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Kidney and Bladder US Mike Ackerley. Kidney Advantage over other modalities? Advantage over other modalities? What do you see normally? What do you see.

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Presentation on theme: "Kidney and Bladder US Mike Ackerley. Kidney Advantage over other modalities? Advantage over other modalities? What do you see normally? What do you see."— Presentation transcript:

1 Kidney and Bladder US Mike Ackerley

2 Kidney 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?

3 Advantages Ease with which the extent of the disease can be determined within the kidney for focal disease Ease with which the extent of the disease can be determined within the kidney for focal disease Ease of assessment of renal pelvic or ureteral dilation when fluid distended Ease of assessment of renal pelvic or ureteral dilation when fluid distended The location and relevance of renal mineralization can also be assessed The location and relevance of renal mineralization can also be assessed –When radiographically ID focal renal pelvic or ureteral mineral opacities and the question of whether hydronephrosis is present Biopsy or fine-needle aspiration can be expedited by ultrasonographic guidance, improving the margin of safety as well. Biopsy or fine-needle aspiration can be expedited by ultrasonographic guidance, improving the margin of safety as well.

4 Normals Length in saggital plane Length in saggital plane –Dog: variable with size of dog –Cat: 2.8 – 4.2 cm Cortex Cortex –In dogs more bright than the liver, but less bright than spleen –In cats variable, may be equal brightness to that of liver and approach that of the spleen Medullary Papillae Medullary Papillae –The renal medulla in dogs and cats is less echogenic 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 used

5 Capsule Pelvis Cortex Medulla

6 Pathology Distension Distension –Diuresis: bilaterally symmetrical and usually mild –Hydronephrosis: pelvic dilation may become very gross, with only a think rim of surrounding parenchymal tissue (idiopathic, or secondary to ureteric obstruction) –Renal calculus: strongly reflective surface with distal acoustic shadowing also present. –Chronic pyelonephritis: the pelvis may dilate while the diverticula remain small –Renal neoplasia: secondary dilation of the renal pelvis and proximal ureter, or mechanical obstruction of the pelvis –Ectopic ureter: due to stenosis of the ureter ending and/or ascending infection –Renal pelvic blood clot: following renal biopsy, coagulopathy, bleeding neoplasm, idiopathic renal hemorrhage, or trauma

7 Hydronephrosis

8 Hydronephrosis

9 Pathology Focal parenchymal abnormalities Focal parenchymal abnormalities –Well circumscribed, anechoic parenchymal lesion –Hypoechoic parenchymal lesion –Hyperechoic parechymal lesion –Heterogeneous/complex parenchymal lesion –Medullary rim sign –Acoustic shadowing

10 Pathology Well circumscribed, anechoic parenchymal lesion Well circumscribed, anechoic parenchymal lesion –Thin smooth wall: single or multiple cysts –Thick/irregular wall:  Cyst  Hematoma  Abscess  neoplasia

11 Pathology Hypoechoic parenchymal lesion Hypoechoic parenchymal lesion –Neoplasia  Lymphosarcoma Hyperechoic parenchymal lesion Hyperechoic parenchymal lesion –Neoplasia  1º: chondrosarcoma, hemangioma  Metastatic: hemangiosarcoma, thyroid adenocarcinoma

12 Pathology Heterogeneous/ Complex parenchymal lesion Heterogeneous/ Complex parenchymal lesion –Neoplasia –Abscess –Hematoma –Granuloma –Acute infarct –Polycystic disease

13 Polycystic Kidneys

14 Renal Infarct

15 Pathology Medullary rim sign Medullary rim sign –Normal in cats –Nephrocalcinosis –Ethylene glycol toxicity –Chronic interstitial nephritis –Cats - FIP

16 Pathology Acoustic Shadowing Acoustic Shadowing –Deep to pelvic fat –Renal calculus

17 Nephrolith

18 Pathology Diffuse parenchymal abnormalities Diffuse parenchymal abnormalities –Increased cortical echogenicity –Decreased corticomedullary definition

19 Pathology Increased cortical echogenicity Increased cortical echogenicity –Normal cats –Inflammatory disease  Glomerulonephritis  Interstitial nephritis  FIP –Acute tubular necrosis/nephrosis (toxins) –Renal dysplasia –Nephrocalcinosis –Neoplasia  Diffuse lymphosarcoma

20 Pathology Decreased corticomedullary definition Decreased corticomedullary definition –End-stage kidneys –Multiple small cysts

21 What can we diagnose? Infarcts Infarcts Cysts/Abscess/Hematoma Cysts/Abscess/Hematoma Renal calculus Renal calculus Big neoplasia Big neoplasia Pelvic Dilation Pelvic Dilation

22 Bladder 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?

23 Advantages Able to evaluate bladder wall thickness Able to evaluate bladder wall thickness Able to visualize non-radiopaque stones/cyrstals (C U) Able to visualize non-radiopaque stones/cyrstals (C U) Cystocentesis Cystocentesis

24 Normals Best when bladder moderately full Ovoid in shape, with slight elongation caudally at trigone Best when bladder moderately full Ovoid in shape, with slight elongation caudally at trigone Don’t normally see ureters Don’t normally see ureters Three layers (∆ with size) Three layers (∆ with size) –Mucosa: Hyperechoic –Muscular: Hypo- –Serosal: Hyper- Normal wall thickness (cat): 1.7 mm ± 0.56 Normal wall thickness (cat): 1.7 mm ± 0.56 Normal wall thickness (dog): 1.6 mm Normal wall thickness (dog): 1.6 mm

25 Pathology Calculi Calculi –acoustic shadows are observed deep to calculi that exceed the diameter of the beam. –echogenicity and acoustic shadow generation are independent of chemical composition (doesn’t matter struvite VS cystine) –Ballottement doesn’t move calculi, but let animal stand and calculi will fall.  Helps differentiate from mineralized bladder wall and colonic shadowing

26 Cystic Calculi

27 Pathology Gas bubbles Gas bubbles –Will float to the top, to differentiate from calculi Blood clots Blood clots –non-shadowing Crystalline sediment Crystalline sediment –Vigorous ballottement –Swirling pattern when standing

28 Blood Clot

29 Pathology Mural changes Mural changes –Cystitis –Neoplasia

30 Pathology Cystitis Cystitis –Chronic cystitis results in diffuse thickening of the bladder wall –bladder wall becomes abnormally hypoechoic, and the normal layering becomes less parallel –normal sonographic appearance of the bladder does not rule out the presence of mild or acute cystitis or idiopathic lower urinary tract disease in cats

31 Chronic Cystitis

32 Pathology Neoplasia Neoplasia –TCC: irregularly shaped, broad-based, hypoechoic masses protruding into the bladder lumen –echo pattern depends on if if fibrosis, mineralization, and necrosis have developed –An abrupt transition often observed between neoplastic mass & adjacent bladder wall

33 Neoplasia

34 Pathology Sonographic appearance of polypoid cystitis, adherent blood clots, and mural hematomas is similar to that of neoplasia Sonographic appearance of polypoid cystitis, adherent blood clots, and mural hematomas is similar to that of neoplasia Observation of ureter dilation adjacent to the bladder wall mass & focal medial iliac lymphadenopathy tends to support the diagnosis of neoplasia Observation of ureter dilation adjacent to the bladder wall mass & focal medial iliac lymphadenopathy tends to support the diagnosis of neoplasia Need aspirate, but must weigh that benefit against the possibility of seeding the needle tract with tumor cells Need aspirate, but must weigh that benefit against the possibility of seeding the needle tract with tumor cells Traumatic catheterization is useful to retrieve cells from the mass Traumatic catheterization is useful to retrieve cells from the mass

35 What can we diagnose? Crystalline sediment Crystalline sediment Calculi Calculi Blood clots? Blood clots? Gas Gas


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