Diagnostic ultrasound ( PDFDrive )

372 PART II Abdominal and Pelvic Sonography
FIG. 9.88 Acute Cortical Necrosis. Transverse sonogram shows a
rim of cortical hypoechogenicity.
FIG. 9.89 Bladder Endometrioma. Transvaginal scan demonstrates
cystic components in a mural mass that are typical for an endometrioma.
(With permission from Damani N, Wilson S. Nongynecologic applications
of transvaginal ultrasound. Radiographics. 1999;19:S179-S200. 83 )
Diabetes Mellitus
Diabetes mellitus is the most common cause of chronic renal
failure. Diabetic nephropathy is believed to be related to glomerular
hyperiltration. Renal hypertrophy occurs. With time,
difuse intercapillary glomerulosclerosis develops, causing a
progressive decrease in renal size. At sonography, the kidneys
are initially enlarged but, with time and progressive renal insuficiency,
the kidneys decrease in size and increase in cortical
echogenicity, and corticomedullary junctions are preserved.
With end-stage disease, the kidneys become smaller and
more echogenic, and the medulla becomes as echogenic as the
cortex. 292
Amyloidosis
Amyloidosis may be primary or secondary and usually is
a systemic disease; 10% to 20% of cases are localized to one
organ system. 293 Patients with amyloidosis oten present with
renal failure. Patients with primary disease are more oten men,
with a mean age of 60 years. Causes of secondary amyloidosis
include multiple myeloma (10%-15%), rheumatoid arthritis
(20%-25%), tuberculosis (50%), familial Mediterranean fever
(26%-40%), RCC, and Hodgkin disease. 293 During the acute
phase, the kidneys are be symmetrically enlarged. With disease
progression, the kidneys shrink; cortical atrophy and increased
echogenicity are shown at ultrasound. Focal renal masses, amorphous
calciication, a central renal pelvic mass that may be a
hemorrhage or amyloid deposit, and perirenal sot tissue masses
may be seen. Similarly, involvement of the ureter and bladder
may be localized or difuse. Wall thickening or masses with or
without calciication may be demonstrated. he diagnosis is made
with biopsy.
Endometriosis
Endometriosis occurs when endometrial tissue is found outside
the uterus in women during the reproductive years. Patients
typically present with pain, infertility, dysmenorrhea, and dyspareunia.
Approximately 1% of women with pelvic endometriosis
will have urinary tract involvement, most frequently in the
bladder. Patients with bladder endometriosis will present with
hematuria. Bladder endometriosis may be focal or difuse. Less
oten the ureter and rarely the kidney are afected. At sonography,
patients with bladder endometriosis may present with a mural
or intraluminal cyst or a complex or solid lesion. Diagnosis is
usually made cystoscopically with biopsy (Fig. 9.89).
Interstitial Cystitis
Interstitial cystitis is a chronic inlammation of the bladder wall
of unknown origin. It usually afects middle-aged women and
has been associated with other systemic diseases, including
systemic lupus erythematosus, rheumatoid arthritis, and polyarteritis.
75 Irritative voiding symptoms predominate, and
hematuria (30%) may occur. 294 At sonography, a small-capacity,
thick-walled bladder is seen (Fig. 9.90). Ureteric obstruction
may be present. In some cases it is impossible to diferentiate
interstitial cystitis from difuse TCC of the bladder; patients
should have cystoscopy with biopsy for conirmation.
NEUROGENIC BLADDER
Voiding is a well-coordinated neurologic process controlled by
areas within the cerebral cortex. hese areas control the detrusor
muscle of the bladder as well as both the internal and the external
urethral sphincter. For simplicity, lesions causing neurogenic
bladder are divided into those causing either detrusor arelexia
(a lower motor neuron lesion) or detrusor hyperrelexia (lesions
above the sacral relux arc).
At sonography, detrusor arelexia results in a smooth, largecapacity,
thin-walled bladder. he bladder may extend high into
the abdomen (Fig. 9.91A). Detrusor hyperrelexia produces a
thick-walled, vertical, trabeculated bladder, oten with associated
upper tract dilatation (Fig. 9.91B and C). A large, postvoid residual
will be seen. 295 If neurogenic bladder dysfunction is not properly