General Sonography II Final Exam

Atherosclerosis → buildup of plaque overtime within artery walls

• clinical hx: male, long term smoker, alcohol abuser, DM, cholesterol (LDL), HTN

• s/sx: often asymptomatic, can cause chest pain, weakness, leg pain, high BP depending on what arteries are affected

• 2D US presentation: starts as hypoechoic plaque within lumen → plaque turns echogenic w/ posterior shadowing and gives artery wall irregular lobulated shape

• color doppler: twinkle artifact from calcification

• DDX: arteriosclerosis (stiff walls, not obstructive), vasculitis (diffuse wall thickening from inflammation, not plaque)

AAA (Abdominal Aortic Aneurysm) → focal dilation of aorta

• clinical hx: older (65+) male, smoker, HTN, Marfan syndrome, DM

• s/sx: asymptomatic/incidental finding, can have palpable pulsatile mass in midline abdomen, audible bruit (turbulence) → rupture can cause excruciating abdominal pain, back pain, shock, expanding abdominal mass (surgical emergency)

• 2D US presentation: focally dilated AO (3 cm or greater), mural hypoechoic thrombus, wall calcifications, usually located infrarenal, can be fusiform or saccular

• color doppler: turbulent helical flow

• DDX: aortic dissection (aorta may be enlarged, but has intimal flap), pseudoaneurysm (focal outpouching w/ narrow neck, but not all 3 layers involved)

Pseudoaneurysm → rupture from intima layer contained in deeper layers of artery wall

• clinical hx: older male, post-catheterization/surgery, trauma

• s/sx: acute pulsatile mass, expending mass, pain with bruising, decreased hematocrit, ± increased WBC with mycotic/infected pseudoaneurysm → symptoms appear within hours/days

• 2D US presentation: heterogenous, pulsating central structure with internal swirling of brighter echogenicity

• color doppler: “yin-yang” sign, “to and fro” PW waveform

• DDX: hematoma (hypoechoic intraluminal echoes, but not color flow or neck connecting), true aneurysm (wide rather than narrow neck continuous w/ artery, chronic rather than acute)

Aortic Dissection → intimal wall tears and allows blood flow between layers

• clinical hx: intimal wall weakness, usually related to surgery, Marfan’s disease, HTN, smoker

• s/sx: sudden severe, sharp pain in upper back, tearing/stabbing/ripping feeling

• 2D US presentation: thin echogenic linear membrane fluttering in lumen creating a true and false lumen

• color doppler: fill in both channels → pw shows regular flow in true and weak/no flow in false; asymmetrical kidney perfusion

• DDX: AAA (focal dilation, no intimal flap)

Congestion → increased pressure in IVC and hepatic vein(s) usually by right-sided heart failure

• clinical hx: older adults, cardiac issues,

• s/sx: epigastric/sternal pain

• 2D US appearance: dilation of IVC and one or more hepatic veins (IVC greater than 3 cm diameter and hepatic veins greater than 13 mm)

• PW: IVC loses “houndstooth” waveform and turns mildly undulating

• DDX: budd-chiari (hepatic vein thrombosis/obstruction, but there is no outflow obstruction in congestion)

IVC Thrombosis → blood clot in IVC (usually from distal vein or organ)

• clinical hx: older, hypercoagulable, immobilized, post trauma or surgery

• s/sx: rapid bilateral leg swelling, lower/pelvic pain, ascites, SOB, chest pain

• 2D US: dilated IVC over 3 cm, intraluminal fill (hypo, echogenic, heterogenous), can be obstruction by IVC tumor

• color doppler: lack of fill of affected region, tumor = vessels will be shown feeding tumor in mass

• DDX: IVC congestion (dilated IVC, no intraluminal echogenic material), budd-chiari (hepatic vein thrombosis, IVC may be occluded)

Fatty Infiltration/Fatty Liver Disease → excess fat builds up in liver cells

• clinical hx: DM, older male, EtoH abuse, obesity

• s/sx: asymptomatic, elevated LFTs, palpable liver

• 2D US: enlarged liver, diffusely echogenic parenchyma, mild → slightly brighter, can still see periportal fat in veins, moderate → increased echoes, slight impaired diaphragm & vessel borders, severe → significantly brighter, less penetration of posterior right lobe, poor visualization of diaphragm & vessels

• DDX: hepatitis (echogenic liver, hepatomegaly, but has bright portal veins), cirrhosis (increased echogenicity, but coarse and nodular)

Glycogen Storage Disease → recessive disease, accumulation of glycogen in liver and kidneys

• clinical hx: presents neonatally, recessive

• s/sx: asymptomatic, abdominal distention, elevated LFTs (ALT, AST, alk phos)

• 2D US: echogenic, homogenous liver, hepatomegaly, kidney enlargement, association w/ having hepatic adenomas (adenoma = well-defined, round, homogenous tumor/can be mildly heterogenous if large

• DDX: fatty liver (diffusely echogenic & hepatomegaly, but usually adults), hepatitis (hepatomegaly, but hypoechoic not echogenic)

Hemochromatosis & Wilson’s Disease → autosomal recessive, excess iron (HC) and copper (WD) deposits in organs including liver

• clinical hx: HC = older adults, WD = young adults/early adulthood

• s/sx: abdominal discomfort, fatigue

• 2D US: echogenic liver, hepatomegaly, can have progressive cirrhotic changes

• DDX: fatty liver & glycogen storage disease (echogenic liver, hepatomegaly, but not recessive)

Acute Hepatitis → inflammation of liver

• clinical hx: HAV → developing countries, contagious, HBV → needles, healthcare workers, Asia, Africa, HCV → needles (Africa, Europe)

• s/sx: asymptomatic initially, can turn to fatigue, GI issues, nausea, and loss of appetite, elevated AST with & ALT x5, jaundice, leukocytosis

• 2D US: can appear normal, but can be hypoechoic tissue, portal triad edema “cuffing” (starry sky), hepatomegaly, splenomegaly, GB wall thickened w/o distention

• DDX: cirrhosis (starry sky appearance can mimic fibrosis, but not acute)

Chronic Hepatitis → continued inflammation of liver (acute hepatitis for 6+ months)

• clinical hx: bouts of acute hepatitis, needle users, past HCV

• s/sx: asymptomatic, dark urine, jaundice, elevated LFTs, elevated bili

• 2D US: fibrotic changes, striations in tissue, coarse texture, decrease in portal triad brightness

• DDX: cirrhosis (coarse, fibrotic tissue, but has nodular contour)

Cirrhosis → chronic liver disease causing fibrosis and scarring

• clinical hx: EtoH abuse, older male, obesity, chronic hepatitis

• s/sx: asymptomatic, can have abdominal discomfort/distention, anorexia/weight loss, jaundice, dark urine, abnormal AST & ALT, elevated bili

• 2D US: early stages → hepatomegaly, later/progressive → right ± left lobe atrophy, compensatory caudate lobe hypertrophy, fibrotic heterogenous liver changes, nodular contour, ± hepatic vein compression w/ flattened waveform, PHTN → ascites, splenomegaly, MPV dilation ± reversal of flow

• DDX: chronic hepatitis (coarse, fibrotic liver, can turn into cirrhosis if prolonged)

Budd-Chiari Syndrome → rare occlusion of hepatic veins ± IVC

• clinical hx: young to middle-aged, hypercoagulable

• s/sx: RUQ pain, rapid onset body fluid accumulation, severe elevated LFTs

• 2D US: intraluminal material isoechoic to liver, hepatomegaly, splenomegaly, ascites, edema

• color doppler: no communication between hepatic vein and IVC

• DDX: IVC thrombosis (reduced/absent venous flow, but no hepatic vein occlusion), portal vein thrombosis (same secondary findings, but echogenic material in lumen of PV)

HVOD (Hepatic Veno Occlusive Disease) → rare condition where sinusoids are blocked and liver can’t drain properly

• clinical hx: stem cell transplant, chemo patients,

• s/sx: tender RUQ, rapid weight gain (body fluid accumulation, significant elevated LFTs, elevated bili w/o biliary cause,

• 2D US: liver swelling, GB wall edema and thickening, dilated MPV, ascites, hepatic artery RI increase

• color doppler:

• DDX:

Hepatic Cyst → usually acquired, true cysts are simple cysts

• clinical hx: middle-aged or older, women typically

• s/sx: asymptomatic, no LFT elevation (if uncomplicated)

• 2D US: well-defined, thin-walled, anechoic w/ posterior acoustic enhancement, can turn infected or hemorrhagic (internal echoes/septations, thick wall)

• color doppler: avascular

• DDX: complicated cyst (pyogenic/amebic abscess, hydatid cyst)

Polycystic Liver Disease → associated with ADPKD

• clinical hx: ADPKD, female

• s/sx: usually asymptomatic

• 2D US: varied multiple simple cysts, hepatomegaly from excessive cyst, cysts can become complicated (infected or hemorrhagic)

• color doppler: avascular if uncomplicated

• DDX: ADPKD, peribiliary cysts, simple cysts

Peribiliary Cysts → rare, fluid-filled sacs forming along bile ducts in liver

• clinical hx: *severe liver disease/underlying liver disease

• s/sx: asymptomatic

• 2D US: discrete, clustered, tubular-appearing cysts at the central hilar area of liver

• color doppler: avascular

• DDX: biliary dilation (mimics appearance of dilated biliary ducts)

Pyogenic Abscess → pus-filled cyst formed d/t infection

• clinical hx: infection (cholangitis, cholecystitis, serious GI infection), iatrogenic

• s/sx: fever, increased WBC, anorexia, N&V, RUQ pain

• 2D US: round, indistinct border, acoustic enhancement, debris filled/can appear solid (echogenic, homogenous, isoechoic heterogenous, septations, altered internal echogenicity), thick echogenic wall

• color doppler: no internal vascularity, peripheral vascularity

• DDX: amebic abscess, hydatid cyst

Amebic Abscess → parasite reaches liver

• clinical hx: recent travel to Central and South America, Africa

• s/sx: RUQ pain, persistent diarrhea, leukocytosis

• 2D US: round/oval, posterior enhancement, uniformly hypoechoic w/ low level internal echoes/debris, ill-defined wall,

• color doppler: avascular

• DDX: pyogenic/hydatid cyst

Hydatid Disease/Echinococcal Cyst → infectious, parasitic disease (tapeworm) in sheep-herding areas

• clinical hx:traveled recently to sheep herding area (

• s/sx: may be asymptomatic, RUQ pain, leukocytosis (if it ruptures)

• 2D US: water lily sign (infolding from collapsed wall), cyst w/ daughter cells, outer wall calcifications,

• color doppler: avascular

• DDX: amebic abscess, pyogenic abscess

Hepatic Candidiasis → rare, fungal infection through bloodstream

• clinical hx: chemo, transplant, immunocompromised

• s/sx: persistent, low-grade fevers

• 2D US: multiple small lesions, uniformly hypoechoic, or wheel within wheel/bullseye appearance (hypoechoic rim, echogenic inner wheel, anechoic center)

• color doppler: avascular

• DDX:

Chronic Granulomatous Disease → congenital defect resulting in increased susceptibility to severe infections

• clinical hx: mostly in children, recurrence in girls,

• s/sx: recurrent infections

• 2D US: ill-defined, hypoechoic mass w/ posterior enhancement, ± calcifications present with posterior shadowing,

• color doppler: avascular

Pneumocystis Carinii → opportunistic infection in immunocompromised

• clinical hx: immunocompromised (AIDS)

• s/sx: low-grade fever, fatigue

• 2D US: diffuse, tiny, non-shadowing echogenic foci, replacement of liver parenchyma from echogenic clumps of calcifications (non-shadowing)

• color doppler: avascular

• DDX: chronic granulomatous disease

Cavernous Hemangioma → benign tumor of liver

• clinical hx: adult female

• s/sx: asymptomatic

• 2D US: typically small (can be large), less than 3 cm, well-defined, homogenous and hyperechoic, scalloped margins or can be heterogenous with hypoechoic center → larger = loses echogenicity w/ hypoechoic center → multiple = hemangiomatosis

• color doppler: hypoperfused

• DDX: HCC, mets

FNH (Focal Nodular Hyperplasia) → common, benign liver mass

• clinical hx: typically women of child-bearing years, long-term birth control

• s/sx: asymptomatic

• 2D US: well-defined, ~5 cm, usually solitary, central hypoechoic scar, isoechoic to hypoechoic to liver

• color doppler: central scar → stellate scar doppler pattern (pinwheel)

• DDX: hepatic adenoma, hemangioma, HCC

Liver Cell Adenoma → rare, benign liver tumor

• clinical hx: oral hormone, glycogen storage disease, typically female

• s/sx: palpable abdominal mass, asymptomatic (can have RUQ pain w/ bleeding tumor)

• 2D US: solitary, up to 15 cm, range of echotexture (echogenic to hypoechoic), calcifications

• color doppler: not as vascular, still hard to distinguish from FNH

• DDX: HCC, hemangioma, FNH

HCC (Hepatocellular Carcinoma) → most common primary malignant neoplasm of the liver

• clinical hx: cirrhosis, HBV, HCV, men

• s/sx: asymptomatic until invasion, weight loss, abdominal swelling (secondary to ascites), elevated serum AFP

• 2D US: hypoechoic, echogenic, complex/heterogenous, usually solitary massive tumor, can be multiple nodules throughout the liver, diffuse infiltrative mass, ascites; **fibrolamellar carcinoma has same appearance, but in adolescents

• color doppler: very vascular, vascular lumen invasion in both hepatic and portal veins

• DDX: liver cell adenoma

Hepatoblastoma → most common primary malignant disease of liver in children under 4

• clinical hx: Beckwith-Wiedmann syndrome (overgrowth syndrome), young/child

• s/sx: painless, palpable mass, high AFP

• 2D US: solitary, solid large mass, displacement of vasculature, poorly marginated borders, mixed echotexture (can have areas of hemorrhage, calcifications, necrosis)

• color doppler: vascular tumor

• DDX: HCC (diff. patient population), Wilm’s Tumor (same presentation as HCC and hepatoblastoma but appears in young adults)

Metastatic Disease (METS) → most common form of neoplastic involvement of the liver

• clinical hx: active CA diagnosis or prior remission history

• s/sx: can be asymptomatic, abnormal LFTs, jaundice, poor appetite, abdominal distention/bloating & weight loss

• 2D US: single or multiple solid lesions, varying sizes, can have bullseye appearance, echogenic, or hypoechoic, enlarged liver, can cause pseudo nodularity

• color doppler: hypo to hypervascular

• DDX: HCC, hemangioma, lymphoma

Lymphoma → lymphocyte proliferation in lymph nodes

• clinical hx: known history of lymphoma

• s/sx: nontender enlarged lymph nodes, night sweats, weight loss, palpable mass, elevated LFTs and alkphos, jaundice

• 2D US: multiple hypoechoic masses, lobular, poor margins, encases vasculature, periportal enlarged hypoechoic lymph nodes, splenomegaly

• color doppler:

• DDX: METS, HCC

Simple Splenic Cysts → secondary cysts from trauma, infection, or infarction (technically pseudocysts, since congenital cysts are rare)

clinical hx: trauma

s/sx: asymptomatic, can have LUQ pain

2D US: round, smooth, well-defined borders, anechoic fluid-filled lumen, no internal echoes (unless complicated, can produce posterior enhancement)

color doppler: avascular

DDX: splenic abscess/infected/complicated cyst

Splenic Abscess → pus-filled sac secondary to infection

clinical hx: underlying infection = endocarditis, septicemia, pancreatitis

s/sx: fever, LUQ tenderness, abdominal pain, left shoulder/flank pain, increased WBC

2D US: simple cyst to mixed echo pattern, hyperechoic nondependent foci representing gas
color doppler:

DDX: pancreatic cyst/infection (if near hilum), simple cyst

Hepatosplenic Candidiasis → severe systemic infection in those w/ weakened immune systems

clinical hx: immunocompromised (AIDS, chemo), fungal infection

s/sx: fever, abdominal pain, splenomegaly, nausea, anorexia

2D US: multiple hypoechoic abscesses, “bulls eye” sign (hypoechoic rim w/ echogenic core), hypoechoic ill-defined nodule, hyperechoic nodule
color doppler: avascular

DDX: splenic abscess (but usually solitary)

Splenic Infarction → blood supply to section of spleen is interrupted, leads to localized necrosis

clinical hx: infection, cardiac conditions

s/sx: acute LUQ pain, fever

2D US: peripheral hypoechoic wedge extending to capsule, normal adjacent parenchyma, later chronic ± fibrotic echogenic changes, ± splenomegaly
color doppler: avascular

DDX: splenic abscess, hematoma

Splenic Trauma → blunt trauma usually resulting in hematoma

clinical hx: usually blunt abdominal trauma, underlying splenomegaly increased risk

s/sx: LUQ pain, low hematocrit from bleeding, abdominal swelling/bloating discomfort

2D US: capsule intact = subcapsular hematoma (conforms to spleen shape), ruptured capsule = free fluid/hematoma may form (check abdominal gutters for free fluid)
color doppler: avascular

DDX: splenic infarction, splenic abscess

Cavernous Hemangioma → most common benign tumor of the spleen

clinical hx: adults, no gender preference

s/sx: asymptomatic

2D US: variable → well-defined echogenic to complex heterogenous pattern w/ hypoechoic regions or isoechoic
color doppler: hypoperfused

DDX: METS, infection

Cystic Lymphangioma → rare benign lymph node collection

clinical hx: usually incidental, manifests in children/young adults

s/sx: asymptomatic, can cause mass effect if large

2D US: mass w/ extensive tissue cystic tissue replacement, when spleen involved multicystic appearance is common
color doppler: avascular

DDX: echinoccocal cyst

Hamartoma → rare benign tumor; overgrowth of normal tissue

clinical hx: adults, no gender preference

s/sx: asymptomatic

2D US: both solid and cystic components, hyperechoic usually, solitary or multiple, well-defined
color doppler: vascular

DDX: hemangioma

Lymphoma → cancer of lymphocytes in spleen

clinical hx: middle-aged/older adults

s/sx: unexplained fevers, night sweats, unintentional weight loss, fatigue

2D US: splenomegaly, hypoechoic lesions, enlarged LUQ lymph nodes, can small/large focal nodular lesions, diffuse or small nodular pattern
color doppler: vascular

DDX:

Metastases → cancer cells metastasized to spleen

clinical hx: current CA (advanced if spread to spleen)

s/sx: can be asymptomatic if microscopic

2D US: varied appearance = hypoechoic, echogenic w/ hypoechoic halo, target or “bulls eye,” well-defined with increase in size
color doppler: vascular

DDX: lymphoma, abscess

Hydropic Gallbladder → distended GB

clinical hx: middle-aged to older, fasting, post-surgery

s/sx: asymptomatic, if not = RUQ pain, fullness/bloating

2D US: no relaxed curves, rounded/bulbous shape, ± distended cystic duct (check for obstruction), maintained thin wall
color doppler: avascular

DDX: acute cholecystitis, cholelithiasis

GB Sludge → thickened bile from stasis

clinical hx: pregnant, fasting, critical illness, obstruction of GB

s/sx: asymptomatic, can have RUQ pain/biliary colic

2D US: layered, homogenous milk to moderately echogenic echoes, changes w/ patient mobility, no acoustic shadowing, can be tumefactive = balled up sludge can mimic mass, GB filled w/ sludge = hepatization (isoechoic to liver)

color doppler: avascular

DDX: polyp/tumor, hemobilia

GB Hemobilia → blood in GB

clinical hx: post-procedure, tumor, trauma, infection

s/sx: RUQ pain, anemic (decreased hematocrit)

2D US: lumen fill of mixed echogenicities = cystic regions/heterogenous woven, distended GB >4 cm AP

color doppler: avascular

DDX: GB sludge

Cholelithiasis → stone in GB

clinical hx: 5 Fs (fat, fourty, female, fertile, fair)

s/sx: commonly asymptomatic, RUQ pain after eating greasy/heavy foods, GB attack/referred pain → right shoulder, back, & sternal chest pain

2D US: well-defined echogenic foci in dependent part of GB producing dark posterior shadowing (stones under 3 mm may not produce shadow), WES sign = wall-echo-shadow sign indicating multiple stones/one large stone, mobile w/ patient positioning

color doppler: avascular

DDX: GB sludge (tumefactive), polyp

Acute Cholecystitis → sudden inflammation of GB

clinical hx: 5 Fs (cholelithiasis common cause of inflammation)

s/sx: constant RUQ pain, positive sonographic Murphy’s sign, N&V, increased WBCs, elevated bilirubin and alk phos if obstruction

2D US: GB wall > 3mm ~6-8 mm, distended lumen (> 4 cm AP and > 10 cm length), gallstones, impacted stone in neck or cystic duct, positive Murphy’s sign, pericholecystic fluid collection

color doppler: increased flow (supportive, not reliable)

DDX: GB sludge

Chronic Cholecystitis → numerous attacks of acute cholecystitis/inflammation causing fibrosis of GB wall

clinical hx: bouts of acute cholecystitis ← also 5 Fs

s/sx: transient RUQ pain, not as reactive to Murphy’s sign

2D US: thickened wall (3.5-4 mm, thickened but not thicker than acute), shrunken, fibrotic GB

color doppler: slightly less flow due to fibrosis

DDX: acute cholecystitis

Gangrenous Cholecystitis → prolonged infection causing GB necrosis

clinical hx: older male, DM (neuropathy can mask pain)

s/sx: fever, hypotension, severe rebound tenderness if abscess leaks, increased WBCs

2D US: usually gallstones and sludge, pericholecystic biloma/rupture of GB wall, sloughed membrane/mucosal layer appearing as intraluminal echo, ± thickened and edematous wall, ulcerations and perforations → pericholecystic biloma/abscess, 80-90% of patients

color doppler: avascular

DDX: acute cholecystitis, chronic cholecystitis

Emphysematous Cholecystitis → rare, air within GB wall

clinical hx: male, DM

s/sx:

2D US: ± gallstones, prominent hyperechoic echo in anterior wall w/ reverbirations & ringdown, can have pericholecystic fluid, loss of defined GB wall layers

color doppler:

DDX: adenomyomatosis

Acalculous Cholecystitis → uncommon, acute cholecystitis w/o stones

clinical hx: critically ill, sepsis patients, HIV, immunocompromised

s/sx: positive Murphy’s sign, increased WBC, can have RUQ pain, fever

2D US: positive Murphy’s sign, distended lumen, GB wall edema

color doppler: wall vascularity

DDX: acute hepatitis, colitis, pancreatitis

Porcelain GB → rare, calcium deposit of GB wall, 25% of patients will develop cancer of the GB wall

clinical hx: association w/ gallstones/chronic cholecystitis, older female

s/sx: asymptomatic

2D US: can appear as mixed speck pattern within wall or more diffuse, clean calcification, posterior shadowing from calcifications

color doppler: avascular

DDX: cholelithaisis, emphysematous GB

Adenomyomatosis → benign, common exaggeration of inner layer of GB wall (mucosal layer)

clinical hx: middle-aged female

s/sx: asymptomatic

2D US: non distended GB, mucosal layer thickening with cystic spaces, focal thickening at fundus more common, produces comet tail artifact, usually on anterior wall, can produce hourglass change of GB shape

color doppler: avascular, can have hypovascular pattern in hypoechoic lesion (adenomyoma)

DDX: emphysematous GB, porcelain GB

Cholesterolosis → benign, polypoid lesions formed in inner wall of GB from cholesterol deposits

clinical hx:

s/sx:

2D US: “strawberry GB”, small, echogenic, well-defined soft-tissue projections connected by stalk to GB wall, no posterior shadow, non mobile, < 10 mm diameter

color doppler: stalk of polyp is vascular

DDX: cholelithasis

Gallbladder Carcinoma → (rare) primary carcinoma of GB

clinical hx: 60+ female, continuous inflammation (chronic cholelithiasis/cholecystitis)

s/sx: weight loss, jaundice, anorexia

2D US: irregular thickening of wall, invasion of liver, intraluminal polypoid mass 10 cm or greater, mass replacing GB fossa, loss of definition between layers, ± increased bili from liver infiltration

color doppler: internal vascular flow

DDX: HCC, cholangiocarcinoma

Choledocholithiasis → stones in biliary tree

clinical hx: 5 Fs → same as cholelithiasis since stone can travel

s/sx: jaundice, elevated bili and alk phos, constant RUQ pain, epigastric pain, fever, pancreatitis

2D US: “double barrel” sign, “too many tubes,” stone has rounded surface, highly echogenic, ± posterior shadowing, peripancreatic head edema/fluid → pancreatitis, gallstones, wall edema and distention

color doppler: may see twinkle artifact from stone

DDX: biliary sludge, cholangiocarcinoma

Biliary Sludge → thickened bile in biliary tree

clinical hx: pregnancy, prolonged fasting, critically ill/post surgery

s/sx: asymptomatic, jaundice, RUQ pain, elevated direct bili, alk phos

2D US: duct filled with non calcified, mid level echogenic material (can’t differentiate from blood on US), biliary dilation, can have “double barrel” sign

color doppler: avascular

DDX: choledocholithiasis, cholangiocarcinoma

Pneumobilia → air within biliary tree secondary to biliary intervention/procedures, emphysematous cholecystitis, prolonged acute cholecystitis

clinical hx: acute abdomen hx, post biliary procedure, prior emphysematous/acute cholecystitis

s/sx: RUQ pain, N&V, jaundice, fever, abdomen distention

2D US: bright echogenic linear structures following portal triads w/ posterior dirty shadowing and revirberations

color doppler: avascular

DDX: chronic liver disease (i.e. cirrhosis)

Acute Cholangitis → inflammation of bile ducts usually from prolonged obstruction, medical emergency

clinical hx: biliary obstruction hx or current

s/sx: fever, RUQ pain, jaundice, leukocytosis, elevated liv transaminase, elevated bili and alk phos

2D US: biliary dilation, hypoechoic mucosal wall thickening, choledocholithasis or sludge, later → liver abscess

color doppler: avascular

DDX: cholecystitis, choledocholithasis

Pyogenic Cholangitis → more chronic form, seen in individuals from south Asia

clinical hx: south Asia, state of stasis

s/sx: RUQ pain, fever, jaundice

2D US: atrophy of involved segment, stones confined to region w/ associated biliary dilation, stones may or may not shadow

color doppler: avascular

DDX: acute cholangitis, cholecystitis

Sclerosing Cholangitis → chronic inflammation disease affecting entire biliary tree

clinical hx: males

s/sx: abnormal liver transaminase, jaundice if obstructive or underlying liver disease, asymptomatic, underlying autoimmune disease

2D US: irregular, circumferential bile duct wall thickening w/ small diverticuli in intrahepatic ducts (beads on string appearance), pinched off intrahepatic ducts from strictures, choledocholithiasis, biliary sludge

color doppler:

DDX: cholangiocarcinoma, choledocholithiasis

Intrahepatic Cholangiocarcinoma → common primary malignancy of liver (least likely location for cholangiocarcinoma

clinical hx: HCV, cirrhosis

s/sx: painless jaundice, dark urine, increased bili & alk phos

2D US: solid mass w/ variable appearance, large hepatic mass, heterogenous, ill-defined, ± biliary dilation

color doppler: hypovascular

DDX: HCC, mets

Hilar Cholangiocarcinoma/Klatskin’s Tumor → tumor at hilar level of liver

clinical hx: HCV, cirrhosis, male

s/sx: abnormal bili & alk phos, jaundice

2D US: dilation of higher order ducts w/ no connection between R & L ducts to CHD, ill-defined tumors with poor borders, isoechoic tumor, portal vein stricture/compression

color doppler:

DDX: HCC, distal cholangiocarcinoma

Distal Cholangiocarcinoma → bile duct cancer outside of liver

clinical hx: older, hx of sclerosing cholangitis

s/sx: jaundice

2D US: well-defined polypoid tumor found in ducts, extends along extrahepatic ducts towards hilum, nodular, intrahepatic dilation, invasion of adjacent structures

color doppler: hypovascular

DDX: pancreatic head tumor, ampullary duodenal tumor

Mirizzi Syndrome → obstruction of CHD by secondary inflammation due to stone impacted in cystic duct

clinical hx: cholecystectomy w/ residual stone or cholecystitis

s/sx: RUQ pain, fever, jaundice

2D US: cholecystitis with large stone in cystic duct, cystic duct stump with large calcified stone, intrahepatic dilation, normal CBD

color doppler:

DDX: cholangiocarcinoma, choledocholithiasis/cholelithiasis

Caroli’s Disease → rare, recessive found in peds, communicating ectasia of intrahepatic ducts

clinical hx: young, peds, renal disease/congenital hepatic fibrosis association, strong association with medullary sponge kidney

s/sx: cramplike upper abdominal pain from stasis

2D US: multiple cystic structures toward porta hepatis, localized masses or scattered cysts communicating with bile ducts, ± sludge & calculi

color doppler: avascular

DDX: sclerosing cholangitis, polycystic liver disease, hepatic cysts

Acute Pancreatitis → sudden inflammation of pancreas from blockage of ducts and increased secretions

clinical hx: gallstones in bile duct, alcohol abuse, obstruction/mass, endoscopy, trauma, drugs, transplant

s/sx: increased amylase (not as useful), increased lipase (more specific), sudden severe epigastric pain, pain radiating to mid back, LUQ pain, N&V, fever, increased WBCs, jaundice (if biliary obstruction)

2D US: pancreas enlargement, hypoechoic parenchyma from edema, irregular ill-defined borders, peripancreatic free fluid, peripancreatic echogenic inflammatory fat, can have focal areas of inflammation/hypoechoic tissue

color doppler: can have hyperemia

DDX: chronic pancreatitis

Chronic Pancreatitis → recurrent attacks of acute pancreatitis, progressive destruction of pancreatic tissue

clinical hx: association w/ chronic alcoholism/biliary disease, increased risk of developing pancreatic cancer

s/sx: asymptomatic, pancreatic insufficiency (digestion issues & glucose intolerance), jaundice if biliary obstruction, lipase can be elevated (more likely than amylase)

2D US: mixed pattern of echogenicity (hyperechoic from fibrosis to hypoechoic from inflammation), calcifications, normal to atrophic size, nodular surface, dilated/calcified pancreatic duct (> 3 mm), solid mass, thrombosis of splenic and portal vein

color doppler:

DDX: acute pancreatitis

Pancreatic Pseudocyst → peripancreatic fluid collection from trauma or pancreatitis (4-6 week onset after pancreatitis)

clinical hx: trauma, hx of pancreatitis

s/sx: patient will feel better because of walled off inflammation, rupture → sudden shock and peritonitis, ascites if ruptures into abdomen

2D US: not always spherical, usually located in lesser sac (anterior to pancreas and posterior to stomach)

color doppler: avascular

DDX: true cyst

Cystic FIbrosis in Pancreas → mucus from CF plugs ducts

clinical hx: pancreatic lipomatosis (fatty replacement of pancreas → obesity, DM, older age), younger patient with respiratory issues (CF)

s/sx: abdominal distention/bloating

2D US: small pancreatic cysts (1-3 mm) → can be seen on ultrasound if bigger than 3 mm, increased pancreas echogenicity

color doppler: avascular

DDX: chronic pancreatitis, pancreatic lipomatosis, autosomal dominant polycystic disease (can rarely manifest in pancreas)

Microcystic Adenoma (Serous Cystadenoma) → rare, benign tumor

clinical hx: female, older

s/sx: asymptomatic

2D US: well-defined tumor, large mass with multiple tiny cysts, no ductal obstruction

color doppler: vascular

DDX: malignant tumor

Macrocystic Adenoma (mucinous cystadenoma) → malignant or benign with malignant potential

clinical hx: female

s/sx: nonspecific abdominal symptoms, weight loss, abdominal mass, jaundice

2D US: usually found in body or tail, well-defined cysts with thick mucinous fluid, internal septations, or solid mural nodules, larger than 2 cm cysts, calcifications → more solid components = more chance for malignancy

color doppler: hypovascular

DDX: pseudocyst

IPMT (Intraductal Papillary Mucinous Tumor) → slow-growing lesion, form of mucinous cystic neoplasm

clinical hx: 60-70 years, no gender preference, recurrent pancreatitis

s/sx: asymptomatic

2D US: originates from main duct

color doppler: hypovascular

DDX: macrocystic adenoma

Adenocarcinoma → most common primary neoplasm of pancreas

clinical hx: usually 60+ y/o, rarely found as hereditary association in male patients

s/sx: head → obstruction of CBD w/ jaundice and hydropic GB, courvoisier sign (palpable non-tender w/ jaundice in GB), body and tail (tail is least common) → weight loss, pain, jaundice, vomiting

2D US: usually found in head, larger and invade adjacent organs, poorly defined mass, isoechoic or hypoechoic, enlargement of involved region, dilated panc duct over 3 mm, dilated CBD at head, displacement and compression of adjacent vessels

color doppler: vascular

DDX: chronic pancreatitis

Insulinoma → most common functioning islet cell tumor of pancreas, usually benign

clinical hx: 40-60 y/o, obese

s/sx: hypoglycemic symptoms, palpitations, headache, confusion, pallor, sweating, slurred speech, coma

2D US: small, well-encapsulated hypoechoic tumor usually in body or tail

color doppler: vascular

DDX: adenocarcinoma, focal pancreatitis

Gastrinoma → second most common functioning islet cell tumor of pancreas from non-insulin secreting panc tumors secreting excessive amounts of gastrin, malignant

clinical hx: 50 y/o,

s/sx: N&V, abdominal pain, weight loss

2D US: typically tumor found in head, peptic and duodenal ulcers present, usually multiple, can be extrapancreatic

color doppler: vascular

DDX:

Pancreatic Lymphoma → malignant neoplasm, usually parapancreatic

clinical hx:

s/sx: abdominal pain, weight loss, palpable mass, jaundice, N&V

2D US: cystic mass in pancreas, multiple nodes along pancreas, duodenum, porta hepatis, and SMV and SMA

color doppler: hypovascular

DDX: adenocarcinoma

Simple Renal Cyst → common lesion of kidney, fluid-filled sac (benign, Bozniak 1)

clinical hx: incidence increases with age (50+), uncommon in children

s/sx: asymptomatic

2D US: anechoic, well-defined smooth, thin wall, round or ovoid, posterior enhancement

color doppler: avascular

DDX: complex cyst

Complex Renal Cyst → any cyst that is not a simple cyst

clinical hx: post-surgery, trauma

s/sx: flank pain, fever, hematuria, WBC increase, can be asymptomatic

2D US: well-defined cystic structure, internal echoes or anechoic, septations, focal hypoechoic inner mural extension, can be hemorrhagic

color doppler: if solid can have vascularity

DDX: malignant tumor, RCC

Milk of Calcium Cyst → calcium buildup in cortex

clinical hx: older, stasis, metabolic issues

s/sx: asymptomatic

2D US: echogenic layering/sediment, posterior revirberations

color doppler: twinkle artifact

DDX: renal calculi

Parapelvic Cysts → renal cysts adjacent to sinus

clinical hx: older age

s/sx: asymptomatic

2D US: no communication w/ collecting system, well-defined anechoic renal sinus cysts, can be multiple, does not follow kidney shape, random distribution, varying size

color doppler: avascular

DDX: hydronephrosis

ADPKD (Autosomal Dominant Polycystic Kidney Disease ) → most common hereditary kidney disorder

clinical hx: 30 y/o develops, associated with polycystic liver disease

s/sx: HTN, palpable masses, swollen abdomen, pain w/ rupture, bouts with kidney stones

2D US: bilateral cortical/medullary cysts, varying sizes, simple/hemorrhagic, enlarged bilateral kidneys, normal tissue replaced with cysts,

color doppler: focal echogenic vascular lesion in background of PKD

DDX: parapelvic cysts, hydronephrosis

ARPKD (Autosomal Recessive Polycystic Kidney Disease) → dilated renal collecting tubes

clinical hx: presents in newborns

s/sx: failure to thrive (newbors)

2D US: bilateral enlarged kidneys, echogenic, small cystic changes (1-2 mm)

color doppler: loss of cortical medullary interface

DDX: MCDK

MCDK (Multicystic Dysplastic Kidney) → common acquired renal dysplasia

clinical hx: male

s/sx: asymptomatic

2D US: unilateral (bilateral incompatible with life), multiple non communicating cysts, absence of normal cortex and sinus, initially → enlarged kidney, in adults → atrophic kidney that may become calcified

color doppler: avascular

DDX: ADPKD

Acquired Cystic Kidney Disease → due to chronic renal failure

clinical hx: dialysis, chronic renal failure risk for RCC

s/sx: asymptomatic

2D US: 3-5 small cysts in each kidney, atrophied, echogenic kidneys, ± internal echoes fro hemorrhage

color doppler: solid vascular tumor

DDX: ADPKD

Retroperitoneal Hematoma → bleeding from trauma or surgery

clinical hx:

s/sx: hematuria, sudden constant flank pain, AKI

2D US: poor differentiation from cortex, hematoma variable appearance, can have mass effect on kidney

color doppler: avascular

DDX: renal abscess, infected cyst

AVF (Arteriovenous Fistula) → abnormal connection between artery and vein in kidney

clinical hx: congenital, iatrogenic, spontaneous

s/sx: hematuria, flank pain, abdominal bruit

2D US: cystic space

color doppler: focal aliasing

DDX: aneurysm

Renal Artery Aneurysm → focal dilation of renal artery

clinical hx: congenital, inflammatory disease

s/sx: asymptomatic

2D US: cystic mass medial to renal hilum, connection to main artery

color doppler: helical flow

DDX: AVF

Renal Artery Stenosis → narrowing of renal artery

clinical hx: older adults, smoking, DM

s/sx: HTN that doesn’t respond to normal medical treatment

2D US: usually unilateral, compare affected kidney to unaffected, kidney is significantly smaller than contralateral kidney

color doppler: increased velocity in artery

DDX: atherosclerosis renal artery aneurysm

Hydronephrosis → dilation of renal collecting system from mechanical obstruction or functional dysfunction (calculi, mass, trauma, pregnancy)

clinical hx: prone to stones (stasis, pregnancy)

s/sx: if stone → renal colic, N&V, hematuria, frequency/urgency

2D US: grade 1 (mild) → pelviectasis, cortex preserved, grade 2 (mild to moderate) → expands into major calyces, cortex preserved, grade 3 (moderate) → expand all calyces, entire pelvis dilated, cortex preserved, grade 4 (severe) → cortical thinning, AKI to CKD, creatinine >1.2

color doppler: avascular

DDX: parapelvic cysts

Nephrolithiasis → very common, calculi

clinical hx: increase incidence with age, associated with underlying kidney anomalies, diet, steroids, medication , family hx

s/sx: renal colic when stone moves down ureter, hematuria, WBC increase from stone passing

2D US: echogenic foci, rounded surface, posterior shadowing

color doppler: twinkle artifact

DDX: milk of calcium cyst (location differs)

Hydroureter → dilation of the ureter from BOO, ureter mass, gravida uterus, uterine fibroid compression

clinical hx: pregnancy, BPH (older males), nephrolithiasis prone (pregnancy, stasis)

s/sx: renal colic, symptoms mimic UTI (frequency, urgency)

2D US: dilated ureter at UVJ

color doppler: avascular

DDX:

VUR (Vesicoureteral Reflex) → common, non-obstructive cause of hydronephrosis (reflux of urine from bladder back up ureters into kidney)

clinical hx: history of recurrent infections, young children

s/sx: dysuria, frequency, urgency, fever, abdominal pain

2D US: hydronephrosis, intermittent dilations of collecting system (post-void changes), displaced ureteral jet in bladder, ureterocele (ballooning of lining of ureter into bladder)

color doppler: avascular

DDX:

Nephrocalcinosis → calcium deposits in kidney parenchyma

clinical hx: chronic glomerulonephritis (cortex), hyperparathyroidism (medullary, more common)

s/sx: asymptomatic

2D US: pyramids more echogenic than cortex, echogenic halo around pyramids

color doppler: avascular

DDX:

MSK (Medullary Sponge Kidney) → congenital, rare dilated collecting tubes, causes recurrent stones

clinical hx: recurrent nephrolithiasis, hematuria, flank pain, renal colic

s/sx:

2D US: unilateral, small anechoic dilations in papillary zone, multiple diffuse hyperechoic calcifications, nephrocalcinosis, focal clusters of echogenic foci with shadowing in pyramids

color doppler: avascular

DDX: Nephrocalcinosis

AML (Angiomyolipoma) → most common benign tumor of kidney

clinical hx: more common in females, right side more common, associated with tuberous sclerosis

s/sx:

2D US: well-defined, hyperechoic spherical lesion, typically echogenic but can be more hypoechoic if hemorrhage

color doppler:

DDX: RCC, renal lipoma

Sinus Lipomatosis → excessive renal fat proliferation

clinical hx: aging, obesity, steroids

s/sx: mild flank pain

2D US: highly echogenic enlarged sinus

color doppler: avascular

DDX:

RCC (Renal Cell Carcinoma) → most common primary malignant tumor of the kidney

clinical hx: male, late middle age, smoking, ACDK, von Hippel Lindau, Tuberous sclerosis

s/sx: microscopic hematuria

2D US: solid, usually isoechoic but can vary, renal vein and IVC involvement, typically solitary and invades into surrounding vasculature

color doppler: vascular

DDX: AML, TCC

TCC (Transitional Cell Carcinoma) → usually in bladder, 90% of collecting system renal tumors

clinical hx: heavy smoking, men, 65+

s/sx: gross hematuria, flank pain if obstructive

2D US: renal sinus hypoechoic mass, irregular bladder wall, collecting system dilation if trigone involved

color doppler: vascular in renal tumor

DDX:

Lymphoma → renal involvement, usually bilateral

clinical hx: AIDS

s/sx: ± flank pain

2D US: kidney may be enlarged, loss of renal sinus pattern, perirenal hypoechoic lobular mass, small hypoechoic parenchymal lesions

color doppler:

DDX:

Nephroblastoma (Wilm’s Tumor) → 2nd most common peds abdominal cancer

clinical hx: 2-5 years, unilateral, Beckwidth-Wiedmann

s/sx: abdominal swelling, abdominal pain

2D US: vascular involvement, large solid mass, distorts renal cortex, sinus, pyramids and contour, hydronephrosis, extension into renal vein, IVC, contralateral kidney, homogenous to complex, calcifications, well-defined

color doppler: hypovascular/vascular

DDX: neuroblastoma, hepatoblastoma

Acute Pyelonephritis → acute infection of urinary tract, usually begins in bladder and ascends ureters

clinical hx: stones, tumors, E. coli, female

s/sx: UTI symptoms, fever, persistent flank pain, leukocytosis

2D US: thickening of renal pelvis, cortex appearance varies (normal, hypoechoic, patchy), as abscess develops → mixed echogenic pattern in parenchyma

color doppler: avascular in region of involvement

DDX: