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1782 PART V Pediatric SonographyABCDEFFIG. 52.8 Normal Renal Appearances at Different Ages. (A) Premature infant. Cortex is prominent and more echogenic than the liver.Prominent hypoechoic renal pyramids. (B) Term infant. Normal fetal lobulations of renal cortex are isoechoic or slightly hyperechoic to liver andspleen. Prominent renal pyramids are hypoechoic. (C) Term infant. Central echo complex is not prominent because of less peripelvic fat. Renalcortex equals the liver in echogenicity. Medullary pyramids (arrows) are relatively larger and appear more prominent. (D) Two-year-old child. Renalcortex is slightly less echogenic than liver. Renal sinus fat begins to develop central echogenicity around vessels. (E) Ten-year-old child. Normalcortex is less echogenic than liver (L) or spleen. Medullary pyramids (arrows) are relatively hypoechoic around the central echo complex of strongspecular echoes. (F) Fourteen-year-old child. Renal cortex is less echogenic than liver or spleen. Pyramids are much less prominent. Renal sinusfat is increased.
CHAPTER 52 The Pediatric Urinary Tract and Adrenal Glands 1783central echo complex is much less prominent compared withthe renal parenchyma because there is less peripelvic fat in theinfant than in the adult. Renal cortical echogenicity is typicallyincreased in the normal premature infant kidney comparedwith the liver and spleen. he echogenicity of the renal cortexin the normal term infant kidney is oten the same as theechogenicity of the adjacent normal liver, whereas in the olderchild and adult kidney, the renal cortex is less echogenic thanthe liver. he medullary pyramids in the infant are relativelylarger and tend to appear more prominent (more hypoechoic).he corticomedullary diferentiation is greater in the infant andchild’s kidney than in the adult, possibly because of increasedresolution from higher frequency transducers and less overlyingbody fat tissue. It may also result from diferences in the cellularcomposition of the renal parenchyma in the infant. heseprominent pyramids in the pediatric kidney can easily be mistakenfor multiple cysts or dilated calyces by those not familiar withthe diferences. Normal pyramids line up around the centralecho complex in a characteristic pattern and can therefore bediferentiated from cysts. he position of the arcuate artery atthe corticomedullary junction can also help to identify a structureas a pyramid.Renal anatomy in the teenager and older child is similar to thatin the adult 5,21,22 (see Fig. 52.8). he renal parenchyma consistsof the cortex, which is peripheral, contains the glomeruli, andhas several extensions to the edge of the renal sinus (the septaor column of Bertin); and the medulla (containing the renalpyramids), which is more central and adjacent to the calyces.he normal cortex produces low-level, backscattered echoes.he medullary pyramids are relatively hypoechoic and arrangedaround the central, echo-producing renal sinus. he arcuatevessels can be demonstrated as intense specular echoes at thecorticomedullary junction. his corticomedullary diferentiationcan be identiied in most children but occasionally cannot bevisualized in those with increased overlying sot tissues. hecentral echo complex consists of strong specular echoes fromthe renal sinus, including the renal collecting system, calycesand infundibula, arteries, veins, lymphatics, peripelvic fat, andpart of the renal pelvis. With distention of the renal collectingsystem, these echoes become separated and small degrees ofhydronephrosis can be demonstrated. Mild degrees of distentioncan be seen in normal children, particularly ater recenthigh intake of luids or diuretics. A normally distended urinarybladder can also cause functional ureteral obstruction and milddistention of the renal collecting systems. Rescanning when thebladder is empty will usually result in resolution of both collectingsystem and ureteral distention in an otherwise normalurinary tract.Normal Bladder Anatomyhe normal urinary bladder is thin walled. Bladder volume andwall thickness are inluenced by the degree of bladder distention.15,16 he distal ureters may be visible at the bladder base,especially if the child is well hydrated, likely related to the normaltransient passage of urine associated with peristalsis (Fig. 52.9).Bladder wall thickness may increase with inlammation ormuscular hypertrophy.FIG. 52.9 Normal Distal Ureters. Transverse bladder image depictsdistal ureteral insertions at the level of the trigone (arrows).CONGENITAL ANOMALIES OF THEURINARY TRACTRenal DuplicationA common congenital anomaly of the urinary tract is duplicationof the collecting system, which may be partial or complete. Incomplete duplication, two pelves and two separate ureters drainthe kidney. he lower-pole ureter usually inserts into the bladderat the normal site. However, the intramural portion of the uretermay be shorter than usual, and vesicoureteral relux (VUR)frequently results. 23 he upper-pole ureter oten inserts ectopically,inferior and medial to the site of the normal ureteral insertion(Weigert-Meyer rule). Its oriice may be stenotic and obstructed.Ballooning of the submucosal portion of this upper-pole uretercauses a ureterocele. In some patients, the upper-pole uretermay have an insertion entirely outside the bladder including theurethra (above, at, or below the external urinary sphincter), inthe uterus or vagina, or in the ejaculatory duct, seminal vesicle,or vas deferens. 24Patients with unobstructed duplications have no more clinicalproblems than their normal counterparts. Patients with complicatedrenal duplications may have UTI, failure to thrive, abdominalmass, hematuria, or symptoms of bladder outlet obstruction froma ureterocele. Female patients with urethral insertion of theupper-pole ureter below the external urinary sphincter or withvaginal or uterine insertion may have chronic, constant urinaryincontinence or frequent dribbling.Duplication of the renal collecting system is diagnosed onsonography when the central echo complex separates into twoparts with an interposed column of normal renal parenchyma(column of Bertin) (Fig. 52.10). Unless collecting system dilationand/or ureteral dilation are present, it is usually impossible todistinguish a partial, uncomplicated duplication from a completeduplication because a normal ureter is diicult to visualizesonographically. 25
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1600 John F. Kennedy Blvd.Ste 1800P
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viiiContributorsOlga R. Brook, MDAs
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xContributorsChristy K. Holland, Ph
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xiiContributorsRupa Radhakrishnan,
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xxiiContentsVOLUME IIPART IV Obstet
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xxivVideo ContentsVideo 12.8 Angiog
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xxviVideo ContentsVideo 26.20 High-
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xxviiiVideo Contents42 Fetal Measur
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2 PART I Physicsphysics. he amplitu
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4 PART I Physics× ms×FIG. 1.4 Ult
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6 PART I Physicsθ 1 = 20°Tissue A
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8 PART I Physicssignature. Broad-ba
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10 PART I PhysicsFIG. 1.13 B-Mode I
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12 PART I PhysicsIn these transduce
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14 PART I PhysicsFIG. 1.17 Tissue H
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16 PART I PhysicsKey Points of Ultr
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18 PART I PhysicsA - Normal liverv
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20 PART I PhysicsFIG. 1.27 Reverber
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22 PART I Physics-0 dBUncorrected-0
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24 PART I Physicsθ = 0°cos θ = 1
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26 PART I PhysicsABFIG. 1.38 Color
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28 PART I PhysicsChanges in Doppler
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30 PART I PhysicsABFIG. 1.44 Wall F
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32 PART I PhysicsABCDFIG. 1.46 Alia
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CHAPTER2Biologic Effects and Safety
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36 PART I PhysicsPressurePulse repe
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38 PART I PhysicsUltrasound imaging
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40 PART I Physicsacoustic power and
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42 PART I PhysicsFIG. 2.6 Acoustic
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44 PART I PhysicsThe AIUM Statement
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46 PART I Physics1. Current ultraso
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48 PART I PhysicsEPIDEMIOLOGYWith a
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50 PART I Physicscontrols whether t
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52 PART I Physics70. Hwang JH, Tu J
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54 PART I PhysicsA B 5 μmFIG. 3.1
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56 PART I Physicsstudies with Levov
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58 PART I Physicsabdominal organs.
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60 PART I PhysicsHarmonic B-Mode Im
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62 PART I PhysicsFIG. 3.9 Contrast-
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64 PART I Physicsdramatic manifesta
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66 PART I Physics5 µmFIG. 3.15 Fra
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68 PART I Physicsplatelet lysis), n
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70 PART I PhysicsEnhancement1 2 3 4
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72 PART I Physics46. Hamilton MF, B
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PART TWO: Abdominal and Pelvic Sono
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76 PART II Abdominal and Pelvic Son
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100 PART II Abdominal and Pelvic So
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ABFIG. 5.20 Microabscesses in Two P
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ABFIG. 6.32 Distal Cholangiocarcino
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CHAPTER7The PancreasThomas Winter a
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CHAPTER8The Gastrointestinal TractS
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ABFIG. 8.16 Lymphadenopathy in Two
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A B CD E FG H IFIG. 8.23 Inlammator
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FIG. 8.56 Gastrointestinal Stromal
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CHAPTER9The Kidney and Urinary Trac
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Remnant ofpronephrosMesonephrosBMes
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CHAPTER11The Adrenal GlandsChristin
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CHAPTER12The RetroperitoneumRaymond
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CHAPTER13Dynamic Ultrasound of Hern
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CHAPTER14The PeritoneumAnthony E. H
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CHAPTER15The UterusDouglas Brown an
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CHAPTER16The AdnexaRochelle Filker
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692 PART III Small Parts, Carotid A
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CHAPTER20The Parathyroid GlandsBonn
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*** *FIG. 21.8 Terminal Ductolobula
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CHAPTER22The ScrotumDaniel Sommers
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CHAPTER23Overview of Musculoskeleta
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CHAPTER25Musculoskeletal Interventi
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ABCDFIG. 25.15 Biceps Tendon Sheath
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CHAPTER27Peripheral VesselsMark E.
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ABFIG. 27.29 Chronic Deep Venous Th
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1000 PART III Small Parts, Carotid
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e2APPENDIXUltrasound Artifacts: A V
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FIG. A.18 Comet-Tail Artifact. On c
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e12APPENDIXUltrasound Artifacts: A
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I-2 IndexAcetabulumdescription of,
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I-4 IndexAnemiafetal, hydrops from,
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I-6 IndexAttenuationcoeicient, 36of
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I-8 IndexBlood low. See also Cerebr
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I-10 IndexBreast(s) (Continued)thic
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I-12 IndexCat-scratch disease, pedi
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I-14 IndexChorion laeve, 1465-1466C
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I-16 IndexContrast agents (Continue
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I-18 IndexCyst(s) (Continued) Cyst(
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I-20 IndexDoppler ultrasound (Conti
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I-22 IndexEndocardial cushion(s), 1
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I-24 IndexFibroma(s) (Continued)par
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I-26 IndexGerminal epithelium, 565G
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I-28 IndexHematoma(s) (Continued)pe
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I-30 IndexHoloprosencephaly (HPE) (
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I-32 IndexImplants, breast (Continu
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I-34 IndexJaundice (Continued)bile
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I-36 IndexLipomyelocele, closed spi
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I-38 IndexMammary ductsnormal sonog
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I-40 IndexMolar pregnancy. See Hyda
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I-42 IndexNonrhizomelic chondrodysp
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I-44 IndexPancreas (Continued)percu
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I-46 IndexPeritoneum (Continued)tum
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I-48 IndexPosterior fossa (Continue
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I-50 IndexPyloric musclehypertrophy
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I-52 IndexSample volume size, Doppl
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I-54 IndexSpectral broadening, in D
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I-56 IndexSuperoanteromedial ridge,
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I-58 Indexhrombosis (Continued)of s
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I-60 IndexTrisomy 18 (Edwards syndr
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I-62 IndexUrinary tract, pediatric
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I-64 IndexWalker-Warburg syndromeco
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DIAGNOSTICULTRASOUND
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DIAGNOSTICULTRASOUND5TH EDITIONCARO
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ABOUT THE EDITORSCarol M. Rumack, M
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ContributorsviiCONTRIBUTORSJacques
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ContributorsixPeter M. Doubilet, MD
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ContributorsxiAna P. Lourenco, MDAs
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ContributorsxiiiWendy hurston, MDAs
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In memory of my parents, Drs. Ruth
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PrefacexviiPREFACEhe ith edition of
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AcknowledgmentsxixACKNOWLEDGMENTSWe
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ContentsxxiCONTENTSVOLUME IPART I P
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Video ContentsxxiiiVIDEO CONTENTS4
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Video Contentsxxv19 The Thyroid Gla
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Video Contentsxxvii33 The Fetal Fac
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Video Contentsxxix52 The Pediatric
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DIAGNOSTICULTRASOUND
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PART FOUR: Obstetric and Fetal Sono
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CHAPTER 28 Overview of Obstetric Im
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ABCDFIG. 28.9 Second-Trimester Biom
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CHAPTER 29 Bioeffects and Safety of
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CHAPTER 30 The First Trimester 1049
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CHAPTER 31 Chromosomal Abnormalitie
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ABCDFIG. 31.12 Sonographic Findings
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CHAPTER32Multifetal PregnancyMary C
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CHAPTER 32 Multifetal Pregnancy 111
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ABFIG. 32.5 Sonographic Findings Se
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CHAPTER33The Fetal Face and NeckAna
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CHAPTER 33 The Fetal Face and Neck
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Page 1313 and 1314:
Page 1315 and 1316:
Page 1317 and 1318:
ABCDFIG. 33.13 Hypertelorism With E
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ABCDFIG. 33.16 Dacryocystocele. (A)
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ABCDEFFIG. 33.24 Unilateral Complet
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CHAPTER 34 The Fetal Brain 1167impo
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CHAPTER 34 The Fetal Brain 1169cmAB
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CingulatePOCalcarineAB21 wkCD25 wkI
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CHAPTER 34 The Fetal Brain 1173FIG.
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CHAPTER 34 The Fetal Brain 1175LTAR
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CHAPTER 34 The Fetal Brain 1177CC12
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CHAPTER 34 The Fetal Brain 1179SPEC
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CHAPTER 34 The Fetal Brain 1181ABCD
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CHAPTER 34 The Fetal Brain 1183asym
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CHAPTER 34 The Fetal Brain 1185FIG.
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CHAPTER 34 The Fetal Brain 1187Cere
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CHAPTER 34 The Fetal Brain 1189loba
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CHAPTER 34 The Fetal Brain 1191ABCF
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CHAPTER 34 The Fetal Brain 1193ABCF
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CHAPTER 34 The Fetal Brain 1195spor
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ABCCCDEFFIG. 34.24 Type 2 Lissencep
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CHAPTER 34 The Fetal Brain 1199ABFI
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CHAPTER 34 The Fetal Brain 120120 w
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CHAPTER 34 The Fetal Brain 1203Ultr
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CHAPTER 34 The Fetal Brain 1205ABCD
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VSSABHHPHCDEFFIG. 34.35 Intracrania
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CHAPTER 34 The Fetal Brain 1209VABC
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CHAPTER 34 The Fetal Brain 1211Huma
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CHAPTER 34 The Fetal Brain 1213121.
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CHAPTER 34 The Fetal Brain 1215221.
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CHAPTER 35 The Fetal Spine 1217ABCF
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CHAPTER 35 The Fetal Spine 1219L1S3
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CHAPTER 35 The Fetal Spine 1221FTFT
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CHAPTER 35 The Fetal Spine 1223FIG.
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CHAPTER 35 The Fetal Spine 1225TABL
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CHAPTER 35 The Fetal Spine 1227Feta
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CHAPTER 35 The Fetal Spine 1229MMAB
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ABCDEFFIG. 35.15 Skin-Covered Myelo
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CHAPTER 35 The Fetal Spine 1233diic
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CHAPTER 35 The Fetal Spine 1235CCSC
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CHAPTER 35 The Fetal Spine 1237chon
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CHAPTER 35 The Fetal Spine 1239BSCT
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CHAPTER 35 The Fetal Spine 124162.
Page 1415 and 1416:
CHAPTER36The Fetal ChestDorothy Bul
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CHAPTER 36 The Fetal Chest 1245seco
Page 1419 and 1420:
CHAPTER 36 The Fetal Chest 1247TABL
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CHAPTER 36 The Fetal Chest 1249Left
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CHAPTER 36 The Fetal Chest 12511ABC
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CHAPTER 36 The Fetal Chest 1253ABCF
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CHAPTER 36 The Fetal Chest 1255cent
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CHAPTER 36 The Fetal Chest 1257Left
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CHAPTER 36 The Fetal Chest 1259ABCD
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CHAPTER 36 The Fetal Chest 1261RTLT
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CHAPTER 36 The Fetal Chest 1263ARig
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CHAPTER 36 The Fetal Chest 12659. B
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CHAPTER 36 The Fetal Chest 1267107.
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CHAPTER 36 The Fetal Chest 1269204.
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CHAPTER 37 The Fetal Heart 1271TABL
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CHAPTER 37 The Fetal Heart 1273TABL
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CHAPTER 37 The Fetal Heart 1275Plac
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CHAPTER 37 The Fetal Heart 1277ADop
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CHAPTER 37 The Fetal Heart 1279LVRV
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CHAPTER 37 The Fetal Heart 1281RARV
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CHAPTER 37 The Fetal Heart 1283RARV
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CHAPTER 37 The Fetal Heart 1285Norm
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CHAPTER 37 The Fetal Heart 1287RVLV
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CHAPTER 37 The Fetal Heart 1289RVTA
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CHAPTER 37 The Fetal Heart 1291LVRA
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CHAPTER 37 The Fetal Heart 1293Aspl
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CHAPTER 37 The Fetal Heart 1295PLVL
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CHAPTER 37 The Fetal Heart 1297HR-L
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CHAPTER 37 The Fetal Heart 129951.
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CHAPTER 38 The Fetal Gastrointestin
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UrogenitalsinusMesonephrosMesonephr
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CHAPTER 39 The Fetal Urogenital Tra
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CHAPTER 40 The Fetal Musculoskeleta
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CHAPTER 41 Fetal Hydrops 1413ABFIG.
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ABCDFIG. 41.2 Ascites. (A) Fluid ou
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CHAPTER 41 Fetal Hydrops 1417A B CD
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CHAPTER 41 Fetal Hydrops 1423later
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CHAPTER 41 Fetal Hydrops 1427CHABCH
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CHAPTER 41 Fetal Hydrops 1429Monoch
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CHAPTER 41 Fetal Hydrops 1431feedin
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CHAPTER 41 Fetal Hydrops 1433TABLE
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CHAPTER 41 Fetal Hydrops 1435sampli
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CHAPTER 41 Fetal Hydrops 1437Predel
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CHAPTER 41 Fetal Hydrops 143973. Ma
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CHAPTER 41 Fetal Hydrops 1441169. I
Page 1615 and 1616:
CHAPTER42Fetal Measurements: Normal
Page 1617 and 1618:
CHAPTER 42 Fetal Measurements 1445F
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CHAPTER 42 Fetal Measurements 1447T
Page 1621 and 1622:
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CHAPTER 42 Fetal Measurements 1451p
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CHAPTER 42 Fetal Measurements 1453d
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CHAPTER 42 Fetal Measurements 1455A
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CHAPTER 42 Fetal Measurements 1459A
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CHAPTER 42 Fetal Measurements 14618
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CHAPTER 42 Fetal Measurements 14631
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CHAPTER43Sonographic Evaluation oft
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CHAPTER 43 Sonographic Evaluation o
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CHAPTER44Cervical Ultrasound and Pr
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CHAPTER 44 Cervical Ultrasound and
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PART FIVE: Pediatric SonographyCHAP
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CHAPTER 45 Neonatal and Infant Brai
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CHAPTER46Duplex Sonography of the N
Page 1747 and 1748:
CHAPTER 46 Duplex Sonography of the
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Page 1757 and 1758:
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Page 1761 and 1762:
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CHAPTER47Doppler Sonography of the
Page 1765 and 1766:
CHAPTER 47 Doppler Sonography of th
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CHAPTER 48 The Pediatric Head and N
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Page 1815 and 1816:
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CHAPTER 49 The Pediatric Spinal Can
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Page 1863 and 1864:
Page 1865 and 1866:
RA B CDEFGFIG. 49.27 Neuroblastoma
Page 1867 and 1868:
Page 1869 and 1870:
Page 1871 and 1872:
Page 1873 and 1874:
CHAPTER50The Pediatric ChestChetan
Page 1875 and 1876:
CHAPTER 50 The Pediatric Chest 1703
Page 1877 and 1878:
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Page 1881 and 1882:
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Page 1889 and 1890:
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Page 1895 and 1896:
Page 1897 and 1898:
Page 1899 and 1900:
Page 1901 and 1902:
Page 1903 and 1904: CHAPTER 51 The Pediatric Liver and
Page 1943 and 1944: ABCFIG. 51.39 Hepatosplenomegaly. W
Page 1947 and 1948: CHAPTER52The Pediatric Urinary Trac
Page 1949 and 1950: CHAPTER 52 The Pediatric Urinary Tr
Page 1951 and 1952: TABLE 52.4 Mean Total Renal Volumes
Page 1953: CHAPTER 52 The Pediatric Urinary Tr
Page 2005 and 2006:
CHAPTER53The Pediatric Gastrointest
Page 2007 and 2008:
CHAPTER 53 The Pediatric Gastrointe
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Page 2015 and 2016:
Page 2017 and 2018:
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CHAPTER 54 Pediatric Pelvic Sonogra
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CHAPTER 55 The Pediatric Hip and Ot
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Page 2099 and 2100:
Page 2101 and 2102:
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Page 2105 and 2106:
Page 2107 and 2108:
Page 2109 and 2110:
ABCDFIG. 55.13 Normal and Dislocate
Page 2111 and 2112:
Page 2113 and 2114:
Page 2115 and 2116:
CHAPTER 56 Pediatric Interventional
Page 2117 and 2118:
Page 2119 and 2120:
Page 2121 and 2122:
Page 2123 and 2124:
Page 2125 and 2126:
Page 2127 and 2128:
Page 2129 and 2130:
Page 2131 and 2132:
ABCFIG. 56.15 Access for Drainage o
Page 2133 and 2134:
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Page 2137 and 2138:
Page 2139 and 2140:
Page 2141 and 2142:
APPENDIXUltrasound Artifacts: A Vir
Page 2143 and 2144:
APPENDIX Ultrasound Artifacts: A Vi
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Page 2173 and 2174:
Page 2175 and 2176:
Page 2177 and 2178:
Page 2179 and 2180:
IndexAAA anastomoses. See Arterial/
Page 2181 and 2182:
Index I-3Adnexa (Continued)transvag
Page 2183 and 2184:
Index I-5Arrays, transducer, 11-12A
Page 2185 and 2186:
Index I-7Bioefects (Continued) Biop
Page 2187 and 2188:
Index I-9Brain, neonatal/infant (Co
Page 2189 and 2190:
Index I-11Carcinoma(s) (Continued)
Page 2191 and 2192:
Index I-13Cervix (Continued)for sym
Page 2193 and 2194:
Index I-15Color Doppler ultrasound
Page 2195 and 2196:
Index I-17Cystic artery, 194promine
Page 2197 and 2198:
Index I-19Diabetes mellituschronic
Page 2199 and 2200:
Index I-21Echinococcal disease (Con
Page 2201 and 2202:
Index I-23Exudate ascites, 506-507E
Page 2203 and 2204:
Index I-25Gallbladder (Continued)ad
Page 2205 and 2206:
Index I-27Gyriabnormalities of, in
Page 2207 and 2208:
Index I-29Hernia(s). See also Diaph
Page 2209 and 2210:
Index I-31Hyperechoic tissue, in br
Page 2211 and 2212:
Index I-33Internal jugular vein (IJ
Page 2213 and 2214:
Index I-35Kidneys, pediatric (Conti
Page 2215 and 2216:
Index I-37Liver transplantation (Co
Page 2217 and 2218:
Index I-39Mesentery, small bowel, 5
Page 2219 and 2220:
Index I-41Nasal bone, fetal (Contin
Page 2221 and 2222:
Index I-43Orbits, fetal (Continued)
Page 2223 and 2224:
Index I-45Patau syndrome. See Triso
Page 2225 and 2226:
Index I-47Pleural efusionsfetal, 12
Page 2227 and 2228:
Index I-49Prostate (Continued)thera
Page 2229 and 2230:
Index I-51Renal transplantation (Co
Page 2231 and 2232:
Index I-53Shunt(s) (Continued) Skel
Page 2233 and 2234:
Index I-55Splenic vein (Continued)t
Page 2235 and 2236:
Index I-57Testis(es) (Continued)cys
Page 2237 and 2238:
Index I-59Transcranial Doppler (TCD
Page 2239 and 2240:
Index I-61Umbilical cord, 1481-1487
Page 2241 and 2242:
Index I-63Vein of Galen (Continued)
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Page 2249:
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