1. Ultrasound of the kidney

2. Normal kidney

3. Normal variant

4. Normal variant Ultrasound appearance :-
Extrarenal pelvis
The renal pelvis projects outside the kidney medial to the renal sinus
Ultrasound appearance :-
Baggy containing anechoic urine
Determined by transverse scan through the renal hilum , .
Note :- it is important to determine the extrarenal pelvis to not confuse it with dilatation of PCS or parapelvic cyst or collectiion

5. Normal variant Renal humps
Areas of renal cortex form a bulge in the renal outline
Can mimic a renal mass
The most common is splenic hump on the left kidney which is a flattening of the upper pole with a lateral prominence just below the margin of the spleen

6. Duplex kidneys Many degree may be occur:-
Two separate kidneys with separate collecting systems and duplex ureters
Separation of the PCS at the renal hilum

7. Ectopic kidneys
Failure of ascend of the kidney from the pelvis to the renal fossa.

8. Ectopic kidneys Sonographic appearance:-
The kidney is seen in the pelvis , usually on the same side.
The kidney may be cross to the other side lying inferior to its normaly placed partner ( crossed renal ectopia )
Sometimes the kidney fused with the lower pole of the other kidney ( crossed fused renal ectopia ), in this case it likes a very long unilateral kidney

10. Horseshoe kidney Ultrasound appearance:
Fusion of lower poles of both kidneys by connecting band of renal tissue or isthmus
Ultrasound appearance:
It is not easy to determine horseshoe kidney by ultrasound_
Determination of the isthmus, not confused with other abdominal masses as lymphadenopathy
Should be suspected when there is unable to detect lower poles of kidney

12. Pelvicalyceal system dilatation and obstructive uropathy

13. Physiological dilatation of PCS
Is considered when there is mild dilatation of PCS
Causes :-
1- Over full of the bladder
2- Extrarenal pelvis
3- Pregnancy

14. Obstructive uropathy Causes of obstruction:-
Stones ( anywhere along the renal tract)
Tumor ( in the UB, PCS or ureter )
Blood clot ( from infection or trauma )
Stricture ( caused by chronic repeated infection )
Idiopathic PUJ obstruction ( usually unilateral , PCS dilatation only ).

15. Obstructive uropathy
Cervical carcinoma ( due to its proximity to the ureter )
Lymphadenopathy
Gynaecological mass
Postsurgical procedure ( ligation of the ureters in gynaecological procedures)
Trauma ( can cause stricture of the ureter or can cause the renal tract to be blocked by blood clot from damage to the kidney )

16. Obstructive uropathy
Urinary tract obstruction causes dilatation of the tract proximal to the site of obstruction .
The dilatation of collecting system may be localised
In long standing obstruction the renal cortex may atrophy , becoming thin
Note :- in the majority of cases , the exact level and cause of obstruction are difficult to identify on ultrasound .

17. Obstructive uropathy Sonographic appearance of hydronephrosis:-
Multiple , well circumscribed cystic areas ( calyces ) with a dilated central cystic area ( renal pelvis ) which communicate with each other

18. Renal calculi
Not all calculi can be seen on a plain radiograph of the abdomen and not all of them can be detected by ultrasound .
Suspected urinary calculi with negative ultrasound = IVU

19. Renal calculi Ultrasound appearance :-
1- Highly reflective structures display distal shadowing
The distal shadow may be difficult to demonstrate due to :-
poximity of hyperechoic sinus echoes distal to the stone or relatively small size of the stone
2- Hydronephrosis may be seen
3- Hydreureters if the stone has travelsed distally
4- The stone can sometimes be identified in the dilated ureter but is frequentlyh obscured by overlying bowel

20. Renal calculi

21. Dilated renal pelvis (p) from obstructing ureteropelvis junction (UPJ) stone (S).
Note echogenic interface between calcified stone and fluid filled renal pelvis

22. mild hydronephrosis .The ultrasound technologist was able to follow the dilated ureter down to the level of the insertion of the ureter into the bladder revealing an obstructing stone at the UPJ.

23. Note the dilated left distal ureter (arrow) caused by obstruction from the UVJ stone.  

24. Renal cysts and cystic diseases

25. Renal cysts Clinical picture : Found in 50% of population
Its incidence increases with age
Solitary or multiple
Usually peripheral in location but may occur adjacent to the renal pelvis
Clinical picture :
Most renal cysts are asymptomatic
Renal pain if there is haemorrhage of the cyst

26. Renal cysts Ultrasound appearance :-
Basic three characterisitcs , anechoic , thin , well defined capsule and posterior enhancement
Haemorrhage or infection can give rise to low level echoes within the cyst
Calcification may be seen in the capsule
Note :- when you calcification of the capsule of renal cyst you must do further evaluation by Ct as calcified wall may be associated with malignancy.

27. Renal cysts
Haemorrhagic cyst

28. Autosomal dominant ( adult) polycystic kidney disease
Is an inherited condition is transmitted as an autosomal dominant trait.
Clinical picture :-
Has a wide spectrum of presentation
Hypertension
Abdominal distension
Haematuria
Urinary tract infection.
Progressive renal failure

29. Autosomal dominant ( adult) polycystic kidney disease
Ultrasound appearance :-
Bilateral enlargement of the kidneys with multiple cysts of various sizes , many having irregular margins and
not communicating with each 0ther.
Some cysts may contain low level echoes as a result of infection or haemorrhage
The liver , spleen and pancreas should also be examined on ultrasound for associated cysts.

30. Autosomal dominant ( adult) polycystic kidney disease

31. ;

32. Autosomal recessive (infantile)
It is autosomal recessive condition
Rarely seen on ultrasound in children as as it carries a high mortality rate .
Ultrasound appearance:-
Tiny cysts replace both kidneys , giving them a hyperechogenic appearance due to multiple reflections from the cyst walls and the overall increased through - transmission

34. Benign focal renal tumors

35. Angiomyolipoma Clinical presentation :_
Benign tumor affect renal parenchyma , containing blood vessels, muscle tissue and fat .
Clinical presentation :_
Asymptomatic if the lesion is small
Renal pain and haematuria with large haemorrhagic lesions

36. Angiomyolipoma Ultrasound appearance:-
Solitary or multiple highly echogenic , rounded lesion in the renal parenchyma
Very small lesions can be detected by U/S due to great contrast differentiation between it and renal parenchyma
Note : In patient with haematuria it may be difficult to confidently differentiate an angiomyolipoma from a malignant renal neoplasm .

37. Angiomyolipoma
multiple small bilateral echogenic foci (arrows).

38. MALIGNANT renal tract masses

39. U/S is the first line of investigation in cases of haematuria
U/S is highly sensetive in detecting larger renal masses ( above 2.5 cm ) and differentiating them from renal cysts.
Small isoechoic masses may be missed by ultrasound .

40. Renal cell carcinoma Clinical presentation :-
Renal cell carcinoma ( adenocarcinoma ) is the most type of renal malignancy
Clinical presentation :-
Asymptomatic if small
Renal pain , haematuria if large

41. Renal cell carcinoma Ultrasound appearance :-
Large masses Usually heterogenous which deform the shape of The mass may contain the areas of cystic degeneration and/0r calcification the kidney
Smaller masses are hyperechoic and may be confused with benign angiomyolipoma .

42. Renal cell carcinoma
A large right renal mass. The mass (M) is distorting the renal contour.

43. How can you differentiate between small renal cell carcinoma and angiomyolipoma
Angiomyolipoma has well defined borders while a renal cell carcinoma is ill defined
When in doubt, CT is able to differentiate by identifying the fat content of the lesion
Chest X-ray can demonstrate if metastses are present in the lung
U/S can detect meatases of the liver and lymph nodes.

44. Thank you