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THE RENAL TRACT 165 the vesicoureteric junction (VUJ). IVU, retrograde cystography and CT are methods of diagnosis. Ultrasound appearances Situated within the collecting system of the kidney, the transitional cell tumour is usually small (compared to the RCC), homogeneous and relatively hypoechoic (Fig. 7.10A). Proximal renal tract dilatation may sometimes be present. These tumours are easy to miss on ultrasound unless the kidney is scanned very carefully, and often are, unless the case is highlighted by clinical symptoms or a high clinical index of suspicion. They can mimic a hypertrophied column of Bertin (see above); CT may differentiate in cases of doubt. Once large, they invade the surrounding renal parenchyma and become indistinguishable from RCC on ultrasound. They frequently spread to the bladder and the entire renal tract should be carefully examined. In the bladder they are potentially easier to see as they are surrounded by urine (Fig. 7.10B). Invasion of the bladder wall can be identified on ultrasound in the larger ones but biopsy is necessary to determine formally the level of invasion. IVU or a retrograde cystogram are the methods of choice for demonstrating a filling defect in the PCS (Fig. 7.11) or ureter; CT may be useful and is also used for staging purposes. Lymphoma Renal involvement of non-Hodgkin’s or Hodgkin’s lymphoma is not uncommon and depends upon the stage of the disease. The ultrasound appearances are highly variable and range from solitary to multiple masses, usually hypoechoic but sometimes anechoic, hyperechoic or mixed. The masses may have increased through transmission of sound and may mimic complex fluid lesions such as haematoma or abscess. The clinical history should help to differentiate these cases. Occasionally diffuse enlargement may occur secondary to diffuse infiltration. Metastases Renal metastases from a distant primary are usually found in cases of widespread metastatic disease and are frequently multiple. A B Figure 7.10 (A) Large, transitional cell carcinoma in the upper pole of the RK. The changes are more subtle than those of renal cell carcinoma, and the renal outline remains intact. (B) Transitional cell carcinoma in the bladder at the right vesicoureteric junction. Blood flow can clearly be seen within the tumour, and right renal and ureteric dilatation was present.
166 ABDOMINAL ULTRASOUND Figure 7.11 IVU with multiple filling defects in the relatively non-dilated PCS of the RK, which represent transitional cell carcinomas. In such cases, the primary diagnosis is usually already known and other abdominal metastases, such as liver deposits and/or lymphadenopathy, are commonly seen on ultrasound. Rarely, a single metastasis is seen in the kidney without other evidence of metastatic spread, making the diagnosis difficult (as the question arises of whether this could be a primary or secondary lesion). CT may identify the primary and frequently picks up other, smaller metastases not identified on ultrasound. 9 PELVICALYCEAL SYSTEM DILATATION AND OBSTRUCTIVE UROPATHY Not all PCS dilatation, i.e. hydronephrosis, is pathological, or indeed obstructive, that is, there can be dilatation without physiological obstruction. Conversely, not all obstructive uropathy necessarily results in PCS dilatation. Physiological dilatation Mild dilatation of the renal collecting system is a common finding, most commonly secondary to an over-distended bladder. Following micturition, the collecting system decompresses and returns to normal. An external renal pelvis (see above) is a nonobstructive ‘baggy’ dilatation of the pelvis and can be regarded as a normal variant. The intrarenal collecting system is normal in this situation (Fig. 7.4, D,E). Pregnancy is another common cause of mild PCS dilatation, more frequently on the right, particularly in the second and third trimester. This is thought to be due partly to pressure on the ureters from the advancing pregnancy and partly hormonal. It is however wrong to assume that the kidney is not obstructed just because the patient is pregnant. If symptomatic, the suspicion of obstruction in a dilated system is increased, particularly if echoes are present in the PCS. Obstructive uropathy Renal obstruction, particularly if long-standing, can irreversibly damage the kidney or kidneys, leading eventually to renal failure. If diagnosed early enough, renal function can be preserved and therefore ultrasound plays a prominent role as one of the first-line investigations in patients with loin pain, renal colic or micturition disorders (Table 7.1). In the vast majority of cases, urinary tract obstruction causes dilatation of the collecting system proximal to the site of obstruction (Fig. 7.12). Whether the hydronephrosis is bilateral or unilateral and whether or not it involves the ureter(s) depends on the cause and site of the obstructing lesion. Dilatation of the collecting system may be localized. Sometimes only one moiety of the kidney may be obstructed by a stone or tumour, whilst the rest of the kidney remains normal. In a duplex kidney, dilatation of the upper pole moiety is a common occurrence due to an anomaly at the VUJ, that is, a ureterocoele. If the obstruction is long-standing the renal cortex may atrophy, becoming thin. Normal thickness of cortex is a good prognostic indicator. Function may be assessed with a nuclear medicine (DTPA) scan prior to further management.
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Abdominal Ultrasound
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Abdominal Ultrasound How, Why and W
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v Contents Contributors Preface ix
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vii Contributors Rosemary Arthur FR
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ix Preface Ultrasound continues to
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ABBREVIATIONS xi MHA MHV MI MPV MRA
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Chapter 1 1 Optimizing the diagnost
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OPTIMIZING THE DIAGNOSTIC INFORMATI
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Chapter 2 17 The normal hepatobilia
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THE NORMAL HEPATOBILIARY SYSTEM 19
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Chapter 3 41 Pathology of the gallb
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PATHOLOGY OF THE GALLBLADDER AND BI
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Chapter 4 79 Pathology of the liver
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PATHOLOGY OF THE LIVER AND PORTAL V
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Page 128 and 129: PATHOLOGY OF THE LIVER AND PORTAL V
Page 134 and 135: Chapter 5 121 The pancreas CHAPTER
Page 136 and 137: THE PANCREAS 123 the patient’s le
Page 138 and 139: THE PANCREAS 125 Acute pancreatitis
Page 140 and 141: THE PANCREAS 127 E F G Figure 5.3 c
Page 142 and 143: A C DISTANCE = 3.43 CM 5%. 13 Over
Page 144 and 145: THE PANCREAS 131 G H I Figure 5.5 c
Page 146 and 147: THE PANCREAS 133 head of pancreas.
Page 148 and 149: THE PANCREAS 135 pancreatic juice i
Page 150 and 151: Chapter 6 137 The spleen and lympha
Page 152 and 153: THE SPLEEN AND LYMPHATIC SYSTEM 139
Page 166 and 167: Chapter 7 153 The renal tract CHAPT
Page 168 and 169: THE RENAL TRACT 155 As with any oth
Page 170 and 171: THE RENAL TRACT 157 A B q 0 LRA AO
Page 172 and 173: THE RENAL TRACT 159 junctions of or
Page 174 and 175: THE RENAL TRACT 161 A B Figure 7.5
Page 176 and 177: THE RENAL TRACT 163 carcinomas, the
Page 180 and 181: THE RENAL TRACT 167 Table 7.1 Sourc
Page 182 and 183: THE RENAL TRACT 169 A B Figure 7.13
Page 184 and 185: THE RENAL TRACT 171 Table 7.2 Diffe
Page 186 and 187: THE RENAL TRACT 173 Ultrasound stil
Page 188 and 189: THE RENAL TRACT 175 CT is useful fo
Page 190 and 191: THE RENAL TRACT 177 Xanthogranuloma
Page 192 and 193: THE RENAL TRACT 179 As with acute t
Page 194 and 195: THE RENAL TRACT 181 der with increa
Page 196 and 197: THE RENAL TRACT 183 ● ● Morphol
Page 198 and 199: THE RENAL TRACT 185 ● ● hydrone
Page 200 and 201: THE RENAL TRACT 187 A Figure 7.27 A
Page 202 and 203: THE RENAL TRACT 189 vascular reject
Page 204 and 205: THE RENAL TRACT 191 B A C Figure 7.
Page 206 and 207: THE RENAL TRACT 193 computerised ul
Page 208 and 209: Chapter 8 195 The retroperitoneum a
Page 210 and 211: THE RETROPERITONEUM AND GASTROINTES
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Chapter 9 215 The paediatric abdome
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THE PAEDIATRIC ABDOMEN 217 A B SPLE
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THE PAEDIATRIC ABDOMEN 219 B A B Fi
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THE PAEDIATRIC ABDOMEN 221 probe de
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THE PAEDIATRIC ABDOMEN 223 When the
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THE PAEDIATRIC ABDOMEN 225 + 78 A 2
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THE PAEDIATRIC ABDOMEN 227 A B C D
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THE PAEDIATRIC ABDOMEN 229 Table 9.
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THE PAEDIATRIC ABDOMEN 231 A LT B C
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THE PAEDIATRIC ABDOMEN 237 mesenter
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THE PAEDIATRIC ABDOMEN 239 E F G Fi
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THE PAEDIATRIC ABDOMEN 241 system i
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Chapter 10 The acute abdomen 243 CH
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THE ACUTE ABDOMEN 245 scan of the p
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THE ACUTE ABDOMEN 247 LIVER LS GB S
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THE ACUTE ABDOMEN 249 D A RT B C E
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THE ACUTE ABDOMEN 251 17. Patlas M,
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Chapter 11 253 Interventional and o
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INTERVENTIONAL AND OTHER TECHNIQUES
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275 Bibliography and further readin
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277 Index A Abdomen, acute gastroin
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INDEX 279 Continuous ambulatory per
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INDEX 281 Intravenous urography (IV
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INDEX 283 Phrygian cap, 29 Pneumobi
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