These are clinical notes for MID students

1. CLINICAL
NOTES FOR MID
STUDENT
PRESENTED BY :
HAFIZA NOOR FATIMA
UNIVERSITY OF LAHORE
FROM BOOK :
REQUISITES

2. KIDNEY

3. Basic Anatomy
Retroperitoneal organ
Size :11cm(10-13cm)
Surface: smooth
SONOGRAPHY :
Renal sinus-echogenic

4. renal vessels & collecting system -thin anechoic
-fluid filled
Lymphatics – no appearance
Pyramids – cone heart shaped
- hypoechoic structures
Cortex – more echogenic than pyramids
11 pyramids & 9 calices
echogenicity : RK<=liver, LK<spleen
Parenchyma : homogeneous

5. TECHNIQUE
 2-5 MHz transducer
APPROACHES :
1. Posterior intercostal approach
Supine position
upper poles of each kidney
Liver or spleen as window
2. Subcostal approach
For lower poles
Deep inspiration
Some times best seen from antero lateral approach in right lateral
decubitus position (especially in obese patients)
3. Posterior approach
Gets probe closer to the kidney
Allow better visualization
Useful for cyst and stones

6. HYDRONEPHROSIS
 Hydronephrosis is a condition that typically occurs when
the kidney swells due to the failure of normal drainage of urine from
the kidney to the bladder.
 This swelling most commonly affects only one kidney, but it can
involve both kidneys.
 Hydronephrosis isn’t a primary disease.
 It’s a secondary condition that results from some other underlying
disease.
 It’s a structural condition that’s the result of a blockage
or obstruction in the urinary tract.

7. SYMPTOMS CAUSES
 pain in the abdomen or flank
 nausea
 vomiting
 pain when urinating
 incomplete voiding
 a fever
 cloudy urine
 painful urination
 burning with urination
 a weak urine stream
 back pain
 bladder pain
 a fever
 chills
 an enlarged prostate gland in
men, which can be due to BPH
or prostatitis
 pregnancy, which causes a
compression due to a growing
fetus
 tumors in or near the ureter
 a narrowing of the ureter from
an injury or birth defect

8. HYDRONEPHROSIS ON ULTRASOUND
 Hydronephrosis [water - kidney condition] refers to a kidney with a
dilated pelvis and collecting system.
 TYPES
mild
Moderate
severe

9. MILD HYDRO OR GRADE 1
 Minimal amount of urine
 Producing slight distention of the collecting system
 May b due to any obstruction

10. MODERATE HYDRO SEVERE HYDRO
 Dilation of collecting system
 But not associated with cortical
thinning
 Less likely due to obstruction
 Also known as marked
hydronephrosis
 Severe dilation that is
associated with cortical
thinning
Grade 2 Grade 3

11. PYONEPHROSIS
 Refers to an obstructed and infected collecting system
 On sonography:
echogenic pus can be seen filling collecting system

12. CYSTIC DISEASES

13. BENIGN CYSTS
 Most common
 Above the age of 50
 If lesion is simple cyst :
anechoic lumen
well defined back wall
acoustic enhancement deep to lesion
no measurable wall thickness

14. SMALL CYST
 May have low level internal echoes
 Not have demonstrable acoustic . E
if benign cyst :
 Contains internal thin septations
(If thick septations than renal cell carcinoma)
 Intraluminal hemorrhage
hemorrhage may cause internal fluid level debris , clots ,
low level internal echoes & fibrinous membranes .( may
refer carcinoma)

15. CALCIFICATION IN CYSTS
 Occur in 1-3% of cysts
 Usually due to hemorrage , infection etc
 These indicates may underlying malignancy
Crystalline material
accumulation in cysts
 Produce shadowing
 If this material is seen on radiograph called as milk of calcium
 Small ring artifacts seen posterior to this crystalline material

16. PERI-PELVIC CYSTS
 Cysts that forms in the renal sinus called ppc
 Are lymphatic in origin
 Bilateral mostly
 Often multiple
 Imp b/c they can be confused with hydro
 May elongate and herniate out from the renal sinus

17. AUTOSOMAL DOMINANT POLYCYSTIC DISEASE
 Effects mostly on kidneys
 So referred as adult PKD
 Sonography
multiple
variably sized cortical & medullary based cysts
bilateral
early normal parenchyma but with the passage of time it cover
complete parenchyma of kidney
when cysts enlarges it causes obstruction in collecting system
and may form stones
calcifications may also seen in the walls of the cyst
crystals also forms in the cyst and produce comet tail artifact
hemorrhage also common and may forms debris or large
complex cyst

18. CRITERIA :
 2 cysts in 1 kidney or 1 cyst in each kidney – a
person younger than 30 y
 2 cysts in each kidney – b/w 30 to 59 y
 4 cysts in each kidney – 60 or above 60

19. ACQUIRED CYSTIC DISEASE
 Acquired cystic kidney disease happens when a person's
kidneys develop fluid-filled sacs, called cysts, over time.
 Acquired cystic kidney disease is not the same
as polycystic kidney disease (PKD), another disease that
causes the kidneys to develop multiple cysts.
 90 % in those who have been 3 years of dialysis
 Hemorrhage is common

20. VON HIPPLE LINDAU DISEASE
 Inherited
 is a rare genetic disorder characterized by visceral cysts and benign
tumors in multiple organ
 multiple cysts kidneys and an increased risk for malignant
transformation of renal cysts into renal cell carcinoma.
 Multiple
 bilateral

21. TUBEROUS SCLEROSIS
 Formation of renal cysts and neoplasms

22. MALIGNANT RENAL NEOPLASMS

23. 1. RENAL CELL CARCINOMA
 Common about 90%
 Male to female ratio is 2:1
 Surgical lesion

25. ON SONOGRAPHY:-
 50% RCC are hyperechoic as compared to normal renal
parenchyma
 40% RCC are echogenic than normal parenchyma
 30% RCC are isoechoic to the normal parenchyma
 10% are hypoechoic
 They contain simple or complex cyst as well
 20% of them are contained with a peripheral rim like of
calcifications
 Some lesions are densely calcified
 On CT & MRI it could be seen that solid mass is not RCC by
examining that there is a presence of fat in this mass . So , it is
not a RCC.
 Cyst with multiple thick septations , thick irregular wall , or a cyst
with solid mural nodule
 Doppler is also helpful for them. Sometimes vascularity is present
and there is the detection of blood flow in them and vise versa.

26. ROBSON SYSTEM :-
 Common staging system for the RCC
 Stage 1: confined to kidney
 S-2: invasion of perinephric fat
 S-3A: invasion of renal vein
 S-3B: is regional nodal metastases
 S-3C: combined venous and nodule involvement
 S-4: invasion of adjacent organs
 S-5: distant metastases

27. MEDULLARY CANCER :-
 Affects patient with sickle cell trait
 in Early age
 Typical RCC
 More commonly associated with malignancy

28. 2. TRANSITIONAL CELL CARCINOMA
 Bilateral
 Multiple
 Too small
on sonography:
 Intraluminal polypoid mass
 Thickening of urothelium
 Nonspecific solid renal mass centered in renal sinus
 It invades in the kidney
 Sometimes it is confused with prominent papillary tips
 Prominent papillary tips are in all calices but TCC appear in 1
or limited number of calices
 Are not better seen on ULT while better seen on urethrogram

29. 3. LYMPHOMA
 Direct invasion of lymph nodes
 Bilateral
sonography
 Multiple , bilateral , hypoechoic mass
 Diffuse infiltration
 Renal enlargement
 Few internal reflectors
 Anechoic appearance of cyst
 Sometimes lack of acoustic enhancement provides a clue that
it is solid and not cystic
 Acoustic enhancement rarely seen
 It particularly surrounds the kidney b/c the growth of the tumor
in perinephric space

31. 4. METASTATIC DISEASE
 Solid
 Infiltrative
 may be Hypovascular
 Sometimes solid with a hyperechoic rim

32. BENIGN RENAL NEOPLASMS

33. 1.ANGIOMYOLIPOMA
 Are tumors composed of muscles , vessels and fats
 Most common
 Middle aged women’s mostly
 When lesion exceeds from 4cm than bleeding occurs
 If it is greater than 4cm than removal should be done
sonography
 Homogenous
 Well defined
 Cortical mass
 Shadowing may be seen it is due to the sound beam attenuation by
the mixture of fat and muscles
 Sometimes produces tip of ice berg sign on scan

35. 2. ONCOCYTOMA
 Large epithelial cells
 If malignant than surgery should be performed
sonography:
 Non specific
 Overlap with renal cancer
on CT
 Stellate central scar
 Rarely seen without contrast

38. 3.JUXTAGLOMERULAR CELL TUMOR
 Rare
 Also called reninoma b/c it secretes renin
 Mostly in young women
 Sign and symptoms relating to severe hypertension
 Sonography is variable
 But are most often hyperechoic

40. 4. MULTILOCULAR CYSTIC NEPHROMA
 Composed of multiple large , non-communicating cystic spaces
 Encapsulated lesion
 Young boys and older women
 Multiple cysts present so that surgically removal should be done

42. INFECTION
 Infection of the renal collecting system and renal parenchyma is
called as pyelonephritis
 It could be resolve in 72hr but some severe forms are not resolve in
72hr
on sonography :
 urethral thickening is seen
 Renal enlargement
 Producing areas of inc or dec echogenicity
 Patchy appearance to the cortex
 Dec vascularity on ULT
 In image acute pyelonephritis

43. RENAL ABSCESS :-
 Complex cystic mass
 Large abscess ______ biopsy
 Small abscess ______ antibiotics

44. PERINEPHRIC ABSCESS :-
 Complex perinephric fluid collections
 Small , anechoic fluid

45. PERINEPHRIC FAT
 Very hypoechoic
 Hypoechoic in patients with renal atrophy

46. XANTHOGRANULOMATOUS
PYELONEPHRITIS
 Chronic inflammatory process
 Associated with long standing urinary obstruction
 Formation of yellow inflammatory masses
 More than 75% will have a stone
 And most of them will have a stag horn variety
sonography
 Stone shadow
 Dilated renal calices
 Perinephric fluid collection
 Perinephric inflammatory tissue

49. EMPHYSEMATOUS PYELONEPHRITIS:-
 Serious infection
 In diabetic women
 Formation of gas in the renal parenchyma stemming from high
tissue glucose concentration
 Vascular disease

52. EMPHYSEMATOUS PYELITIS :-
 Less serious
 Gas forms in the collecting system
 But not the parenchyma
sonography
 Bright reflectors
 Dirty shadows or ring down artifact

53. RENAL CALCULI

54.  Kidney stones, or renal calculi, are solid masses
made of crystals.
 Kidney stones usually originate in your kidneys, but
can develop anywhere along your urinary tract.
 Common in 70 age
 Common in males
Risk Factors
 Low fluid intake
 Diets high in animal protein

55. TYPES
1. Calcium containing stones
 most common
 calcium present in the forms of calcium oxalate & calcium
phosphate
2. Uric acid stones
 5-10%
 Commonly associated with gout
3. Pure uric acid stones
 Are radiolucent
4. Cistine stones
 <5%
 Are related to cistinuria (rare metabolic disorder)
 Radiolucent
 Composed of struvite & apatite
 Often develop into staghorn calculi
 In image staghorn calculus is present

56. SONOGRAPHY
 Depends upon their size not their composition
 Stones with sufficient size
echogenic & acoustic shadowing
 Small stones
echo & shadow but shadow is seen by the use of
high frequency transducer
 Color doppler use for some stones which are produced
a short color ring down artifact called twinkle artifact
 In women transvaginal sonograpgy is also done
 Now a days non enhanced CT is preferred b/c it is more
reliable than sonography but in pregnant ladies we
prefer ultrasound.

58. NEPHROCALCINOSIS
 is a term originally used to describe deposition of
calcium salts in the renal parenchyma due to
hyperparathyroidism.

59. TYPES
1. Medullary nephrocalcinosis
calcifications in the medullary pyramids
CAUSES:
tubular ectasia
renal tubular acidosis
hyperparathyrodism
in early stage:
It produces echogenicity at the periphery of pyramids
And than involve all the pyramid
With progressive calcification shadowing begans to
develop

61. 2. DIFFUSE CORTICAL NEPROCALCINOSIS
 Is rare
 Secondary to cortical necrosis

62. RENAL PARENCHYMAL DISEASE
 Increased parenchymal echogenicity
 It means inc. echogenicity of renal parenchyma
than liver or kidney

64. RENAL TRAUMA
 Kidney (renal) trauma is when a kidney is injured by
an outside force
 can result from direct, blunt, penetrating and
iatrogenic injury.
Renal Hematomas
 echogenic Hetrogenous mixed
Subscapular Hematomas
 Difficult to detect in acute stages b/c they almost
isoechoic to the kidney
 Causes reduction of blood flow
 Many vascular lesions are detected on CT