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Kidney and Bladder Kidney and Bladder USUS
Mike AckerleyMike Ackerley
KidneyKidney
Advantage over other modalities?Advantage over other modalities? What do you see normally?What do you see normally? What can we diagnose?What can we diagnose?
AdvantagesAdvantages Ease with which the extent of the disease Ease with which the extent of the disease
can be determined within the kidney for can be determined within the kidney for focal diseasefocal disease
Ease of assessment of renal pelvic or Ease of assessment of renal pelvic or ureteral dilation when fluid distendedureteral dilation when fluid distended
The location and relevance of renal The location and relevance of renal mineralization can also be assessedmineralization can also be assessed– When radiographically ID focal renal pelvic or When radiographically ID focal renal pelvic or
ureteral mineral opacities and the question of ureteral mineral opacities and the question of whether hydronephrosis is presentwhether hydronephrosis is present
Biopsy or fine-needle aspiration can be Biopsy or fine-needle aspiration can be expedited by ultrasonographic guidance, expedited by ultrasonographic guidance, improving the margin of safety as well. improving the margin of safety as well.
NormalsNormals Length in saggital planeLength in saggital plane
– Dog: variable with size of dogDog: variable with size of dog– Cat: 2.8 – 4.2 cmCat: 2.8 – 4.2 cm
CortexCortex– In dogs more bright than the liver, but less bright than In dogs more bright than the liver, but less bright than
spleenspleen– In cats variable, may be equal brightness to that of liver In cats variable, may be equal brightness to that of liver
and approach that of the spleenand approach that of the spleen Medullary PapillaeMedullary Papillae
– The renal medulla in dogs and cats is less echogenic The renal medulla in dogs and cats is less echogenic than the cortex. than the cortex.
Arcuate vessels Arcuate vessels Pelvic recess Pelvic recess Renal vessels Renal vessels Renal pelvis Renal pelvis
– If high resolution (7.5 – 10 MHz) transducer is usedIf high resolution (7.5 – 10 MHz) transducer is used
Capsule
Pelvis
Cortex
Medulla
PathologyPathology DistensionDistension
– Diuresis: bilaterally symmetrical and usually mildDiuresis: bilaterally symmetrical and usually mild– Hydronephrosis: pelvic dilation may become very gross, Hydronephrosis: pelvic dilation may become very gross,
with only a think rim of surrounding parenchymal tissue with only a think rim of surrounding parenchymal tissue (idiopathic, or secondary to ureteric obstruction)(idiopathic, or secondary to ureteric obstruction)
– Renal calculus: strongly reflective surface with distal Renal calculus: strongly reflective surface with distal acoustic shadowing also present.acoustic shadowing also present.
– Chronic pyelonephritis: the pelvis may dilate while the Chronic pyelonephritis: the pelvis may dilate while the diverticula remain smalldiverticula remain small
– Renal neoplasia: secondary dilation of the renal pelvis Renal neoplasia: secondary dilation of the renal pelvis and proximal ureter, or mechanical obstruction of the and proximal ureter, or mechanical obstruction of the pelvispelvis
– Ectopic ureter: due to stenosis of the ureter ending Ectopic ureter: due to stenosis of the ureter ending and/or ascending infectionand/or ascending infection
– Renal pelvic blood clot: following renal biopsy, Renal pelvic blood clot: following renal biopsy, coagulopathy, bleeding neoplasm, idiopathic renal coagulopathy, bleeding neoplasm, idiopathic renal hemorrhage, or traumahemorrhage, or trauma
HydronephrosisHydronephrosis
HydronephrosisHydronephrosis
PathologyPathology
Focal parenchymal abnormalitiesFocal parenchymal abnormalities– Well circumscribed, anechoic Well circumscribed, anechoic
parenchymal lesionparenchymal lesion– Hypoechoic parenchymal lesionHypoechoic parenchymal lesion– Hyperechoic parechymal lesionHyperechoic parechymal lesion– Heterogeneous/complex parenchymal Heterogeneous/complex parenchymal
lesionlesion– Medullary rim signMedullary rim sign– Acoustic shadowingAcoustic shadowing
PathologyPathology
Well circumscribed, anechoic Well circumscribed, anechoic parenchymal lesionparenchymal lesion– Thin smooth wall: single or multiple Thin smooth wall: single or multiple
cystscysts– Thick/irregular wall: Thick/irregular wall:
CystCyst HematomaHematoma AbscessAbscess neoplasianeoplasia
PathologyPathology
Hypoechoic parenchymal lesionHypoechoic parenchymal lesion– NeoplasiaNeoplasia
LymphosarcomaLymphosarcoma
Hyperechoic parenchymal lesionHyperechoic parenchymal lesion– NeoplasiaNeoplasia
11º: chondrosarcoma, hemangiomaº: chondrosarcoma, hemangioma Metastatic: hemangiosarcoma, thyroid Metastatic: hemangiosarcoma, thyroid
adenocarcinomaadenocarcinoma
PathologyPathology
Heterogeneous/ Complex Heterogeneous/ Complex parenchymal lesionparenchymal lesion– NeoplasiaNeoplasia– AbscessAbscess– HematomaHematoma– GranulomaGranuloma– Acute infarctAcute infarct– Polycystic diseasePolycystic disease
Polycystic KidneysPolycystic Kidneys
Renal InfarctRenal Infarct
PathologyPathology
Medullary rim signMedullary rim sign– Normal in catsNormal in cats– NephrocalcinosisNephrocalcinosis– Ethylene glycol toxicityEthylene glycol toxicity– Chronic interstitial nephritisChronic interstitial nephritis– Cats - FIPCats - FIP
PathologyPathology
Acoustic ShadowingAcoustic Shadowing– Deep to pelvic fatDeep to pelvic fat– Renal calculusRenal calculus
NephrolithNephrolith
PathologyPathology
Diffuse parenchymal abnormalitiesDiffuse parenchymal abnormalities– Increased cortical echogenicityIncreased cortical echogenicity– Decreased corticomedullary definitionDecreased corticomedullary definition
PathologyPathology Increased cortical echogenicityIncreased cortical echogenicity
– Normal catsNormal cats– Inflammatory diseaseInflammatory disease
GlomerulonephritisGlomerulonephritis Interstitial nephritisInterstitial nephritis FIPFIP
– Acute tubular necrosis/nephrosis (toxins)Acute tubular necrosis/nephrosis (toxins)– Renal dysplasiaRenal dysplasia– NephrocalcinosisNephrocalcinosis– NeoplasiaNeoplasia
Diffuse lymphosarcomaDiffuse lymphosarcoma
PathologyPathology
Decreased corticomedullary Decreased corticomedullary definitiondefinition– End-stage kidneysEnd-stage kidneys– Multiple small cystsMultiple small cysts
What can we diagnose?What can we diagnose?
InfarctsInfarcts Cysts/Abscess/HematomaCysts/Abscess/Hematoma Renal calculusRenal calculus Big neoplasiaBig neoplasia Pelvic DilationPelvic Dilation
BladderBladder
Advantage over other modalities?Advantage over other modalities? What do you see normally?What do you see normally? What can we diagnose?What can we diagnose?
AdvantagesAdvantages
Able to evaluate bladder wall Able to evaluate bladder wall thicknessthickness
Able to visualize non-radiopaque Able to visualize non-radiopaque stones/cyrstals (C U)stones/cyrstals (C U)
CystocentesisCystocentesis
NormalsNormals
Best when bladder moderately full Ovoid in Best when bladder moderately full Ovoid in shape, with slight elongation caudally at shape, with slight elongation caudally at trigonetrigone
Don’t normally see uretersDon’t normally see ureters Three layers (Three layers (∆∆ with size) with size)
– Mucosa: HyperechoicMucosa: Hyperechoic– Muscular: Hypo-Muscular: Hypo-– Serosal: Hyper-Serosal: Hyper-
Normal wall thickness (cat): 1.7 mm Normal wall thickness (cat): 1.7 mm ± 0.56± 0.56 Normal wall thickness (dog): 1.6 mmNormal wall thickness (dog): 1.6 mm
PathologyPathology
CalculiCalculi– acoustic shadows are observed deep to acoustic shadows are observed deep to
calculi that exceed the diameter of the calculi that exceed the diameter of the beam.beam.
– echogenicity and acoustic shadow echogenicity and acoustic shadow generation are independent of chemical generation are independent of chemical composition (doesn’t matter struvite VS composition (doesn’t matter struvite VS cystine)cystine)
– Ballottement doesn’t move calculi, but let Ballottement doesn’t move calculi, but let animal stand and calculi will fall. animal stand and calculi will fall. Helps differentiate from mineralized bladder wall Helps differentiate from mineralized bladder wall
and colonic shadowingand colonic shadowing
Cystic CalculiCystic Calculi
PathologyPathology
Gas bubblesGas bubbles– Will float to the top, to differentiate from Will float to the top, to differentiate from
calculicalculi Blood clotsBlood clots
– non-shadowingnon-shadowing Crystalline sedimentCrystalline sediment
– Vigorous ballottementVigorous ballottement– Swirling pattern when standingSwirling pattern when standing
Blood ClotBlood Clot
PathologyPathology
Mural changesMural changes– CystitisCystitis– NeoplasiaNeoplasia
PathologyPathology
CystitisCystitis– Chronic cystitis results in diffuse Chronic cystitis results in diffuse
thickening of the bladder wall thickening of the bladder wall – bladder wall becomes abnormally bladder wall becomes abnormally
hypoechoic, and the normal layering hypoechoic, and the normal layering becomes less parallel becomes less parallel
– normal sonographic appearance of the normal sonographic appearance of the bladder does not rule out the presence of bladder does not rule out the presence of mild or acute cystitis or idiopathic lower mild or acute cystitis or idiopathic lower urinary tract disease in cats urinary tract disease in cats
Chronic CystitisChronic Cystitis
PathologyPathology
NeoplasiaNeoplasia– TCC: irregularly shaped, broad-based, TCC: irregularly shaped, broad-based,
hypoechoic masses protruding into the hypoechoic masses protruding into the bladder lumen bladder lumen
– echo pattern depends on if if fibrosis, echo pattern depends on if if fibrosis, mineralization, and necrosis have mineralization, and necrosis have developed developed
– An abrupt transition often observed An abrupt transition often observed between neoplastic mass & adjacent between neoplastic mass & adjacent bladder wall bladder wall
NeoplasiaNeoplasia
PathologyPathology Sonographic appearance of polypoid cystitis, Sonographic appearance of polypoid cystitis,
adherent blood clots, and mural hematomas is adherent blood clots, and mural hematomas is similar to that of neoplasia similar to that of neoplasia
Observation of ureter dilation adjacent to the Observation of ureter dilation adjacent to the bladder wall mass & focal medial iliac bladder wall mass & focal medial iliac lymphadenopathy tends to support the lymphadenopathy tends to support the diagnosis of neoplasiadiagnosis of neoplasia
Need aspirate, but must weigh that benefit Need aspirate, but must weigh that benefit against the possibility of seeding the needle against the possibility of seeding the needle tract with tumor cells tract with tumor cells
Traumatic catheterization is useful to retrieve Traumatic catheterization is useful to retrieve cells from the masscells from the mass
What can we diagnose?What can we diagnose?
Crystalline sedimentCrystalline sediment CalculiCalculi Blood clots?Blood clots? GasGas