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Kidney and Bladder US

Kidney and Bladder US. Mike Ackerley. Kidney. Advantage over other modalities? What do you see normally? What can we diagnose?. Advantages. Ease with which the extent of the disease can be determined within the kidney for focal disease

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Kidney and Bladder US

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  1. Kidney and Bladder US Mike Ackerley

  2. Kidney • Advantage over other modalities? • What do you see normally? • What can we diagnose?

  3. Advantages • Ease with which the extent of the disease can be determined within the kidney for focal disease • Ease of assessment of renal pelvic or ureteral dilation when fluid distended • The location and relevance of renal mineralization can also be assessed • When radiographically ID focal renal pelvic or ureteral mineral opacities and the question of whether hydronephrosis is present • Biopsy or fine-needle aspiration can be expedited by ultrasonographic guidance, improving the margin of safety as well.

  4. Normals • Length in saggital plane • Dog: variable with size of dog • Cat: 2.8 – 4.2 cm • Cortex • In dogs more bright than the liver, but less bright than spleen • In cats variable, may be equal brightness to that of liver and approach that of the spleen • Medullary Papillae • The renal medulla in dogs and cats is less echogenic than the cortex. • Arcuate vessels • Pelvic recess • Renal vessels • Renal pelvis • If high resolution (7.5 – 10 MHz) transducer is used

  5. Capsule Pelvis Cortex Medulla

  6. Pathology • Distension • Diuresis: bilaterally symmetrical and usually mild • Hydronephrosis: pelvic dilation may become very gross, with only a think rim of surrounding parenchymal tissue (idiopathic, or secondary to ureteric obstruction) • Renal calculus: strongly reflective surface with distal acoustic shadowing also present. • Chronic pyelonephritis: the pelvis may dilate while the diverticula remain small • Renal neoplasia: secondary dilation of the renal pelvis and proximal ureter, or mechanical obstruction of the pelvis • Ectopic ureter: due to stenosis of the ureter ending and/or ascending infection • Renal pelvic blood clot: following renal biopsy, coagulopathy, bleeding neoplasm, idiopathic renal hemorrhage, or trauma

  7. Hydronephrosis

  8. Hydronephrosis

  9. Pathology • Focal parenchymal abnormalities • Well circumscribed, anechoic parenchymal lesion • Hypoechoic parenchymal lesion • Hyperechoic parechymal lesion • Heterogeneous/complex parenchymal lesion • Medullary rim sign • Acoustic shadowing

  10. Pathology • Well circumscribed, anechoic parenchymal lesion • Thin smooth wall: single or multiple cysts • Thick/irregular wall: • Cyst • Hematoma • Abscess • neoplasia

  11. Pathology • Hypoechoic parenchymal lesion • Neoplasia • Lymphosarcoma • Hyperechoic parenchymal lesion • Neoplasia • 1º: chondrosarcoma, hemangioma • Metastatic: hemangiosarcoma, thyroid adenocarcinoma

  12. Pathology • Heterogeneous/ Complex parenchymal lesion • Neoplasia • Abscess • Hematoma • Granuloma • Acute infarct • Polycystic disease

  13. Polycystic Kidneys

  14. Renal Infarct

  15. Pathology • Medullary rim sign • Normal in cats • Nephrocalcinosis • Ethylene glycol toxicity • Chronic interstitial nephritis • Cats - FIP

  16. Pathology • Acoustic Shadowing • Deep to pelvic fat • Renal calculus

  17. Nephrolith

  18. Pathology • Diffuse parenchymal abnormalities • Increased cortical echogenicity • Decreased corticomedullary definition

  19. Pathology • Increased cortical echogenicity • Normal cats • Inflammatory disease • Glomerulonephritis • Interstitial nephritis • FIP • Acute tubular necrosis/nephrosis (toxins) • Renal dysplasia • Nephrocalcinosis • Neoplasia • Diffuse lymphosarcoma

  20. Pathology • Decreased corticomedullary definition • End-stage kidneys • Multiple small cysts

  21. What can we diagnose? • Infarcts • Cysts/Abscess/Hematoma • Renal calculus • Big neoplasia • Pelvic Dilation

  22. Bladder • Advantage over other modalities? • What do you see normally? • What can we diagnose?

  23. Advantages • Able to evaluate bladder wall thickness • Able to visualize non-radiopaque stones/cyrstals (C U) • Cystocentesis

  24. Normals • Best when bladder moderately full Ovoid in shape, with slight elongation caudally at trigone • Don’t normally see ureters • Three layers (∆ with size) • Mucosa: Hyperechoic • Muscular: Hypo- • Serosal: Hyper- • Normal wall thickness (cat): 1.7 mm ± 0.56 • Normal wall thickness (dog): 1.6 mm

  25. Pathology • Calculi • acoustic shadows are observed deep to calculi that exceed the diameter of the beam. • echogenicity and acoustic shadow generation are independent of chemical composition (doesn’t matter struvite VS cystine) • Ballottement doesn’t move calculi, but let animal stand and calculi will fall. • Helps differentiate from mineralized bladder wall and colonic shadowing

  26. Cystic Calculi

  27. Pathology • Gas bubbles • Will float to the top, to differentiate from calculi • Blood clots • non-shadowing • Crystalline sediment • Vigorous ballottement • Swirling pattern when standing

  28. Blood Clot

  29. Pathology • Mural changes • Cystitis • Neoplasia

  30. Pathology • Cystitis • Chronic cystitis results in diffuse thickening of the bladder wall • bladder wall becomes abnormally hypoechoic, and the normal layering becomes less parallel • normal sonographic appearance of the bladder does not rule out the presence of mild or acute cystitis or idiopathic lower urinary tract disease in cats

  31. Chronic Cystitis

  32. Pathology • Neoplasia • TCC: irregularly shaped, broad-based, hypoechoic masses protruding into the bladder lumen • echo pattern depends on if if fibrosis, mineralization, and necrosis have developed • An abrupt transition often observed between neoplastic mass & adjacent bladder wall

  33. Neoplasia

  34. Pathology • Sonographic appearance of polypoid cystitis, adherent blood clots, and mural hematomas is similar to that of neoplasia • Observation of ureter dilation adjacent to the bladder wall mass & focal medial iliac lymphadenopathy tends to support the diagnosis of neoplasia • Need aspirate, but must weigh that benefit against the possibility of seeding the needle tract with tumor cells • Traumatic catheterization is useful to retrieve cells from the mass

  35. What can we diagnose? • Crystalline sediment • Calculi • Blood clots? • Gas

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