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437 Cards in this Set
- Front
- Back
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Largest organ in the body
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Liver
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Size of liver
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13-15 cm long
1500 g (adult) |
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What is the liver made up of?
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biliary epithelial cells, hepatocytes, and Kupffer cells (phagocytes)
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One liver cell can do more than ___ separate metabolic functions.
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500
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What is the liver divided into?
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Tiny lobules (functional unit of liver)
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fibrous layer of connective tissue around liver (except bare area in posterior-superior region)
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Glisson's capsule
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Area of peritoneal reflection around bare area
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Coronary ligament
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Caudal part of coronary ligament is reflected onto diaphragm and rt kidney, called...
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hepatorenal ligament
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Below hepatorenal ligament is a potential peritoneal space
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Morrison's pouch (hepatorenal space)
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What is Morrison's pouch bounded by?
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liver, kidney, colon, and the hepatorenal pouch
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What is the ant and post rt lobe of liver separated by?
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Rt hepatic vein
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normal, mostly in women, may extend to iliac crest, extension of rt lobe of liver
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Reidel's lobe
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Usually in epigastric regions and left hypochondrium, varies in size and shape, smaller than rt lobe of liver
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Left lobe
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What is the medial and lateral segments of lt lobe of liver divided by?
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Lt hepatic vein
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What separates the rt and lt lobes of liver?
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Middle hepatic vein and main lobar fissure
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Where does the main lobar fissure run from?
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Rt portal to neck of gb
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posterioinferior portion of lt lobe of liver
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Quadrate lobe
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umbilical vein, divides medial seg of lt lobe of liver, runs in the inferior or free edge or the falciform ligament, seen as rounded echogenic structure with shadows
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Ligamentum teres
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conducted umbilical vein to liver in fetus, extends from umbilicus to diaphragm, AP extends from rectus muscle to bare area of liver, divided medial seg of lt lobe
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Falciform ligament
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smallest lobe of liver with its own perfusion and rainage systems, located on posterior-superior surface of rt lobe with IVC as posterior border
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Caudate lobe
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What separates the caudate lobe from lt lobe of liver?
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Ligamentum venosum (ductal venosum)
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___ runs over ant part of inferior caudate lobe separating it from ant left hepatic.
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LPV
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between diaphragm and liver on either side of falciform ligament
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Rt and lt anterior subphrenic space
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between rt lobe, rt kidney, and rt colic flexure
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rt posterior subphrenic space
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between the coronary ligament and the liver and diaphragm
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Rt kidney extraperitoneal space
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Portal triad
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hepatic artery, portal vein, cbd
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branch of celiac, liver receives 20-30% of oxygenated blood from it
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hepatic artery
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liver receives 70-80% of oxygenated blood from it, carries nutrients from intestines, echogenic well defined borders
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portal vein
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confluence of splenic and smv, divides into rt and lt portal veins which supply the rt and lt lobes of the liver with nutrient rich blood
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main portal vein
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Where does hepatic and portal blood mix?
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sinusoids
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capillaries that connect hepatic arterioles, hepatic venules, and terminal portal venules (which unite to form hepatic veins)
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sinusoids
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How does blood leave the liver?
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rt, lt, and middle hepatic veins
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drain toward the rt atrium and increase in size as they approach the diaphragm, drain into the IVC, do not have echogenic walls and branch as they go caudal, course intersegmental
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hepatic veins
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Liver functions
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excretory, metabolic, storage, synthesis
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Liver function excretory
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detoxifies drugs and phagocytizes bacteria
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Liver function metabolic
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fats to cholesterol and ketones, glucose from simple sugars
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Liver function storage
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bile (secretes 1-2 liters per day)
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Liver function synthesis
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fats, carbohydrates, proteins, and bile
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AST
(formerly SGOT) |
aspartate aminotransferase, found in liver, muscle, and tissues with high metabolic rates, increase does not indicate disease
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Liver abnormalities that DO increase AST
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acute hepatitis, cirrhosis, fatty changes, hepatic necrosis, injury to liver, mets
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AST increases NOT related to liver
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mono, myocardial infarction
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ALT
(formerly SGPT) |
alanin aminotranferase, produced in hepatocytes, all forms of hepatitis show increase, moderately increased either with obstructive jaundice or hepatocellular disease, shock and drug toxicity cause liver cell death which elevates ALT
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Alkaline Phosphatase
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enzyme produnced in liver, kidneys, bones, intestines, and placenta, increased alk phos with normal alt and ast associated with bile dict obstruction, primary biliary cirrhosis, or slerosing cholangitis
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Nonbiliary elevated Alk Phos...
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associated with abscess, liver cancer, cirrhosis
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LDH
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lactate dehydrogenase
multiple organ systems, primarily used to detect MI and PI(pulmonary infarction), mild increase with hepatitis, cirrhosis, hepatic congestion, and obstructive jaundice, moderate increase with mono |
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Albumin
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blood protein made by the liver, maintains osmotic pressure in blood, decreased levels associated with liver dysfunction, malnutrition, and some renal diseases
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Prothrombin
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produced by liver, is a clotting factor affected by the level of vitamin K
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PT
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prothrombin time
test before invasive procedure normal limits vary, usually given in INT (international normalized ratio) INR=pt's PT/control standard 1 = normal 1.5 is cutoff for large core biopsies 2.0 is cutoff for fine needle biopsies |
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Prolonged PT
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compromised liver functions with poor prognosis, can revert if liver repairs itself, usually seen with mets and cirrhosis
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Shortened PT
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extra hepatic ductal obstruction, gb cancer, cholecystitis
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y-globulins
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enzymes produced in the liver, sensitive indicators of liver dysfunctions BUT elevation can be seen in almost any liver disease as well as normal pts
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Bilirubin
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bile pigment from odl rbc breakdown, formed by Kupffer cells and excreted by hepatocytes
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Serum bilirubin
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protein that increses with chronic inflammatory disease
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Conjugated (direct) bilirubin
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increase with ductal obstruction
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Unconjugated (indirect) bilirubin
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increases with isolated acute hepatocellular disease
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Total bilirubin
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mixture of both and increases with chronic liver cell disease (cirrhosis)
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Indications for a liver scan
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suspected mets, abnormal LFTs, elevation of parenchyma (cirrhosis or hepatitis), jaundice, portal hypertension
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benign reversible fat deposits in liver (mainly rt lobe)
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Fatty infiltration
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Causes of fatty infiltration of liver
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alcohol, obesity, pregnancy, hepatitis, starvation, glycogen storage disease, corticosteriod therapy, diabetes mellitus, massive tetracycline therapy
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another characteric of fatty infiltration, should be suspected in pts who have mass-like hypoechoic areas in the typical location in a liver that is otherwise increase in echogenicity
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Fatty Focal Sparing
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Most common areas for fatty focal sparing in liver
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anterior to the gb or the pv and post portion of the lt lobe of liver
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Clinical features of fatty infiltration
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hepatomegaly, ruq discomfort, may be asymptomatic
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diffuse inflammatory process of the liver, most common types HAV, HBV, and HCV
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Acute viral hepatitis
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What is acute viral hepatitis associated with?
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malaise, nausea, fever, pain, jaundice, enlarged tender liver, hepatosplenomegaly, hypoechoic liver, increased echogenicity of PV walls, thickened gb wall
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Chronic viral hepatitis
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liver parenchyma is course and echogenic, walls of the portal system blend with the liver echogenicity
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diffuse fibrotic process that involves the entire liver, most commonly caused by ETOH abuse, hep B and C
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cirrhosis
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What is cirrhosis associated with?
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fatigue, weight loss, diarrhea, dull ruq pain, abd girth, ascites
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late features of cirrhosis
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small nodular echogenic liver with decrease through transmission, caudate lobe may be sparred, ascites, portal hypertension, collateral vessels, patent umblical vein
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autosomal recessive disorder of carbohydrate metabolism, usually occurs in infancy or young childhood, hypoglycemic. hepatomegaly, fatty liver infiltration with diffuse increase liver echogenicity
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Glycogen storage disease
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Most common type of glycogen storage disease
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Von Gierke's
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caused by a parasite, usually asymptomatic, may cause pain if cysts become large, honey comb or solid appearance, jaundice and increase alkaline phosphatase
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echinococcal cyst (hydatid)
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Fungal infection (candidiasis)
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AIDS, organ transplant, malignancy, ruq pain, fever, focal lesions (wheel within a wheel)
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Cavernous hemangioma
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asymptomatic and usually in women, normal LFTs, usually small round in the rt lobe, subcapsular, homogenous with increase through transmission
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Focal nodular hyperplasia
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usually echogenic, in the rt lobe, similar appearance to adenomas, hepatomas
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Hepatocellular carcinoma
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hepatoma associated with longstanding cirrhosis, hypoechoic in early stage and becomes hyperechoic, may be singular mass or multiple, increased AST, ALT, alkaline phos, 70% of time AFP will be present, weight loss, jaundice, cirrhosis symptoms
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Hepatoblastoma
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found during infancy or childhood, abd enlargement, hepatomegaly, weight loss, nausea, vomiting, precocious puberty, heterogenous, hyperechoic or cystic with interal septations
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Causes of jaundice
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Hepatocellular disease (nonobstructive):
hepatitis, drug-induced cholestais, fatty liver, cirrhosis Hemolytic disease: sickle cell anemia, Cooley's anemia Surgical jaundice (obstructive): choledocolithiasis, pancreatic pseudocyst, mass in head of pancreas, hepatoma, metastic carcinoma, cholangiocarcinoma |
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Portal vein obstruction
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thrombosis, invasion of portal vein by tumor, clinical findings include hepatocellular carcinoma, pancreatic or GI cancer, or lymphoma, sono findings are nonvisualization of the portal vein, echoes within the portal vein, dilatation of the splenic and SMV (prox to the level of obstruction)
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Budd-Chiari syndrome
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obstruction of hepatic veins caused by thrombosis or compression from a liver mass, clinical findings include abd pain, jaundice, abnormal LFTs, hepatomegaly, ascites, sono findings are reduced or nonvisualization of hep veins, hep veins prox to obstruction may be dilated, large and hypoechoic caudate lobe, ascites, abnormal doppler flow
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Size of gb
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3-4 cm in diameter, 7-10 cm in length
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Normal thickness of gb wall
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<3mm
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infected bile, thickened bile duct
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Cholangitis
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hyperplastic change in gb wall due to benign tumors on wall
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adenomyomatosis
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calfcified gb wall
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porcelain gb
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wall echo shadow, gb wall covered in stones
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wall echo shadow
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massive enlargement usually with cystic duct obstruction
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hydrops
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carcinoma that arises at the union of the rt and lt hepatic ducts, intrahepatic dilatation without extrahepatic dilatation
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Klatskin's tumor
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usually in children, mostly female/ abdominal mass, ruq pain, fever, and jaundice/ congenital dilatation of biliary tree/ localized dilatation of cbd, diverticuli from cbd, invagination of cbd into duodenum, dilatation of entire cbd and chd
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choledochal cyst
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enlarged gb due to distal cbd obstruction (ex: pancreas ca, diabetes, cbd ca, or duodenal ca)
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Courvoisier's sign
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folds back on itself at the neck
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Hartman's pouch
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CBD upper limits
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7mm
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CBD with gb
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3-4 mm
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What is GB ca assoc with?
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calculi and chronic mechanical irritation, polypoid mass, jaundice, weight loss, cbd obstruction, chronic cholecystitis, and porcelain gb
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Bile duct is ___ to portal veins with a stellate pattern
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anterior
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distal acoustic enhancement, parallel channel, numerous tubes within liver
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portal veins
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GB contracts due to ____
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cholecystokinin
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Adenomyomatosis of gb
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hyperplasia of epithelial and muscle elements of wall/ Rokitansky-Aschoff sinuses: intramural diverticula/ localized, annular, and diffuse varieties/ most common in fundus/ us shows nonspecific wall thickening, bile, sludge, or calculi/ pedunculated: don't move
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Sludge is ___ and does not always become stones
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not significant
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Causes of sludge
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alcohol, fasting, biliary obstruction, IV hyperalimention
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Differential dx of sludge
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If fever or pain, could be pus or hemorrhage
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Most common of biliary ca
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GB cancer
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Most common obstruction to biliary system
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pancreatic cancer
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GB cancer
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solid mass inf undus without bile/ irregular thick gb wall/ symmetrically thick wall/ soft tissue mass that casts shadow and not gravity dependent/ assoc with stones and chronic cholecystitis/ artifact: partial volume/ mucosal folds
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strawberry gb
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Cholesterosis
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stone obstructing the cystic duct/ dilataion of the common bile duct and intrahepatic ducts with normal bile duct
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Mirizzi's syndrome
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Adenomyomatosis
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Rokitansky-Aschoff sinuses
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inflammation of the gb secondary to cystic duct obstruction/ assoc with gallstones and tenderness over gb, wall thickening, fatty food intolerance, fever, pericholecystic fluid
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Acute cholecystitis
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cholecystitis without gb
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Acalculous cholecystitis
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Right hepatic duct and left hepatic duct doin to form the ___, which joins with the cystic duct to make the ___, which is ___ to the duodenal bulb and pancreas and enters the 2nd part of the duodenum at the ____. CBD and pancreatic duct join in duodenum here.
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CHD/ CBD/ posterior/ ampulla of Vater
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Outside the liver, the duct is always ___ to the portal vein.
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anterior
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The normal lumen of the CBD is ___. Older pts can be up to ___.
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<8mm / 10-12mm
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CHD is ___ to the right portal and is ____.
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anterior/ <4 or 5mm
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Intrahepatic obstruction signs
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double barrel shotgun/ too many tubes/ stellate formation at porta hepatis/ distal enhancement
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Extrahepatic obstruction signs
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CBD >6mm/ false negative if obstruction is less than 24 hours since ducts not dilated yet/ false positive if stone has passed
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With intrahepatic dilatation and a normal CBD and normal GB, look for:
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ductal tumors (if it is confined to one lobe, check that duct)/ sclerosing cholangitis/ metastases/ biliary atresia/ choledochal cyst
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inflammation and fibrosis of bile duct with intrahepatic calculi
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sclerosing cholangitis
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most common and fatal liver disorder in children
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biliary atresia
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With intrahepatic biliary dilatation when CBD and GB are enlarged, look for:
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cbd stones/ pseudo cyst/ acute pancreatitis (swollen head blocks flow)/ chronic pancreatitis (fibrotic shrunken head obstructs)/ pancreatic head cancer
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With intrahepatic biliary dilatation when the cbd is dilated and the gb is small look for:
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chronic cholecystitis
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Intrahepatic congenital abnormality
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no evidence of biliary radicals/ untreatable
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Extrahepatic congenital abnormality
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anastomosis to jejunum (dilated intrahepatic radicals)
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Classic triad of common duct wall outpouching
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jaunice, ruq pain, ruq mass
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Caroli's disease
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segmental saccular dilatation of intrahepatic ducts/ may be assoc with cystic kidney disease (renal tubular ectasia) leads to bile stasis/ stones/ bacteria/ abscess/ cholangitis/ us shows multiple liver cysts continuous with biliary tree/ stones may be seen
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Cholangitis
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inflammation of bd assoc with bacteria (usually assoc with obstruction from choledocholithiasis, biliary stricture, neoplasms)/ signs and symptoms are Charcot's triad (biliary colic)/ labs: leukocytosis, elevated serum bilirubin, elevated alkaline phosphatase, bactremia
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Charcot's triad (biliary colic)
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jaundice, chills, fever
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stone in cbd (usually from gb)
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choledocholithiasis
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signs and symptoms of choledocholithiasis
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jaundice, biliary colic, cholangitis
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Labs and u/s of choledocholithiasis
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elevated serum bilirubin, elevated alk phos/ see stones in duct
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dilated ducts, ruq pain, elevated lft's, jaundice/ these are thought to be secondary to papillary inflammation and edema/ CMV is also probable cause/ may have sclerosing cholangitis-like pattern with irregular areas of dilatation and duct wall thickening
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AIDS
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Adenocarcinoma and squamous cell ca
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signs and symptoms are anorexia, weight loss, ruq pain, jaundice/ predisposition thought to be inflammation, cholethiasis, chronic ulcerative colitis, all branches may be affected
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Klatskin tumor
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arises at the confluence of the hepatic ducts/ poor prognosis sinec tumor is a considerable size when found/ us: dilatation of intrahepatic ducts, but not extrahepatic ducts; small solid mass at hepatic hilum; lymphadenopathy is commonly assoc with this
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Hepato-biliary scan
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fat soluble radionublide is injected/ if cbd and cystic duct are patent, radionuclide will appear in gb and bowel within half hour postinjection
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retroperitoneal organ lying transversely in the body
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pancreas
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3 parts of pancreas
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head, body, tail
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The pancreas is relatively ___ in children.
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larger
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Approx size of pancreas
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head: 2.5cm/ body: 2cm/ tail: 2cm (AP)
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The pancreas lies ___ to the IVC and right renal vein and ___ to the 2nd part of the duodenum
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ant/ medial
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The CBD is seen ___ to the head of the pancreas and the GDA is ____ to the surface.
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post and lateral/ ant and lateral
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____ are seen in the head of the pancreas
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CBD and GDA
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The ___ is the largest part of the pancreas and is ____ to the SMV, SMA, splenic vein, and aorta.
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body/ ant
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You can see the left renal vein ___ to the SMA and ___ to the aorta.
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post/ ant
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The tail of the pancreas is __ to the lt kidney and ___ to the splenic hilum. ___ forms the sup border and the ___ forms the post border.
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ant/ medial/ Splenic artery/ splenic vein
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primary duct that runs the entire length of the pancreas and enters the second part of the duodenum at the ampulla of vater along with the cbd.
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Duct of Wirsung
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secodary duct that enters second part of duodenum approx 2cm prox to the Ampulla of Vater
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Santorini's duct
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echogenicity of pancreas
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homogenous equal or slightly greater than the liver
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The pancreas has ___ so it blends in with the retroperitoneal fat
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no true capsule
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Pancreatic duct can be seen as cystic tube ___ in caliper decreasing toward tail.
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2-3mm
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Endocrine function of pancreas
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secrete insuin via the islets of Langerhans
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Exocrine enzymes of pancreas
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trypsin, lipase, and amylase
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Pancreatitis
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inflammation/ older pts: alcohol (more common in men), biliary tract disease (women), trauma, surgery perforated peptic ulcer, drugs/ younger pts: mumps, mono/ hereditary: cystic fibrosis and congenital pancreatitis (rare)
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Acute Edematous pancreatitis
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inflammatory and edema enlarges and swells/ can be assoc with intraperitoneal or retroperitoneal fluid
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Acute hemorrhagic pancreatitis
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autodigestion of pancreas tissue with areas of fresh blood and fat necrosis/ least common and most urgent/ us shows heterogenous to homogenous texture with ductal enlargement and fluid around it
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Chronic pancreatitis
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continued distrction of parenchyma usually with alcoholism and biliary disease/ us sees small pancreas
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pancreatic cancer/ most common usually in the head of the pancreas/ us appears with irregular borders, parenchymal pattern changes, pancreas enlarges, duct dilataion, and cbd enlargement
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adenocarcinoma
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pancreas cancer/ irregular cystic lobulated tumor with thick walls usually in body or tail
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cystadenocarcinoma
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pancreas cancer/ small, well-circumscribed mass usually in the tail/ 75% cause endocrine hypersecretion/ solid mass with cystic degeneration
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islet cell carcinoma
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Pancreas cancer labs
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increased alk phos/ increased bilirubin due to obstruction leading to jaundice and mets/ lymphadenopathy may be seen
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benign, well-circumscribed with low level echoes/ most frequent benign tumor found in body or tail of pancreas/ solid with cystic degeneration/ 75% hypersecretion, 25% non functioning, 10% become cancer
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islet cell tumor
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lobulated with cystic area (cannot be differentiated from cancer), rare, arising in duct in tail of pancreas, benign
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cystadenoma
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Other benign tumors of pancreas
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papilloma of duct/ duct cell adenoma/ cysts (true cysts are usually in the head and cont with the duct)/ abscess/ lymphomas, mets
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take on shape of the available space/ have well-defined borders/ pancreatic enzymes outside the duct/ most common in alcoholic pts
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pancreatic pseudocyst
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largest mass of reticuloendothelial tissue in the body
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spleen
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size of spleen
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12-14cm in length/ 7cm wide/ 3cm AP
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The spleen is ___ to diaphragm and ___ to stomach.
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inf/ posteriolateral
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Lt. kidney, lt adrenal, tail of panc, and lt colic flexure are all related to ___
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visceral surface of spleen
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Spleen may be ___.
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ectopic
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Accessory spleen is usually found...
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around the hilum.
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Spleen measurement
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12-14 cm long, 7 c wide, 3 cm AP
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The spleen is ___ to the diaphragm and ___ to the stomach.
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inf/ posteriolateral
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Lt kidne, lt adrenal, tail of panc, and lt colic flexure are all related to the __ of the spleen.
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visceral surface
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Asplenia
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congenital absence/ rare and often assoc with congenital heart disease
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Spleen has ___ with fibers penetrating into spleen.
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fibroplastic capsule
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Spleen is ____
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intraperitoneal (surrounded by peritoneum)
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Is the spleen essential to life?
|
no
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Functions of spleen
|
-main component of reticuloendothelial system
-breaks down hemoglobin and form bile pigments -filters blood -forms antibodies and immunity -reservoir for blood -blood formation in fetus or during severe anemia |
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Primary malignant tumors of spleen
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sarcoma from capsule/ lymphoma from splenic tissue
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Secondary malignant tumor of spleen
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mets from breast/ melanoma, or ovaries
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Benign tumors of the spleen
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congenital cysts (polycytic disease)/ hemangioma (most common)/ lymphangioma
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Most common benign tumor of the spleen
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hemangioma
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Spleen abscess/ granulomatous disease
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causes: histoplasmosis, tuberculosis/ us: calcified fociwith shadowing are seen in the spleen
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Splenic rupture
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common in trauma/ spontaneous rupture occurs with diseases in which the spleen enlarges and softens
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Pt position for scanning the spleen
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supine, left lateral oblique, prone
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Sonolucencies seen in spleen
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cysts, abscesses, lymphoma, mets
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Decreased echogenicity of spleen caused by:
|
congestion multile myeloma, lymphopoiesis, granulocytopoiesis, erythopoiesis
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Increased echogenicity of spleen caused by:
|
leukemia or lymphoma
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Size and mass of spleen varies with...
|
energy and nutritional state
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Spleen is considered enlarged when...
|
it extends past the aorta anteriorly on trv scan with pt supine (but this can occur nomrally in very thin pts)
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Accessory spleen
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most common congenital anomaly/ splenic tissue separate from the spleen is usually found near the splenic hilum or adjacent to the tail of the panc
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Causes of minimal splenic enlargement
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acute splenitis, congestion, febrile, bacteria, toxins, lupus, infections
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Causes of moderate splenic enlargement
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leukemia, mono, chronic splenitis, tb, sarcoid tumor, chronic congestion, cancer, iron anemia, hemolytic anemia, cirrhosis (with portal hypertension)
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Cause of massive splenic enlargement
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chronic leukemia, lymphoma, hodgkins, parasites, primary tumors
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|
|
Kidneys are ____ along with ureters
|
retroperitoneal
|
|
|
The kidneys are surrounded by a ____ not connected to the cortex seen as a ____
|
fibrous sheath/ strong specular reflector
|
|
|
Around the kidneys' fibrous capsule is ____
|
a collection of perinephric fat
|
|
|
Adrenal gland is___, ___, and ___ to the kidney
|
sup, ant, and medial
|
|
|
Gerotas fascia
|
fibrous sheath that enlcoses the kidney, fat, and adrenal gland
|
|
|
Two distinct areas of renal parenchyma which surrounds the renal sinus
|
a) outer cortex
b) inner medullary pyramids |
|
|
Kidney parenchyma is measured from...
|
the margin of the sinus to the kidney surface
|
|
|
Renal size varies with...
|
age, size, and sex
|
|
|
Average size of adult kidney
|
11.5 cm long, 6 cm wide, 3.5 cm thick
|
|
|
Renal cortex on us
|
uniform, closely spaced, relatively low level echoes of an intensity less than the liver or spleen
|
|
|
Medullary pyramids on us
|
hypoechoic rounded areas between the cortex and renal sinus and are separated from each other by bands of cortex called columns of Bertin which extend to the sinus
|
|
|
(renal) Arcuate vessels on us
|
specular echoes seen between the cortex and medulla
|
|
|
inner echogenic area of kidney containing fat, calyces, infundibula, renal pelvis, connective tissue, renal vessels, and lymphatics
|
renal sinus
|
|
|
entrace to renal sinus which alows the blood vessels, nerves, lymphatic vessels, and the ureter to pass through
|
renal hilum
|
|
|
The superior end of the ureter is expanded to form a funnel-shaped sac called ___ which is in the sinus. It divides into 2 or 3 tubes called the ____ which in turn divide into 8 or 18 ____
|
renal pelvis/ major calyces/ minor calyces
|
|
|
The minor calyces are indented by the ___ of the medullary pyramid called the ____.
|
apex/ renal papilla
|
|
|
Calyces are not seen in fluid restricted patients due to collapse, but appear as channels during ____ crossing the sinus/ if rena pelvis partially ____, it may appear as a fluid filled structure medial to the kidney
|
diuresis/ extrarenal
|
|
|
Borders anterior to right kidney
|
right adrenal, liver, duodenum, right colic (hepatic) flexure, small intestine
|
|
|
Borders anterior to the left kidney
|
left adrenal, stomach, spleen, pancreas, jejunum
|
|
|
Borders posterior to kidneys
|
diaphragm, quadratus lumborum, psoas muscle
|
|
|
Function of kidneys
|
-excretion of inorganic compounds (Na, K, Ca)
-Excretion of organic compounds (creatinine) -blood pressure regulation -erythrocyte volume regulation -vitamin d and ca metabolism |
|
|
Ultimate goals of kidneys
|
1)maintain salt and water balance
2) regulate fluid volume in body 3) maintain acid base balance |
|
|
In the embryo,kidneys form in the ___ in AP orientation then ascend and rotate/ usually complete by __ year of life/ incomplete ascension leads to ____
|
pelvis/ 5th or 6th/ ectopic kidneys
|
|
|
Renal congenital abnormalites- Number
|
solitary kidney, unilateral renal agenesis, supranumary, bilateral renal agensis (Potter's syndrome)
|
|
|
one functioning kdney and the other atrophied
|
solitary kidney
|
|
|
bilateral renal agensis assoc with oligo, pulmonary hypoplasia, and is fatal soon after birth
|
Potter's syndrome
|
|
|
Renal congenital abnormalities - Shape
|
hypertrophic columns of Bertin, fetal lobulation, dromedary humps, renunculus and fusion of the kidneys (horseshoe and lump), also cystic diseases (infantile polycystic, adult polycystic, and multicystic)
|
|
|
most common cause of abd mass in newborn/ usually unilateral with kidney presenting with cysts of various shapes owing to atresia of the ureter, pelvis, or both
|
Multicystic Dysplastic Kidney (Potter 2)
|
|
|
least common and most fatal of the 3 anomalies of kidney shape/ autosomal recessive and 2:1 in females more/ us sees bilateral, echogenic,enlarged kidneys (cysts too small to be seen)/ if survival is past infancy, hepatic fibrosis and/or bleeding from esophageal varices causes death (Potter 1)
|
Infantile Polycystic Kidney Disease
|
|
|
autosomal dominant may be latent and manifest later in life for unknown reasons/ us: bilateral, randomly distributed cortical cysts of various sizes/ assoc with liver cysts, spleen cysts, and panc cysts/ distruction of renal tissue leads to renal failure (Potter 3)
|
Adult Polycystic Kidney Disease
|
|
|
dominant or recessive/ pts present with renal failure/ us: small cysts confined to the medullary portion of both kidneys
|
Medullary cystic disease
|
|
|
Renal transplants
|
placed in the ileopelvic region/ baseline should be done immediately after to determine location, size, and texture
|
|
|
Acute renal failure causes
|
acute rejection, acute tubular necrosis, arterial obstruction
|
|
|
Acute renal rejection appearance
|
enlarged with increased cortical echogencitiy, decreased renal sinus echogenicity, irregular sonolucent areas in cortex, enlarged and decreased echogenicity of pyramids, distortion of renal outline, and indistinct corticomedullary junction
|
|
|
Acute tubular necrosis rejection
|
normal sonogram
|
|
|
Rejection due to acute renal arterial occlusion
|
normal sonogram, however duplex Doppler may reveal absence or reduction of diastolic flow
|
|
|
Perinephri fluid collections assoc with transplant are...
|
lymphocele, urinoma, abscess, and hematoma
|
|
|
Two types of hydronephrosis
|
intrinsic and extrinsic
|
|
|
Intrinsic hydro causes
|
stricture, renal calculi, renal neoplasm, bleeding and blood clot, ureterocele, pylonephrosis, or tuberculosis
|
|
|
Extrinsic hydro causes
|
pregnancy (usually rt side), pelvic mass, bladder neck obstruction, neurogenic bladder, trauma, retroperitoneal fibrosis, prostatic hypertrophy, urethritis, inflammatory lesions (pelvic, gi, retroperitoneal)
|
|
|
Causes of congenital hydronephrosis, present at birth
|
UPJ obstruction, ectopic ureterocele, retrocaval ureter, posterior urethral valves
|
|
|
False positive hydronephrosis- conditions that mimic hydro are:
|
normal diuresis, overextended bladder, parapelvic cyst, renal sinus lipomatosis, extra renal pelvis, reflux (vesicoureteral), diabetes insipidus
|
|
|
False negative hydronephrosis
|
severe dehydration or nephrolithiasis with intermittent obstruction
|
|
|
Nephrolithiasis
|
kidney stones/ highly echogenic foci with post shadowing and may be composed of uric acid, cystine, or calcium all of which appear the same/ staghorn calculi ae large stones in the center of the kidney
|
|
|
Lab values in nephrolithiasis
|
chronic obstruction: increased serum creatinine and BUN
acute: no specific lab values (urine may show hematuria and/or bacteria) |
|
|
occurs as a result of deterioration of renal function (chronic or acute)/ lab values are increased serum bun and serum creatinine
|
renal failure
|
|
|
Prerenal causes of renal failure
|
secondary to systemic cause as a result of vascular disorders
|
|
|
artheriosclerosis of the renal arteries resulting in ischemia of kidney/ develops rapidly in pts with severe hypertension
|
Nephrosclerosis
|
|
|
may result from occlusion or stenosis of renal artery
|
infarction
|
|
|
may cause renal hypoperfusion secondary to heart failure
|
congestive heart failure
|
|
|
most common cause of acute renal failure/ destruction of the tubular epithelial cells of the proximal and distal convoluted tubules may occur from ingestion or inhalation of toxins, ischemia due to trauma, hemorrhage, acute interstitial nephritis, cortical necrosis, and diseases of the glomeruli
|
Acute Tubular Necrosis (ATN)
|
|
|
infection is the msot commo disease of the urinary tract and the combination of parenchymal, caliceal, and pelvic inflammation constitutes this/ infection is usually from bacteria ascending from the bladder or from adjacent lymph nodes
|
pyelonephritis
|
|
|
Renal Immunological injuries
|
nephrotic syndrome, glomerulonephritis, systemic lupus erythematosus
|
|
|
deposition of antigen-antibody complexes on the glomerulus accompanies by proteinuria, hyperlipidemia, and edema
|
Nephrotic syndrome
|
|
|
Glomerulonephritis
|
frequently follows infecions
|
|
|
autoimmune disease/ increases the echogenicity of the kidney
|
Systemic lupus erythematosus
|
|
|
Metabolic disorders of kidneys
|
diabetes mellitus, amyloidosis, gout, nephrocalcinosis/ these are assoc with renal failure
|
|
|
chronic nephrotoxicity
|
caused by exposure to radiation,heavy metals, industrial solvents, and drugs
|
|
|
US appearanc of renal failure
|
acute: normal sized or enlarged
chronic: normal size or small Echogenicity increases as case progresses from acute to chronic/ there is no correlation between echogenicity, renal size, and degree of decreased renal function |
|
|
Postrenal causes of renal failure
|
urinary tract obstruction/ hydro which may be congenital or acquired
|
|
|
Renal Medical Disease Type 1
|
Increased cortical echogenicity and increaed corticomedullary differentiation/ these are due to glomerular infiltrate such as acute and chronic glomerulonephritis, acute lupus nephritis, and renal transplant rejection/ these increase echogenicity to greater than liver or spleen and can decrease size of kidney
|
|
|
Renal Medical Disease Type 2
|
distortion of normal anatomy involving corte and medullary pyramids/ usually seen with focal lesions (cysts, abcesses, hematoma, bacterial nephritis (lobar nephronia), infantile polycystic disease, chronic pyelonephritis, and chronic glomerulonephritis
|
|
|
Angiomyolipoma
|
benign solid tumor/ aka renal hamartoma/ tumor composed of fat, muscle, and blood vessels/ discrete highly echogenic mass found in the cortex/ symptoms: flank pain, hematuria/ usually found in autopsy
|
|
|
Renal adenoma
|
benign counterpart of renal cell carcinoma/ asymptomatic or painless hematuria/ small well-defined isoechoic mass found in cortex
|
|
|
Hyperneprhoma
|
malignant renal tumor/ aka adenocarcinoma, renal cell carcinoma, and von grawitz tumor/ affects males more than females 2:1/ after age 50/ hematuria, mass with increased vascularity with irregular branching/ unilateral, dolitary, and encapsulated/ varied echogenicity/ look for metastases via blood stream infiltrating rnal vein and ivc/ also look for mets to the other kidney, ureter, peritoneum, liver, spleen
|
|
|
Transitional cell carcinoma
|
affects the urothelium and my be located anywehre within the urinary system/ occus in the renal pelvis, usually asymptomatic but may have some pain/ painless hematuria/ known to be invasive/ tumor not well-defined or encapsulated within the renal pelvis/ appears as a bulky discrete mass/ hypoechoic or isoechoic
|
|
|
aka nephroblastoma/ most common malignancy of renal origin in children/ abdominal mass, hypertension, nausea, hematuria/ early on encapsulated, later on it may extend into perirenal area/ varied us appearance
|
Wim's tumor
|
|
|
The bladder is located immediately behind the ___
|
pubic bone
|
|
|
The bladder is located immediately behind the ___
|
pubic bone
|
|
|
The bladder apex points ___ and is connected to the umbilicus by the _____.
|
anteriorly/ median umbilical ligament (remains of fetal urachus)
|
|
|
The bladder apex points ___ and is connected to the umbilicus by the _____.
|
anteriorly/ median umbilical ligament (remains of fetal urachus)
|
|
|
The ureters enter at ___ angle and urethra extends from ___ to ___.
|
superolateral/ neck to exterior of body
|
|
|
The ureters enter at ___ angle and urethra extends from ___ to ___.
|
superolateral/ neck to exterior of body
|
|
|
Bladder wall measurement
|
normally 3-6 mm
|
|
|
Bladder wall measurement
|
normally 3-6 mm
|
|
|
Normal volume of bladder without discomfort is...
|
500mL
|
|
|
Normal volume of bladder without discomfort is...
|
500mL
|
|
|
Ureters are on ___ surface near medial edge and cross ___ to common iliacs
|
anterior/ anterior
|
|
|
Ureters are on ___ surface near medial edge and cross ___ to common iliacs
|
anterior/ anterior
|
|
|
Congenital abnormalities of the ureters
|
double of bifid, narrowing, strictures, diverticuli, hydroureter (usually due to polycystic kidney and/or acquired reason like low ureteral obstruction)
|
|
|
Congenital abnormalities of the ureters
|
double of bifid, narrowing, strictures, diverticuli, hydroureter (usually due to polycystic kidney and/or acquired reason like low ureteral obstruction)
|
|
|
Primary Megaureter
|
nonobstructing, nonrefluxing/ includes prune-belly syndrome (eagle-barrett), deficiency of abdominal musculature, urinary tract abnormalities, and retroperitoneal fibrosis which fixes ureters and prevents peristalsis leading to functional obstruction
|
|
|
Primary Megaureter
|
nonobstructing, nonrefluxing/ includes prune-belly syndrome (eagle-barrett), deficiency of abdominal musculature, urinary tract abnormalities, and retroperitoneal fibrosis which fixes ureters and prevents peristalsis leading to functional obstruction
|
|
|
Secondary Megaureter
|
due to reflux of urine or obstruciton
|
|
|
Secondary Megaureter
|
due to reflux of urine or obstruciton
|
|
|
Urachal Cysts
|
the urachus connects the apex of the bladder with the allantois (an embryological structure with no function in humans) through the umbilical cord/ Normally it fibroses at birth, but may in part or in whole remain patent/ located in the space of Retzius
|
|
|
Urachal Cysts
|
the urachus connects the apex of the bladder with the allantois (an embryological structure with no function in humans) through the umbilical cord/ Normally it fibroses at birth, but may in part or in whole remain patent/ located in the space of Retzius
|
|
|
The bladder is located immediately behind the ___
|
pubic bone
|
|
|
The bladder apex points ___ and is connected to the umbilicus by the _____.
|
anteriorly/ median umbilical ligament (remains of fetal urachus)
|
|
|
The ureters enter at ___ angle and urethra extends from ___ to ___.
|
superolateral/ neck to exterior of body
|
|
|
Bladder wall measurement
|
normally 3-6 mm
|
|
|
Normal volume of bladder without discomfort is...
|
500mL
|
|
|
Ureters are on ___ surface near medial edge and cross ___ to common iliacs
|
anterior/ anterior
|
|
|
Congenital abnormalities of the ureters
|
double of bifid, narrowing, strictures, diverticuli, hydroureter (usually due to polycystic kidney and/or acquired reason like low ureteral obstruction)
|
|
|
Primary Megaureter
|
nonobstructing, nonrefluxing/ includes prune-belly syndrome (eagle-barrett), deficiency of abdominal musculature, urinary tract abnormalities, and retroperitoneal fibrosis which fixes ureters and prevents peristalsis leading to functional obstruction
|
|
|
Secondary Megaureter
|
due to reflux of urine or obstruciton
|
|
|
Urachal Cysts
|
the urachus connects the apex of the bladder with the allantois (an embryological structure with no function in humans) through the umbilical cord/ Normally it fibroses at birth, but may in part or in whole remain patent/ located in the space of Retzius/ clinical: silent until infection then abd pain and/or urinary complaints/ us: echo-free tubular structure in lower-mid abdominal wall; upper pole may extend from umbilicus to bladder
|
|
|
pouchlike envaginations of bladder wall/ clinically infection due to stasis/ us: varies in size and may appear separate from bladder; round, well-defined thin-walled cystic masses; it should disappear after voiding
|
Diverticuli of bladder
|
|
|
complete reduplication of bladder is rare; unilateral reflex, obstruction or infection/ us: sees 2 separate bladders separated by a peritoneal fold
|
Reduplication
|
|
|
common abnormality in children secondary to anomalies such as ectopia, posterior urethral valve, prune-belly, neurogenic bladder, and primary congenital abnormalities/ clinically may cause chronic renal failure with scarring and atrophic changes/ us: Cysto-Conray (20%) is injected into the bladder; each kidney is scanned while the contrast is injected; with increasing grade of reflux, there is increasing kidney dilatation
|
Vesicoureteral Reflux
|
|
|
the lower portion continuous with the urethra is the neck/ in males, BPH or cancer is the usual cause of obstruction and with prolonged obstruction, the walls become thickened and trabeculate/ us: thickened irregular-walled bladder
|
Bladder neck obstruction
|
|
|
infection or inflammation of the bladder/ usually due to diverticula, urethral obstruction, fistulas, cystoceles, bladder neoplasm, pyelonephritis, neurogenic dysfunction/ us: inflammatory changes and thickening when it is long standing; with neurogenic bladder, a pus-urine level may be seen
|
Cystitis
|
|
|
papilloma/ epithelial/ may be papillary growths, nodular infiltrating/ us: small to massive tumors projecting from the bladder wall; some may invaginate bladder wall and may be smooth or irregular/ may mimic BPH or cystitis
|
Primary Benign Tumor of Bladder
|
|
|
95% are transitional cell carcinoma/ 5% are squamous cell carcinoma/ invasive growths, with 40% having mets to lymph nodes and invasion of prostate and seminal vesicles/ us: small to massive solid tumors projecting from the bladder wall/ some may invaginate bladder wall and may be smooth or irregular/ may mimic BPH or cystitis
|
Primary Benign Tumore of Bladder
|
|
|
Triangular shaped structures superior and anteromedial to kidney
|
adrenal glands
|
|
|
Adrenal gland measurements
|
1 x 3 x 5cm / proportionally larger at birth
|
|
|
encloses kidneys, adrenals, and perinephric fat
|
Gerota's fascia
|
|
|
____ is posterior to ivc and ant to the right crus of the diaphragm
|
Right adrenal
|
|
|
____ is between spleen and aorta posterior to the panc tail
|
Left adrenal
|
|
|
Normal adrenals are hard to see with us due to...
|
size and echogenicity similar to surrounding retroperitoneal fat
|
|
|
Recommended modality to visualize adrenal glands
|
CT
|
|
|
___ will sometimes displace adrenal glands
|
Tumors
|
|
|
Right adrenal anterior pathology displacement
|
retroperitoneal fat, ivc, rt renal vein
|
|
|
Right adrenal posterior pathology displacement
|
rt. kidney
|
|
|
Left adrenal ant pathology displacement
|
splenic vein
|
|
|
Left adrenal post pathology displacement
|
lt. kidney
|
|
|
The two distinct endocrine organs of adrenals are...
|
cortex and medulla
|
|
|
Adrenal cortex produces...
|
steroids
|
|
|
3 Zones of adrenal cortex
|
1) zona glomerulosa: mineralocorticoids (regulates electrolyte metabolism)
2) zona fasiculata 3) zona reticularis: produces glucocorticoids (regulates carbohydrate metabolism) and androgens (regulates androgens and estrogen) |
|
|
Cortical hormones are regulated by ...
|
adrenocorticotropic hormones (ACTH) or ant. pituitary
|
|
|
Decrease in adrenal cortical function leads to ...
|
increased ACTH, which then stimulates the adrenal cortex.
|
|
|
Increase in concentration of adrenal hormones leads to...
|
decrease in ACTH secretion, which in turn leads to a drop in the activity of the adrenal cortex.
|
|
|
Adrenal cortex may be affected by lesions that produce ___ or ____.
|
an excess or deficiency of steroid hormones/ Pituitary tumor may alter ACTH
|
|
|
Adrenal medulla produces...
|
epinephrine (adrenaline) and norepinephrine
|
|
|
produced by adrenal medulla/ dilates coronary vessels and constricts skin and kidney vessels/ increases coronary output, raises oxygen consumption, and causes hyperglycemia
|
Epinephrine
|
|
|
produced by adrenal medulla/ constricts all arterial vessels except coronary arteries, which dilate
|
Norepinephrine
|
|
|
The adrenal medulla regulates...
|
blood pressure
|
|
|
Fight or flight response
|
epinephrine/ stimulates metabolic rate which allows more energy to be available
|
|
|
adrena cortex malfunction/ prolonged exposure to elevated plasma corticosteroids/ produces truncal obesity, rounded faces, mild hypertension, cardiac enlargement, and edema/ us: solid, cystic or complex appearing with focal zones of necrosis
|
Adrenocortical Hyperfunction or Cushing's Syndrome
|
|
|
adrenal cortex malfunction/ hyperaldosteronism due to the increased secretion of aldostrone producing sodium retention, which leads to hypertension/ us: solid, cystic , or complex appearing with focal zones of necrosis
|
Conn's syndrome
|
|
|
adrenal cortex malfunction/ exclusive oversecretion of androgens leading to virilism or masculinization in a female/ hypersecretion of estrogens in the male produces feminizing syndrome/ us: solid, cystic, or complex appearing with focal zones of necrosis
|
Adrenogenital Syndrome
|
|
|
adrenal cortex malfunction/ hypotension, small hearts, malaise, weight loss, skin pigmentation, loss of body hair and menstrual irregularity/ 60% due to idiopathic destruction, probably autoimmune in nature
|
Adrenocortical Hypofunction or Addison's disease
|
|
|
adrenal medulla malfunction/ paroxysmal or sustained hypertension, angina, cardiac arrythmias, and headaches/ these features are dueto the concentration of catecholamines released into the circulation/ us: may grow quite large, appear cystic, solid, or solid with calcified components
|
Pheochromocytoma
|
|
|
adrenal medulla malfunction/ termed a nonfunctioning tumor (does not produce epinephrine or norepinephrine)/ arises from sympathetic nervous tissue/ most children are asymptomatic presenting with a palpable mass/ us: tumor that appears echogenic and may be quite large
|
Neuroblastoma
|
|
|
most commonly found from bronchogenic ca, lung adenocarcinoma, breast or stomach cancer/ us: varied size and echogenicity of mets
|
Adrenal Metastases
|
|
|
pt may be asymptomatic/ us: strong back wall, no internal echoes, good through transmission/ have tendency to become calcified, which may appear as an echcogenic struction, with an echogenic back wall, but with poor transmission (adrenal)
|
Adrenal cysts
|
|
|
(adrenal) especially seen in infants/ us: varies from cystic to complex depending on age of hematoma, ending in calcification
|
Adrenal Hematoma
|
|
|
ant to the spine adn post to pancreatic body/ sup aspect is most posterior
|
aorta
|
|
|
which aspect of the aorta is most posterior?
|
superior
|
|
|
2-3 cm long and has 3 branches: splenic art, lt gastric art, hep art
|
celiac axis
|
|
|
branch of celiac/ sup to panc to spleen
|
splenic artery
|
|
|
branch of celiac/ enters porta hepatis with portal vein/ gastroduodenal art branches off
|
hepatic art
|
|
|
branch of hepatic artery/ delineates the anteriolateral aspect of the pancreatic head
|
hepatic artery
|
|
|
lies post to the body of the panc
|
superior mesenteric artery
|
|
|
originates from abd. aorta close to umbilicus and is rarely seen on us
|
inferior mesenteric artery
|
|
|
The ___ is the only vessel posterior to the ivc.
|
right renal artery
|
|
|
The aorta enters the abdomen at the ____ and follows the curvature of the spine to bifurcate at __.
|
L1/ L4
|
|
|
If there is a separation between the aorta and the spine....
|
adenopathy, fibrosis, or hematoma should be ruled out.
|
|
|
Normal AP dimension of aortic lumen should be ...
|
<3cm
thoracic: 2.5cm diaphragm: 2.5-3cm mid-abdomen: 2-2.5 cm renals: 1.8 - 2 cm bifurcation: 1.5 - 1.7cm iliac: 1 - 1.3 cm |
|
|
increased aortic diameter greater than 3cm
|
aortic aneurysm/
aneurysm: 3-6 cm significant: >5cm surgical emergency: >6cm |
|
|
aortic aneurysm surgical emergency
|
>6cm
|
|
|
Aortic aneurysm survival rate of 1 year >6cm
|
50%
|
|
|
Aortic aneurysm risk of fatal rupture >7cm
|
75%
|
|
|
the 3 layers of the vessel are dilated to form aneurysm/ clinical: pulsatile abd mass, back paiin, most start below renal arteries and extend down to common iliacs
|
true aneurysm
|
|
|
Causes of true AAA
|
arteriosclerosis with hypertension, Marfan's syndrome (assoc with aneurysm of first portion that usually extends to affect the aortic valve leading to aortic insufficiency), infection (esp bacterial endocarditis), trauma, congenital, syphilis
|
|
|
gradual, spindle shaped dilatation of the vascular lumen, usually below renal arteries to bif
|
fusiform aneurysm
|
|
|
uniform dilatation within the long diameter producing lengthening of the expanded vessel
|
cylindrical aneurysm
|
|
|
localized, spherical outpouching of the vessel wall/ often contains thrombus/ least common type
|
Saccular aneurysm
|
|
|
small spherical aneurysm (1 - 1.5cm) usually within cerebral circulation (middle cerebral artery)
|
berry aneurysm
|
|
|
US findings of aneurysm
|
generally, vessel shows irregularities, tortuosities, and aortic wall calcification/ accurate AP diameter should be done
|
|
|
Intima (inner wall) of aorta dissects and pulls away from the other two walls/ hemorrhage occurs between walls/ 70% begin in ascending aorta/ may be caused by cystic aneurysms (Marfan's syndrome), hemorrhage of vasa vasorum, and spontaneous rupture of intima/ clinical: severe pain that mimics myocardial infarction/ site of pain may indicate site of aneurysm/ most severe in males with hypertension
|
Dissecting aneurysm
|
|
|
Us findings of dissecting aneurysm
|
demonstration of intimal flap which moves with pulsation/ differentiation between true and false lumen is difficult
|
|
|
blood leaked out of aorta (extravasation) and has been walled off so that the wall of the aneurysm is not the wall of the vessel/ trauma is most common cause/ us: mass adjacent to vessel, echogenicity is variable
|
False aneurysm
|
|
|
Rt of aorta and post to panc head/ extends from union of common iliacs to the right of L5 and travels cephalad then curves ant to enter RT ATRIUM
|
IVC
|
|
|
The IVC normally ___ on exhalation and ___ on inhalation or with Valsalva.
|
contracts/ expands
|
|
|
The IVC remains dilated with....
|
hepatomegaly, pulmonary hypertension, congestive heart disease, constrictive pericarditis, right artrial myxoma, atherosclerotic heart disease, and right ventricular failure
|
|
|
Most common tumor of the IVC
|
renal cell carcinoma/ usually on right due to close proximity/ venous tumors appear as intraluminal diffuse low amplitude echoes coming from lumen/ may extend to renal artery/ Wilm's tumor in children is similar to renal cell ca.
|
|
|
Causes of IVC displacement
|
-Mass in post caudate or rt lobe of liver
-Rt renal artery aneurysm -Lymphadenopathy -Tortuous aorta -Rt renal masses -Retroperitoneal liposarcoma -Leiomyosarcoma -Osteosarcoma -Rhabdomyosarcoma |
|
|
Left renal vein runs ___ to aorta and ___ to SMA
|
ant/ post
|
|
|
formed by the confluence of the smv and splenic vein in the region of the neck of the panc
|
Portal Vein
|
|
|
runs post to the pancreatic body and tail
|
splenic vein
|
|
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post to the body of the panc but ant to the uncinate process
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Superior Mesenteric Vein
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Two lobes connected by a narrow band called the isthmus
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thyroid
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Common carotid and internal jugular lie ___ and __ to margins of the thyroid.
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posterior and lateral
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____ lie ant to the lateral aspect of the thyroid defining the anterolateral borders.
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Strap muscles
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Thyroid measurements
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Lobe: 4-6 cm long, 1.5-2cm wide, 2-3cm height
Isthmus: 2 cm long, 2cm wide, 2-6 cm height |
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benign/ most common nodule in thyroid/ may be 5 to 30 mm/ varied appearance ranging from very echogenic to solid homogenous mass with few internal echoes (resembling a cyst)/ mostly presents as a solid mass, often with anechoic halo created by blood and edematous tissue compressing surrounding tissue
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adenomas
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usually developmental such as thyroglossal duct or brachial cleft/ no internal echoes, smooth walls, good sound transmission
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cysts
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well-defined cysts with irregular borders and multiple septations
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Hemmorhagic cysts (thyroid)
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diffuse thyroid enlargement and decreased echogenicity of lobes/ one lobe (usually right) may be larger
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Acute thyroiditis
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diffuse enlargement with decreased echogenicity (thyroid)
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subacute thyroiditis
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diffusely abnormal pattern, multiple small low-level echoes with a decrease in the overall echogenicity of the gland
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Hashimoto's thyroiditis
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enlarged in initial stages andmy have normal echo pattern/ in later stages may have multiple discrete nodules (50%), diffusely nodular in homogenous gland with no normal tissue (50%), nodules may display cystic degeneration and calcification
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Goiter
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diffusely enlarged lobes and isthmus, homogenous, as in normal gland or heterogenous/ only one lobe may enlarge
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Grave's disease
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80% are papillary/ 2mm to 10cm/ usually singular and hypoechoic/ cystic degeneration and specks of calcification may be present (thyroid)
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Carcinoma
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Sac divided by septum (median raphe)/ each space contains a testis, epididymis, portion of spermatic cord, and the ductus deferens/ ovoid and 4-5 cm long
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Scrotum
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septum that divides the scrotal sac
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median raphe
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innermost wall of scrotum is lined with this thin double layer of peritoneum/ this space may contain a small amount of fluid
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tunica vaginalis
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dense fibrous capsule that covers each testicle and enters the gland to form about 200 cone shaped lobules
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tunica albuginea
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Two functions of cone-shaped lobes formed by tunca albuginea
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1) spermatogenesis 2) secretion of testosterone by Leydig cells
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Secretions are carried though of lobules of the testis to the ___.
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rete testis
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Series of ducts that drain the rete testis, then pierce the tunica albuginea and entering the head of the epididymis
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efferent ductules
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Normal US appearance of testis
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homogenous medium level echogenicity/ post and sup, the epididymal head is distinguished due to its coarser more echogenic pattern/ the body is hard to see due to being post to testis and tail is rarely seen/ brightly echogenic band seen in sup aspect represents the mediastinum
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Trv of right mediastinum is seen in ____ position/ on left it is seen in _____ position.
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9 o'clock/ 3 o'clock
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Between the layers of the tunica vaginalis, ____ is normally seen.
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a small amount of fluid
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The testicular vein and artery of the ____, which runs along the post side of the testicle in region of epididymis are not normally seen.
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pampiniform plexus
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_____ scan used to compare both epididymis and testicles is the best way to find lesions.
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Transverse
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enlarged and hypoechoic epididymis/ gonorrhea, syphilis, mumps, and/or tuberculosis
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acute epididymitis
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thickened, echogenic, may have calcifications/ from uti or trauma
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chronic epididymitis
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cystic structure sup to the testis/ may be loculated with low level echoes/ cystic mass of epididymis containing spermatozoa
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spermatocele
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enlarged with decreased echogenicity/ abscess appears as localized area of inhomogenecity/ inflammation due to trauma, metastasis, mumps, or infection elsewhere in the body
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orchitis
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usually hypoechoic compared to the rest of the testis but well circumscribed/ most common malignant tumor of pts between 30 and 40 yrs/ elevated follicle stimulating hormone
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seminoma
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areas of hemorrhage and necrosis seen within this poorly circumscribed tumor/ can be benign or extremely malignant
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Teratoma
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enlarged due to edema with areas of infarcts and necrosis/ usually in prepubertal boys/ torsion of spermatic cord causes strangulation of blood supply to testis which causes edema
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Testicular torsion
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Intratesticular hemorrhage shows...
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echogenic areas
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numerous tortuous structures post to testis and extending superiorly past epidiymis/ may enlarge when pt is scanned upright/ enlargement of veins and spermatic cord usually on left side
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Varicocele
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accumulation of serous fluid between parietal and visceral layers of the tunica vaginalis/ usually from inflammation of epididymis or testis/ testis and epididymis surrounded by fluid
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Hydrocele
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peristalsis of mass and/or echogenic foci that represent air within the bowel loops will be seen/ herniation of abdominal contents into scrotal sac
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Inguinal hernia
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congenital condition in which the testicles fail to descend into the scrotum
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cryptochordism
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multiple small calcifications are scattered throughout the testicles/ microlithiasis has no clinical significance, except that it may be a precursor to a malignancy, such as seminoma
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Microlithiasis
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Dome shaped muscle separating the thorax from the abdominal cavity/ cover the sup border of the liver and spleen/ seen on us as curvilinear interface between the lungs and liver/spleen
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diaphragm
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between liver/spleen and diaphragm/ common site for abscess formation
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subphrenic space
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right and left fibromuscular bundles that attach to the lumbar vertebra L3 on the right and L1 on the left/ act as anchors to the diaphragm
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Crura of diaphragm
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Crura of diaphragm can be visualized ___ to aorta ablove level of the celiac and below the celiac the crura extends along the ____ aspects of the vertebral columns
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ant/ lateral
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Long, the entire right crus can be seen as...
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a solid hypoechoic long oriented structure immediately post and parallel to the ivc/ should not be confused with the right renal aartery which appears as a circular structure crossing ant to the crus and post to the ivc.
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The ___ is also noted as a hypoechoic long structure/ parallel to the aorta ending cephalically near the EGJ/ this is the anterior decussation of the crus
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The right crus
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Trv, the right crus is seen ___ to the ivc and extending between the ivc and the aorta until it reaches ant to the aorta/ The right adrenal and right kidney are ___ to the right crus.
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posterior/ posterolateral
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The left crus cannot...
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be seen long.
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Trv, the left crus can be seen as hypoechoic structure running ___ to the aorta/ It is closely assoc with the ___, ____, and ___.
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ant and lateral/ left adrenal, splenic vasculature/ EGJ
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abnormal collection of serous fluid in the peritoneum
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ascites
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anechoic/freely mobile ascites/ usually benign/ free floating in the abdomen
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Transudative
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internal echoes/ loculated ascites/ assoc with infection and malignancy
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Exudative
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With ascites, bowel matted or fixed to posterior abdomen wall is usually assoc with...
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malignancy.
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assoc with coagulated hematoma (trauma)
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nonmobile fluid
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Pathology Assoc with Ascites
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-congestive heart failure
-kidney failure -malignancy -pyogenic peritonitis -portal venous system obstruction -acute cholecystitis -postoperative -infection (inflammatory process) -liver failure/disease (end stage fatty liver or cirrhosis) -ruptured aneurysm -tuberculosis -obstruction of lymph nodes/vessels -ectopic gestation |
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Clinical presentation of ascites
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enlarged abdomen
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US findings of ascites: Accumulations occur (supine) in the following order
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1. inferior tip of right lobe of liver
2. superior portion - right flank 3. pelvic cul-de-sac 4. right paracolic gutter - lateral and ant to liver 5. Morrison's pouch |
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Ascites is found __ to diaphragm.
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inferior
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With gross massive ascites, extrahepatic portion of falciform ligament seen ____
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attaching liver to abdominal wall.
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Ascites may cause gb wall...
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to appear thickened.
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With ascites, you may see...
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patent umbilical vein
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Disproportional accululations in lesser sac suggests...
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adjacent pathology (i.e. acute pancreatitis, pancreatic cancer)
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circumscribed collection of pus (acute/chronic)/ cavity formed by liquefactive necrosis within solid tissue
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abcess
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Pathology assoc with abscesses
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-penetrating trauma (wounds)
-retained products of conception -chronic bladder disease -long standing hematoma -UTI -postsurgical procedures -PID -sepsis (blood borne pathogen) -postcholecystectomy (site of gb) -infected ascites with septa/debris -amebic abcess (densely echogenic) -GI tract: peptic ulcer perforation/ bowel spill during surgery (peritonitis) |
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Clinical presentation of abscesses
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pain, spiking fever, chills, elevated white blood cell count, solitary or multiple sites, tenderness
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abcess assoc with sepsis/ penetrating trauma to liver/ located within liver parenchyma/ differential diagnosis: solid tumor, usually round lesion with scattered internal echoes, variable through transmission
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Intrahepatic abscess
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abscess assoc with cholecystectomy/ located inferior to liver/ fluid collection ant to right kidney (Morrison's pouch)/ bed of GB (postcholecystectomy)
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subhepatic abscess
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abscess assoc with bacterial spill into peritoneum during surgical procedure, bowel rupture, peptic ulcer perforation, trauma/ located above liver, inf to diaphragm, transmission variables, gas (dirty shadowing)
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subphrenic abscess
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US findings assoc with abscess
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variable, complex, solid, cystic lesion with septa, debris, and scattered with echoes/ through transmission may be good/ mass-cyst with shaggy-thick irregular walls/ mass displacing surrounding structures/ complex mass with dirty gas shadowing from within/ presence of gas within a mass demonstrates an abscess
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Abscess differential diagnosis
|
necrosing tumor with fluid center (these usually have thicker walls and no gas)
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Abscess can be told from ascites by...
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moving patient/ ascites moves even if it is slightly.
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|
nonspecific reactions to underlying pulmonary or systemic disease such as cirrhosis/ obtaining fluid may help in diagnosis of cause
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Pleural effusion
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US appearance of pleural effusion
|
usually echo-free, wedge shaped area that lies posteriomedial to liver and post to diaphragm/ some may contain internal echoes sometimes indicating the presence of a neoplasm/ these echoes may be due to blood or pus (empyema) esp. when collection is loculated/ loculated effusions are not necessarily adjacent to diaphragm, but may be anywhere along chest wall
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effusions that lie between the lung and the diaphragm
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Subpulmonic
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Right sided effusions may be easily seen through...
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diaphragm and liver.
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Left effusions are more difficult to see supine, but are more easily seen ....
|
oblique through the spleen.
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