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DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Sonography of the Gallbladder CRT04210 · Ultrasound Imaging START READING NOTES Study Sonography of the Gallbladder using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic SONOGRAPHY OF THE GALLBLADDER GALLBLADDER MEASUREMENTS NON-DISTENDED GALLBLADDER INADEQUATE FAST NON-FASTING GALLBLADDER ANATOMY OF THE GALLBLADDER GALLBLADDER FOLDS GALLBLADDER SEPTATIONS ANATOMIC VARIANT: THE PHRYGIAN CAP THE GALLBLADDER NECK CYSTIC DUCT CYSTIC DUCT AND BILE DUCT GALLSTONES SMALL CALCULI FALSE GALLSTONES CALCULI OR GAS? CHECK THE CYSTIC DUCT Summary word slide SHADOW PRODUCTION EXPERIMENT WITH GALLSTONE AND FOCAL ZONE SHADOWS NEAR GALLBLADDER CRITICAL ANGLE SHADOWS FROM THE GALLBLADDER SHADOWS NEAR THE GALLBLADDER NON-VISUALIZATION OF THE GALLBLADDER NON-VISUALIZATION OF GB FINDING THE NON-VIZ GALLBLADDER DOUBLE ARC SHADOW SIGN FINDING THE NON-VIZUALIZED GALLBLADDER BOWEL GAS NEAR THE GALLBLADDER SHADOWS NON-SHADOWING ECHOGENIC FOCI IN GB GALLBLADDER POLYPS CHOLESTEROL POLYPS GALLBLADDER MASS SLUDGE SLUDGE AND OBSTRUCTING STONE HEPATIZATION OF THE GALLBLADDER SLUDGE OR LIVER MASS? TUMEFACTIVE SLUDGE GB WALL THICKNESS THICKENENED GALLBLADDER WALL DIFFUSE GB WALL THICKENING GALLBLADDER AND ASCITES IMPACTED GALLSTONE ACUTE CHOLECYSTITIS COMPLICATIONS OF ACUTE CHOLECYSTITIS GANGRENOUS CHOLECYSTITIS PERICHOLECYSTIC COLLECTIONS EMPHYSEMATOUS CHOLECYSTITIS Gallbladders affected by emphysematous cholecystitis are five times more likely to perforate. PORCELAIN GALLBLADDER ACALCULOUS CHOLECYSTITIS HYPERPLASTIC CHOLECYSTOSES ADENOMYOMATOSIS “COMET TAIL” ARTIFACT SCLEROSING CHOLANGITIS GALLBLADDER CARCINOMA SLUDGE AND GALLSTONES DOPPLER FINDINGS IN GALLBLADDER CARCINOMA GB CARCINOMA GALLBLADDER METASTASES SONOGRAPHY OF THE GALLBLADDER SONOGRAPHY OF THE GALLBLADDER Since ultrasound is the primary imaging modality in the evaluation of the gallbladder, it is a “bread and butter” type of study. In patients with right upper quadrant symptoms, ultrasound not only evaluates the gallbladder, but adjacent structures such as liver, bile ducts, pancreas, right kidney and great vessels. SONOGRAPHY OF THE GALLBLADDER The gallbladder is an excellent organ to image by sonography, because it is a fluid-filled structure with no internal echoes. It is visualized as an anechoic pear-shaped structure outlined by a smooth thin wall. Any abnormality within the gallbladder becomes outlined by the bile and is easily seen. SONOGRAPHY OF THE GALLBLADDER As with any structure imaged by ultrasound, it must be examined in two perpendicular (orthogonal) planes in order to be able to reconstruct a proper 3-dimensional mental picture of the object and to avoid artifacts SONOGRAPHY OF THE GALLBLADDER This is a transverse section of the gallbladder. Based on its purely fluid content, the gallbladder is used as a standard of reference for fluid-containing structures in the right upper quadrant. Cysts in the liver and right kidney can be compared to the gallbladder, as long as they are at similar depths. SONOGRAPHY OF THE GALLBLADDER If the echogenicity of their contents is the same as that of the gallbladder, then they are simple cysts. If their contents is more echogenic, then the cysts contain true echoes and are not simple cysts. One should be mindful of the fact that it is possible to have a congenital duplication of the gallbladder, which is rare. Also there are structures that can mimic the gallbladder. These include omental cysts, enteric duplication cysts, choledochal cysts, aneurysms, abscesses. GALLBLADDER MEASUREMENTS The size of the gallbladder is quite variable, so that it is not a very useful indicator of disease. In general the normal gallbladder is < 5cm transversely, and < 10cm longitudinally. A gallbladder larger than this is usually abnormally enlarged, such as a Courvoisier gallbladder, which enlarges on the basis of distal extrahepatic biliary duct obstruction. NON-DISTENDED GALLBLADDER A post-prandial gallbladder cannot be differentiated from an abnormal diseased, contracted gallbladder. An empty gallbladder is difficult to scan and results are unreliable. The gallbladder should always be examined in the fasting state, when it is maximally distended. NON-DISTENDED GALLBLADDER This is accomplished by an overnight fast, usually starting by midnight before the scan. The ultrasound is usually performed in the morning, when the bowel is quiet and abdominal gas is at a minimum. If the patient has not had a proper overnight fast, fasting for approximately 8 hours is considered adequate. INADEQUATE FAST An inadequate fast may result in slight gallbladder wall contraction and mild wall thickening, which in turn may lead to incorrect diagnosis. NON-FASTING GALLBLADDER One should avoid the temptation of scanning the gallbladder without a proper fast. Even if gallstones are visualized, the complete diagnosis may be compromised because of suboptimal visualization, as in this case of a non-fasting patient with right upper quadrant pain. NON-FASTING GALLBLADDER Two gallstones are seen in the fundus (short arrows), but the potentially obstructing stone (long arrow) in the gallbladder neck was not seen until the patient underwent a proper fast. In retrospect the stone was present on the original image shown here (long arrow). ANATOMY OF THE GALLBLADDER The fundus is the rounded curved end of the gallbladder. The body is the central portion, while the neck is the tapered part. The gallbladder is connected to the biliary system by the cystic duct, which contains numerous folds called valves of Heister. Stones are easily trapped within these folds. ANATOMY OF THE GALLBLADDER After the cystic duct joins the common hepatic duct, the extrahepatic bile duct is called the common bile duct. GB TECHNIQUE GALLBLADDER FOLDS Folds within the gallbladders are non-pathologic. A particular fold, called the junctional fold, normally occurs in the mid to proximal end of the gallbladder, closer to the gallbladder neck (arrow). This fold may cause an acoustical shadow due to an artifact and should not be mistaken for a stone or calcification. GALLBLADDER SEPTATIONS Rarely gallbladders contain true septations. These are congenital in origin and are of no clinical significance. A gallbladder folded back upon itself may simulate septations. In fact, sometimes during different degrees of inspiration and expiration, one can observe the gallbladder folding and unfolding. This is of no known clinical consequence. ANATOMIC VARIANT: THE PHRYGIAN CAP When the fundus of the gallbladder folds over on itself, it creates the appearance of a cap, called the “phrygian cap” (arrow). Occurring in 4% of the population, this

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Sonography In Hiv CRT04210 · Ultrasound Imaging START READING NOTES Study Sonography In Hiv using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic Sonography In Hiv Sonography of Abdominal Lymph Nodes and SONOGRAPHIC FINDINGS The parenchyma of the spleen is homogenous, with a fine, velvet-like echo pattern. Lymph nodes larger than 1.5 to 2 cm are considered pathological in an adult with HIV. Splenic lesions Sonography of the Heart Sonography of the Renal HIVAN Sonography of the liver TB are found in the lymph nodes and spleen . TB of the bowel TB of the pancreas Diagnostic ultrasound 5th edition by Carol Rumack 2018 SONOGRAPHY IN HIV/TB Sonography In Hiv The Focused Assessment with Sonography for HIV/TB (FASH) protocol, has been developed to help diagnose the extrapulmonary and disseminated forms of tuberculosis (TB) that are frequently seen in patients who have the human immunodeficiency virus (HIV) The main objectives of the FASH ultrasound exam are to detect effusions that may suggest pleural, pericardial, or abdominal TB; enlarged abdominal lymph nodes; and focal lesions in the spleen, which may suggest miliary or disseminated TB encountered in severely immunocompromised patients. Sonography of Abdominal Lymph Nodes and Spleen: The FASH Protocol In recent years, ultrasound has proved to be a useful tool in evaluating HIV patients suspected of co-infection with EPTB. Detection of abdominal lymphadenopathy and splenic microabscesses are typical findings suggestive of abdominal TB. SONOGRAPHIC FINDINGS Normal lymph nodes are small round or oval structures whose size ranges from a few millimetres up to 1 cm; they are usually not visible in the abdomen unless they are enlarged. The parietal nodes are located in the retroperitoneum, close to the large vessels . These nodes are a continuation of the lymphatics, which drain from the lower half of the body. The visceral lymph nodes are located at the root of the mesentery as well as in the portal area. They drain lymphatics from the bowels, pancreas, and hepatobiliary system. Sonography In Hiv Although normal-sized abdominal lymph nodes cannot be detected through ultrasound, superficial lymph nodes (such as those in the axilla or the inguinal region) may be visible, especially when using high-frequency linear transducers. When visible, they appear as round, hypoechoic structures surrounded by a connective tissue capsule, and often show an echogenic center (hilus fat sign) due to central fat and connective tissue The parenchyma of the spleen is homogenous, with a fine, velvet-like echo pattern. It resembles the liver, but is often slightly less echogenic. Lobulation with a variable outer contour of the spleen can be seen as a normal variant. Accessory spleens are often located in the hilar region of the spleen, along the gastrosplenic ligament, or at the caudal pole of the organ. They have the same echo pattern as the spleen itself, are often round, and are usually small (< 2.5 cm). Lymph nodes larger than 1.5 to 2 cm are considered pathological in an adult with HIV. Pathological enlarged nodes in TB are often hypoechoic and rounded. The markedly low echogenicity is due to loss of internal structures caused by caseous necrosis. The lymphadenopathy may be discrete, or nodes might be conglomerated into a larger mass. On rare occasions, tuberculous lymph nodes may appear hyperechoic. Lymph node masses may cause obstruction of ureters, the pancreas, and biliary tract, or (less often) the digestive system. Splenic lesions In patients with disseminated TB, splenic microabscesses may appear as multiple small hypoechoic lesions a few millimetres in size. These microabscesses are distributed throughout the spleen and represent miliary seeding. Again, as the transducer fans through the spleen, they will appear to be blinking. Sonography of the Heart Ultrasound is an excellent tool for evaluating the aetiology of dyspnoea, peripheral oedema, and the source of cardiomegaly seen on a CXR. Congestive heart failure (CHF) is probably the most common cause of these symptoms and findings; however, there are also other causes, which are treated differently. Sonography In Hiv In an HIV-prevalent tropical setting, common cardiac causes of dyspnoea and oedema are pericardial effusion with tamponade (most often due to TB), dilated cardiomyopathy (for example, peripartum or HIV-cardiomyopathy), post-rheumatic heart disease (causing mitral valve disease in particular), cor pulmonale, and hypertensive heart disease. Sonography of the Renal Renal and urinary tract disease is common in adults and children throughout all continents. Numerous protocols for point-of-care renal and bladder ultrasound examination have been developed, especially for patients with flank pain or abdominal pain and urinary symptoms. These protocols focus on identifying hydronephrosis, bladder distension, and stone disease. Sonography In Hiv The aetiologic spectrum leading to urinary tract obstruction is broad: common causes of urinary tract obstruction in resource-limited settings include external compression of the ureters from lymphadenopathy due to malignancy, TB, or other masses; occlusion of the ureters from stone disease; and chronic infections, such as urinary schistosomiasis. Sonography In Hiv Calcification at any level along the urinary tract (including the kidneys) may be a consequence of TB, arising either from concomitant metabolic conditions or from the side effects of drugs, such as the protease inhibitor atazanavir HIVAN In ultrasound examinations of patients with HIV, normal-sized kidneys with hyperechoic cortex are often seen. The pyramids may seem slightly hypoechoic in comparison. These changes may be found even when the results of renal function tests are normal. Focal segmental glomerulosclerosis is the most frequent underlying pathology of HIVAN. The morphology is non-specific; it can also be found in other renal diseases, such as diabetic glomerulosclerosis and other forms of chronic glomerulonephritis. Sonography of the liver Involvement of the liver in TB is common (up to 80% in autopsies of PTB). On histological analysis, multiple hepatic granulomata are often present. Clinical manifestations of this involvement are less frequently seen. Elevations of alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) are the most frequent laboratory findings, though these are non-specific. Hypo- and hyperglobulinemia are common, although these are more

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Sonographic Terminology CRT04210 · Ultrasound Imaging START READING NOTES Study Sonographic Terminology using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic CUHAS Ultrasound image Echogenicity Echogenicity of a structure is described relative to surrounding or adjacent tissue Due to sickle cell nephropathy, Right kidney Hypoechoic:spleen Liver Sonographic Terminology Anechoic Isoechoic-The same intensity Another example of an oval-shaped solid isoechoic mass adjacent to the lower pole of the spleen. ECHOTEXTURE Homogeneous Heterogeneous IMAGE ARTIFACTS Useful image artifacts Posterior acoustic enhancement False posterior acoustic enhancement ATTENUATION This pelvic mass causing sound attenuation and shadowing is due to a large dense posterior myoma in the uterus. POSTERIOR ACOUSTIC SHADOWING Complete lack of acoustical & anatomical information in the area of shadowing Types of shadows Summary;types of echoes sharp/clean/black shadow The arrows point to a gray The arrow points to a gray REVERBERATION TYPES OF MASSES SONOGRAPHIC FEATURES:CYSTIC MASSES SONOGRAPHIC FEATURES:SOLID MASSES COMPLEX MASSES An example of a complex, predominantly cystic mass. Predominantly cystic Predominantly solid Unusual sonographic features:Echogenic cyst SONOGRAPHIC FEATURES OF A MASS This is a lobulated, anechoic liver mass with suggestion of a few internal echoes. CUHAS SONOGRAPHIC TERMINOLOGY Ultrasound image Composed of a variety of bright dots on a film that vary in intensity according to the strength of returning echoes from tissues or structures in the body Provides anatomic and non-anatomic information Echogenicity Brightness of the dots generated by returning echoes from the body Intensity of echoes reflected by tissues or structures from inside the body Echogenicity of a structure is described relative to surrounding or adjacent tissue Echogenicity Echogenicity Hyperechoic High intensity echoes — Moderate intensity Hypoechoic Low intensity echoes Anechoic No internal echoes Isoechoic Same intensity echoes Echogenicity of a structure is described relative to surrounding or adjacent tissue Hyperechoic High intensity echoes The hyperechoic solid mass within this spleen represents a focal deposit of lymphoma. Due to sickle cell nephropathy, the cortex of this kidney is hyperechoic relative to the adjacent liver parenchyma, which, due to its size, becomes the standard of comparison for most adjacent parenchymal organs. Right kidney The round mass in this kidney is relatively hyperechoic when compared to the adjacent renal cortex. The echogenicity of a mass is compared to its organ of origin. Although the tumor itself is not very bright in echogenicity, it contains tiny hyperechoic foci due to microcalcifications scattered throughout the mass, which is a renal cell carcinoma (hypernephroma). Hypoechoic:spleen This is an image the spleen, which is of moderate echogenicity, and contains several hypoechoic masses (arrows) representing deposits of lymphoma.The masses are hypoechoic relative to surrounding normal splenic parenchyma. The relative echogenicity of a mass is compared to the echogenicity of the organ to which it relates. Liver A large lobulated hypoechoic masses of low echogenicity represent metastatic deposits within the liver . The masses are hypoechoic relative to adjacent normal liver parenchyma. M Sonographic Terminology In this transverse scan of the scrotum, the normal right (R) testis is moderately echogenic, while the left (L) is enlarged and hypoechoic due to testicular cancer. The standard for comparison in this case is the contralateral normal-sized (right) testis. L Anechoic Anechoic means without echoes or having no internal echoes. Simple fluid generally has no internal reflections and is anechoic. Isoechoic-The same intensity The dominant mass in this picture is an enlarged spleen. Adjacent to the spleen are two small round isoechoic masses representing splenules or accessory spleens. They are of the same echogenicity as the spleen itself. Another example of an oval-shaped solid isoechoic mass adjacent to the lower pole of the spleen. The mass is of the same echogenicity as the spleen. ECHOTEXTURE Homogeneous -uniform echoes Heterogeneous -non-uniform echoes Echotexture refers to the uniformity of echoes within a mass. Echotexture can be homogeneous, in which case the echoes are uniform, or inhomogeneous, in which case the echoes are non-uniform. Homogeneous Uniform echoes Fine, smooth texture Includes slightly coarse texture The liver in this patient with chronic hepatitis has a very homogeneous echotexture. Sonographic Terminology This mass is almost entirely filled with low-level homogeneous internal echoes, which are very uniform in their appearance and distribution. The straight line in the mass is due to an interface of fluid and blood in an ovarian endometrioma, which is shown on this sagittal transvaginal scan. Heterogeneous Non-uniform echoes Irregular texture Sonographic Terminology This liver is very heterogeneous in its echotexture due to multiple small hyperechoic rounded masses scattered throughout the parenchyma due to a myriad of small hemangiomas in this case of diffuse hemangiomatosis. Sonographic Terminology This heterogeneous mass with echoes of variable intensities: high, medium and none, represents the internal contents of a hemorrhagic ovarian cyst. IMAGE ARTIFACTS Improper representation of structures on an image due to certain characteristics of the imaging technique Non-anatomic information derived from sonography Sometimes useful for proper image interpretation and diagnosis Other times a hindrance Useful image artifacts Posterior enhancement Attenuation Acoustical shadowing Reverberation Posterior acoustic enhancement Increased intensity in echoes from reflectors behind a structure that weakly attenuates sound Classical feature of fluid -usually signifies fluid Other terms, Increased sound transmission “Flashlight” effect Sonographic Terminology This round anechoic liver cyst causes posterior enhancement of sound, manifested by increased echogenicity emanating from the entire posterior border of the cyst. The “veil” of increased echogenicity makes the underlying liver parenchyma look brighter than normal. False posterior acoustic enhancement The increased echogenicity (arrow) behind this myoma (M) is not due to posterior enhancement, but rather to reverberations from bowel or bone posterior to the mass. The increased echogenicity does not come from the entire back border of the mass and may extend beyond its border. The echogenicity is not uniform and fades with depth. M ATTENUATION Decrease in amplitude and intensity of sound waves passing through a medium Weakening of echoes (both penetrating and returning) Due to absorption, scattering, and beam divergence Caused by a solid mass This pelvic mass

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Sonographic CRT04210 · Ultrasound Imaging START READING NOTES Study Sonographic using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic CUHAS PATIENT POSITIONS supine Left decubitus and Sitting Sitting CUHAS SONOGRAPHIC ABDOMINAL TRANSDUCER POSITIONS PATIENT POSITIONS supine:midline position supine: arms above head midline sagittal supine sub costal:mid clavicular line (Rt. sagittal) subxiphoid:Transverse supine Trnsverse:Tilted slightly cephalad Transverse supine Right coronal,slightly obliqued Right coronal supine Left coronal,obliqued Left flank intercostal transverse Left decubitus and Sitting Right sagittal, slightly obliqued medially Right sagittal Sitting Sagittal:Inclined posteriorly Transverse:Inclined posteriorly ← PREVIOUS TOPICNEXT TOPIC →VIEW ALL MODULE NOTESVIEW SEMESTER NOTESVIEW ALL LEVEL NOTESALL DIAGNOSTIC RADIOLOGY NOTES Need These Notes as PDF? Need a clean, well-formatted PDF copy for offline study, revision or printing? Request the complete notes directly through WhatsApp. GET WELL-FORMATTED PDF NOTES

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Renal Sonography CRT04210 · Ultrasound Imaging START READING NOTES Study Renal Sonography using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic URINARY SYSTEM -SONOGRAPHY EMBRYOLOGY PHYSIOLOGY Functions of the Urinary System Renal Anatomical Variants 1.Agenesis SONOGRAPHIC FINDINGS Cake kidney Crossed fused ectopia Duplication Horseshoe kidney Pelvic kidney Renal ptosis Sono Abnormal mobility of a kidney Sigmoid kidney Thoracic kidney Retrocaval Ureter SIZE Child Infant TECHNIQUE • Spatial compounding can be used to improve visualization of structures posterior to a highly attenuating structure. Prevoid and postvoid bladder volumes may be included. Simple cyst Sono-findings Parapelvic cyst Peripelvic cyst Adult polycystic kidney disease Multicystic dysplasia Renal abscess Acute tubular necrosis (ATN) Chronic renal failure Glomerulonephritis Pyelonephritis Pyonephrosis Emphysematous Pyelitis Tuberculosis Three parasitic infections of the urinary tract: Schistosomiasis Hydronephrosis(rerfe to previous lectures) Grade 1 Ddx Hydroureter Nephrolithiasis-previous lectures Adenoma Angiomyolipoma Lipoma Medullary sponge kidney Mesoblastic nephroma Nephrocalcinosis Renal sinus lipomatosis Renal cell carcinoma Clinical findings Wilms’ tumor (nephroblastoma) Metastases Infarction Renal artery stenosis Renal artery aneurysm Doubling of the normal artery Arteriovenous fistula sono Renal vein thrombosis Renal vein tumor extension Bladder exstrophy Bladder diverticulum Bladder ureterocele Urachal sinus Bladder calculus Cystitis Bladder sludge Bladder malignancy Bladder polyp Bladder Fistulas URINARY SYSTEM -SONOGRAPHY MDU EMBRYOLOGY Discuss the embryology Development of the Kidneys and Ureter Development of the Bladder Development of the Urethra PHYSIOLOGY The nephron is the basic functional unit of the kidney. Each kidney contains over one million nephrons. Functions of the Urinary System Produces urine and erythropoietin. Influences blood pressure, blood volume, and intake or excretion of salt and water through the renin–angiotensin system. Regulates serum electrolytes. Regulates acid–base balance. RENAL ANATOMY(REFERS TO PREVIOUS LECTURES) Renal Vasculature(REFERS TO PREVIOUS LECTURES) Pause Renal Anatomical Variants Refers to previous lectures Hypertrophied column of Bertin Congenital Anomalies 1.Agenesis Absence of the kidney(s) Unilateral or bilateral Clinical findings Asymptomatic when unilateral Fatal when bilateral Associated with genital anomalies SONOGRAPHIC FINDINGS Empty renal fossa(e) Large, contralateral kidney Ddx Pelvic kidney Surgical removal Crossed fused ectopia Cake kidney Variant of a horseshoe kidney Found in the pelvis Clinical findings Asymptomatic Pelvic mass SONOGRAPHIC FINDINGS Fusion of entire medial aspect of both kidneys Anterior rotation of the renal pelvis Ddx Crossed fused ectopia Renal mass Crossed fused ectopia Both kidneys are fused in the same quadrant Two separate collecting systems Two normally located adrenal glands Clinical findings Asymptomatic Abdominal mass SONOGRAPHIC FINDINGS One single, large kidney Irregular contour Inferior pole is directed medially Ddx Renal mass Cake kidney Sigmoid kidney Duplication Two distinct collecting systems May involve kidney, ureter, and/or renal pelvis May be partial or complete Clinical findings Asymptomatic Flank pain SONOGRAPHIC FINDINGS Increase in renal length Two distinct collecting systems The superior system is most likely to obstruct Ddx Hypertrophied column of Bertin Renal mass Horseshoe kidney Fusion of the kidneys usually at the inferior poles Connected by an isthmus of functioning parenchyma or nonfunctioning fibrotic tissue Anterior rotation of the renal pelves and ureters Separate collecting systems Most common form of renal fusion Clinical findings Asymptomatic Pulsatile abdominal mass SONOGRAPHIC FINDINGS Bilateral low-lying medially placed kidneys with partial or complete fusion of the inferior poles “Dipping effect” of both inferior poles Isthmus of tissue demonstrated anterior to the abdominal aorta Isthmus echo texture is similar to the renal cortex Ddx Renal mass Lymphadenopathy Bowel Retroperitoneal tumor Pelvic kidney Failure to ascend with development Associated with a short ureter Renal artery and vein are located more inferior Renal vein drains directly into the inferior vena cava (IVC) Asymptomatic Pelvic pain SONOGRAPHIC FINDINGS Elongated core of echogenic tissue surrounded by less echogenic parenchyma Located in the lower abdomen or pelvis Empty ipsilateral renal fossa Lies in an oblique plane Ddx Bowel Pelvic mass Renal ptosis Unusual mobile kidney that descends from the normal position toward the pelvis Poor support structures Clinical findings Asymptomatic Sono Abnormal mobility of a kidney Ddx Pelvic kidney Horseshoe kidney note Nephroptosis is a rare condition where a person's kidney drops down into the pelvis when they stand up. Sigmoid kidney Variant of the horseshoe kidney clinical findings Asymptomatic Abdominal mass SONOGRAPHIC FINDINGS Superior pole of one kidney is fused with the inferior pole of the contralateral kidney S-shaped Ddx Bowel Abdominal mass Thoracic kidney migrates into the chest through a herniation in the diaphragm Rare finding Clinical findings Chest mass SONOGRAPHIC FINDINGS Elongated core of echogenic tissue surrounded by less echogenic parenchyma Located in the chest Not easily demonstrated on ultrasound Ddx Chest mass Hypoplasia Ureteropelvic Junction Obstruction Congenital Megacalyces Congenital Megaureter Retrocaval Ureter Circumcaval ureter, also known as retrocaval ureter, is a term used to describe an abnormal course of a ureter that encircles the inferior vena cava. SIZE Adult 9.0 to 12.0 cm in length. 4.0 to 5.0 cm in width. 2.5 to 3.0 cm in height. Minimum of 1 cm in cortical thickness. Child 7.0 to 8.0 cm in length. Formula(expected size) Infant 5.0 to 6.0 cm in length. Formula (expected size) Normal Sonographic Appearance—Adult Kidney Normal Sonographic- Pediatric Kidney TECHNIQUE Examination Technique and Imaging Optimization Use the highest-frequency abdominal transducer possible to obtain optimal resolution for penetration depth. Place gain settings to display the normal adult renal cortex as moderate or low-level echogenicity and the renal sinus as the most echogenic with adjustments to reduce echoes within the vessels. Position the focal zone(s) at or below the region of interest. Sufficient imaging depth to visualize structures posterior to the region of interest. Harmonic imaging and decreasing the compression (dynamic range) can be used to reduce artifactual echoes within anechoic structures and improve prominence of posterior acoustic shadowing. • Spatial compounding can be used to improve visualization of structures posterior to a highly attenuating structure. Evaluation and documentation of the superior, inferior, medial, and lateral aspects of each kidney in the coronal or sagittal plane. Evaluation and documentation of the superior pole, renal hilum, and inferior pole of each kidney

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Molar Pregnancy CRT04210 · Ultrasound Imaging START READING NOTES Study Molar Pregnancy using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic Molar Pregnancy GENERAL CONSIDERATION Molar pregnancy-Types Complete Mole Partial mole Natural history of hydatidiform mole Signs and Symptoms Diagnosis Physical exam demonstrates:- Ultrasound is a reliable and sensitive technique. Molar Pregnancy: US Findings Hydatidiform mole: Partial Mole Theca lutein cysts Malignant Mole Follow-up following molar pregnancy Molar Pregnancy Molar Pregnancy Also known as Gestational Trophoblastic Disease(GTD) Molar pregnancy is a form of abnormal pregnancy Results from a defective fertilization process Characterized by vesicular swelling of placental tissue hence appearing like vesicles. GENERAL CONSIDERATION GTD is a complex condition that results from process of reproduction It is a neoplastic process that span from a locally generative process to a highly malignant neoplasm. It includes a tumor spectrum of :- Hydatidiform mole Invasive mole Choriocarcinoma A unique tumor in that:First and only disseminated solid tumor that has proved to be highly sensitive to chemotherapy. Molar pregnancy-Types Hydatidiform mole (benign) Complete Hydatidiform mole Partial Hydatidiform mole Major difference between the two types is that partial moles contain fetal/embryonic tissue and complete moles do not. Malignant Mole(Choriocarcinoma) Transformation of benign mole into malignant mole- invasive mole Complete Mole Results from fertilization of a blighted (empty) ovum by a paternal chromosome, which then duplicates to reach the haploid compliment of 46 chromosomes Lack fetal tissues Uterus is filled with generalized swelling of trophoblastic (placental) tissue. Homozygous Empty Ovum 23 X 46 XX Partial mole Fertilization of a normal 23X ovum by two independent sperms resulting in 69 chromosomes. Presence of both fetal tissues and abnormal placental tissues 23X 69XXX Natural history of hydatidiform mole 80% of molar gestations will resolve completely after evacuation. The remaining 20% will develop persistent trophoblastic disease being:- 15% invasive mole 5% choriocarcinoma. After an initial molar evacuation the risk for a second mole is increased to between 4 to 5 times. After a single spontaneous resolution following fertility and reproductive function returns to within normal limits. Signs and Symptoms Amenorrhea – b’se it is a pregnancy Vaginal bleeding ( 90%) usually after 12 wks of amenorrhea Passage of vesicles (grape like masses) per vagina Hyper emesis gravidarum ( severe nausea &vomiting) – exaggerated early pregnancy symptoms Size of the uterus is inconsistent with gestational age( with no fetal heart beat and fetal movement) usually soft Preeclampsia in the 1sttrimester or other pregnancy induced hypertension. Signs and Symptoms Ovarian (Theca lutein) cysts Features of hyperthyroidism(Anxiety, restlessness, excessive sweating) etc. Clinically, not possible to determine fetal parts, Fetal heart rate Larger uterus/FH than expected GA. Is due to expansion of endometrial cavity by placental tissues and retained blood. However in some cases, FH may be smaller than expected GA Signs and Symptoms In approximately ½ of patients diagnosis is at the time of spontaneous passage of the characteristic vesicles. Abortion usually occurs at about 16-18 weeks compared to 10-12 weeks in other usual spontaneous abortions. Diagnosis Suspicion: clinical history and physical exam Quantitative beta-HCG Ultrasound is the standard for identifying both complete and partial molar pregnancies. The classic image is of grape appearance Physical exam demonstrates:- – Absence of fetal parts and foetal heart sounds in most cases. – Bilateral ovarian masses (theca- lutein cyst) in 15 – 30% Sometimes features of hyperthyroidism Diagnosis Ultrasound is a reliable and sensitive technique. LAB: Elevated hCG in urine and serum In most instances hCG regress and disappear within 14 weeks of evacuation of molar pregnancy. If hCG persists or stagnates or rises it must be concluded that viable tumor cells still persists and this leads to persistent GTD. Ultrasound is a reliable and sensitive technique. Elevated hCG in urine and serum In most instances hCG regress and disappear within 14 weeks of evacuation of molar pregnancy. If hCG persists or stagnates or rises it must be concluded that viable tumor cells still persists and this leads to persistent GTD. Molar pregnancy Complete mole No gestational sac Uterus filled with hypoechoic and hyperchoic contents. Numerous small cystlike spaces within the mass Check HCG-level (very high usually) Extreme nausea and projectile vomiting Molar Pregnancy: US Findings Complete Mole: Heterogeneous, irregular endometrial mass echogenicity variable “cluster of grapes” relatively late appearance + Myometrial invasion Partial Mole: Fetus w/ a “thick placenta” Theca lutein cysts Molar pregnancy (Complete mole) Complete Mole Molar Pregnancy A 44 year old woman presents with a 2 month history of amenorrhea. She now complains of severe vaginal bleeding and abdominal pain. She has a beta HCG level of approximately 200,000 units. Hydatidiform mole: Partial Mole In a ‘partial mole’, the mass may contain both these abnormal cells and often a fetus that has severe defects. In this case the fetus will be consumed( destroyed) by the growing abnormal mass very quickly. Partial Mole Complete Mole Partial Mole Theca lutein cysts Bilateral, involving both ovaries Thick walled Complex cystic masses: arranged in spoke-wheel pattern Theca Lutein cysts Malignant Mole Malignant Mole most commonly develops after molar pregnancy, but may occur after any gestational experience: abortion, ectopic, preterm or term pregnancy Invades the myometrium or adjacent structures it may totally penetrate the myometrium leading to uterine rupture and haemoperitoreum(Blood in the peritoneum). Follow-up following molar pregnancy Important because of the possibility of persistent molar Following molar evacuation, perform serial hCG determination as follows:- . Weekly to non-detectable levels (ie <5MIu/ml) on 3 consecutive successive assays. . Then monthly for 6 months. . Then bimonthly for 6 months Physical work-up is equally important to rule-out metastatic disease:- . Ask for headache, visual disturbance, cough, difficulty in breathing . Involution of the uterus. . Regression of cystic ovarian enlargement (theca lutein cysts) . Obtain a baseline chest X-Ray. Follow-up following molar pregnancy Place the patient on oral conceptive pills during follow-up. NOTE: Avoid IUCD – Risk of perforation Avoid Depo- provera -Irregular bleeding At completion of follow-up pregnancy

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Interaction of Ultrasound With Matter CRT04210 · Ultrasound Imaging START READING NOTES Study Interaction of Ultrasound With Matter using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic INTERACTION OF ULTRASOUND WITH MATTER Objectives Introduction Terminologies Acoustic impedance (z) Acoustic boundaries Acoustic mismatch The Interaction Processes Reflection of ultrasound Specular reflections Diffuse/Non-specular Reflections (Scattering) Non-specular Reflections (Scattering) The intensity of an echo Angle of incidence and Echo intensity Reflections Acoustic mismatch and Echo intensity Acoustically homogeneous media Negative role of gas Coupling gel Transducer matching layer Refraction of ultrasound Significance of Refraction in ultrasonography Absorption Effect of Viscosity on ultrasound absorption Effect of Relaxation time on ultrasound absorption Effect of Relaxation time on ultrasound absorption cont.. Effect of beam frequency on ultrasound absorption Significance of absorption in ultrasonography Attenuation of ultrasound in tissue Ultrasonic half value thickness (HVT) ULTRASONIC HALF VALUE THICKNESSES FOR DIFFERENT MATERIALS AT Acoustic windows Acoustic barriers INTERACTION OF ULTRASOUND WITH MATTER J.J. John Objectives At the end of this lecture, students should be able to Describe : How an ultrasound beam propagates through tissues Attenuation of ultrasound beam The interactions processes Practical implications of each interaction process Introduction In ultrasonography, a beam of ultrasound must be directed into the tissues of the subject over a selected area of interest. The ultrasonic energy will then interact with the tissues along its path. The interaction processes are influenced by the characteristics of the ultrasound wave, as well as the physical properties of the tissues through which the beam passes. So different types of tissues will respond differently to an ultrasound beam. Terminologies Acoustic impendance Acoustic mismatch Acoustic boundary/interface Attenuation Acoustic impedance (z) Acoustic impedance is a measure of the resistance of the particles of the medium to mechanical vibrations. This resistance increases in proportion to the density of the medium, and the velocity of ultrasound in the medium. Mathematically: Also known as the characteristic acoustic impedance of a medium. It differ from one medium to the other. Acoustic impedance (z) Acoustic boundaries Positions within tissue where the values of acoustic impedance change are very important in ultrasound interactions. These positions are called acoustic boundaries, or tissue interfaces. For example, urine in the bladder will have an acoustic impedance value which differs from that of the bladder wall, hence their common interface constitutes an acoustic boundary. URINE Acoustic boundaries The unique features of diagnostic ultrasound as an imaging modality are determined by the nature and distribution of the multitude of acoustic boundaries within the tissues of the body. And the extent to which an acoustic boundary affects a beam of ultrasound incident upon it will depend on the magnitude of the difference between the acoustic impedance values of the two structures on either side of the boundary. Acoustic mismatch Acoustic mismatch can be defined as the difference in acoustic impedance (Z) values of the two media forming the boundary. For example an acoustic mismatch for: Muscle/fat boundary= (1.7-1.38)= 0.32 Bone/fat boundary= (7.80-1.38)= 6.42 Soft tissue/air = (1.63-0.0004)= 1.6296 Soft tissue/water = (1.63-1.48)= 0.15 The Interaction Processes Reflection Specular reflection Non specuar reflection (Scattering) Refraction Absorption Reflection of ultrasound This is the most important single interaction process in ultrasound image formation. When a beam of ultrasound strikes an acoustic boundary, some of the beam energy is transmitted across the boundary, while some is redirected backwards(reflected). Depending on the size of the boundary relative to that of the ultrasound beam, or on irregularities of shape on the surface of the reflector. Two types of reflection can occur, these are: Specular reflections Non-specular/Diffuse reflections (Scattering) Specular reflections Specular reflections occur when the boundary is smooth and larger than the beam dimensions. For this type of reflection, a simple law similar to that governing the reflection of light is obeyed Angle of incidence (i) = angle of reflection (r) The reflected beam is referred to as the echo and the probability that an echo will go back to the transducer and be detected increases as the angles i and r decrease. Diffuse/Non-specular Reflections (Scattering) This is the reflection of ultrasound in many direction Occurs when the reflecting interface is irregular in shape, and its dimensions are smaller than the diameter of the ultrasound beam The direction of scatter does not obey the simple law of reflection, but depends on the relative sizes of the scattering target and the ultrasound beam diameter The dimensions of the interface should be about one wavelength of the ultrasound beam or less for scattering to occur Non-specular Reflections (Scattering) Since the wavelengths for typical diagnostic beams are 1 mm or less. and Within the organs, there are many structures which have dimensions of less than 1 mm, so scattered ultrasound provides much useful information about the internal texture of organs. Scattered echoes are much weaker than specularly reflected echo but the high sensitivity of modern ultrasound equipment makes it possible to utilize information from scattered ultrasound for imaging Scattering shows very strong frequency dependence, increasing rapidly as the frequency of ultrasound is increased. The intensity of an echo The intensity of an echo due to specular reflection depends on the Angle of incidence Acoustic mismatch The proportion of beam intensity that is reflected from the interface represented by the reflection coefficient which is given as ratio of the intensity of a reflected beam to that of incidence beam (Ir/Ii) For a given intensity at the source, echo sizes will vary in proportion to this ratio Angle of incidence and Echo intensity The most useful specular reflection takes place when the ultrasound beam strikes a reflector at 90° to the surface of the boundary. This is referred to as normal incidence. On the Normal incidence, angles i and r are equal to zero, and the echo goes straight back with a high probability of being picked up by the transducer Reflections IMAGE A The diaphragm is a large and relatively smooth surface

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Image characteristics and Optimization CRT04210 · Ultrasound Imaging START READING NOTES Study Image characteristics and Optimization using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic IMAGE CHARACTERISTICS IN ULTRASONOGRAPHY AND OPTIMIZATION Ultrasound Image Image characteristics and Optimization Echogenicity L R Echotexture Homogeneous Image Optimization in ultrasonoghaphy Introduction Resolution Spatial resolution Axial resolution Lateral resolution Factors Affecting Lateral Resolution Effect of Beam width Effect of beam frequency Effect of scan line density Line Density Spatial resolution versus tissue depth Use of Multifrequency Transducers Broad Band Transducers Multiple centre-frequency transducers Frame rates, Scan line density, and Tissue Depth For high lateral resolution: For large tissue depths: For very high framing rates (rapid motion) Contrast resolution Temporal resolution IMAGE CHARACTERISTICS IN ULTRASONOGRAPHY AND OPTIMIZATION J. J. John (DDR-CUHAS) Ultrasound Image In B-mode, it composed of a variety of bright dots that vary in intensity. Intensity vary according to the strength of electricals signals hence, returning echoes from tissues or structures in the body. The location of each dot corresponds to the anatomic location of each echo-generating organ or structure Provides anatomic and non-anatomic information (artifacts) An ultrasound image is composed of a variety of bright dots that vary in intensity according to the strength of the returning echoes from internal tissues and/or structures in the body. The location of each dot corresponds to the anatomic location of each echo-generating organ or structure. Each image provides a dot-for-dot correct anatomic representation of organs and structures in the body. On the image there is also non-anatomic information, which is the result of things happening to the ultrasound beam before, during or after it strikes a reflecting surface. These phenomena, which are the result of the imaging technique itself, are called artifacts and are discussed elsewhere. Image characteristics and Optimization An ultrasound image is composed of a variety of bright dots that vary in intensity according to the strength of the returning echoes from internal tissues and/or structures in the body. Some of the returning echoes are strong and register as bright white dots on the image. The brightest areas with the highest intensity echoes are called hyperechoic. Areas with echoes of lesser strength are hypoechoic. There is no specific name for echoes of moderate strength. Areas with no echoes are anechoic and therefore black on the images. When two structures generate the same kind of echoes, they are isoechoic. Echogenicity We are considering intensity of echoes and image apperance ECHOGENICITY Focus on the intensity of echoes reflected by tissues or structures from inside the body. Brightness of the dots generated by returning echoes from the body. Echogenicity is the intensity of echoes reflected by tissues or structures from inside the body. Literally and simplistically, it means the ability of something to generate echoes. ECHOGENICITY Intensity of dots forming the image vary according to the strength of electricals signals processed and hence the returning echoes from tissues or structures in the body. Some of the returning echoes are strong and register as bright white dots on the image. Some are weak and register as less bright dots on the image. ECHOGENICITY The brightest areas with the highest intensity echoes are called hyperechoic. Areas with echoes of lesser strength are hypoechoic. There is no specific name for echoes of moderate strength. Areas with no echoes are anechoic and therefore black on the images. When two structures generate the same kind of echoes, they are isoechoic. ECHOGENICITY Hyperechoic High intensity echoes Hypoechoic Low intensity echoes Anaechoic No internal echoes Isoechoic Same intensity echoes Word slide Summary of previous page ECHOGENICITY Echogenicity of a structure is described relative to surrounding or adjacent tissue When we describe echogenicity of a structure, we describe it in relative terms comparing the echogenicity of the structure to that of surrounding or adjacent echoes. QUESTION: True or false? Echogenicity is an inherent property of a specific tissue. ANSWER: False. Echogenicity of a structure is an not absolute property. It is a relative thing, relative to the surrounding tissue. ECHOGENICITY Hyper echoic:- High intensity or bright echoes, which are more echogenic than the standard to which comparison is made, usually the surrounding tissue. Hyperechoic means high intensity or bright echoes, which are more echogenic than the standard to which comparison is made, usually the surrounding tissue. Image characteristics and Optimization The round hyperechoic solid mass (arrow) under the capsule of this moderately echogenic liver is a hemangioma. The normal liver is the standard for comparison in this case. The hyperechoic solid mass within this spleen represents a focal deposit of lymphoma. Image characteristics and Optimization Due to sickle cell nephropathy, the cortex of this kidney is hyperechoic relative to the adjacent liver parenchyma, which, due to its size, becomes the standard of comparison for most adjacent parenchymal organs. Image characteristics and Optimization The round mass (arrow) in this kidney is relatively hyperechoic when compared to the adjacent renal cortex (arrowheads). The echogenicity of a mass is compared to its organ of origin. Although the tumor itself is not very bright in echogenicity, it contains tiny hyperechoic foci due to microcalcifications scattered throughout the mass, which is a renal cell carcinoma (hypernephroma). ECHOGENICITY Hypoechoic:- Means low intensity echoes or less echogenic than the surrounding tissue. Image characteristics and Optimization This is an image the spleen, which is of moderate echogenicity, and contains several hypoechoic masses (arrows) representing deposits of lymphoma. The masses are hypoechoic relative to surrounding normal splenic parenchyma. The relative echogenicity of a mass is compared to the echogenicity of the organ to which it relates. L In this case the large lobulated hypoechoic masses (arrows) of low echogenicity represent metastatic deposits within the liver (L). The masses are hypoechoic relative to adjacent normal liver parenchyma. R L In this transverse scan of the scrotum, the normal right (R) testis is moderately echogenic, while the left (L) is enlarged and hypoechoic due to testicular cancer. The

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Gynecology Uss CRT04210 · Ultrasound Imaging START READING NOTES Study Gynecology Uss using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic INTRODUCTION Gynecology Uss Uterus parts LAYERS The thickness of the basal layer is typically consistent, although minimal changes may occur throughout the menstrual cycle. The endometrial cavity, also referred to as the uterine cavity, is located between the two functional layers of the endometrium. Uterine Size and Shape Uterine Positions Uterus position Congenital anomalies UTERINE PATHOLOGY This lack of blood supply results in necrosis and clinically the patient will present with acute, localized pelvic pain. Fibroids may also affect the contractile motion of the uterus, thus leading to interference with sperm migration. Leiomyosarcoma Nabothian Cyst VAGINAL PATHOLOGY Cervical Carcinoma GYNOCOLOGY – ULTRASOUND INTRODUCTION The uterus is a pear-shaped, retroperitoneal organ that lies anterior to the rectum, posterior to the urinary bladder, and is bounded laterally by the broad ligaments . Its primary function is to provide a place for the products of conception to implant and develop. The uterus can be divided into four major divisions: fundus, corpus, isthmus, and cervix. Gynecology Uss The largest part of the uterus is the corpus, or body. The corpus is located inferior to the fundus. The isthmus is the area located between the corpus and the cervix. During pregnancy, the isthmus may be referred to as the lower uterine segment. Gynecology Uss The cervix is the rigid component of the uterus that is located inferior to the isthmus, and it is the portion of the uterus that projects into the vagina. The cervix is marked superiorly by the internal os, which is in contact with the isthmus, and inferiorly by the external os, which is in close contact with the vagina. Uterus parts Fundus. The uppermost and widest part of your uterus. It connects fallopian tubes. Corpus. The main body of uterus. This is where a fertilized egg implants during pregnancy. Isthmus. The part of uterus between corpus and cervix. It’s where uterus starts to narrow or thin. Cervix. The lowest part of uterus. cervix opens to vagina. LAYERS The uterine wall consists of three layers . The outermost layer is referred to as the serosal layer or perimetrium, which is continuous with the fascia of the pelvis. The middle layer is the myometrium or muscular layer, which constitutes the bulk of the uterine tissue, providing the area where contractile motion occurs. The inner mucosal layer of the uterus is referred to as the endometrium. The endometrium can be further divided into a deep or basal layer and a superficial or functional layer The thickness of the basal layer is typically consistent, although minimal changes may occur throughout the menstrual cycle. The functional layer of the endometrium is the component that is shed during menstruation; thus, the thickness of the functional layer of endometrium will vary during the menstrual cycle as a result of hormonal stimulation The endometrial cavity, also referred to as the uterine cavity, is located between the two functional layers of the endometrium. This cavity is contiguous with the lumen of the fallopian tubes laterally, and the cervix inferiorly. Uterine Size and Shape The size and shape of the uterus depends on the age of the patient, parity, and the presence of pathology or congenital anomalies that may alter its contour. The normal neonatal uterus is tubular in appearance and may exhibit distinct endometrial echoes in the first week of life as a result of maternal hormone stimulation. Following the neonatal period, the cervical anteroposterior 579 diameter is equal to or slightly greater than that of the uterine fundus Gynecology Uss The uterus grows minimally during prepubertal years, whereas after puberty, the uterine fundus becomes much larger than the cervix, consequently providing the pear-shaped appearance of the normal adult uterus. Following menopause, the uterus typically becomes much smaller than the premenopausal uterus Uterine Positions The uterine position within the pelvis is variable The normal position of the uterus is considered to be anteversion or anteflexion. Anteversion describes the uterine position in which the body tilts forward or anteriorly, forming a 90-degree angle with the vagina. Gynecology Uss Anteflexion of the uterus denotes the position in which the uterine body folds forward, possibly coming in contact with the cervix. Retroversion of the uterus is the position in which the uterine body tilts backward or posteriorly, without a bend where the cervix and body meet. Retroflexion is the uterine position that results in the uterine body tilting backward and actually coming in contact with the cervix Gynecology Uss The uterus may also be oriented more to the left or right of the midline, resulting in a variation between anatomic midline and functional midline. The uterus that is located more on the left is referred to as a levoverted uterus, whereas the uterus that is located on the right is referred to as dextroverted uterus Uterus position Retroverted uterus. Commonly called a tipped or tilted uterus. This is when your uterus is tilted or tipped backward so it curves toward your spine instead of forward toward your abdomen. Anteflexed uterus. Your uterus is anteflexed when it’s bent forward. The tilt is severe and can put pressure on your abdomen or bladder and cause painful symptoms. Retroflexed uterus. Your uterus is retroflexed when it’s bent backward. The tilt puts pressure on your lower back Congenital anomalies Bicornuate uterus. A heart-shaped uterus. Arcuate uterus. Similar to a bicornuate uterus but with less of a dip or heart shape. Septate uterus. When uterus is divided into two parts by a membrane. Unicornuate uterus. When have one fallopian tube and an irregularly shaped uterus. Didelphys uterus. When you’re born with two uteruses Gynecology Uss Bicornuate uterus (Fig. 17-8). A bicornuate uterus, also referred to as bicornis unicollis, is present when the endometrium divides into two endometrial cavities, with a prominent concavity noted in the outline of the uterine

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Common Gynecological Anomalies – Part 2 CRT04210 · Ultrasound Imaging START READING NOTES Study Common Gynecological Anomalies – Part 2 using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic Common Gynaecological Anomalies- Part 2 ADNEXAL MASSES: NORMAL ANATOMY Us evaluation of adnexal masses Morphologic features suggestive of benignity 1.Simple ovarian cysts Simple ovarian cysts: US Findings Simple ovarian cysts 2.Paraovarian cyst PARAOVARIAN CYST 3.Complex cysts Complex Cyst 4.Endometriosis Endometriosis- Endometrioma ENDOMETRIOMAS: Endometriosis- Sonographic pitfall Clot/Debris Clear Cell Carcinoma ENDOMETRIOSIS 5.HEMORRHAGIC CYST HEMORRHAGIC CYSTS: 6.Dermoid 7.CYSTIC TERATOMA DERMOID CYSTS: CFI may be helpful 9.Polycystic ovary disease PCOD: US Findings Morphologic features suggestive of malignancy B.SOLID ADNEXIAL MASSES Kruckenberg Tumor SOLID OVARIAN MASSES: Fibromas Fibrothecoma Be careful to differentiate from: Dermoid- Benign masses Common Gynaecological Anomalies- Part 2 MDU,BMI,ECHO&ECG,DDR ADNEXAL MASSES: Role of Ultrasound Dx of benign disease may result in less invasive or elective surgery may eliminate need for surgery altogether Dx of malignancy allows prompt referral to experienced gyn-oncologic surgeon Indeterminate US consider MRI NORMAL ANATOMY Oval Echogenic central stroma Small anechoic cysts 3 x 2 x 1 to 2 cm inpremenopausal women NORMAL ANATOMY Normal Ovaries Us evaluation of adnexal masses Location Morphology pattern recognition for benign pathology Size Echotexture:cystic, complex (mixed cystic and solid), or solid. Vascularity Associated findings A.CYSTIC ADNEXIAL MASSES Morphologic features suggestive of benignity Smooth walls No septations Thin septations that are avascular Absence of solid components or mural nodularity 1.Simple ovarian cysts Size Likely benign if: < 6 cm in premenopausal < 5 cm in postmenopausal > 3 cm get follow up to ensure regression or stability More common than originally thought Postmenopausal follicular cysts > 5 cm increased likelihood of malignancy less likely to resolve > 3 cm get follow-up Simple ovarian cysts: US Findings Anechoic Well defined Thin wall Posterior enhancement Sharp Back wall Simple ovarian cysts Follicular cysts- Functional cysts Anechoic cysts have a thin wall, are completely anechoic, and are enhanced through transmission. Regardless of their size, they are unlikely to be malignant In women of menstrual age, the most common anechoic cyst is the functional cyst These usually are small < 2 cm in diameter; however, they may enlarge up to 10 cm. Simple ovarian cysts They typically regress spontaneously. At times, birth control pills are necessary to suppress their growth. When an anechoic cyst is seen that is larger than 6 cm, the likelihood of neoplasm is high. If there are no wall irregularities or septations, the cyst is most likely secondary to a benign neoplasm such as a cystadenoma 2.Paraovarian cyst 10% of all adnexal masses Adjacent to ovary Less likely to resolve If > 6 cm may lead to torsion Rarely malignant They arise from the broad ligament. Their size does not change during the menstrual cycle. PARAOVARIAN CYST Clear plane between cyst and ovary 3.Complex cysts Seen in Malignant/Infected cysts/ Haemorrhagic cysts Features Thick walled Septated Echocomplex; Mixed echogenicity Mural Nodularity Complex Cyst Note the Thick walls and Mural Nodularity 4.Endometriosis Ectopic location of endometrial tissue outside uterus. Location varies: peritoneal cavity, pelvic organs, ligaments extra pelvic. Functionalis layer, Repetitive cycles of hemorrhage Begins 2 – 7 days before menses but sever during Menses. Similar repeated period related pains. Past uterine surgery may implant endometrial cells along incision. Endometriosis- Endometrioma In most cases, sonography cannot demonstrate the tiny ectopicimplant Difficult to see by US especially if lesions small. Cystic or complex lesions may be seen (endometriomas). The localized form of the disease creates an endometrioma. This is seen as a cyst on transabdominal scanning Ultrasound shows a diffuse low-level echoes are seen: the “chocolate” cyst echoes due to blood ENDOMETRIOMAS: US Findings Homogeneous, low-level echoes ENDOMETRIOMAS: US Findings Low- lovel internal echoes Endometriosis- Sonographic pitfall Masses may give septations and nodularity. DD cancer. MRI helps to confirm presence of blood. Laparatomy is gold standard. Rx may be surgical but Hormonal suppression may be done. Oophrectomy and Hysterectomy for severe cases. Clot/Debris : ENDOETRIOMA Mural Nodularity Clear Cell Carcinoma ENDOMETRIOMA: Mural Nodules ENDOMETRIOSIS Beware mural irregularities or nodules increased incidence of clear cell and endometroid Ca. May have vascular wall Adhesions If US features suggestive but non-specific confirm with MRI CAs rarely contain hemorrhage laparoscopy 5.HEMORRHAGIC CYST Hemorrhagic cysts more often present with acute pain contain clot solitary HEMORRHAGIC CYSTS: US Findings Pattern of internal echoes variable but changes over time Ultimately resolves Thin, regular wall Increased through transmission No internal vascularity HEMORRHAGIC CYSTS: US Findings Diffuse homogeneous, low level echoes HEMORRHAGIC CYSTS: US Findings Lace-like or spider web pattern of internal echoes/septations HEMORRHAGIC CYSTS: US Findings Dependent debris HEMORRHAGIC CYSTS: US Findings Echogenic clot HEMORRHAGIC CYSTS: Evolving Appearance HEMORRHAGIC CYSTS: US Findings No internal vascularity HEMORRHAGIC CYSTS For questionable clot versus mural nodule check vascularity roll patient HEMORRHAGIC CYSTS If solid appearing focus adherent and avascular, obtain f in 6 weeks (esp. if clinical presentation is atypical) clot should change 6.Dermoid Dermoids are the most common ovarian neoplasm. Rare forms of dermoids include the specialized tumors of struma ovarii (with thyroid tissue) and carcinoid tumors. Malignant degeneration (into squamous cell carcinoma) of dermoids is rare. This typically occurs in older women. Immature teratomas occur in young women 10 to 20 years of age. 7.CYSTIC TERATOMA Most common ovarian neoplasm Most common in the reproductive years Contains txs from all 3 germ cell layers Typically assx, found incidentally Complications: torsion, rupture Malignant transformation < 2% DERMOID CYSTS: US Findings Echogenic mass Posterior sound attenuation DERMOID CYSTS: US Findings Fat/fluid level Floating debris (hairball) DERMOID CYSTS: US Findings Mural nodules, +/- Ca++ DERMOID CYSTS: US Findings Echogenic linear speckles CFI may be helpful pedunculated leiomyoma 9.Polycystic ovary disease Polycystic ovary disease, which includes Stein-Leventhal syndrome (infertility, hirsutism, and oligomenorrhea), is one of the most common endocrine disorders. The diagnosis is made on the basis of clinical, sonographic, and biochemical criteria. Luteinizing hormone is elevated and follicle-stimulating hormone levels are