chronic 
    1. Shows a mixed echotexture
      • Because the blood has become clotted 
 
Fig : Renal Trauma
 
 
Ureteric Stone
 
Stone in middle or distal ureter cannot be seen by ultrasonography
  1. Echogenic mass 
  2. Posterior acoustic shadowing 
  3. Dilated ureter 

Fig : Ureteric Stone


Hydronephrosis
 
It is defined as aseptic dilatation of the pelvi-calyceal system of kidney due to partial or complete obstruction to the outflow of urine
 
It is the commonest cause of enlarged kidney

Causes 

  • Causes Of Unilateral Hydronephrosis
    • Extramural obstruction
      1. Tumour from adjacent structures (Cervix, prostate, rectum, colon or caecum)
      2. Idiopathic retroperitoneal fibrosis
      3. Retrocaval ureter
    • Intramural obstruction
      1. Pelviureteric junction obstruction (Due to congenital narrowing / physiological narrowing)
      2. Ureterocele
      3. Congenital small ureteric orifice
      4. Inflammatory stricture of ureter
      5. Neoplasm of the ureter or bladder cancer involving the ureteric orifice
    • Intraluminal obstruction
      1. Stone in the pelvis or ureter
      2. Sloughed papilla in papillary necrosis
  • Causes Of bilateral Hydronephrosis
    • From lower urinary tract obstruction
      • Congenital
        1. Posterior urethral valves
        2. Urethral atresia
      • Acquired
        1. Benign enlargement of prostate
        2. Carcinoma of prostate
        3. Postoperative bladder neck scarring
        4. Urethral stricture
    • From upper urinary tract obstruction
      • Idiopathic retroperitoneal fibrosis
    • From pregnancy
 

Presentation

  1. Mild dull aching pain in loin
  2. Heaviness after ingestion of excess amount of fluid
  3. Palpable mass in loin 
  4. Reduced urine output
 
Sonographic findings
  1. Multiple well circumscribed cystic area (Calyces)
  2. Dilated central cystic area
 
Grades of hydronephrosis
  • Normal
  • Grade 1 – Mild
    • Renal pelvis > 1 cm width
    • No calcyceal dilatation 
  • Grade 2 – Moderate 
    • Calcyceal dilatation 
  • Grade 3 – Severe
    • Loss of renal cortex 

 


* To assess the grade bladder must be emptied 


Normal Parameters Of The KUB
 
Full bladder, lateral wall thickness : Up to 4 mm

 


Points To Examine In Urinary Bladder 
  1. Urinary bladder walls
  2. Wall thickness
  3. Volume
    • Maximum cytometric capacity (MCC)
      MCC = AP x T x L x 0.52
      Normal : 500 – 1000 ml
    • Post voidal residue (PVR)
      Normal : Up to 30 ml

 

Fig : Longitudinal Scan Of Urinary Bladder
 
Fig : Transverse Scan Of Urinary Bladder



Causes Of Generalized Thickening Of The Bladder Wall

  1. Chronic infection or cystitis
  2. Schistosomiasis
  3. Diverticulum 
  4. Neurogenic bladder 
  5. Prostatic obstruction 


Causes Of Localized Thickening Of The Bladder Wall

  1. Bladder fold due to incomplete filling
  2. Tumors (Sessile or polypoid)
  3. Localized infection 
  4. Schistosomiasis
  5. Hematoma following trauma



Causes Of Overdistended Bladder

  1. BEP
  2. Urethral stricture in male
  3. Urethral calculi in male
  4. Bruising of urethral in female 
  5. Neurogenic bladder
 
 
Causes Of Small Bladder
  1. Recurrent cystitis
  2. Later schistosomiasis
  3. Radiotherapy or surgery for malignancy 
  4. Infiltrating neoplasms 
 
 * Always ask the patient to drink more fluid without voiding and rescan in 1 – 2 hours before diagnosing a small bladder 


Cystitis


Presentation

  1. Frequency
  2. Urgency
  3. Dysuria
  4. Incontinence 
  5. Suprapubic pain


Sonographic findings

  1. Thick irregular wall 
  2. Trabeculation may be present 
  3. Internal fine echoes due to presence of debris
  4. Sludge 
 
Fig : Chronic Cystitis
 


Urinary Bladder Polyp

  1. Hyperechoic polypoidal structure
  2. Long stalk 
  3. Freely mobile – Change of posture & rescan 
 

 

Fig : Urinary Bladder Polyp



Tumors Of UB – TCC

  1. Mass with mixed echogenicity
  2. Sludge in urinary bladder
  3. Irregular margin 
 
Fig : Urinary Bladder Tumor



Bladder Calculi

  1. Single / multiple, small / large echogenic mass
  2. Posterior acoustic shadowing 
  3. Maybe adherent to bladder mucosa 
 
Fig : Bladder Calculi
 
 
 
Prostate
 
Normal Parameters Of Prostate
 
Anteroposterior diameter : 2 cm
Longitudinal : 2 cm 
Transverse : 3 cm 
Weight : 8 gm

 
Benign Enlargement Of Prostate

It is the enlargement of the prostate gland due to benign overgrowth of chiefly glandular tissues, commonly occurring in elderly men, leading to bladder outflow obstruction.

Pathogenesis
With advancing age, testosterone level reduces significantly 
                 ↓
But oestrogenic steroids are not decreased equally 
                 
Due to the oestrogenic effect, prostate become enlarged 
                 ↓
Benign enlargement of prostate

Presentation
  1. Features of LUTS (Prostatism)
  2. Acute or chronic retention of urine
  3. Bulging of the suprapubic region
  4. Distended bladder with or without tenderness
  5. Dull on percussion and desire of micturition while percussion 
  6. DRE reveals a enlarged prostate which is smooth, firm, non tender, prominent medial sulcus and examining finger is not blood stained 
 
Sonographic presentation 
  1. Increase in volume of the prostate, exceeding 30 mL 
  2. The central gland is enlarged
  3. Hypoechoic or mixed echogenicity 
  4. Calcification may be seen both within the enlarged gland as well as in the pseudocapsule (representing compressed peripheral zone) 
  5. PVR is elevated




Uterus And Ovary


Indications Of Pelvic Ultrasound

  1. Pelvic pain 
  2. Pelvic mass
  3. Amenorrheoa
  4. Dysmenorrhoea 
  5. Abnormal vaginal discharge or bleeding
  6. To confirm position of IUCD
  7. Infertility
  8. Genital tract development abnormalities 



Normal Parameters Of Uterus

In a normal postpubertal nulliparous uterus….

Length : 4.5 – 9.0 cm 
Anteroposterior diameter : 1.5 – 3.0 cm
Transverse diameter : 4.5 – 5.5 cm 


In a parous uterus, diamensions will increase by 1.0 – 1.2 cm

In children….
Length : 2.0 – 3.3 cm 
Anteroposterior diameter : 0.5 – 1.0 cm 


Anteroposterior diameter of the cervix should not exceed the anteroposterior diameter of the uterine body in case of children 



Normal Parameters Of Cervix 


Nulliparous : 2.5 x 2.5 cm

Parous :  3.5 cm is considered as broad cervix 


Normal Parameters Of Ovary


Volume = 0.52 x L x W x HDuring reproductive life : 8 – 21.9 cc 

During menopause : More than 8 cc is abnormal 


Echogenicity Of Pelvic Ultrasound 

  • Vaginal wall : Hypoechoic
  • Vaginal muosa : Hyperechoic
  • Uterus : Hypoechoic 
  • Endometrium 
    • First half of menstruation : Hypoechoic
    • Second half of menstruation : Hyperechoic 
  • Myometrium : Hypoechoic 
  • Perimetrium : Echogenic / Hyperechoic 
 
Fig : Longitudinal Scan Of Uterus
 
Fig : Transverse Scan Of Uterus
 


Endometrial Thickness In Sonography

  • Menstrual phase : 4 – 8 mm  
  • Proliferative phase : 6 – 10 mm 
  • Secretory phase : 7 – 14 mm 
During secretory phase endometrium is thin & hypoechoic structure

In proliferative phase, endometrium is hyperechogenic surrounded by a hypoechogenic rim  


Fig : Endometrial Lining Changes



Causes Of Thickened Endometrium

  1. Early intrauterine pregnancy
  2. Incomplete abortion 
  3. Ectopic pregnancy
  4. Retain products of pregnancy
  5. Trophoblastic diseass
  6. Endometritis
  7. Endometrial polyp
  8. Endometrial carcinoma 
 
 

Congenital Anomalies Of Uterus

 
Congenital anomalies of uterus is categorized into VII classes
 


Classes
Types
Class I Uterine hypoplasia and / or agenesis
Class II Unicornuate uterus
Class III Uterus didelphys
Class IV Bicornuate uterus
Class V Septate uterus
Class VI Arcuate uterus
Class VII Drug related ; Diethylstilbestrol (DES)

Septate and arcuate uterus are more dangerous as there is more change of abortion 


 
Abnormal Positions Of Uterus 

  1. Anteversion of uterus
    • Fundus of the uterus has gone behind the cervix
  2. Retroversion of uterus 
    • Fundus of the uterus has gone in front of the cervix
  3. Anteflexed uterus
    • Uterus bends forwards at the cervix
  4. Retroflexed uterus 
    • Uterus bends backwards at the cervix 
 
 
IUCD In-situ 
  1. Appear as a linear or interrupted hyperechogenic lines within the endometrial cavity or cervical canal 
  2. May produce distal acoustic shadowing 

Fig : IUCD In-situ



Fluid In Posterior Cul-de-sac / Pouch Of Douglas (POD)/ Retrouterine Pouch


Causes

  • Physiological causes
    1. Ruptured follicles
    2. Retrograde menstruation
  • Pathological causes
    1. Ruptured ectopic pregnancy
    2. PID
    3. Pelvic abscess
    4. Hydatidiform mole
    5. Tubo-ovarian abscess
    6. Gross ascites
 
Sonographic findings
  1. Appears as a hypoechoic collection below the cervix
 
Fig : Posterior Cul-de-sac
 
 

Cryptomenorrhoea

In case of impeforated hymen or in patients undergone circumcision, blood will accumulate in the endometrial cavity or in the vagina

Accumulation of blood in endometrial cavity is called as haematometrium
Accumulation of blood in the vagina is called as haemotocolpos  

  1. Homogeneous
  2. Hypoechoic lesion in the endometrial cavity and / or in the vaginal canal 
 
Fig : Haematometrium and haematocolpos
 
 
Uterine Malignancy
  1. Poorly defined mass in the uterus 
  2. Hypoechoic with internal echoes due to necrosis
  3. Distension of the endometrial cavity 
 
Fig : Uterine Malignancy


Fibroid Uterus / Leiomyoma


Fibroid is a benign smooth muscle tumor of the uterus that is composed of muscular & fibrous connective tissues


Common in….

  1. Nulliparous women
  2. In those who are having one child infertility
 
Types Of Fibroids 

 

 

Presentation

  1. Menstrual abnormalities 
    • Progressive menorrhagia
    • Metrorrhagia
    • Dysmenorrhoea
  2. Dyspareunia
  3. Lower abdominal swelling
  4. Recurrent pregnancy loss
  5. Infertility 
 
Sonographic findings
  1. Well defined margin
  2. Homogenous, hypoechoic, nodular masses arising from the myometrium 
  3. Almost always multiple
  4. Sometimes hyperechoic due to central necrosis and calcification
  5. Subserous fibroids 
    • Bulge out and has a whorl appearance 
  6. Intramural
    • Would not bulge out and staying within the myometrium
  7. Submucosal 
    • Distorts the normal contours of the endometrial canal of uterus as it pushes the mucosa to the opposite side 
    • Confused with polyp and adhesions 
  8. Malignant transformation is rare

 

Fig : Fibroids

 

 
Adenomyosis
 
It is the ingrowth of the myometrium, both glandular and stromal components, directly into the endometrium 
 
 
Presentation
  1. Menorrhagia
  2. Dysmenorrhoea 
  3. Dyspareunia
  4. Frequency of micturation
  5. Lump in the lower abdomen 
 
Sonographic findings
  1. Posterior wall is thicker than the anterior wall of uterus
  2. Multiple cystic area anywhere in the uterus, but mainly posterior wall 
  3. Heterogenous myometerium 
  4. No differentiation of endometrium and myometrium 


Uterine Polyp

  1. Stalk is present
  2. Uterine cavity is apart 
  3. Echogenic structure 



Difference Between Fibroids And Uterine Polylp 


Traits
Fibroids
Uterine Polyp
1. Echogenicity Hypoechoic Echogenic
2. Stalk Absent Present
3. Uterine walls Opposed to each other Separated from each other



Ovaries
 
Normally the ovaries are less echogenic than the uterus and less homogeneous due to presence of small follicles
 
 
Ovarian Cysts 
  1. Physiological cyst
    • Up to 2.5 cm : No need to mention 
    • When it is > 4 cm, it is mentioned as a follicular cyst
    • Smooth walled
    • No internal echoes 
    • Good posterior acoustic enhancement 
  2. Pathological cyst
    • Cyst with septa
    • Cyst with nodule
    • Cyst with hemorrhage
    • Cyst with calcification
    • Has a strong posterior acoustic enhancement
  3. Polycystic ovarian disease 
    • Mentioned below
  4. Multicystic ovary
    • Ovaries are normal in size
    • Occurs due to hyperstimulation by FSH
    • May present in both ovaries 
  5. Dermoid
    • Large (Up to 40 cm)
    • Unilateral or bilateral
    • Shows….
      • Fat fluid level 
      • Fluid fluid level 
      • Dermoid nodules
      • Honeycomb appearance 
      • Acoustic shadowing due to calcification
  6. Chocolate cyst
    • Internal echoes or low level echoes
    • Occurs during menstruation (Periodical)
    • Regress with cessation of menstruation

 

Fig : Ovarian Cyst
 
Fig : Dermoid Cyst

 

 
Polycystic Ovarian Disease

PCOS is a multifactorial and polygenic conditions, characterized by excessive androgen production by the ovaries, manifested by amenorrhea, hirsutism and obesity associated with enlarged polycystic ovaries


Diagnosis is based upon the presence of any two of the following three criteria….


  1. Oligo and/or anovulation
  2. Hyperandrogenism (clinical and/or biochemical)
  3. Polycystic ovaries
 

Presentation 

  1. Obesity
  2. Infertility
  3. Menstrual abnormalities (Oligomenorrhoea, amenorroea)
  4. Hirsutism
 
Sonographic findings
  1. Enlarged ovaries
  2. Multiple tiny cysts arranged peripherally (Pearl on string appearance)
  3. Cysts are > 10 in number in each ovary
  4. Cysts are < 10 mm 
  5. Stroma is thick and echogenic
  6. Endometrium will be thick 
 
Fig : Polycystic Ovarian Disease


Malignant Cyst / Mass
  1. Large cyst > 10 cm, without any internal echoes 
  2. Small cyst with nodules or thick septa 
  3. Solid cystic mass
  4. Heterogeneous mixed echogenecity (Due to hemorrhage)


Ectopic Pregnancy 
 
It is the implantation of a fertilized ovum in a site other than normal site of implantation
 
Sites Of Ectopic Pregnancy
  • Fallopian tubes
  • Uterine cornu
  • Ovary
  • Cervix
  • Abdominal cavity

 

Risk Factors / Aetiological Factors Of Ectopic Pregnancy
  • Pelvic inflammatory diseases
  • Use of intrauterine contraceptive devices (IUCDs)
  • Ovulation inducing pregnancy
  • Assisted reproductive technology (ART) pregnancies
  • Tubal damage and Tubal surgery

 

Presentation 
  1. Short period of amenorrhoea
  2. Lower abdominal pain, which is colicky in nature
  3. Slight dark per-vaginal bleeding 
  4. Anaemia
  5. Tense and tender abdomen 
  6. Shifting dullness 
 
Sonographic findings
  1. Ectopic sac and an embryo 
  2. Pooled blood in pelvic cul-de-sac 
  3. Enlarged fluid filled follopian tube 
  4. Decidual reaction in the uterus 
  5. Empty uterine cavity 
 
Fig : Ectopic Pregnancy

 
 
To view obstetric ultrasonography, please click on the link below.
 
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Laura Bush
1 year ago

Thanks for sharing this article here about the Ultrasonography exam. Your article is very informative and I will share it with my other friends as the information is really very useful. Keep sharing your excellent work. If anyone looking for the best Medical Course Online, license-medical is the best platform.

Laura Bush
1 year ago

Thanks for sharing this article here about the Ultrasonography exam. Your article is very informative and I will share it with my other friends as the information is really very useful. Keep sharing your excellent work. If anyone looking for the best Medical Course Online, license-medical is the best platform.