Normal Appearances Articles Normal Abdominal Ultrasound Normal Abdominal Ultrasound Clinical History A 30-year old female presented with an acute onset of abdominal pain on the right. Case Description An abdominal ultrasound was requested. Diagnosis/ Discussion/ Treatment/ Follow-up The patient was managed conservatively, and the symptoms resolved spontaneously over time. Sonograms Pancreas Abdominal aorta Left lobe liver in longitudinal orientation Left lobe liver in transverse orientation Right lobe liver in transverse orientation Right lobe liver in longitudinal orientation Patent portal vein showing hepatopetal (antegrade) flow Right kidney A thin-walled gallbladder Common bile duct Left kidney Spleen
Normal Abdominal Ultrasound Clinical History A 30-year old female presented with an acute onset of abdominal pain on the right. Case Description An abdominal ultrasound was requested. Diagnosis/ Discussion/ Treatment/ Follow-up The patient was managed conservatively, and the symptoms resolved spontaneously over time. Sonograms Pancreas Abdominal aorta Left lobe liver in longitudinal orientation Left lobe liver in transverse orientation Right lobe liver in transverse orientation Right lobe liver in longitudinal orientation Patent portal vein showing hepatopetal (antegrade) flow Right kidney A thin-walled gallbladder Common bile duct Left kidney Spleen
Hepatic/Liver Articles Normal Appearances Bladder Mass with Liver Metastasis Hepatic Haemangioma Normal Transplant Liver Transplant Liver Collection Normal Appearances Normal Abdominal Ultrasound Clinical History A 30-year old female presented with an acute onset of abdominal pain on the right. Case Description An abdominal ultrasound was requested. Diagnosis/ Discussion/ Treatment/ Follow-up The patient was managed conservatively, and the symptoms resolved spontaneously over time. Sonograms Pancreas Abdominal aorta Left lobe liver in longitudinal orientation Left lobe liver in transverse orientation Right lobe liver in transverse orientation Right lobe liver in longitudinal orientation Patent portal vein showing hepatopetal (antegrade) flow Right kidney A thin-walled gallbladder Common bile duct Left kidney Spleen Bladder Mass with Liver Metastasis Bladder Tumour Clinical History A 91-year old man with sudden health deterioration and in critical condition presented with haematuria, anaemia, thrombocytopaenia, and abnormal LFT. An abdominal ultrasound was requested as a first line of imaging. Case Description Ultrasound revealed a 7 cm heterogeneous mass in the urinary bladder (bladder tumour) with an irregular outline. The liver appeared enlarged with heterogeneous parenchymal echotexture and multiple hypoechoic lesions throughout, suggestive of metastases. Diagnosis/ Discussion/ Treatment/ Follow-up Unfortunately, the patient passed away. Sonograms Left lobe of the liver in a longitudinal orientation with multiple hypoechoic lesions Left lobe of the liver in a transverse orientation showing multiple hypoechoic lesions Right lobe of the liver containing multiple lesions, and showing the portal vein The portal vein on colour Doppler imaging showing normal hepatopetal flow Sonogram of the partly filled urinary bladder showing a bladder wall mass Hepatic Haemangioma Focal Hepatic Lesion Clinical History A 49-year old man presented with right upper quadrant pain which was gradually worsening. The patient was referred to have an abdominal ultrasound to rule out gallbladder calculi Case Description Ultrasound was able to rule out the presence of gallbladder calculi. However, there was a 25 mm hyperechoic focal lesion in the left hepatic lobe with appearances suggestive of a haemangioma. MRI of the liver was performed with contrast which confirmed this to be a haemangioma. Diagnosis/ Discussion/ Treatment/ Follow-up Since hepatic haemangiomas are benign lesions, and in this case the lesion was not large, therefore, no further action was taken regarding this. The patient’s pre-existing symptoms were managed conservatively. Sonograms Left hepatic lobe showing a 2.5 cm echogenic lesion Colour Doppler imaging showing no evidence of flow within the lesion in the left hepatic lobe B-mode ultrasound showing the echogenic lesion in the left hepatic lobe Axial MRI showing the lesion in the left hepatic lobe, confirming it to be a haemangioma Normal Transplant Liver Normal Doppler Ultrasound Assessment of a Transplant Liver Clinical History A 45-year old with a history of chronic polycystic liver and kidney disease had a recent liver transplant. Doppler ultrasound was requested to assess the blood flow in and out of the transplant liver. Case Description Ultrasound was performed using a 3 MHz curvilinear transducer. The examination started on B-mode to visualise the entire hepatic outline and parenchyma. Colour Doppler was used to evaluate patency of the hepatic veins, common hepatic artery, and the main portal veins and its branches. Spectral Doppler was further used to examine the flow pattern and velocity in the hepatic vessels. Diagnosis/ Discussion/ Treatment/ Follow-up The vessels examined in transplant liver assessment include: The right hepatic vein. The middle hepatic veins. The left hepatic vein. The main portal vein. The right portal vein. Middle portal vein. Left portal vein. The common hepatic artery. The parameters deduced from the haemodynamic spectral Doppler studies include: peak systolic velocity (PSV), end diastolic velocity (EDV), pulsatility index (PI), resistivity index (RI), and the wave pattern. Sonograms Longitudinal view of the left hepatic lobe showing the caudate lobe Spectral Doppler of the right hepatic vein Transverse view of the transplant liver showing the hepatic veins in B-mode Middle hepatic vein Left hepatic vein Main portal vein Hepatic artery Hepatic artery showing the Doppler ultrasound values Transplant Liver Collection Abnormal Intrahepatic Collection of a Liver Transplant Clinical History A 50-year old man with recurrent history of liver transplantations presented with delirium, diarrhoea, and vomiting. Liver function test was abnormal. Ultrasound was requested as a first line of imaging to assess the biliary tree or other possible cause for symptoms. Case Description Ultrasound revealed a large tubular and tortuous heterogeneous hypoechoic area within the liver suggestive of intrahepatic collection. No internal vascularity was observed within the area of abnormality. The hepatic vessels were patent on Doppler interrogation. Diagnosis/ Discussion/ Treatment/ Follow-up Triple-phase liver CT confirmed the presence of branching fluid attenuation in the right hepatic lobe in keeping with collections. The hepatic collection was drained. Sonograms Right lobe liver with a heterogeneous collection CDI right lobe liver showing the collection adjacent to the hepatic veins CDI right lobe liver showing the hepatic collection adjacent to the hepatic veins CDI RLL showing the hepatic collection adjacent to the main portal vein Spectral Doppler of the patent hepatic vein Microvascular imaging (MVI) showing the patent hepatic veins adjacent to the hepatic collection Axial CT showing the hepatic collection Coronal CT showing the hepatic collection Axial CT post pigtail drain insertion Intrahepatic collection in the transplant liver Keywords
Uterine/Uterus Articles Septate Uterus Haematometra Septate Uterus Müllerian Duct Abnormality 2-D Ultrasound Clinical History A 45-year old female presented with lower abdominal pain. Transabdominal and Transvaginal ultrasound of the pelvis was requested for further assessment. Case Description Mullerian duct abnormality was seen incidentally during a pelvic ultrasound of a 45-year old due to lower abdominal pain. These features can be better confirmed with a more definitive diagnosis using 3-D ultrasound of the pelvis. HyCoSy can also be used if infertility is an indication. However, these were not carried out at the time of the patient’s visit. Diagnosis/ Discussion/ Treatment/ Follow up No treatment was required at the time. Sonograms Bicornuate uterus transvaginal USS Bicornuate uterus TVUSS Bicornuate uterus Bicornuate uterus anterior horn Bicornuate uterus posterior horn Bicornuate uterus transverse view Haematometra Haematometra Presenting as Pelvic Pain Clinical History A 47-year old lady presented with an acute onset of pelvic pain towards the left iliac fossa. The patient was known to be on long-term contraception and had a history of multiple caesarean sections. An ultrasound of the pelvis was requested for an initial assessment. Case Description Ultrasound revealed a distended endometrial cavity containing a localised hypoechoic collection measuring 39 x 23 x 28 mm which suggests haematometra with no cervical or vaginal involvement. Diagnosis/ Discussion/ Treatment/ Follow up The patient had an MRI of the pelvis which confirmed the haematometra to be caused by a scar. The collection was drained surgically. Sonograms Transabdominal sonogram of the uterus showing the hypoechoic structure in the endometrial cavity Transvaginal sonogram of the uterus showing the hypoechoic structure in the endometrial cavity Transvaginal sonogram in an axial orientation showing the hypoechoic structure in the endometrial cavity The distended endometrial cavity with its measurements Sagittal MRI of the uterus showing the distended endometrial cavity with a possible adhesion towards the internal Os
Kidneys Articles Parapelvic Renal Cyst Horseshoe Kidney Normal Transplant Kidney Renal Cell Carcinoma Renal Subcapsular Haematoma Parapelvic Renal Cyst Parapelvic Simple Renal Cyst Mimicking Hydronephrosis on MRI Clinical History A 74-year old man had an MRI of his spine which revealed an area of possible hydronephrosis in his right kidney. An ultrasound of his kidneys was requested to confirm this. Case Description Ultrasound revealed a 6 cm parapelvic simple cyst (renal cyst) in the lower pole. There was also another 2 cm simple cyst adjacent to the former. Diagnosis/ Discussion/ Treatment/ Follow up These findings were confirmed by an outpatient contrast CT scan of the urinary tract carried out months later. Sonograms A right parapelvic renal cyst B-Mode A right parapelvic renal cyst colour Doppler Imaging An axial CT scan post-ultrasound confirming the right parapelvic cyst to be a Bosniak 1 category A coronal CT scan post-ultrasound confirming the right parapelvic cyst to be a Bosniak 1 category Horseshoe Kidney Horseshoe Kidney in a Patient with UTI Symptoms Clinical History A 48-year old man presented with UTI symptoms. Case Description Ultrasound performed on the patient’s abdomen revealed a horseshoe kidney with the isthmus anterior to the IVC and abdominal aorta inferiorly. The patient had no prior imaging of his abdomen, therefore, this was the first time the variant was found. Diagnosis/ Discussion/ Treatment/ Follow up The patient’s symptoms were managed with the appropriate antibiotic therapy. Sonograms Sonogram acquired above the umbilicus using a transverse probe orientation showing the isthmus of the horseshoe kidney with the abdominal aorta (red), IVC (blue), and spine posteriorly Left moiety of the horseshoe kidney Right moiety of the horseshoe kidney CT scan of the horseshoe kidney Normal Transplant Kidney Normal Ultrasound Assessment of the Renal Allograft Clinical History A 43-year old man with a recent history of renal transplant surgery was referred to have an ultrasound assessment of the new renal allograft. Case Description The renal allograft appeared normal in size, outline, echotexture, and perfusion with no evidence of renal artery stenosis encountered. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound report was sent to the referring nephrologist. During ultrasound assessment of the renal allografts, it is important to use a high frequency curvilinear transducer (6 – 7 MHz). This provides a reasonable balance between the acquisition of great image resolution, and having enough depth to visualise the graft and structures deep to and surrounding the graft. Sonograms B-Mode sonogram of the normal transplant kidney in the left iliac fossa (LIF) Colour Doppler imaging of the normal transplant kidney showing excellent perfusion of the graft Power Doppler imaging of the normal transplant kidney showing excellent perfusion of the graft Colour Doppler imaging of the transplant renal artery showing the point of anastomosis with the left external iliac artery Spectral Doppler imaging of the left external iliac artery measuring the peak systolic velocity (PSV) prior to the anastomosis Spectral Doppler imaging of the left external iliac artery measuring the peak systolic velocity (PSV) at the level of the anastomosis Spectral Doppler imaging of the transplant renal artery Spectral Doppler of the segmental artery within the transplant kidney Spectral Doppler of the intrarenal artery at the lower pole Spectral Doppler of the intrarenal artery at the interpolar region of the graft Spectral Doppler of the intrarenal artery at the upper pole Renal Cell Carcinoma Renal Cell Carcinoma Clinical History A 55-year old man presented with symptoms of frank haematuria. Case Description Renal ultrasound revealed a 5.4 cm heterogeneous vascular lesion in the midpole of the right kidney. Diagnosis/Discussion/Treatment/ Follow up The lesion was confirmed on CT with subtle evidence of invasion of the tumour into the a branch of the right renal vein. The patient had a right nephrectomy. Histology confirmed the diagnosis of clear cell renal cell carcinoma. Subsequent CT showed no evidence of disease recurrence. Sonograms B-mode longitudinal view of the right renal mass Right renal mass in b-mode Right renal mass in axial orientation CDI right renal mass showing some internal vascularity Axial CT scan of the right renal mass Post right nephrectomy coronal CT scan Post right nephrectomy axial CT An Incidental Finding of an Asymptomatic Renal Mass Clinical History A 48-year old man presented with left flank pain and overall discomfort. An ultrasound of the abdomen was requested to assess for left renal calculi that might explain the symptoms. Case Description Ultrasound revealed a 5 cm heterogeneous echogenic mass in the right kidney with some evidence of vascularity within it. Diagnosis/ Discussion/ Treatment/ Follow up A subsequent whole body CT scan confirmed the presence of the 5 cm mass arising from the midpole of the right kidney and showing heterogeneous contrast enhancement. The patient had a right nephrectomy. The histology analysis of the surgical samples confirmed the lesion to he renal cell carcinoma (RCC). Sonograms Right renal mass with callipers Right renal mass longitudinal view CDI right renal mass with some internal vascularity Normal left kidney Coronal CT showing the right renal mass Renal Subcapsular Haematoma Subcapsular Haematoma Clinical History A 74-year old man presented with a recent history of fall and an acute kidney injury (AKI) was referred to have a renal ultrasound as an initial imaging assessment. Case Description Ultrasound revealed a 12 cm heterogeneous structure within the subcapsular layer of the left kidney with no internal vascularity seen within the abnormality. Appearances were suggestive of a subcapsular haematoma. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a subsequent contrast CT which confirmed the ultrasound findings. A followup ultrasound months later revealed the haematoma to have mostly resolved. Subcapsular haematoma can mimic renal masses on ultrasound. However, the absence of internal vascularity and the location of the abnormality within the renal capsule are two features that can help improve the diagnostic confidence of ultrasound practitioners in clinical settings Sonograms B-mode left kidney with a subcapsular haematoma Left renal subcapsular haematoma with measurement callipers CDI showing some normal intrarenal vessels but no flow in the haematoma Coronal CT scan showing the left renal subcapsular haematoma Follow up ultrasound of the left kidney showing resolved haematoma after 4 months B-mode ultrasound showing what is left of the resolved left renal subcapsular haematoma
Appendix Articles Complicated Appendicitis Perforated Appendicitis Complicated Appendicitis Acute Complicated Appendicitis in a 31-year Old Male Clinical History A 31-year old presented with 1 day history of central abdominal pain radiating to the right iliac fossa. Raised WCC and CRP. Case Description The patient was referred to have an ultrasound of the abdomen and pelvis to include the appendix. Ultrasound revealed an abnormal appendix in the RIF measuring 14 mm in AP calibre with significant probe tenderness observed while scanning the area. There was also evidence of mesenteric fat stranding around the inflamed appendix with hypervascularity within the appendix wall. An echogenic focus was seen within the appendix suggestive of a small appendicolith. Diagnosis/ Discussion/ Treatment/ Follow Up The patient had laparoscopic appendectomy and the appendix specimen was sent for histology analysis. Histology revealed an inflamed appendix with focal mucosal ulceration in keeping with complicated appendicitis. Sonograms Longitudinal section of the inflamed appendix in the RIF Transverse section of the inflamed appendix in the RIF Power Doppler imaging showing evidence of vascularity within the wall of the inflamed appendix Power Doppler imaging 2 A tiny calcific focus within the inflamed appendix, suggestive of an appendicolith Perforated Appendicitis Complicated Appendicitis with Perforations Clinical History A 19-year old male presented with a 4-day history of abdominal pain radiating to the right iliac fossa, some fever, diarrhoea, and vomiting. Blood tests revealed elevated inflammatory markers. Case Description Ultrasound revealed a 98 x 43 x 58 mm heterogeneous hypoechoic area in the right iliac fossa posterolateral to the caecum and anterior to the psoas muscle fibres. Also, there was mesenteric fat stranding around it. These were all at the site of the patient’s maximum tenderness. The normal appendix tissue was not seen leading the sonographer to raise the suspicion of appendiceal perforation. Diagnosis/ Discussion/ Treatment/ Follow up The patient had an emergency appendectomy and the surgical specimen analysed histologically confirmed the diagnosis of perforated appendicitis. Sonograms Sonogram acquired using a high frequency linear probe showing a heterogeneous hypoechoic structure in the RIF Sonogram acquired using a curvilinear probe showing a heterogeneous hypoechoic structure in the RIF Sonogram acquired using a curvilinear probe showing a heterogeneous hypoechoic structure in the RIF Power Doppler showing no evidence of vascularity Sonogram acquired using a high frequency linear probe showing a heterogeneous hypoechoic structure in the RIF Panoramic view of the RIF
Popliteal Artery Occlusion Articles Occluded Popliteal Artery Popliteal Artery Occlusion Co-existing with Popliteal Vein DVT Occluded Popliteal Artery Clinical History An 80-year old man with metastatic bowel cancer presented with a sudden onset of right leg swelling. Case description An 80-year old man with metastatic bowel cancer presented with a sudden onset of right leg swelling. The patient was referred to have an ultrasound Doppler of the veins of his right lower limb to rule out deep venous thrombosis (DVT). Although DVT was ruled out, however, the popliteal artery appeared occluded. The patient was referred to the vascular team for further management of the occluded popliteal artery. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to the vascular team for further management. Sonograms Occluded popliteal artery with arrow Color Doppler showing the absence of flow in the popliteal artery. Patent popliteal vein (in blue) Color Doppler showing no flow in the popliteal artery Popliteal Artery Occlusion Co-existing with Popliteal Vein DVT Clinical History A 92-year old lady presented with pain and swelling in the right leg. The WELLS score was 2 upon an initial specialist clinical assessment. Doppler ultrasound of the lower limb veins was requested to rule out deep venous thrombosis (DVT). Case Description Ultrasound revealed the presence of an occlusive thrombus in the popliteal vein. There was also an occluded superficial femoral artery (SFA). However, the popliteal artery was patent. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred urgently to vascular surgery for further management. Unfortunately, the patient passed away Sonograms Patent right common femoral artery Partially occluded right superficial femoral artery (proximal) Partially occluded right superficial femoral artery (mid) Partially occluded right superficial femoral artery (distal) Colour Doppler imaging of the distal right superficial femoral artery showing some distal patency towards the popliteal artery Patent right popliteal artery Occluded right popliteal vein containing thrombus (blood clot), in keeping with deep venous thrombosis (DVT) Axial orientation of the right popliteal vein showing occlusion, and the patent artery posteriorly
Occluded Popliteal Artery Clinical History An 80-year old man with metastatic bowel cancer presented with a sudden onset of right leg swelling. Case description An 80-year old man with metastatic bowel cancer presented with a sudden onset of right leg swelling. The patient was referred to have an ultrasound Doppler of the veins of his right lower limb to rule out deep venous thrombosis (DVT). Although DVT was ruled out, however, the popliteal artery appeared occluded. The patient was referred to the vascular team for further management of the occluded popliteal artery. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to the vascular team for further management. Sonograms Occluded popliteal artery with arrow Color Doppler showing the absence of flow in the popliteal artery. Patent popliteal vein (in blue) Color Doppler showing no flow in the popliteal artery
Complicated Appendicitis Articles Acute Complicated Appendicitis in a 31-year Old Male Acute Complicated Appendicitis in a 31-year Old Male Clinical History A 31-year old presented with 1 day history of central abdominal pain radiating to the right iliac fossa. Raised WCC and CRP. Case Description The patient was referred to have an ultrasound of the abdomen and pelvis to include the appendix. Ultrasound revealed an abnormal appendix in the RIF measuring 14 mm in AP calibre with significant probe tenderness observed while scanning the area. There was also evidence of mesenteric fat stranding around the inflamed appendix with hypervascularity within the appendix wall. An echogenic focus was seen within the appendix suggestive of a small appendicolith. Diagnosis/ Discussion/ Treatment/ Follow Up The patient had laparoscopic appendectomy and the appendix specimen was sent for histology analysis. Histology revealed an inflamed appendix with focal mucosal ulceration in keeping with complicated appendicitis. Sonograms Longitudinal section of the inflamed appendix in the RIF Transverse section of the inflamed appendix in the RIF Power Doppler imaging showing evidence of vascularity within the wall of the inflamed appendix Power Doppler imaging 2 A tiny calcific focus within the inflamed appendix, suggestive of an appendicolith
Acute Complicated Appendicitis in a 31-year Old Male Clinical History A 31-year old presented with 1 day history of central abdominal pain radiating to the right iliac fossa. Raised WCC and CRP. Case Description The patient was referred to have an ultrasound of the abdomen and pelvis to include the appendix. Ultrasound revealed an abnormal appendix in the RIF measuring 14 mm in AP calibre with significant probe tenderness observed while scanning the area. There was also evidence of mesenteric fat stranding around the inflamed appendix with hypervascularity within the appendix wall. An echogenic focus was seen within the appendix suggestive of a small appendicolith. Diagnosis/ Discussion/ Treatment/ Follow Up The patient had laparoscopic appendectomy and the appendix specimen was sent for histology analysis. Histology revealed an inflamed appendix with focal mucosal ulceration in keeping with complicated appendicitis. Sonograms Longitudinal section of the inflamed appendix in the RIF Transverse section of the inflamed appendix in the RIF Power Doppler imaging showing evidence of vascularity within the wall of the inflamed appendix Power Doppler imaging 2 A tiny calcific focus within the inflamed appendix, suggestive of an appendicolith
Bladder and Renal Calculus Articles Urolithiasis in the Bladder and Kidney of a 75-year Old Man Urolithiasis in the Bladder and Kidney of a 75-year Old Man Patient History A 75-year old man presented with macroscopic haematuria Case Description The patient was referred to have an ultrasound examination of his kidneys and bladder as part of the (NICE guideline) diagnostic workup for haematuria in individuals above 45-years old. The bladder contained a 13 mm intraluminal mobile calculus (Urolithiasis). The right kidney contained an 8 mm non-obstructing calculus within its lower pole. Diagnosis/ Discussion/ Treatment/ Follow Up The patient had a follow up CT scan which confirmed the findings. The bladder calculus was removed transurethral. Sonograms Transverse section of the well-filled urinary bladder containing a calculus A dual-screen image of the urinary bladder with the patient initially in supine position, then asked to roll on to the left lateral decubitus position. This manoeuvre shows evidence of calculus movement which confirms that the calculus is within the bladder lumen A longitudinal image of the right kidney showing a 6 mm calculus at its lower pole A transverse image of the right renal lower pole showing the calculus A transverse image of the right renal lower pole with colour Doppler imaging, showing twinkling artefact
Urolithiasis in the Bladder and Kidney of a 75-year Old Man Patient History A 75-year old man presented with macroscopic haematuria Case Description The patient was referred to have an ultrasound examination of his kidneys and bladder as part of the (NICE guideline) diagnostic workup for haematuria in individuals above 45-years old. The bladder contained a 13 mm intraluminal mobile calculus (Urolithiasis). The right kidney contained an 8 mm non-obstructing calculus within its lower pole. Diagnosis/ Discussion/ Treatment/ Follow Up The patient had a follow up CT scan which confirmed the findings. The bladder calculus was removed transurethral. Sonograms Transverse section of the well-filled urinary bladder containing a calculus A dual-screen image of the urinary bladder with the patient initially in supine position, then asked to roll on to the left lateral decubitus position. This manoeuvre shows evidence of calculus movement which confirms that the calculus is within the bladder lumen A longitudinal image of the right kidney showing a 6 mm calculus at its lower pole A transverse image of the right renal lower pole showing the calculus A transverse image of the right renal lower pole with colour Doppler imaging, showing twinkling artefact
UTI in a Paediatric Patient Clinical History A 14-year old boy presented with long-standing recurrent UTI symptoms with some fever. Case Description Ultrasound revealed a thick and irregular urinary bladder wall outline. There was some debris seen within the bladder lumen. The pre void bladder volume was 182 ml, while the post void bladder volume was 105 ml (incomplete bladder emptying). In addition, there was also an area of focal thickening seen in the left ureteric orifice measuring 16 mm x 11 mm (L x AP). Although the ureters were not obstructed as there was no hydroureter, and the bladder jets were within optimal limits. There was no hydronephrosis either, however, the left urothelium was mildly thickened as seen in the left renal pelvis indicating a UTI. Diagnosis/ Discussion/ Treatment/ Follow up The patient was placed on antibiotics therapy which helped resolve the symptoms. Sonograms A distended urinary bladder showing an increased wall thickness. Note the numerous debris within the bladder lumen A dual-screen image of the bladder volume measurement Thickening of the left ureteric orifice (transverse orientation) appearing as an echogenic protrusion into the bladder lumen Thickening of the left ureteric orifice (longitudinal orientation) appearing as an echogenic protrusion into the bladder lumen Bladder jet from the left ureteric orifice indicating a lack of obstruction in the bladder inlet A dual-screen image of the bladder showing b-mode and colour Doppler simultaneously. Good bladder jets were recorded from both right and left ureteric orifices Left kidney transverse view showing thickness of the urothelium Axial left kidney showing urothelial thickening Post void with a significant amount of post void residual bladder volume of 105 ml
A Large Adnexal Mass in a Patient with Endometrial Cancer Clinical History A 74-year old lady presented with abdominal distension and discomfort. Case Description Ultrasound of the abdomen and pelvis (TA and TV) revealed a grossly thickened endometrium measuring 27 mm in AP calibre with heterogeneous echotexture. In addition there was a 131 mm complex non-vascular cystic mass (endometrial cancer) in the left adnexa/ left hemipelvis. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a whole body contrast CT which confirmed the ultrasound findings (endometrial cancer) in addition to the diagnosis of some omental cake with nodal peritoneal deposits and ascites in keeping with gynaecological malignancy. The adnexal cyst appeared to herniate through the left inguinal canal. The tumour markers (Ca125 and Ca19.9) were significantly elevated. Subsequently, the patient had an omental biopsy which confirmed metastatic high grade carcinoma. Sonograms Transabdominal view of the pelvis showing a 131 mm x 68 mm (L x AP) heterogeneous cystic mass in the left adnexa Transvaginal longitudinal view of the uterus showing an abnormally thickened endometrium of 26 mm (AP) Power Doppler imaging of the left adnexal complex cyst showing no evidence of internal vascularity PDI of the left adnexal cystic mass Free fluid in the right upper quadrant in keeping with ascites Ascites in the left upper abdominal quadrant adjacent to the spleen; subphrenic and within the splenorenal recess Ascites in the LUQ Axial CT showing the cyst in the LIF Sagittal CT showing the left adnexal cystic mass herniating into the left inguinal canal
Bladder Diverticulum Coexisting with Bladder Wall Thickening and a Small Prostatic Cyst Clinical History A 78-year old gentleman presented with a recent history of urinary incontinence with some microscopic haematuria and pain in the lower abdomen. An ultrasound of the renal tract was requested to further investigate. Case Description Ultrasound revealed a 3 mm defect in the posterolateral wall of the urinary bladder with a small diverticulum. The bladder wall was irregular in outline and has an increased thickness of up to 7 mm in AP calibre. Posterior to the bladder, the prostate contained a 20 mm simple cyst. Diagnosis/ Discussion/ Treatment/ Follow up Bladder diverticulum occurs when there is a breach in the bladder wall due to a loss of wall integrity and weakness of the bladder muscles. Bladder diverticulum can be single or multiple and are commonly age-related. The term microscopic haematuria, also called non-visible haematuria, is commonly used when the presence of blood cells within the urine is only detectable via laboratory testing. Sonograms B-mode of the urinary bladder showing the tiny defect (top arrow) and the diverticulum (bottom arrow) Bladder wall thickening measuring 7 mm in AP calibre Longitudinal view of the bladder showing the diverticulum (three arrows) and a small simple cyst in the prostate (single arrow) CDI showing no flow in the prostate simple cyst
Cancer of the Fallopian Tube Articles Fallopian Tube Cancer Fallopian Tube Cancer Clinical History A 67-year old lady presented with severe lower abdominal pain with some change in bowel habit and loose stool. Case Description The patient was initially referred to have a CT scan of the whole body with contrast. This revealed a large predominantly cystic structure in the pelvis centrally. The mass was further investigated using a pelvic ultrasound (TA and TV). Ultrasound revealed a 13 cm mass with solid and cystic components in the central pelvis. The mass showed some evidence of internal vascularity within its solid component. There was also free fluid in the anterior and posterior cul-de-sac. Ultrasound features were suggestive of malignancy (fallopian tube cancer). Diagnosis/ Discussion/ Treatment/ Follow up The patient had laparotomy which revealed the mass to be a stage II HGS cancer of the fallopian tube. Sonograms TVUSS showing a mass with cystic and solid component in the mid pelvis. The mass is a Stage II HGS cancer of the left fallopian tube Colour Doppler imaging of the mass showing some active flow within the solid component Triplex studies evaluation of the pelvic mass using b-mode, CDI, and spectral Doppler Free fluid in the rectouterine pouch of Douglas
A Large Complex Ovarian Cyst Mimicking a Fibroid Clinical History A 54-year old lady presented with a large mass in the centre of the lower abdomen mimicking a fibroid. Case Description Ultrasound performed (TA and TV) revealed a large 21 cm complex cystic mass (complex ovarian cyst) emanating from the pelvis into the abdomen with multiple septations within it. A subsequent MRI pelvis confirmed the large multicystic pelvic lesion to be a possible neoplasm arising from the left ovary. The patient had a whole body contrast staging CT that revealed no extra-ovarian disease presence. Diagnosis/ Discussion/ Treatment/ Follow up Total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed and the cyst was analysed histologically. Histology revealed the lesion to be a benign mucinous cystadenoma. Sonograms Transabdominal ultrasound showing the large complex cyst in the pelvis Transvaginal ultrasound showing the complex cyst in the pelvis Transvaginal ultrasound showing the complex cyst in the pelvis Colour Doppler imaging of the complex cyst in the pelvis Sagittal MRI of the complex cyst in the pelvis Coronal CT of the large pelvic complex cyst
Fallopian Tube Cancer Clinical History A 67-year old lady presented with severe lower abdominal pain with some change in bowel habit and loose stool. Case Description The patient was initially referred to have a CT scan of the whole body with contrast. This revealed a large predominantly cystic structure in the pelvis centrally. The mass was further investigated using a pelvic ultrasound (TA and TV). Ultrasound revealed a 13 cm mass with solid and cystic components in the central pelvis. The mass showed some evidence of internal vascularity within its solid component. There was also free fluid in the anterior and posterior cul-de-sac. Ultrasound features were suggestive of malignancy (fallopian tube cancer). Diagnosis/ Discussion/ Treatment/ Follow up The patient had laparotomy which revealed the mass to be a stage II HGS cancer of the fallopian tube. Sonograms TVUSS showing a mass with cystic and solid component in the mid pelvis. The mass is a Stage II HGS cancer of the left fallopian tube Colour Doppler imaging of the mass showing some active flow within the solid component Triplex studies evaluation of the pelvic mass using b-mode, CDI, and spectral Doppler Free fluid in the rectouterine pouch of Douglas
Haematometra Presenting as Pelvic Pain Clinical History A 47-year old lady presented with an acute onset of pelvic pain towards the left iliac fossa. The patient was known to be on long-term contraception and had a history of multiple caesarean sections. An ultrasound of the pelvis was requested for an initial assessment. Case Description Ultrasound revealed a distended endometrial cavity containing a localised hypoechoic collection measuring 39 x 23 x 28 mm which suggests haematometra with no cervical or vaginal involvement. Diagnosis/ Discussion/ Treatment/ Follow up The patient had an MRI of the pelvis which confirmed the haematometra to be caused by a scar. The collection was drained surgically. Sonograms Transabdominal sonogram of the uterus showing the hypoechoic structure in the endometrial cavity Transvaginal sonogram of the uterus showing the hypoechoic structure in the endometrial cavity Transvaginal sonogram in an axial orientation showing the hypoechoic structure in the endometrial cavity The distended endometrial cavity with its measurements Sagittal MRI of the uterus showing the distended endometrial cavity with a possible adhesion towards the internal Os
Incidental Calcifications within the Ductus Deferens Clinical History A 65-year old man presented with the feeling of some palpable lumps within the scrotum, lateral to the testis. Case Description Ultrasound performed using a 15 MHz linear transducer revealed some focal calcifications within the left spermatic cord. Furthermore, the left epididymal head contained two tiny simple cysts. Diagnosis/ Discussion/ Treatment/ Follow up The patient was managed conservatively. Calcifications within the ductus deferens are benign findings that are incidentally detected on imaging of the region. It can occur with increasing age, in patients with diabetes mellitus, or in men with a history of chronic infection. Sonograms B-mode sonogram showing the calcification within the left spermatic cord B-mode sonogram showing multiple calcifications within the left spermatic cord Calcifications within the left spermatic cord and a normal left testis inferiorly Calcification adjacent to the normal left testis
Hepatobiliary Articles Hepatic/Liver Gallbladder Pancreas Biliary tree Spleen Hepatic/Liver Normal Appearances Normal Abdominal Ultrasound Clinical History A 30-year old female presented with an acute onset of abdominal pain on the right. Case Description An abdominal ultrasound was requested. Diagnosis/ Discussion/ Treatment/ Follow-up The patient was managed conservatively, and the symptoms resolved spontaneously over time. Sonograms Pancreas Abdominal aorta Left lobe liver in longitudinal orientation Left lobe liver in transverse orientation Right lobe liver in transverse orientation Right lobe liver in longitudinal orientation Patent portal vein showing hepatopetal (antegrade) flow Right kidney A thin-walled gallbladder Common bile duct Left kidney Spleen Bladder Mass with Liver Metastasis Bladder Tumour Clinical History A 91-year old man with sudden health deterioration and in critical condition presented with haematuria, anaemia, thrombocytopaenia, and abnormal LFT. An abdominal ultrasound was requested as a first line of imaging. Case Description Ultrasound revealed a 7 cm heterogeneous mass in the urinary bladder (bladder tumour) with an irregular outline. The liver appeared enlarged with heterogeneous parenchymal echotexture and multiple hypoechoic lesions throughout, suggestive of metastases. Diagnosis/ Discussion/ Treatment/ Follow-up Unfortunately, the patient passed away. Sonograms Left lobe of the liver in a longitudinal orientation with multiple hypoechoic lesions Left lobe of the liver in a transverse orientation showing multiple hypoechoic lesions Right lobe of the liver containing multiple lesions, and showing the portal vein The portal vein on colour Doppler imaging showing normal hepatopetal flow Sonogram of the partly filled urinary bladder showing a bladder wall mass Hepatic Haemangioma Focal Hepatic Lesion Clinical History A 49-year old man presented with right upper quadrant pain which was gradually worsening. The patient was referred to have an abdominal ultrasound to rule out gallbladder calculi Case Description Ultrasound was able to rule out the presence of gallbladder calculi. However, there was a 25 mm hyperechoic focal lesion in the left hepatic lobe with appearances suggestive of a haemangioma. MRI of the liver was performed with contrast which confirmed this to be a haemangioma. Diagnosis/ Discussion/ Treatment/ Follow-up Since hepatic haemangiomas are benign lesions, and in this case the lesion was not large, therefore, no further action was taken regarding this. The patient’s pre-existing symptoms were managed conservatively. Sonograms Left hepatic lobe showing a 2.5 cm echogenic lesion Colour Doppler imaging showing no evidence of flow within the lesion in the left hepatic lobe B-mode ultrasound showing the echogenic lesion in the left hepatic lobe Axial MRI showing the lesion in the left hepatic lobe, confirming it to be a haemangioma Normal Transplant Liver Normal Doppler Ultrasound Assessment of a Transplant Liver Clinical History A 45-year old with a history of chronic polycystic liver and kidney disease had a recent liver transplant. Doppler ultrasound was requested to assess the blood flow in and out of the transplant liver. Case Description Ultrasound was performed using a 3 MHz curvilinear transducer. The examination started on B-mode to visualise the entire hepatic outline and parenchyma. Colour Doppler was used to evaluate patency of the hepatic veins, common hepatic artery, and the main portal veins and its branches. Spectral Doppler was further used to examine the flow pattern and velocity in the hepatic vessels. Diagnosis/ Discussion/ Treatment/ Follow-up The vessels examined in transplant liver assessment include: The right hepatic vein. The middle hepatic veins. The left hepatic vein. The main portal vein. The right portal vein. Middle portal vein. Left portal vein. The common hepatic artery. The parameters deduced from the haemodynamic spectral Doppler studies include: peak systolic velocity (PSV), end diastolic velocity (EDV), pulsatility index (PI), resistivity index (RI), and the wave pattern. Sonograms Longitudinal view of the left hepatic lobe showing the caudate lobe Spectral Doppler of the right hepatic vein Transverse view of the transplant liver showing the hepatic veins in B-mode Middle hepatic vein Left hepatic vein Main portal vein Hepatic artery Hepatic artery showing the Doppler ultrasound values Transplant Liver Collection Abnormal Intrahepatic Collection of a Liver Transplant Clinical History A 50-year old man with recurrent history of liver transplantations presented with delirium, diarrhoea, and vomiting. Liver function test was abnormal. Ultrasound was requested as a first line of imaging to assess the biliary tree or other possible cause for symptoms. Case Description Ultrasound revealed a large tubular and tortuous heterogeneous hypoechoic area within the liver suggestive of intrahepatic collection. No internal vascularity was observed within the area of abnormality. The hepatic vessels were patent on Doppler interrogation. Diagnosis/ Discussion/ Treatment/ Follow-up Triple-phase liver CT confirmed the presence of branching fluid attenuation in the right hepatic lobe in keeping with collections. The hepatic collection was drained. Sonograms Right lobe liver with a heterogeneous collection CDI right lobe liver showing the collection adjacent to the hepatic veins CDI right lobe liver showing the hepatic collection adjacent to the hepatic veins CDI RLL showing the hepatic collection adjacent to the main portal vein Spectral Doppler of the patent hepatic vein Microvascular imaging (MVI) showing the patent hepatic veins adjacent to the hepatic collection Axial CT showing the hepatic collection Coronal CT showing the hepatic collection Axial CT post pigtail drain insertion Intrahepatic collection in the transplant liver Keywords Gallbladder Calculus Cholecystitis Ultrasound Diagnosed Gallstones that were Radiolucent on a Recent CT Scan Clinical History A 55-year old lady presented with abdominal pain and tenderness in the right upper quadrant. Case Description A contrast CT scan of the abdomen and pelvis was performed which revealed an inflamed gallbladder wall with no radio-opaque gallstone seen. However, ultrasound was recommended to rule out gallstones. Diagnosis/ Discussion/ Treatment/ Follow up The patient had an uneventful laparoscopic cholecystectomy. Ultrasound is more sensitive in the diagnosis of cholelithiasis than CT scan. Some gallbladder calculi (cholelithiasis) can be radioluscent, therefore missed on CT. This is why abdominal ultrasound is the recommended first line of imaging, when it is available, for cases with clinically suspected cholelithiasis. Sonograms B-mode image showing the gallbladder containing some calculi B-mode image of the gallbladder calculus impacted in the gallbladder neck Longitudinal view of the normal common bile duct B-mode image of the gallbladder showing an increased wall thickness of 5.5 mm in AP calibre Axial CT of the gallbladder performed just prior to ultrasound showing some wall inflammation, however, no radiopaque calculus was seen A Gallbladder Filled with Numerous Radiolucent Calculi Clinical History A 56-year old lady presented with abdominal pain and some bowel symptoms. Case Description CT abdomen and pelvis with contrast revealed mild thickening of the gallbladder wall, however, no radiopaque calculus (radiolucent calculi) was seen. Ultrasound was advised. An ultrasound of the abdomen after adequate fasting (>6 hours) revealed a mildly thick-walled gallbladder filled with numerous calculi (radiolucent calculi). Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to the surgical team to discuss plans for cholecystectomy if clinically indicative. Sonograms Longitudinal image of the gallbladder containing numerous calculi within its lumen Axial Image of the gallbladder containing numerous calculi Gallbladder wall showing some increased thickness of 5 mm in AP calibre (normal = up to 3 mm) Longitudinal view of the gallbladder filled with numerous calculi Normal calibre of the common bile duct Axial CT of the gallbladder , performed recently, showing wall inflammation with no radiopaque calculi within the lumen Gallbladder Adenomyomatosis Figure of 8 Gallbladder with a Focal Fundal Thickening Clinical History A 56-year old lady presented with an acute onset of epigastric tenderness and pain radiating to the right upper abdominal quadrant. Ultrasound of the abdomen was requested for an initial assessment. Case Description Ultrasound revealed a ‘figure of 8’ gallbladder morphology with mild focal thickening at the fundal half (focal fundal thickening). There were also two tiny flecks of interstitial gas pockets within the gallbladder wall that appeared as reverberation artefacts and twinkling on colour Doppler imaging. Diagnosis/ Discussion/ Treatment/ Follow up The patient had magnetic resonance cholangiopancreaticography (MRCP) which further confirmed the ultrasound findings of adenomyomatosis. Gallbladder adenomyomatosis is a benign condition in which there is hypertrophy of the gallbladder mucosal epithelium with an invagination into its interstices. This leads to the formation of gas pockets within the gallbladder wall known as Rokitansky-Aschoff sinuses. Sonograms Figure 8 gallbladder B-mode gallbladder showing a focal thickening of the folded fundus with gas pocket in the wall Twinkle artefact from the gallbladder interstitial gas pocket Figure 8 gallbladder Axial MRI of the gallbladder Gallbladder Polyps Coexisting with Adenomyomatosis Clinical History A 48-year old lady presented with a long-term history of right upper quadrant abdominal pain. The patient was referred to have an ultrasound of the abdomen to check for possible gallbladder calculi (gallstones). Case Description An abdominal ultrasound was performed using a 6 MHz curvilinear transducer. Ultrasound revealed multiple tiny gallbladder polyps. The largest polyp measured up to 4 mm x 4 mm in length and AP diameter. The gallbladder was thin-walled and contained no calculus within its lumen. However, there were multiple gas pockets within the gallbladder wall that appeared as ‘comet tail’ artefacts in keeping with Rokintansky Aschoff sinuses. These ultrasound appearances of the gallbladder have been known to be related to gallbladder adenomyomatosis. Diagnosis/ Discussion/ Treatment/ Follow up The patient was placed on an ultrasound pathway where the gallbladder would be monitored every six months to check for any abrupt change in appearances. Sonograms B-mode of the gallbladder showing a comet-tail artefact Arrows pointing at the comet-tail artefact Longitudinal view of the gallbladder on B-mode Two tiny gallbladder polyps Axial view of the gallbladder showing two polyps Normal common bile duct Pancreas Intraductal Papillary Mucinous Neoplasm (IPMN) Cystic Pancreatic Mass in an 81-Year Old Lady Presenting with an Abnormal LFT Clinical History An 81-year old lady presented with acute deterioration of her recent liver function tests which progressively worsened. ALP – 890, Bilirubin 28, ALT 195. Case Description Abdominal ultrasound performed revealed the presence of a 42 mm complex cystic lesion (cystic pancreatic mass) at the pancreatic head. The gallbladder was also distended with a thickened and oedematous wall morphology. Also, there was sludge seen within the gallbladder lumen. The common bile duct was dilated at 9 mm in AP calibre. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have an MRCP which confirmed the ultrasound findings including the complex cystic lesion at the pancreatic head which was suggested to be due an IPMN. IPMNs are commonly benign tumours, however, some have been reported to progress into being cancerous. In this case, the cystic pancreatic lesion was causing some biliary obstruction. Sonograms Dilated CBD measuring 9 mm in AP calibre A distended thin-walled gallbladder containing some sludge within its lumen A cystic lesion at the head of the pancreas (HOP) adjacent to the thick-walled gallbladder Cystic lesion at the head of pancreas (HOP) with some normal pancreatic tissues seen around it Acute Pancreatitis A Case of Acute Pancreatitis Mimicking Pancreatic Malignancy Clinical History A 62-year old man presented with symptoms of right upper quadrant abdominal pain, vomiting, raised inflammatory markers, and deranged LFT. An abdominal ultrasound was requested as a first line of imaging to assess for features of cholecystitis. Case Description Ultrasound revealed a large heterogeneous cystic structure within the epigastrium posterior to the duodenum, with no internal vascularity seen in the structure. Although the pancreas was not clearly visualised on this examination, the said cystic structure was suggested to be related to the pancreas, due to its proximity. In addition, there was also a mild trace of ascites in the hepatorenal pouch of Morrison, right and left iliac fossae, with the thin-walled gallbladder containing some sludge within its lumen. Due to these findings, an urgent review was advised. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have a contrast-enhanced CT scan of the whole body which confirmed the presence of a large heterogeneous mass replacing the head and body of pancreas. The mass was seen to have a cystic/ necrotic component. Suggestive of a pancreatic tumour (Acute Pancreatitis). However, the patient’s blood results and clinical evaluation were more inflammatory than tumoral. The patient had ERCP, cytology, and endoscopic ultrasound (EUS), which aided the diagnosis of acute pancreatitis. A follow up whole body CT scan 3 months post treatment confirmed resolution of the pancreatic collection in keeping with chronic (acute Pancreatitis) pancreatitis. Sonograms A heterogeneous cystic mass at the head of pancreas (HOP) CDI of the HOP mass Free fluid in the hepatorenal pouch of Morrison Sludge in the lumen of the thin-walled gallbladder An initial CT (coronal slice) of the abdomen showing the mass in the region of the pancreatic head One year later CT showed the inflammatory mass (pancreatitis confirmed on EUS) in the pancreatic area has reduced post treatment Biliary tree Choledocholithiasis Multiple Biliary Calculi Clinical History A 76-year old man presented with abdominal pain, vomiting, and jaundice. His blood test showed raised infection markers and deranged LFTs. Abdominal ultrasound was requested as the first line of imaging. Case Description Ultrasound revealed multiple large calculi within the lumen of the dilated common bile duct (multiple biliary calculi) measuring 12 mm in AP dimension. The gallbladder was thick-walled and contained some tiny calculi within its lumen. Diagnosis/ Discussion/ Treatment/ Follow up The patient had magnetic resonance cholangiopancreaticography (MRCP) which confirmed the ultrasound findings. Sonograms Thick-walled gallbladder Axial sonogram of the thick-walled gallbladder Dilated common bile duct containing multiple oval-shaped echogenic structures Dilated common bile duct containing multiple oval-shaped echogenic structures MRCP; coronal image showing the dilated CBD containing multiple filling-defects Multiple oval-shaped structures within the lumen of the CBD Calculus Within the Common Bile Duct Causing Biliary Obstruction Clinical History A 49-year old man presented with abdominal pain. Case Description An abdominal ultrasound was done using a 2 – 5 MHz curvilinear transducer. This revealed multiple calculus within the common bile duct and another calculus within the lumen of the collapsed gallbladder. These findings were also confirmed on MRCP done afterwards. Diagnosis/ Discussion/ Treatment/ Follow up The patient had ERCP and cholecystectomy. Sonograms Sonogram of the pancreas showing the head, body, and uncinate process of the pancreas. The pancreatic tail is partly obscured by bowel gas shadowing. A short segment of the left hepatic lobe and duodenum are displayed anterior to the pancreas. No pancreatic duct dilatation An obstructive calculus in the common bile duct. The calculus measures 11 mm and the common bile duct measures 10 mm in AP calibre A 10 mm immoble calculus at the neck of the nearly empty gallbladder An Obstructive Calculus in the Common Bile Duct Clinical History A 61 year old lady presented with an acute onset of epigastric pain and loss of appetite. The patient is known to have uncomplicated cholelithiasis which was diagnosed 2 decades ago. Presently, the bloods revealed raised alkaline phosphatase of 200. Case Description Abdominal ultrasound revealed a distended gallbladder with multiple calculi. There was also intra and extrahepatic biliary dilatation present. The common bile duct measured 15 mm in AP calibre with a calculus (obstructive calculus) seen towards the distal end of the lumen. However, the pancreatic duct was not dilated. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound findings were confirmed on a subsequent MRCP. Sonograms The right hepatic lobe showing dilatation of the IHD and CBD Longitudinal section of the gallbladder containing multiple tiny calculi An obstructive calculus in the distal CBD Spleen Splenic Haemangioma An Incidental Diagnosis of Splenic Haemangioma Clinical History A 75-year old lady was referred to have an ultrasound of the urinary tract due to some evidence of frank haematuria. Case Description Although ultrasound did not reveal any renal or bladder lesion, while examining the left kidney, a 16 mm hypoechoic lesion was discovered within the spleen. The lesion had a uniformly roundish outline with some evidence of internal vascularity. Ultrasound features were suggestive of a splenic haemangioma. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound findings were confirmed on a subsequent CT. Splenic haemangiomas are some of the most commonly encountered splenic lesions on ultrasound. They are benign slow-growing tumours of the spleen. Due to their nature, they contain evidence of vascular enhancement on imaging. Sonograms Splenic haemangioma B-mode Splenic haemangioma showing the measurement callipers CDI showing the splenic haemangioma with some evidence of internal vascularity Axial CT scan showing the splenic haemangioma with evidence of enhancement Keywords
Ultrasound Appearances of Polycystic Ovaries Clinical History A 34-year old lady with primary infertility was referred to have an ultrasound of the pelvis (TA and TV) to examine the ovaries. The clinician had suspected PCOS from the patient’s recent blood results. Case Description Ultrasound (TA and TV) revealed bulky ovaries; right measuring 15 ml and left 13 ml in volume. There were also multiple peripherally arranged follicles all less than 10 mm in diameter within both ovaries. These features are suggestive of polycystic ovarian morphology (polycystic ovaries). Diagnosis/ Discussion/ Treatment/ Follow up Although ultrasound is not definitive in diagnosing Polycystic Ovarian Syndrome (PCOS), hormonal analysis of the haematological samples are more accurate for this. However, some ultrasound features like bulky ovaries (> 10 ml volume), multiple peripherally arranged follicles less than 10 mm can raise sonographic suspicion of the disease. Sonograms A dual screen (TV) sonogram of the right ovary in longitudinal and transverse orientations. The ovarian volume is 15.44 ml which is above the normal of 10 ml in a premenopausal woman A dual screen (TV) sonogram of the left ovary in longitudinal and transverse orientations. The ovarian volume is 13.19 ml which is above the normal of 10 ml in a premenopausal woman A TV longitudinal sonogram of the normal retroverted uterus showing the homogeneous myometrium and endometrium
Subcapsular Haematoma Clinical History A 74-year old man presented with a recent history of fall and an acute kidney injury (AKI) was referred to have a renal ultrasound as an initial imaging assessment. Case Description Ultrasound revealed a 12 cm heterogeneous structure within the subcapsular layer of the left kidney with no internal vascularity seen within the abnormality. Appearances were suggestive of a subcapsular haematoma. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a subsequent contrast CT which confirmed the ultrasound findings. A followup ultrasound months later revealed the haematoma to have mostly resolved. Subcapsular haematoma can mimic renal masses on ultrasound. However, the absence of internal vascularity and the location of the abnormality within the renal capsule are two features that can help improve the diagnostic confidence of ultrasound practitioners in clinical settings Sonograms B-mode left kidney with a subcapsular haematoma Left renal subcapsular haematoma with measurement callipers CDI showing some normal intrarenal vessels but no flow in the haematoma Coronal CT scan showing the left renal subcapsular haematoma Follow up ultrasound of the left kidney showing resolved haematoma after 4 months B-mode ultrasound showing what is left of the resolved left renal subcapsular haematoma
Forearm Inflammatory Intramuscular Collection Clinical History A 51-year old man presented with an acute large swelling on the left forearm with erythema and tenderness. Case Description Ultrasound performed using a linear transducer at 14 MHz revealed a large hypervascular collection within the intramuscular layer of the affected forearm suggestive of an abscess. Diagnosis/ Discussion/ Treatment/ Follow up A further ultrasound performed 3 months later revealed a significant reduction in the said collection, still some internal vascularity, and a tract to the skin surface suggestive of a resolving collection. Sonograms Panoramic view of the forearm showing the 8 cm abscess in B-mode Intramuscular abscess of the forearm longitudinal view Intramuscular abscess of the forearm transverse view CDI showing hypervascularity in axial view CDI showing hypervascularity in longitudinal view B-mode longitudinal view of the forearm abscess Forearm collection Ultrasound 3 months later revealing a significant reduction in the abscess
Bladder Tumour Clinical History A 91-year old man with sudden health deterioration and in critical condition presented with haematuria, anaemia, thrombocytopaenia, and abnormal LFT. An abdominal ultrasound was requested as a first line of imaging. Case Description Ultrasound revealed a 7 cm heterogeneous mass (bladder tumour) in the urinary bladder with an irregular outline. The liver appeared enlarged with heterogeneous parenchymal echotexture and multiple hypoechoic lesions throughout, suggestive of metastases. Diagnosis/ Discussion/ Treatment/ Follow up Unfortunately, the patient passed away. Sonograms Left lobe of the liver in a longitudinal orientation with multiple hypoechoic lesions Left lobe of the liver in a transverse orientation showing multiple hypoechoic lesions Right lobe of the liver containing multiple lesions, and showing the portal vein The portal vein on colour Doppler imaging showing normal hepatopetal flow Sonogram of the partly filled urinary bladder showing a bladder wall mass
Gallbladder Articles Calculus Cholecystitis Gallbladder Adenomyomatosis Calculus Cholecystitis Ultrasound Diagnosed Gallstones that were Radiolucent on a Recent CT Scan Clinical History A 55-year old lady presented with abdominal pain and tenderness in the right upper quadrant. Case Description A contrast CT scan of the abdomen and pelvis was performed which revealed an inflamed gallbladder wall with no radio-opaque gallstone seen. However, ultrasound was recommended to rule out gallstones. Diagnosis/ Discussion/ Treatment/ Follow up The patient had an uneventful laparoscopic cholecystectomy. Ultrasound is more sensitive in the diagnosis of cholelithiasis than CT scan. Some gallbladder calculi (cholelithiasis) can be radioluscent, therefore missed on CT. This is why abdominal ultrasound is the recommended first line of imaging, when it is available, for cases with clinically suspected cholelithiasis. Sonograms B-mode image showing the gallbladder containing some calculi B-mode image of the gallbladder calculus impacted in the gallbladder neck Longitudinal view of the normal common bile duct B-mode image of the gallbladder showing an increased wall thickness of 5.5 mm in AP calibre Axial CT of the gallbladder performed just prior to ultrasound showing some wall inflammation, however, no radiopaque calculus was seen A Gallbladder Filled with Numerous Radiolucent Calculi Clinical History A 56-year old lady presented with abdominal pain and some bowel symptoms. Case Description CT abdomen and pelvis with contrast revealed mild thickening of the gallbladder wall, however, no radiopaque calculus (radiolucent calculi) was seen. Ultrasound was advised. An ultrasound of the abdomen after adequate fasting (>6 hours) revealed a mildly thick-walled gallbladder filled with numerous calculi (radiolucent calculi). Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to the surgical team to discuss plans for cholecystectomy if clinically indicative. Sonograms Longitudinal image of the gallbladder containing numerous calculi within its lumen Axial Image of the gallbladder containing numerous calculi Gallbladder wall showing some increased thickness of 5 mm in AP calibre (normal = up to 3 mm) Longitudinal view of the gallbladder filled with numerous calculi Normal calibre of the common bile duct Axial CT of the gallbladder , performed recently, showing wall inflammation with no radiopaque calculi within the lumen Gallbladder Adenomyomatosis Figure of 8 Gallbladder with a Focal Fundal Thickening Clinical History A 56-year old lady presented with an acute onset of epigastric tenderness and pain radiating to the right upper abdominal quadrant. Ultrasound of the abdomen was requested for an initial assessment. Case Description Ultrasound revealed a ‘figure of 8’ gallbladder morphology with mild focal thickening at the fundal half (focal fundal thickening). There were also two tiny flecks of interstitial gas pockets within the gallbladder wall that appeared as reverberation artefacts and twinkling on colour Doppler imaging. Diagnosis/ Discussion/ Treatment/ Follow up The patient had magnetic resonance cholangiopancreaticography (MRCP) which further confirmed the ultrasound findings of adenomyomatosis. Gallbladder adenomyomatosis is a benign condition in which there is hypertrophy of the gallbladder mucosal epithelium with an invagination into its interstices. This leads to the formation of gas pockets within the gallbladder wall known as Rokitansky-Aschoff sinuses. Sonograms Figure 8 gallbladder B-mode gallbladder showing a focal thickening of the folded fundus with gas pocket in the wall Twinkle artefact from the gallbladder interstitial gas pocket Figure 8 gallbladder Axial MRI of the gallbladder Gallbladder Polyps Coexisting with Adenomyomatosis Clinical History A 48-year old lady presented with a long-term history of right upper quadrant abdominal pain. The patient was referred to have an ultrasound of the abdomen to check for possible gallbladder calculi (gallstones). Case Description An abdominal ultrasound was performed using a 6 MHz curvilinear transducer. Ultrasound revealed multiple tiny gallbladder polyps. The largest polyp measured up to 4 mm x 4 mm in length and AP diameter. The gallbladder was thin-walled and contained no calculus within its lumen. However, there were multiple gas pockets within the gallbladder wall that appeared as ‘comet tail’ artefacts in keeping with Rokintansky Aschoff sinuses. These ultrasound appearances of the gallbladder have been known to be related to gallbladder adenomyomatosis. Diagnosis/ Discussion/ Treatment/ Follow up The patient was placed on an ultrasound pathway where the gallbladder would be monitored every six months to check for any abrupt change in appearances. Sonograms B-mode of the gallbladder showing a comet-tail artefact Arrows pointing at the comet-tail artefact Longitudinal view of the gallbladder on B-mode Two tiny gallbladder polyps Axial view of the gallbladder showing two polyps Normal common bile duct
Complicated Appendicitis with Perforations Clinical History A 19-year old male presented with a 4-day history of abdominal pain radiating to the right iliac fossa, some fever, diarrhoea, and vomiting. Blood tests revealed elevated inflammatory markers. Case Description Ultrasound revealed a 98 x 43 x 58 mm heterogeneous hypoechoic area in the right iliac fossa posterolateral to the caecum and anterior to the psoas muscle fibres. Also, there was mesenteric fat stranding around it. These were all at the site of the patient’s maximum tenderness. The normal appendix tissue was not seen leading the sonographer to raise the suspicion of appendiceal perforation. Diagnosis/ Discussion/ Treatment/ Follow up The patient had an emergency appendectomy and the surgical specimen analysed histologically confirmed the diagnosis of perforated appendicitis. Sonograms Sonogram acquired using a high frequency linear probe showing a heterogeneous hypoechoic structure in the RIF Sonogram acquired using a curvilinear probe showing a heterogeneous hypoechoic structure in the RIF Sonogram acquired using a curvilinear probe showing a heterogeneous hypoechoic structure in the RIF Power Doppler showing no evidence of vascularity Sonogram acquired using a high frequency linear probe showing a heterogeneous hypoechoic structure in the RIF Panoramic view of the RIF
Endometrial/Endometrium Articles Endometrial polyp Endometrial Carcinoma Cervical Mass Endometrial polyp Endometrial Polyp in an 80-Year Old Clinical History An 80-year old lady presented with abdominal bloating and discomfort. Case Description An ultrasound of the abdomen and pelvis revealed a 17 mm oval-shaped lesion sitting within the fluid-filled endometrial cavity with evidence of a feeder vessel seen within it. Appearances are in keeping with an endometrial polyp. Diagnosis/ Discussion/ Treatment/ Follow up The polyp was surgically removed and the specimen was histologically examined which confirmed the ultrasound findings. Sonograms 2-D, B-mode transvaginal ultrasound showing the large endometrial polyp with some fluid within the endometrial cavity Endometrial polyp with measurement callipers Endometrial polyp with colour Doppler showing a tiny ‘feeder vessel’ Endometrial polyp with power Doppler showing a tiny ‘feeder vessel’ Post-op appearance of the normal endometrium Endometrial Polyp Presenting as Painful Heavy Menstrual Bleeding Clinical History A 48-year old lady presented with a history of heavy and painful menstrual bleeding with the presence of clots. Gynaecological ultrasound was requested to assess for uterine fibroids or any related causes. Case Description Transvaginal ultrasound revealed a 2 cm polyp within the endometrial cavity of the retroverted uterus with a feeder vessel seen extending from the adjacent myometrium. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to gynaecology where she had hysteroscopy to confirm the polyp prior to its removal (polypectomy) Sonograms Transvaginal B-mode sonogram of the endometrium showing the oval-shaped polyp PDI image of the endometrial polyp showing the feeder vessel Endometrium Endometrial Carcinoma A Large Adnexal Mass in a Patient with Endometrial Cancer Clinical History A 74-year old lady presented with abdominal distension and discomfort. Case Description Ultrasound of the abdomen and pelvis (TA and TV) revealed a grossly thickened endometrium measuring 27 mm in AP calibre with heterogeneous echotexture. In addition there was a 131 mm complex non-vascular cystic mass (endometrial cancer) in the left adnexa/ left hemipelvis. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a whole body contrast CT which confirmed the ultrasound findings (endometrial cancer) in addition to the diagnosis of some omental cake with nodal peritoneal deposits and ascites in keeping with gynaecological malignancy. The adnexal cyst appeared to herniate through the left inguinal canal. The tumour markers (Ca125 and Ca19.9) were significantly elevated. Subsequently, the patient had an omental biopsy which confirmed metastatic high grade carcinoma. Sonograms Transabdominal view of the pelvis showing a 131 mm x 68 mm (L x AP) heterogeneous cystic mass in the left adnexa Transvaginal longitudinal view of the uterus showing an abnormally thickened endometrium of 26 mm (AP) Power Doppler imaging of the left adnexal complex cyst showing no evidence of internal vascularity PDI of the left adnexal cystic mass Free fluid in the right upper quadrant in keeping with ascites Ascites in the left upper abdominal quadrant adjacent to the spleen; subphrenic and within the splenorenal recess Ascites in the LUQ Axial CT showing the cyst in the LIF Sagittal CT showing the left adnexal cystic mass herniating into the left inguinal canal Cervical Mass A Large Cervical Mass Presenting as PMB Clinical History A 64-year old lady presented with a 2-week history of postmenopausal vaginal bleeding. A gynaecology ultrasound was requested to assess for endometrial thickening. Case Description Transabdominal and transvaginal ultrasound were performed to assess the uterus, endometrium and ovaries. Ultrasound revealed a 3.3 cm echogenic oval-shaped lesion in the cervical cavity (cervical mass) with some fluid around it. The endometrium measured 0.7 cm and contained some echogenic materials that could be seen to migrate towards the cervical canal. Diagnosis/ Discussion/ Treatment/ Follow up Based on the ultrasound appearances and the patient’s symptoms, the features of the cervical lesion are suggestive of a cervical mass or polyp. A low-lying intracavitary fibroid could be a possible differential diagnosis. Sonograms Cervical lesion in longitudinal view with callipers Cervical lesion in axial view with callipers Endometrial cavity fluid CDI showing no flow in the cervical lesion Echogenic content in the endometrium about to migrate into the cervix Echogenic content of the endometrium migrating into the cervix Keywords
Bladder Mass with Liver Metastasis Articles Bladder Tumour Bladder Tumour Clinical History A 91-year old man with sudden health deterioration and in critical condition presented with haematuria, anaemia, thrombocytopaenia, and abnormal LFT. An abdominal ultrasound was requested as a first line of imaging. Case Description Ultrasound revealed a 7 cm heterogeneous mass in the urinary bladder (bladder tumour) with an irregular outline. The liver appeared enlarged with heterogeneous parenchymal echotexture and multiple hypoechoic lesions throughout, suggestive of metastases. Diagnosis/ Discussion/ Treatment/ Follow-up Unfortunately, the patient passed away. Sonograms Left lobe of the liver in a longitudinal orientation with multiple hypoechoic lesions Left lobe of the liver in a transverse orientation showing multiple hypoechoic lesions Right lobe of the liver containing multiple lesions, and showing the portal vein The portal vein on colour Doppler imaging showing normal hepatopetal flow Sonogram of the partly filled urinary bladder showing a bladder wall mass
Bladder Tumour Clinical History A 91-year old man with sudden health deterioration and in critical condition presented with haematuria, anaemia, thrombocytopaenia, and abnormal LFT. An abdominal ultrasound was requested as a first line of imaging. Case Description Ultrasound revealed a 7 cm heterogeneous mass in the urinary bladder (bladder tumour) with an irregular outline. The liver appeared enlarged with heterogeneous parenchymal echotexture and multiple hypoechoic lesions throughout, suggestive of metastases. Diagnosis/ Discussion/ Treatment/ Follow-up Unfortunately, the patient passed away. Sonograms Left lobe of the liver in a longitudinal orientation with multiple hypoechoic lesions Left lobe of the liver in a transverse orientation showing multiple hypoechoic lesions Right lobe of the liver containing multiple lesions, and showing the portal vein The portal vein on colour Doppler imaging showing normal hepatopetal flow Sonogram of the partly filled urinary bladder showing a bladder wall mass
Penile Doppler Assessment Articles Penile Doppler Assessment Penile Doppler Assessment Clinical information A 27-year old man presented with problems maintaining erections. A Doppler ultrasound of the penis was requested to provide an insight to the situation while assessing the penile blood vessels for a vasculogenic aetiology. Case Description Ultrasound was performed using a high frequency linear transducer of up to 16 MHz after administering 20 mcg of Caverject IM. The assessment was carried out every 5 minutes post injection. The corporal bodies were initially examined in B-mode to assess for any (Peyronie’s) plaques. Afterwhich, the right and left cavernosal arteries were interrogated using colour and spectral Doppler ultrasound to evaluate the flow velocities. Both peak systolic and end diastolic velocity parameters are the most useful in determining arterial or venous insufficiency causes of erectile dysfunction. Diagnosis/ Discussion/ Treatment/ Follow up Venous Insufficiency Sonographs Right corpus cavernosum 5 minutes after caverject administration. Left corpus cavernosum 5 minutes after caverject administration. Spectral Doppler of the left cavernosal artery during tumescence phase of erection. Spectral Doppler of the right cavernosal artery during tumescence phase of erection. Spectral imaging of the left cavernosal artery showing in axial orientation. Spectral imaging of the right cavernosal artery showing in axial orientation.
Urinary Bladder Articles Bladder and Renal Calculus Bladder Mass with Liver Metastasis Bladder Cancer Bladder Diverticulum Bladder and Renal Calculus Urolithiasis in the Bladder and Kidney of a 75-year Old Man Patient History A 75-year old man presented with macroscopic haematuria Case Description The patient was referred to have an ultrasound examination of his kidneys and bladder as part of the (NICE guideline) diagnostic workup for haematuria in individuals above 45-years old. The bladder contained a 13 mm intraluminal mobile calculus (Urolithiasis). The right kidney contained an 8 mm non-obstructing calculus within its lower pole. Diagnosis/ Discussion/ Treatment/ Follow Up The patient had a follow up CT scan which confirmed the findings. The bladder calculus was removed transurethral. Sonograms Transverse section of the well-filled urinary bladder containing a calculus A dual-screen image of the urinary bladder with the patient initially in supine position, then asked to roll on to the left lateral decubitus position. This manoeuvre shows evidence of calculus movement which confirms that the calculus is within the bladder lumen A longitudinal image of the right kidney showing a 6 mm calculus at its lower pole A transverse image of the right renal lower pole showing the calculus A transverse image of the right renal lower pole with colour Doppler imaging, showing twinkling artefact Bladder Mass with Liver Metastasis Clinical History A 91-year old man with sudden health deterioration and in critical condition presented with haematuria, anaemia, thrombocytopaenia, and abnormal LFT. An abdominal ultrasound was requested as a first line of imaging. Case Description Ultrasound revealed a 7 cm heterogeneous mass in the urinary bladder with an irregular outline. The liver appeared enlarged with heterogeneous parenchymal echotexture and multiple hypoechoic lesions throughout, suggestive of metastases. Diagnosis/ Discussion/ Treatment/ Follow-up Unfortunately, the patient passed away. Sonograms Bladder Tumour Clinical History A 91-year old man with sudden health deterioration and in critical condition presented with haematuria, anaemia, thrombocytopaenia, and abnormal LFT. An abdominal ultrasound was requested as a first line of imaging. Case Description Ultrasound revealed a 7 cm heterogeneous mass (bladder tumour) in the urinary bladder with an irregular outline. The liver appeared enlarged with heterogeneous parenchymal echotexture and multiple hypoechoic lesions throughout, suggestive of metastases. Diagnosis/ Discussion/ Treatment/ Follow up Unfortunately, the patient passed away. Sonograms Left lobe of the liver in a longitudinal orientation with multiple hypoechoic lesions Left lobe of the liver in a transverse orientation showing multiple hypoechoic lesions Right lobe of the liver containing multiple lesions, and showing the portal vein The portal vein on colour Doppler imaging showing normal hepatopetal flow Sonogram of the partly filled urinary bladder showing a bladder wall mass Bladder Cancer Transitional Cell Carcinoma of the Urinary Bladder Clinical History A 74-year old man presented with painless frank haematuria. Case Description Ultrasound revealed a 17 mm hypoechoic mass (carcinoma) in the posterolateral wall of the urinary bladder lateral to the right ureteral orifice. The mass showed some evidence of vascularity within it. The kidneys appear unremarkable. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a whole body CT to further characterise the mass. CT revealed the lesion in the bladder with no evidence of extravesical involvement. The patient had transurethral resection of the bladder tumour (TURBT). A subsequent histology analysis of the specimen sample confirmed a Grade 3 bladder cancer. No disease recurrence recorded on follow-up evaluations. Sonograms B-Mode ultrasound showing the mass in the posterolateral wall Longitudinal view of the bladder mass in the posterior bladder wall Colour Doppler Imaging of the bladder mass showing some internal vascularity CDI showing evidence of right ureteric jets adjacent to the bladder mass. Evidently, no ureteric obstruction caused by the bladder mass CDI showing ureteric jets bilaterally Normal right kidney Normal left kidney Bladder Diverticulum Bladder Diverticulum Coexisting with Bladder Wall Thickening and a Small Prostatic Cyst Clinical History A 78-year old gentleman presented with a recent history of urinary incontinence with some microscopic haematuria and pain in the lower abdomen. An ultrasound of the renal tract was requested to further investigate. Case Description Ultrasound revealed a 3 mm defect in the posterolateral wall of the urinary bladder with a small diverticulum. The bladder wall was irregular in outline and has an increased thickness of up to 7 mm in AP calibre. Posterior to the bladder, the prostate contained a 20 mm simple cyst. Diagnosis/ Discussion/ Treatment/ Follow up Bladder diverticulum occurs when there is a breach in the bladder wall due to a loss of wall integrity and weakness of the bladder muscles. Bladder diverticulum can be single or multiple and are commonly age-related. The term microscopic haematuria, also called non-visible haematuria, is commonly used when the presence of blood cells within the urine is only detectable via laboratory testing. Sonograms B-mode of the urinary bladder showing the tiny defect (top arrow) and the diverticulum (bottom arrow) Bladder wall thickening measuring 7 mm in AP calibre Longitudinal view of the bladder showing the diverticulum (three arrows) and a small simple cyst in the prostate (single arrow) CDI showing no flow in the prostate simple cyst
Penile Doppler Assessment Clinical information A 27-year old man presented with problems maintaining erections. A Doppler ultrasound of the penis was requested to provide an insight to the situation while assessing the penile blood vessels for a vasculogenic aetiology. Case Description Ultrasound was performed using a high frequency linear transducer of up to 16 MHz after administering 20 mcg of Caverject IM. The assessment was carried out every 5 minutes post injection. The corporal bodies were initially examined in B-mode to assess for any (Peyronie’s) plaques. Afterwhich, the right and left cavernosal arteries were interrogated using colour and spectral Doppler ultrasound to evaluate the flow velocities. Both peak systolic and end diastolic velocity parameters are the most useful in determining arterial or venous insufficiency causes of erectile dysfunction. Diagnosis/ Discussion/ Treatment/ Follow up Venous Insufficiency Sonographs Right corpus cavernosum 5 minutes after caverject administration. Left corpus cavernosum 5 minutes after caverject administration. Spectral Doppler of the left cavernosal artery during tumescence phase of erection. Spectral Doppler of the right cavernosal artery during tumescence phase of erection. Spectral imaging of the left cavernosal artery showing in axial orientation. Spectral imaging of the right cavernosal artery showing in axial orientation.
Horseshoe Kidney in a Patient with UTI Symptoms Clinical History A 48-year old man presented with UTI symptoms. Case Description Ultrasound performed on the patient’s abdomen revealed a horseshoe kidney with the isthmus anterior to the IVC and abdominal aorta inferiorly. The patient had no prior imaging of his abdomen, therefore, this was the first time the variant was found. Diagnosis/ Discussion/ Treatment/ Follow up The patient’s symptoms were managed with the appropriate antibiotic therapy. Sonograms Sonogram acquired above the umbilicus using a transverse probe orientation showing the isthmus of the horseshoe kidney with the abdominal aorta (red), IVC (blue), and spine posteriorly Left moiety of the horseshoe kidney Right moiety of the horseshoe kidney CT scan of the horseshoe kidney
An Ovarian Tumour with an Initial Presentation of RIF Pain Clinical History A 76-year old lady presented with a few weeks history of right sided abdominal pain, tenderness, and bloating. Although the blood results were normal, the patient was referred to have an ultrasound of the abdomen and pelvis to rule out cholelithiasis or ovarian abnormality. Case Description Ultrasound (TA and TV) revealed a large heterogeneous mass in the right adnexa with cystic and solid components and some internal vascularity. The right renal pelvis was also mildly dilated at 10 mm in AP calibre, suggesting mass effect on the right ureter by the mass. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have a pelvic MRI then whole body CT scan for staging prior to surgery. Subsequently, the patient had a total abdominal hysterectomy with bilateral salpingo oophorectomy. Future MRI scans revealed no evidence of disease recurrence. The post-operative histology analysis of the right ovary revealed a low grade serous carcinoma (Ovarian Tumour) arising in a borderline serous tumour. Sonograms TVUSS showing a cystic mass in the right adnexa with some solid components PDI of the right adnexal complex cystic mass showing some internal vascularity B Mode showing the right adnexal mass with its cystic component Axial CT image of the right adnexal complex cystic mass T1 axial MRI of the right adnexal mass
Peripheral Arteries Articles Popliteal Artery Occlusion Popliteal Artery Aneurysm Popliteal Artery Occlusion Occluded Popliteal Artery Clinical History An 80-year old man with metastatic bowel cancer presented with a sudden onset of right leg swelling. Case description An 80-year old man with metastatic bowel cancer presented with a sudden onset of right leg swelling. The patient was referred to have an ultrasound Doppler of the veins of his right lower limb to rule out deep venous thrombosis (DVT). Although DVT was ruled out, however, the popliteal artery appeared occluded. The patient was referred to the vascular team for further management of the occluded popliteal artery. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to the vascular team for further management. Sonograms Occluded popliteal artery with arrow Color Doppler showing the absence of flow in the popliteal artery. Patent popliteal vein (in blue) Color Doppler showing no flow in the popliteal artery Popliteal Artery Occlusion Co-existing with Popliteal Vein DVT Clinical History A 92-year old lady presented with pain and swelling in the right leg. The WELLS score was 2 upon an initial specialist clinical assessment. Doppler ultrasound of the lower limb veins was requested to rule out deep venous thrombosis (DVT). Case Description Ultrasound revealed the presence of an occlusive thrombus in the popliteal vein. There was also an occluded superficial femoral artery (SFA). However, the popliteal artery was patent. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred urgently to vascular surgery for further management. Unfortunately, the patient passed away Sonograms Patent right common femoral artery Partially occluded right superficial femoral artery (proximal) Partially occluded right superficial femoral artery (mid) Partially occluded right superficial femoral artery (distal) Colour Doppler imaging of the distal right superficial femoral artery showing some distal patency towards the popliteal artery Patent right popliteal artery Occluded right popliteal vein containing thrombus (blood clot), in keeping with deep venous thrombosis (DVT) Axial orientation of the right popliteal vein showing occlusion, and the patent artery posteriorly Popliteal Artery Aneurysm Incidental Finding of a Popliteal Artery Aneurysm during a DVT Ultrasound Clinical History An 83-year old man presented with left leg swelling, erythema, and shortness of breath. Case Description Ultrasound revealed a 27 mm popliteal artery aneurysm in the left popliteal fossa. The patient also had a positive extensive DVT in the deep veins of the left lower limb. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to the vascular specialist for further management. Sonograms B-Mode longitudinal view of the left popliteal artery aneurysm B-Mode axial view of the left popliteal artery aneurysm Colour Doppler imaging of the left popliteal artery aneurysm in longitudinal orientation Colour Doppler imaging of the left popliteal artery aneurysm in transverse orientation
Septate Uterus Articles Müllerian Duct Abnormality 2-D Ultrasound Müllerian Duct Abnormality 2-D Ultrasound Clinical History A 45-year old female presented with lower abdominal pain. Transabdominal and Transvaginal ultrasound of the pelvis was requested for further assessment. Case Description Mullerian duct abnormality was seen incidentally during a pelvic ultrasound of a 45-year old due to lower abdominal pain. These features can be better confirmed with a more definitive diagnosis using 3-D ultrasound of the pelvis. HyCoSy can also be used if infertility is an indication. However, these were not carried out at the time of the patient’s visit. Diagnosis/ Discussion/ Treatment/ Follow up No treatment was required at the time. Sonograms Bicornuate uterus transvaginal USS Bicornuate uterus TVUSS Bicornuate uterus Bicornuate uterus anterior horn Bicornuate uterus posterior horn Bicornuate uterus transverse view
Hernia Articles Port Site Hernia Port Site Hernia Post-laparoscopic Port site or Incisional Hernia Clinical History A 25-year old woman who recently had laparoscopic appendectomy presented with abdominal pain and swelling post op, with a palpable mass that was felt under the port site. Case Description An abdominal ultrasound done with a 2 – 5 MHz curvilinear transducer and a 10 MHz (high frequency transducer) revealed a 24 mm breech in the abdominal wall at the port site containing omental fat and some surrounding fluid. Ultrasound findings are in keeping with port site hernia. Diagnosis/ Discussion/ Treatment/ Follow-up Patient had the hernia repaired. Sonograms Port site hernia, image acquired using a low frequency curvilinear transducer Port site hernia showing the protrusion of the mesenteric fat content with a tiny trace of adjacent fluid within the herniated sac. No bowel loop seen within the sac. image acquired using a high frequency linear transducer Port site hernia Power Doppler showing no evidence of vascularity within the protruding mesenteric fat, as would be expected
Port Site Hernia Articles Post-laparoscopic Port site or Incisional Hernia Post-laparoscopic Port site or Incisional Hernia Clinical History A 25-year old woman who recently had laparoscopic appendectomy presented with abdominal pain and swelling post op, with a palpable mass that was felt under the port site. Case Description An abdominal ultrasound done with a 2 – 5 MHz curvilinear transducer and a 10 MHz (high frequency transducer) revealed a 24 mm breech in the abdominal wall at the port site containing omental fat and some surrounding fluid. Ultrasound findings are in keeping with port site hernia. Diagnosis/ Discussion/ Treatment/ Follow-up Patient had the hernia repaired. Sonograms Port site hernia, image acquired using a low frequency curvilinear transducer Port site hernia showing the protrusion of the mesenteric fat content with a tiny trace of adjacent fluid within the herniated sac. No bowel loop seen within the sac. image acquired using a high frequency linear transducer Port site hernia Power Doppler showing no evidence of vascularity within the protruding mesenteric fat, as would be expected
An Extratesticular Intrascrotal Right Epidermoid Cyst Clinical History A 60-year old man presented to the hospital after he had noticed a swollen structure posterior to his right testicle. Upon clinical evaluation, the structure felt to be outside the testis, suggestive of an epididymal cyst. The tumour markers were negative. An ultrasound of the testes was requested for further evaluation. Case Description Using a high frequency (15MHz) linear transducer, ultrasound revealed a roundish lesion within the right hemiscrotum with concentric morphology and no internal vascularity. The lesion appears as a concentric ring of alternating echogenicity with a well-defined outline and no internal vascularity. Ultrasound features were in keeping with an intrascrotal extratesticular epidermoid cyst and this corresponded with the site of concern the patient pointed at during the ultrasound encounter. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound report was sent to the referring clinician. At the time of compiling this report, the patient was known to have been managed conservatively as surgery is not clinically indicated. Epidermoid cysts are uncommon benign intratesticular or intrascrotal lesions encountered sonographically. They present as painless swelling or lump within the scrotum. Intrascrotal extratesticular epidermoid cysts are reportedly rare in the current literature. Ultrasound is the ideal imaging modality of choice in examining the scrotum for masses or lumps felt. Sonogram B-mode sonogram of the extratesticular right hemiscrotal lesion. B-mode sonogram of the extratesticular right hemiscrotal lesion. CDI sonogram of the extratesticular right hemiscrotal lesion. B-mode sonogram showing the lesion adjacent to the inferior pole of the unremarkable right testicle
Orchitis Articles Right Orchitis in a 30-year Old Male with a Coexisting Left Varicocoele Epididymo-orchitis Presenting as Painful Hemiscrotal Swelling Right Orchitis in a 30-year Old Male with a Coexisting Left Varicocoele Patient History A 30-year old male presented with an acute onset of right testicular pain. Case Description An ultrasound of the testes was performed using a 15 MHz linear transducer. Ultrasound revealed a hypoechoic and striated right testicle with evidence of hypervascularity on colour Doppler imaging. Appearances were in keeping with right orchitis. There was also evidence of dilatation of the left pampiniform plexus with a flow reversal of more than 2 seconds on spectral Doppler imaging. Appearances were suggestive of left varicocoele. Diagnosis/ Discussion/ Treatment/ Follow up The patient’s symptoms resolved after antibiotic therapy. Sonograms Grayscale image of the inflamed right testicle showing some hypoechoic striations across the testicular parenchyma in keeping with blood vessels Colour Doppler Imaging of the inflamed right testicle showing hypervascularity A dual-screen image of the right and left testes in colour Doppler mode. A normal left testicular vascularity can be seen Dilatation of the left pampiniform plexus veins Flow reversal on Valsalva manoeuvre for more than 2 seconds in the dilated left pampiniform plexus veins confirming varicocoele Epididymo-orchitis Presenting as Painful Hemiscrotal Swelling Clinical History A 25-year old man presented with symptoms of swelling and pain in the left hemiscrotum. The patient was referred to have an inpatient ultrasound on the same day. Case Description Ultrasound revealed a bulky and heterogeneous left epididymis (epididymo-orchitis). The left testis and epididymis both showed evidence of a significantly increased vascularity within them. There was also some reactive hydrocoele in the left hemiscrotum with a heterogeneous collection adjacent to the left epididymis. Diagnosis/ Discussion/ Treatment/ Follow up The patient’s symptoms resolved after completing antibiotic therapy. A subsequent ultrasound post-treatment confirmed the resolution of symptoms. Sonograms A panoramic image of the left hemiscrotum, in B-mode, showing an inflamed left epididymis B-mode image of the inflamed left testis and left epididymis Heterogeneous (complex) fluid collection in the left hemiscrotum adjacent to the left epididymis. No internal vascularity seen in the collection, as it is not a lesion B-mode left hemiscrotum showing the bulky and inflamed left epididymis Colour Doppler imaging showing hypervascularity of the left testis and epididymis in a ‘christmas tree’ fashion
Right Orchitis in a 30-year Old Male with a Coexisting Left Varicocoele Patient History A 30-year old male presented with an acute onset of right testicular pain. Case Description An ultrasound of the testes was performed using a 15 MHz linear transducer. Ultrasound revealed a hypoechoic and striated right testicle with evidence of hypervascularity on colour Doppler imaging. Appearances were in keeping with right orchitis. There was also evidence of dilatation of the left pampiniform plexus with a flow reversal of more than 2 seconds on spectral Doppler imaging. Appearances were suggestive of left varicocoele. Diagnosis/ Discussion/ Treatment/ Follow up The patient’s symptoms resolved after antibiotic therapy. Sonograms Grayscale image of the inflamed right testicle showing some hypoechoic striations across the testicular parenchyma in keeping with blood vessels Colour Doppler Imaging of the inflamed right testicle showing hypervascularity A dual-screen image of the right and left testes in colour Doppler mode. A normal left testicular vascularity can be seen Dilatation of the left pampiniform plexus veins Flow reversal on Valsalva manoeuvre for more than 2 seconds in the dilated left pampiniform plexus veins confirming varicocoele
Haematoma Articles Subpectoral Haematoma Subpectoral Haematoma Clinical History A 78-year old lady presented with swelling and bruising on her left arm secondary to a recent fall. Patient is on Apixaban for an underlying heart condition, however, the recent blood results revealed a sudden drop in haemoglobin, which led the clinicians to withhold the apixaban medication. Also a cardiac pacemaker was recently inserted. Case Description Ultrasound revealed an 8 cm heterogeneous hypoechoic non-vascular area in the intramuscular layer of the anterior chest region, posterior to the pectoralis muscle. Appearances suggested an intramuscular (subpectoral haematoma) haematoma. Diagnosis/ Discussion/ Treatment/ Follow up The patient had CT which confirmed the findings. Sonograms B-mode sonogram, acquired using a 9 MHz linear transducer, showing the subpectoral haematoma B-mode sonogram showing the subpectoral haematoma B-mode sonogram, acquired using a 12 MHz linear transducer, showing the subpectoral haematoma Axial CT of the chest showing the subpectoral haematoma
Müllerian Duct Abnormality 2-D Ultrasound Clinical History A 45-year old female presented with lower abdominal pain. Transabdominal and Transvaginal ultrasound of the pelvis was requested for further assessment. Case Description Mullerian duct abnormality was seen incidentally during a pelvic ultrasound of a 45-year old due to lower abdominal pain. These features can be better confirmed with a more definitive diagnosis using 3-D ultrasound of the pelvis. HyCoSy can also be used if infertility is an indication. However, these were not carried out at the time of the patient’s visit. Diagnosis/ Discussion/ Treatment/ Follow up No treatment was required at the time. Sonograms Bicornuate uterus transvaginal USS Bicornuate uterus TVUSS Bicornuate uterus Bicornuate uterus anterior horn Bicornuate uterus posterior horn Bicornuate uterus transverse view
Subpectoral Haematoma Clinical History A 78-year old lady presented with swelling and bruising on her left arm secondary to a recent fall. Patient is on Apixaban for an underlying heart condition, however, the recent blood results revealed a sudden drop in haemoglobin, which led the clinicians to withhold the apixaban medication. Also a cardiac pacemaker was recently inserted. Case Description Ultrasound revealed an 8 cm heterogeneous hypoechoic non-vascular area in the intramuscular layer of the anterior chest region, posterior to the pectoralis muscle. Appearances suggested an intramuscular (subpectoral haematoma) haematoma. Diagnosis/ Discussion/ Treatment/ Follow up The patient had CT which confirmed the findings. Sonograms B-mode sonogram, acquired using a 9 MHz linear transducer, showing the subpectoral haematoma B-mode sonogram showing the subpectoral haematoma B-mode sonogram, acquired using a 12 MHz linear transducer, showing the subpectoral haematoma Axial CT of the chest showing the subpectoral haematoma
Renal Cell Carcinoma Clinical History A 55-year old man presented with symptoms of frank haematuria. Case Description Renal ultrasound revealed a 5.4 cm heterogeneous vascular lesion in the midpole of the right kidney. Diagnosis/Discussion/Treatment/ Follow up The lesion was confirmed on CT with subtle evidence of invasion of the tumour into the a branch of the right renal vein. The patient had a right nephrectomy. Histology confirmed the diagnosis of clear cell renal cell carcinoma. Subsequent CT showed no evidence of disease recurrence. Sonograms B-mode longitudinal view of the right renal mass Right renal mass in b-mode Right renal mass in axial orientation CDI right renal mass showing some internal vascularity Axial CT scan of the right renal mass Post right nephrectomy coronal CT scan Post right nephrectomy axial CT
Abscess and Collection Articles Left Groin Abscess Left Groin Abscess Clinical History A 35-year old female presented with an onset of painful and tender swelling in the left groin. The patient has a history of intravenous drug injection into the groin. An ultrasound of the groin was requested to examine the swelling for further management. Case Description The left groin swelling was initially examined using a curvilinear ultrasound transducer to assess any mass or collection deep within the groin while limiting compromise on the image resolution. This revealed a 9 cm heterogeneous collection within the left groin (Left Groin Abscess) at the site of concern pointed by the patient. The collection was seen deep in the intramuscular compartment with a regular outline, some cystic internal component, and air bubbles floating in the dependent areas of the collection, appearing as echogenic rim with some comet tail artefacts at the anterior surface of the collection. The overall ultrasound features are congruent with an abscess in the deep muscle compartment of the left groin/ upper thigh. Using a high frequency linear transducer did not provide any tangible information as the collection was too deep to be fully examined by the high frequency transducer. Therefore, in this case, the curvilinear evaluation of the mass on ultrasound was sufficient. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound findings were congruent with the patient’s overall clinical picture. However, an MRI of the groin was requested for confirmation prior to a consideration of drainage. MRI confirmed a 9 cm collection in the right adductor compartment with air-fluid levels present, some lymphedema, and reactive lymph nodes. Sonograms Power Doppler imaging showing no evidence of vascularity within the groin abscess B-mode image of the left groin abscess B-mode ultrasound showing the left groin abscess with evidence of comet tail artefact from the gas pockets within its anterior surface A coronal MRI image of the groin showing the large collection in the upper and medial aspect of the left thigh
Left Groin Abscess Clinical History A 35-year old female presented with an onset of painful and tender swelling in the left groin. The patient has a history of intravenous drug injection into the groin. An ultrasound of the groin was requested to examine the swelling for further management. Case Description The left groin swelling was initially examined using a curvilinear ultrasound transducer to assess any mass or collection deep within the groin while limiting compromise on the image resolution. This revealed a 9 cm heterogeneous collection within the left groin (Left Groin Abscess) at the site of concern pointed by the patient. The collection was seen deep in the intramuscular compartment with a regular outline, some cystic internal component, and air bubbles floating in the dependent areas of the collection, appearing as echogenic rim with some comet tail artefacts at the anterior surface of the collection. The overall ultrasound features are congruent with an abscess in the deep muscle compartment of the left groin/ upper thigh. Using a high frequency linear transducer did not provide any tangible information as the collection was too deep to be fully examined by the high frequency transducer. Therefore, in this case, the curvilinear evaluation of the mass on ultrasound was sufficient. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound findings were congruent with the patient’s overall clinical picture. However, an MRI of the groin was requested for confirmation prior to a consideration of drainage. MRI confirmed a 9 cm collection in the right adductor compartment with air-fluid levels present, some lymphedema, and reactive lymph nodes. Sonograms Power Doppler imaging showing no evidence of vascularity within the groin abscess B-mode image of the left groin abscess B-mode ultrasound showing the left groin abscess with evidence of comet tail artefact from the gas pockets within its anterior surface A coronal MRI image of the groin showing the large collection in the upper and medial aspect of the left thigh
Paediatric UTI Clinical History A 7-year old female presented with recurrent UTI symptoms. Ultrasound or the renal tract was requested. Case Description Ultrasound revealed some floating debris in the urinary bladder. There was also evidence of focal hypertrophy of the bladder base surrounding the right and left ureteric orifices measuring 10 mm and 13 mm respectively. Multiple bladder jets were observed in the right ureteric orifice while none was seen in the left within a minute of close evaluation. Diagnosis/ Discussion/ Treatment/ Follow up The patient was commenced on antibiotic therapy in light of the ultrasound findings (UTI) and clinical manifestations. Sonograms Axial sonogram of the urinary bladder showing two echogenic protrusions at the bladder base in the region of the ureteric orifices Power Doppler imaging showing no evidence of vascularity within the protrusions Power Doppler imaging showing evidence of good bladder jets on the right ureteric orifice, ruling out right inlet obstruction A dilated left distal ureter at 12 mm (AP) posterior to the urinary bladder No right ureteric dilatation Post void examination showing a completely emptied urinary bladder Normal right kidney with no hydronephrosis Hydronephrotic left kidney
Haematoma Articles Calf Haematoma Intramuscular Haematoma in the Upper Arm Intramuscular Haematoma of the Thigh Following Anticoagulation Calf Haematoma Clinical History A 62-year old lady presented with left sided calf tenderness (Calf Haematoma) and swelling. Her recent D-Dimer test value was elevated, raising the suspicion of DVT. The patient was referred to have a venous Doppler ultrasound of her affected lower limb to rule out DVT. Case Description Ultrasound revealed no DVT. However, there was a 20 cm heterogeneous non-vascular complex area of fluid collection in the medial aspect of the left popliteal fossa, extending to the mid-lower leg region. The distal compartment of the collection contained hypoechoic contents. Appearances were in keeping with a Morel-Lavallee type of injury with a collection of blood products of varying chronology in the region demonstrated. This was seen to cause a slight displacement of the medial gastrocnemius muscle fibres. Diagnosis/ Discussion/ Treatment/ Follow up Morel-Lavellee also called ‘degloving’ injury, is a rare injury that occurs from the separation or tear of the skin and subcutaneous tissues away from the rest of the underlying muscle fibres. In this case, it led to an accumulation of blood products and some fluid collection within the affected region. Sonograms A panoramic view of the left medial calf showing the heterogeneous fluid collection in the intramuscular layer Power Doppler imaging showing no evidence of flow within the collection B-mode axial sonogram of the calf collection B-mode longitudinal sonogram of the calf collection PDI of the calf collection, again showing no vascularity Intramuscular Haematoma in the Upper Arm Clinical History A 42-year old lady with a recent history of a peripherally inserted central catheter (PICC line) insertion in her left upper arm developed an acute onset of pain and swelling around the PICC line insertion. Ultrasound of the arm was requested to rule out venous thrombosis or soft tissue haematoma or collection. Case Description Ultrasound revealed a 7 cm hypoechoic, heterogeneous, and non-vascular structure within the intramuscular layer of the brachium deep to the site of the line insertion. Appearances were suggestive of an intramuscular haematoma. In addition to the recent PICC line insertion, the patient had other preexisting conditions that supports the ultrasound findings Diagnosis/ Discussion/ Treatment/ Follow up The patient was continually managed for her comorbidities while the arm haematoma was managed conservatively. However, prior anticoagulation therapy (for other comorbidities) was discontinued. Sonograms CDI showing flow in the left subclavian vein B-mode showing the PICC line in the subclavian vein (arrow) Left arm intramuscular haematoma on B-mode Panoramic view of the intramuscular haematoma Haematoma measuring 7 cm x 2 cm Axial image of the intramuscular haematoma PDI showing no evidence of vascularity within the haematoma Intramuscular Haematoma of the Thigh Following Anticoagulation Clinical History A 39-year old man presented with an acute onset of tense swelling of the right lateral thigh region. The patient was on anticoagulation therapy, at the time of this occurrence, for a different condition. Ultrasound of the thigh was requested to assess for haematoma or other collections. Case Description Ultrasound revealed an 8 cm heterogeneous non-vascular haematoma within the intramuscular layer of the right lateral thigh region. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a CT angiogram of the lower limbs to assess the potential source of an acute bleed within the vessels. The ultrasound findings were confirmed on CT. However, there was no evidence of contrast extravasation to the pool of haematoma seen on CT. Sonograms B-mode showing the right thigh haematoma in longitudinal view Distal end of the right thigh haematoma Transverse view of the right thigh haematoma Right thigh haematoma in transverse view Transverse view of the distal portion of the right thigh haematoma Longitudinal view right thigh haematoma Panoramic view of the right thigh intramuscular haematoma PDI showing no flow signal in the haematoma Coronal view of the thigh haematoma on CT scan
Calf Haematoma Clinical History A 62-year old lady presented with left sided calf tenderness (Calf Haematoma) and swelling. Her recent D-Dimer test value was elevated, raising the suspicion of DVT. The patient was referred to have a venous Doppler ultrasound of her affected lower limb to rule out DVT. Case Description Ultrasound revealed no DVT. However, there was a 20 cm heterogeneous non-vascular complex area of fluid collection in the medial aspect of the left popliteal fossa, extending to the mid-lower leg region. The distal compartment of the collection contained hypoechoic contents. Appearances were in keeping with a Morel-Lavallee type of injury with a collection of blood products of varying chronology in the region demonstrated. This was seen to cause a slight displacement of the medial gastrocnemius muscle fibres. Diagnosis/ Discussion/ Treatment/ Follow up Morel-Lavellee also called ‘degloving’ injury, is a rare injury that occurs from the separation or tear of the skin and subcutaneous tissues away from the rest of the underlying muscle fibres. In this case, it led to an accumulation of blood products and some fluid collection within the affected region. Sonograms A panoramic view of the left medial calf showing the heterogeneous fluid collection in the intramuscular layer Power Doppler imaging showing no evidence of flow within the collection B-mode axial sonogram of the calf collection B-mode longitudinal sonogram of the calf collection PDI of the calf collection, again showing no vascularity
Extensive Occlusive Venous Thrombosis of the Left Upper Limb Clinical History A 64-year old lady with a peripherally inserted central catheter (PICC line) through her left upper limb, presented with a sudden onset of swelling in her left arm. A vascular ultrasound was requested to rule out thrombosis. Case Description Ultrasound revealed an extensive occlusive thrombus in the basilic vein, axillary vein, subclavian vein, and jugular vein of the left side. The PICC line was also visualised within the lumen of the thrombosed vein. Diagnosis/ Discussion/ Treatment/ Follow up The insertion of PICC lines can sometimes be for administering certain treatments. Patients who develop any adverse symptom (swelling, pain, redness) post PICC line insertion are prime candidates for an upper limb venous Doppler ultrasound. It is vital to rule out an onset of thrombosis in these patients to avoid dangerous outcomes. Sonograms CDI occluded left jugular vein CDI occluded left jugular vein CDI occluded left subclavian vein with PICC line in situ B-mode occluded left axillary vein with PICC line in situ B-mode occluded left basilic vein with PICC line in situ
Transitional Cell Carcinoma of the Urinary Bladder Clinical History A 74-year old man presented with painless frank haematuria. Case Description Ultrasound revealed a 17 mm hypoechoic mass (carcinoma) in the posterolateral wall of the urinary bladder lateral to the right ureteral orifice. The mass showed some evidence of vascularity within it. The kidneys appear unremarkable. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a whole body CT to further characterise the mass. CT revealed the lesion in the bladder with no evidence of extravesical involvement. The patient had transurethral resection of the bladder tumour (TURBT). A subsequent histology analysis of the specimen sample confirmed a Grade 3 bladder cancer. No disease recurrence recorded on follow-up evaluations. Sonograms B-Mode ultrasound showing the mass in the posterolateral wall Longitudinal view of the bladder mass in the posterior bladder wall Colour Doppler Imaging of the bladder mass showing some internal vascularity CDI showing evidence of right ureteric jets adjacent to the bladder mass. Evidently, no ureteric obstruction caused by the bladder mass CDI showing ureteric jets bilaterally Normal right kidney Normal left kidney
Lower Leg Soft Tissue Lesion with Concerning Ultrasound Features Clinical History A 72-year old mass presented with pain and swelling to the left calf. An initial Doppler ultrasound was requested to assess for DVT. Case Description Ultrasound ruled out DVT. However, during the examination, the sonographer could palpate a lump below the patient’s calf. This corresponded to a 3 cm oval-shaped well-defined heterogeneous vascular lesion in the deep subcutaneous compartment. Further evaluation with MRI was recommended. Diagnosis/ Discussion/ Treatment/ Follow up The patient declined having an MRI or any other studies in relation to this. Sonograms B-mode sonogram of an oval-shaped mass in the deep subcutaneous layer of the right lower leg Colour Doppler imaging of the oval-shaped deep subcutaneous mass showing a significant amount of internal vascularity B-mode virtual convex view of the deep subcutaneous mass showing some compression effect on the adjacent muscle fibres B-mode sonogram of the mass with measurement callipers Power Doppler imaging of the mass again showing a significant amount of vascularity within the mass
Urinary Tract Infection Articles UTI in a Paediatric Patient Paediatric UTI UTI in a Paediatric Patient Clinical History A 14-year old boy presented with long-standing recurrent UTI symptoms with some fever. Case Description Ultrasound revealed a thick and irregular urinary bladder wall outline. There was some debris seen within the bladder lumen. The pre void bladder volume was 182 ml, while the post void bladder volume was 105 ml (incomplete bladder emptying). In addition, there was also an area of focal thickening seen in the left ureteric orifice measuring 16 mm x 11 mm (L x AP). Although the ureters were not obstructed as there was no hydroureter, and the bladder jets were within optimal limits. There was no hydronephrosis either, however, the left urothelium was mildly thickened as seen in the left renal pelvis indicating a UTI. Diagnosis/ Discussion/ Treatment/ Follow up The patient was placed on antibiotics therapy which helped resolve the symptoms. Sonograms A distended urinary bladder showing an increased wall thickness. Note the numerous debris within the bladder lumen A dual-screen image of the bladder volume measurement Thickening of the left ureteric orifice (transverse orientation) appearing as an echogenic protrusion into the bladder lumen Thickening of the left ureteric orifice (longitudinal orientation) appearing as an echogenic protrusion into the bladder lumen Bladder jet from the left ureteric orifice indicating a lack of obstruction in the bladder inlet A dual-screen image of the bladder showing b-mode and colour Doppler simultaneously. Good bladder jets were recorded from both right and left ureteric orifices Left kidney transverse view showing thickness of the urothelium Axial left kidney showing urothelial thickening Post void with a significant amount of post void residual bladder volume of 105 ml Paediatric UTI Clinical History A 7-year old female presented with recurrent UTI symptoms. Ultrasound or the renal tract was requested. Case Description Ultrasound revealed some floating debris in the urinary bladder. There was also evidence of focal hypertrophy of the bladder base surrounding the right and left ureteric orifices measuring 10 mm and 13 mm respectively. Multiple bladder jets were observed in the right ureteric orifice while none was seen in the left within a minute of close evaluation. Diagnosis/ Discussion/ Treatment/ Follow up The patient was commenced on antibiotic therapy in light of the ultrasound findings (UTI) and clinical manifestations. Sonograms Axial sonogram of the urinary bladder showing two echogenic protrusions at the bladder base in the region of the ureteric orifices Power Doppler imaging showing no evidence of vascularity within the protrusions Power Doppler imaging showing evidence of good bladder jets on the right ureteric orifice, ruling out right inlet obstruction A dilated left distal ureter at 12 mm (AP) posterior to the urinary bladder No right ureteric dilatation Post void examination showing a completely emptied urinary bladder Normal right kidney with no hydronephrosis Hydronephrotic left kidney
Right Ovarian Hemorrhagic Cyst Articles Haemorrhagic Cyst in a 26-year old Female Presenting as Pelvic Pain Haemorrhagic Cyst in a 26-year old Female Presenting as Pelvic Pain Patient History A 26-year old female presented with pelvic pain. The patient had a history of cystectomy. Case Description Ultrasound of the pelvis (transabdominal and transvaginal) revealed a 51 mm haemorrhagic cyst within the right ovary with a mild trace of free fluid in the adnexa. Diagnosis/ Discussion/ Treatment/ Follow Up The patient was managed conservatively and the cyst resolved over time as it was no longer present on subsequent scans a year later. Sonograms Transabdominal view of the right ovarian cyst Transvaginal view of the right ovarian haemorrhagic cyst Transvaginal view of the right ovarian hemorrhagic cyst with some normal right ovarian tissues in view Power Doppler imaging of the right ovarian hemorrhagic cyst viewed transvaginally Right ovarian hemorrhagic cyst on transvaginal view showing the cyst (CC), ovarian tissue with normal follicles (OV) and a mild trace of free fluid (FF) adjacent to the right ovary
Haemorrhagic Cyst in a 26-year old Female Presenting as Pelvic Pain Patient History A 26-year old female presented with pelvic pain. The patient had a history of cystectomy. Case Description Ultrasound of the pelvis (transabdominal and transvaginal) revealed a 51 mm haemorrhagic cyst within the right ovary with a mild trace of free fluid in the adnexa. Diagnosis/ Discussion/ Treatment/ Follow Up The patient was managed conservatively and the cyst resolved over time as it was no longer present on subsequent scans a year later. Sonograms Transabdominal view of the right ovarian cyst Transvaginal view of the right ovarian haemorrhagic cyst Transvaginal view of the right ovarian hemorrhagic cyst with some normal right ovarian tissues in view Power Doppler imaging of the right ovarian hemorrhagic cyst viewed transvaginally Right ovarian hemorrhagic cyst on transvaginal view showing the cyst (CC), ovarian tissue with normal follicles (OV) and a mild trace of free fluid (FF) adjacent to the right ovary
Tumour Thrombus in the IVC Clinical History A 60-year old man presented with pain in the right upper quadrant and in the epigastrium. Abdominal ultrasound was requested to examine the liver and biliary tree for a possible cause. Case Description Ultrasound revealed an occluded IVC containing thrombus-like material. The occlusion (tumour thrombus) extends a few millimetres into the proximal portion of one of the hepatic veins. Mild ascites in the RUQ and pleural effusion seen in the right lung. The gallbladder was empty with an oedematous wall appearance, which might have been secondary to the irritation caused by the ascites. An urgent CT pulmonary angiogram was recommended to further examine the occluded IVC and to assess the extent of the thrombus. Diagnosis/ Discussion/ Treatment/ Follow up An urgent CTPA revealed the IVC thrombus to be extending into the right atrium of the heart. A further CT contrast abdomen and pelvis suggested the thrombus might be a tumour as it was also seen to encase the right renal vessels and beyond the IVC. Overall, appearances were suggestive of either a thrombus due to hyperviscosity syndrome or a malignant tumour, possibly leiomyosarcoma. Sonograms Right upper quadrant showing the liver and the occluded IVC posteriorly Colour Doppler Imaging showing the occluded IVC Colour Doppler Imaging showing the occluded IVC Empty oedematous gallbladder, probably due to the ascites A tiny trace of free fluid in the hepatorenal (Morrison’s) pouch Colour Doppler showing patent hepatic veins. The right hepatic vein might be occluded B-mode showing an occlusive thrombus in the right branch of the hepatic vein Sagittal CT showing the occlusive thrombus in the IVC
Post-laparoscopic Port site or Incisional Hernia Clinical History A 25-year old woman who recently had laparoscopic appendectomy presented with abdominal pain and swelling post op, with a palpable mass that was felt under the port site. Case Description An abdominal ultrasound done with a 2 – 5 MHz curvilinear transducer and a 10 MHz (high frequency transducer) revealed a 24 mm breech in the abdominal wall at the port site containing omental fat and some surrounding fluid. Ultrasound findings are in keeping with port site hernia. Diagnosis/ Discussion/ Treatment/ Follow-up Patient had the hernia repaired. Sonograms Port site hernia, image acquired using a low frequency curvilinear transducer Port site hernia showing the protrusion of the mesenteric fat content with a tiny trace of adjacent fluid within the herniated sac. No bowel loop seen within the sac. image acquired using a high frequency linear transducer Port site hernia Power Doppler showing no evidence of vascularity within the protruding mesenteric fat, as would be expected
Jugular Articles Jugular Vein Thrombus Caused by a Supraclavicular Mass Jugular Vein Thrombus Caused by a Supraclavicular Mass Clinical History A 69-year old male presented with a sudden onset of pain and swelling of his left upper limb after a recent insertion of a pacemaker device. A vascular ultrasound was requested to examine his upper limb veins for deep venous thrombosis (DVT). Case Description Ultrasound using a multifrequency linear transducer set at 8 MHz revealed an occlusive thrombus in the entire left subclavian vein adjacent to the pacemaker (jugular vein thrombus). Diagnosis/ Discussion/ Treatment/ Follow up The result was urgently sent to the referring clinician who commenced the patient on the appropriate anticoagulation therapy. Sonograms B-mode of the internal jugular vein showing an occlusive thrombus Colour Doppler showing the occluded IJV Colour Doppler showing the occluded IJV Axial segment of the IJV showing the occlusive thrombus A heterogeneous left supraclavicular mass CDI showing evidence of internal vascularity in the left supraclavicular mass
Jugular Vein Thrombus Caused by a Supraclavicular Mass Clinical History A 69-year old male presented with a sudden onset of pain and swelling of his left upper limb after a recent insertion of a pacemaker device. A vascular ultrasound was requested to examine his upper limb veins for deep venous thrombosis (DVT). Case Description Ultrasound using a multifrequency linear transducer set at 8 MHz revealed an occlusive thrombus in the entire left subclavian vein adjacent to the pacemaker (jugular vein thrombus). Diagnosis/ Discussion/ Treatment/ Follow up The result was urgently sent to the referring clinician who commenced the patient on the appropriate anticoagulation therapy. Sonograms B-mode of the internal jugular vein showing an occlusive thrombus Colour Doppler showing the occluded IJV Colour Doppler showing the occluded IJV Axial segment of the IJV showing the occlusive thrombus A heterogeneous left supraclavicular mass CDI showing evidence of internal vascularity in the left supraclavicular mass
Endometrial polyp Articles Endometrial Polyp in an 80-Year Old Endometrial Polyp Presenting as Painful Heavy Menstrual Bleeding Endometrial Polyp in an 80-Year Old Clinical History An 80-year old lady presented with abdominal bloating and discomfort. Case Description An ultrasound of the abdomen and pelvis revealed a 17 mm oval-shaped lesion sitting within the fluid-filled endometrial cavity with evidence of a feeder vessel seen within it. Appearances are in keeping with an endometrial polyp. Diagnosis/ Discussion/ Treatment/ Follow up The polyp was surgically removed and the specimen was histologically examined which confirmed the ultrasound findings. Sonograms 2-D, B-mode transvaginal ultrasound showing the large endometrial polyp with some fluid within the endometrial cavity Endometrial polyp with measurement callipers Endometrial polyp with colour Doppler showing a tiny ‘feeder vessel’ Endometrial polyp with power Doppler showing a tiny ‘feeder vessel’ Post-op appearance of the normal endometrium Endometrial Polyp Presenting as Painful Heavy Menstrual Bleeding Clinical History A 48-year old lady presented with a history of heavy and painful menstrual bleeding with the presence of clots. Gynaecological ultrasound was requested to assess for uterine fibroids or any related causes. Case Description Transvaginal ultrasound revealed a 2 cm polyp within the endometrial cavity of the retroverted uterus with a feeder vessel seen extending from the adjacent myometrium. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to gynaecology where she had hysteroscopy to confirm the polyp prior to its removal (polypectomy) Sonograms Transvaginal B-mode sonogram of the endometrium showing the oval-shaped polyp PDI image of the endometrial polyp showing the feeder vessel Endometrium
A Large Cervical Mass Presenting as PMB Clinical History A 64-year old lady presented with a 2-week history of postmenopausal vaginal bleeding. A gynaecology ultrasound was requested to assess for endometrial thickening. Case Description Transabdominal and transvaginal ultrasound were performed to assess the uterus, endometrium and ovaries. Ultrasound revealed a 3.3 cm echogenic oval-shaped lesion in the cervical cavity (cervical mass) with some fluid around it. The endometrium measured 0.7 cm and contained some echogenic materials that could be seen to migrate towards the cervical canal. Diagnosis/ Discussion/ Treatment/ Follow up Based on the ultrasound appearances and the patient’s symptoms, the features of the cervical lesion are suggestive of a cervical mass or polyp. A low-lying intracavitary fibroid could be a possible differential diagnosis. Sonograms Cervical lesion in longitudinal view with callipers Cervical lesion in axial view with callipers Endometrial cavity fluid CDI showing no flow in the cervical lesion Echogenic content in the endometrium about to migrate into the cervix Echogenic content of the endometrium migrating into the cervix Keywords
Endometrial Polyp in an 80-Year Old Clinical History An 80-year old lady presented with abdominal bloating and discomfort. Case Description An ultrasound of the abdomen and pelvis revealed a 17 mm oval-shaped lesion sitting within the fluid-filled endometrial cavity with evidence of a feeder vessel seen within it. Appearances are in keeping with an endometrial polyp. Diagnosis/ Discussion/ Treatment/ Follow up The polyp was surgically removed and the specimen was histologically examined which confirmed the ultrasound findings. Sonograms 2-D, B-mode transvaginal ultrasound showing the large endometrial polyp with some fluid within the endometrial cavity Endometrial polyp with measurement callipers Endometrial polyp with colour Doppler showing a tiny ‘feeder vessel’ Endometrial polyp with power Doppler showing a tiny ‘feeder vessel’ Post-op appearance of the normal endometrium
Abdominal Aortic Aneurysm Articles Severe case of Abdominal Aortic Aneurysm (AAA) Severe case of Abdominal Aortic Aneurysm (AAA) Clinical History A 90-year old lady presented with a palpable lump towards the left side of the abdomen. Case Description Ultrasound revealed an 83 mm abdominal aortic aneurysm which corresponds to the palpable mass pointed by the patient. Diagnosis/ Discussion/ Treatment/ Follow up A subsequent contrast-enhanced CT scan of the thorax abdomen and pelvis confirmed this diagnosis. The patient was managed conservatively as surgery was contraindicated based on other comorbidities. Sonograms Longitudinal section of the AAA colour Doppler imaging Transverse section of the AAA colour Doppler imaging B-Mode of the AAA Sagittal contrast CT showing large AAA in arterial phase
Normal Ultrasound Assessment of the Renal Allograft Clinical History A 43-year old man with a recent history of renal transplant surgery was referred to have an ultrasound assessment of the new renal allograft. Case Description The renal allograft appeared normal in size, outline, echotexture, and perfusion with no evidence of renal artery stenosis encountered. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound report was sent to the referring nephrologist. During ultrasound assessment of the renal allografts, it is important to use a high frequency curvilinear transducer (6 – 7 MHz). This provides a reasonable balance between the acquisition of great image resolution, and having enough depth to visualise the graft and structures deep to and surrounding the graft. Sonograms B-Mode sonogram of the normal transplant kidney in the left iliac fossa (LIF) Colour Doppler imaging of the normal transplant kidney showing excellent perfusion of the graft Power Doppler imaging of the normal transplant kidney showing excellent perfusion of the graft Colour Doppler imaging of the transplant renal artery showing the point of anastomosis with the left external iliac artery Spectral Doppler imaging of the left external iliac artery measuring the peak systolic velocity (PSV) prior to the anastomosis Spectral Doppler imaging of the left external iliac artery measuring the peak systolic velocity (PSV) at the level of the anastomosis Spectral Doppler imaging of the transplant renal artery Spectral Doppler of the segmental artery within the transplant kidney Spectral Doppler of the intrarenal artery at the lower pole Spectral Doppler of the intrarenal artery at the interpolar region of the graft Spectral Doppler of the intrarenal artery at the upper pole
Severe case of Abdominal Aortic Aneurysm (AAA) Clinical History A 90-year old lady presented with a palpable lump towards the left side of the abdomen. Case Description Ultrasound revealed an 83 mm abdominal aortic aneurysm which corresponds to the palpable mass pointed by the patient. Diagnosis/ Discussion/ Treatment/ Follow up A subsequent contrast-enhanced CT scan of the thorax abdomen and pelvis confirmed this diagnosis. The patient was managed conservatively as surgery was contraindicated based on other comorbidities. Sonograms Longitudinal section of the AAA colour Doppler imaging Transverse section of the AAA colour Doppler imaging B-Mode of the AAA Sagittal contrast CT showing large AAA in arterial phase
An Occlusive Thrombus in the Subclavian Vein Clinical History A 69-year old male presented with a sudden onset of pain and swelling of his left upper limb after a recent insertion of a pacemaker device. A vascular ultrasound was requested to examine his upper limb veins for deep venous thrombosis (DVT). Case Description Ultrasound using a multifrequency linear transducer set at 8 MHz revealed an occlusive thrombus in the entire left subclavian vein adjacent to the pacemaker. Diagnosis/ Discussion/ Treatment/ Follow Up The result was urgently sent to the referring clinician who commenced the patient on the appropriate anticoagulation therapy. Sonograms B-mode ultrasound showing an occlusive thrombus in the left subclavian vein Colour Doppler imaging showing an absence of flow signal in the subclavian vein Colour Doppler imaging showing an absence of flow signal in the subclavian vein Colour Doppler imaging showing an absence of flow signal in the subclavian vein
Incidental Finding of a Popliteal Artery Aneurysm during a DVT Ultrasound Clinical History An 83-year old man presented with left leg swelling, erythema, and shortness of breath. Case Description Ultrasound revealed a 27 mm popliteal artery aneurysm in the left popliteal fossa. The patient also had a positive extensive DVT in the deep veins of the left lower limb. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to the vascular specialist for further management. Sonograms B-Mode longitudinal view of the left popliteal artery aneurysm B-Mode axial view of the left popliteal artery aneurysm Colour Doppler imaging of the left popliteal artery aneurysm in longitudinal orientation Colour Doppler imaging of the left popliteal artery aneurysm in transverse orientation
A Large Intramuscular Haematoma Coexisting with Lesser Trochanter Osteochondroma Clinical History A 35-year old man presented with a medial right thigh mass that he had felt for two weeks. An ultrasound was requested to assess the nature of the mass. Case Description Ultrasound was performed using linear and curvilinear transducers. This revealed a large area of intramuscular haematoma with some linear calcific component within the medial upper thigh compartment. Diagnosis/ Discussion/ Treatment/ Follow up A subsequent MRI revealed a sessile osteochondroma at the right lesser trochanter with no significant cartilage and an adjacent haemorrhagic fluid extending from the right ischiofemoral interval to the adductor compartment caudally. Sonograms B-mode right thigh haematoma Axial view right thigh haematoma CDI showing no flow in the right thigh haematoma Right thigh haematoma with a curvilinear transducer CDI right thigh haematoma Right thigh haematoma with measurement callipers Right and left comparison image of the upper thigh at the level of the haematoma Coronal MRI showing the right thigh haematoma
Right Ovarian Dermoid Cyst Clinical History A 30-year old female presented with recent onset of lower abdominal pain with raised inflammatory markers. Ultrasound was requested to rule out appendicitis or ovarian cyst causing the pain. Case Description On ultrasound, the appendix was normal. However, there was a 37 mm heterogeneous, non-vascular, echogenic lesion (ovarian dermoid cyst) in the right adnexa attached to the right ovary suggestive of an ovarian dermoid. The lesion was seen to be attached to a normal right ovarian tissue. The otherwise normal left ovary contained a small collapsing corpus luteum with some associated mild free fluid in the pouch of Douglas, secondary to this. Diagnosis/ Discussion/ Treatment/ Follow up The patient was managed conservatively with the lesion being monitored six-monthly for 2 years, with follow up ultrasound scans (TA and TV) showing stable appearances. Sonograms Transabdominal sonogram of the dermoid in the right ovary Transvaginal sonogram of the dermoid in the right ovary Transvaginal sonogram of the dermoid in the right ovary Colour Doppler imaging showing no vascularity in the right ovarian dermoid cyst The normal left ovary showing a collapsing follicle Free fluid in the pouch of Douglas
Parapelvic Renal Cyst Articles Parapelvic Simple Renal Cyst Mimicking Hydronephrosis on MRI Parapelvic Simple Renal Cyst Mimicking Hydronephrosis on MRI Clinical History A 74-year old man had an MRI of his spine which revealed an area of possible hydronephrosis in his right kidney. An ultrasound of his kidneys was requested to confirm this. Case Description Ultrasound revealed a 6 cm parapelvic simple cyst (renal cyst) in the lower pole. There was also another 2 cm simple cyst adjacent to the former. Diagnosis/ Discussion/ Treatment/ Follow up These findings were confirmed by an outpatient contrast CT scan of the urinary tract carried out months later. Sonograms A right parapelvic renal cyst B-Mode A right parapelvic renal cyst colour Doppler Imaging An axial CT scan post-ultrasound confirming the right parapelvic cyst to be a Bosniak 1 category A coronal CT scan post-ultrasound confirming the right parapelvic cyst to be a Bosniak 1 category
Mixed Germ Cell Tumour of the Testis Clinical History A 21-year old male presented with a 3-week history of increased swelling in the left hemiscrotum. The patient was referred urgently to urology. An ultrasound of the scrotum was requested as an initial diagnostic approach. Case Description Ultrasound performed, using a 15 MHz linear transducer, revealed 7.5 cm heterogeneous mass occupying the entire left hemiscrotum. The mass showed strong evidence of internal vascularity on power Doppler imaging (PDI). Diagnosis/ Discussion/ Treatment/ Follow up The tumour markers (HCG, AFP, and LDH) were significantly raised, further confirming the ultrasound findings. CT scan of the chest, abdomen and pelvis with contrast was performed to adequately stage the disease. The patient had radical left orchiectomy and histology analysis of the tumour samples confirmed a diagnosis of a mixed germ cell testicular tumour (50 % yolk sac and 50 % embryonal carcinoma). Sonograms B-mode of the left testicular mass next to the normal right testis CDI comparing the vascularity of the testes Left testicular mass with measurement callipers in longitudinal and axial views PDI of the left testicular mass showing some internal vascularity Axial CT showing the left testicular mass Keywords Testicular cancer, Yolk sac carcinoma, Embryonal carcinoma
A Large Extratesticular Epidermoid Cyst Clinical History A 74-year old man presented with a fast-growing painful swelling next to the left testicle. Case Description Ultrasound performed, using a 15 MHz linear transducer, revealed a 7 cm heterogeneous mass adjacent to the left testis. The mass contained numerous anechoic patches with no evidence of internal vascularity. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have an MRI to help characterise the scrotal mass. The MRI revealed the left paratesticular mass to have appearances as the adjacent testis and was unable to provide detailed characteristics of the mass. The patient had left orchiectomy and the samples were examined histologically. Histology confirmed the paratesticular mass to contain keratinised stratified squamous epithelium with a diagnosis of an epidermoid cyst. Sonograms Right and left testes (T) with the mass (M) laterally Left hemiscrotal heterogeneous mass Axial view of the left hemiscrotal mass PDI showing no flow signal in the mass B-mode shoeing the left hemiscrotal mass lateral to the left testis Coronal MRI showing the left hemiscrotal mass (double arrows) next to the left testis (single arrow) Keywords
Intramuscular Haematoma in the Upper Arm Clinical History A 42-year old lady with a recent history of a peripherally inserted central catheter (PICC line) insertion in her left upper arm developed an acute onset of pain and swelling around the PICC line insertion. Ultrasound of the arm was requested to rule out venous thrombosis or soft tissue haematoma or collection. Case Description Ultrasound revealed a 7 cm hypoechoic, heterogeneous, and non-vascular structure within the intramuscular layer of the brachium deep to the site of the line insertion. Appearances were suggestive of an intramuscular haematoma. In addition to the recent PICC line insertion, the patient had other preexisting conditions that supports the ultrasound findings Diagnosis/ Discussion/ Treatment/ Follow up The patient was continually managed for her comorbidities while the arm haematoma was managed conservatively. However, prior anticoagulation therapy (for other comorbidities) was discontinued. Sonograms CDI showing flow in the left subclavian vein B-mode showing the PICC line in the subclavian vein (arrow) Left arm intramuscular haematoma on B-mode Panoramic view of the intramuscular haematoma Haematoma measuring 7 cm x 2 cm Axial image of the intramuscular haematoma PDI showing no evidence of vascularity within the haematoma
Haematometra Articles Haematometra Presenting as Pelvic Pain Haematometra Presenting as Pelvic Pain Clinical History A 47-year old lady presented with an acute onset of pelvic pain towards the left iliac fossa. The patient was known to be on long-term contraception and had a history of multiple caesarean sections. An ultrasound of the pelvis was requested for an initial assessment. Case Description Ultrasound revealed a distended endometrial cavity containing a localised hypoechoic collection measuring 39 x 23 x 28 mm which suggests haematometra with no cervical or vaginal involvement. Diagnosis/ Discussion/ Treatment/ Follow up The patient had an MRI of the pelvis which confirmed the haematometra to be caused by a scar. The collection was drained surgically. Sonograms Transabdominal sonogram of the uterus showing the hypoechoic structure in the endometrial cavity Transvaginal sonogram of the uterus showing the hypoechoic structure in the endometrial cavity Transvaginal sonogram in an axial orientation showing the hypoechoic structure in the endometrial cavity The distended endometrial cavity with its measurements Sagittal MRI of the uterus showing the distended endometrial cavity with a possible adhesion towards the internal Os
Endometrial Polyp Presenting as Painful Heavy Menstrual Bleeding Clinical History A 48-year old lady presented with a history of heavy and painful menstrual bleeding with the presence of clots. Gynaecological ultrasound was requested to assess for uterine fibroids or any related causes. Case Description Transvaginal ultrasound revealed a 2 cm polyp within the endometrial cavity of the retroverted uterus with a feeder vessel seen extending from the adjacent myometrium. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to gynaecology where she had hysteroscopy to confirm the polyp prior to its removal (polypectomy) Sonograms Transvaginal B-mode sonogram of the endometrium showing the oval-shaped polyp PDI image of the endometrial polyp showing the feeder vessel Endometrium
Hepatic Haemangioma Articles Focal Hepatic Lesion Focal Hepatic Lesion Clinical History A 49-year old man presented with right upper quadrant pain which was gradually worsening. The patient was referred to have an abdominal ultrasound to rule out gallbladder calculi Case Description Ultrasound was able to rule out the presence of gallbladder calculi. However, there was a 25 mm hyperechoic focal lesion in the left hepatic lobe with appearances suggestive of a haemangioma. MRI of the liver was performed with contrast which confirmed this to be a haemangioma. Diagnosis/ Discussion/ Treatment/ Follow-up Since hepatic haemangiomas are benign lesions, and in this case the lesion was not large, therefore, no further action was taken regarding this. The patient’s pre-existing symptoms were managed conservatively. Sonograms Left hepatic lobe showing a 2.5 cm echogenic lesion Colour Doppler imaging showing no evidence of flow within the lesion in the left hepatic lobe B-mode ultrasound showing the echogenic lesion in the left hepatic lobe Axial MRI showing the lesion in the left hepatic lobe, confirming it to be a haemangioma
Focal Hepatic Lesion Clinical History A 49-year old man presented with right upper quadrant pain which was gradually worsening. The patient was referred to have an abdominal ultrasound to rule out gallbladder calculi Case Description Ultrasound was able to rule out the presence of gallbladder calculi. However, there was a 25 mm hyperechoic focal lesion in the left hepatic lobe with appearances suggestive of a haemangioma. MRI of the liver was performed with contrast which confirmed this to be a haemangioma. Diagnosis/ Discussion/ Treatment/ Follow-up Since hepatic haemangiomas are benign lesions, and in this case the lesion was not large, therefore, no further action was taken regarding this. The patient’s pre-existing symptoms were managed conservatively. Sonograms Left hepatic lobe showing a 2.5 cm echogenic lesion Colour Doppler imaging showing no evidence of flow within the lesion in the left hepatic lobe B-mode ultrasound showing the echogenic lesion in the left hepatic lobe Axial MRI showing the lesion in the left hepatic lobe, confirming it to be a haemangioma
Polycystic Ovaries Articles Ultrasound Appearances of Polycystic Ovaries Ultrasound Appearances of Polycystic Ovaries Clinical History A 34-year old lady with primary infertility was referred to have an ultrasound of the pelvis (TA and TV) to examine the ovaries. The clinician had suspected PCOS from the patient’s recent blood results. Case Description Ultrasound (TA and TV) revealed bulky ovaries; right measuring 15 ml and left 13 ml in volume. There were also multiple peripherally arranged follicles all less than 10 mm in diameter within both ovaries. These features are suggestive of polycystic ovarian morphology (polycystic ovaries). Diagnosis/ Discussion/ Treatment/ Follow up Although ultrasound is not definitive in diagnosing Polycystic Ovarian Syndrome (PCOS), hormonal analysis of the haematological samples are more accurate for this. However, some ultrasound features like bulky ovaries (> 10 ml volume), multiple peripherally arranged follicles less than 10 mm can raise sonographic suspicion of the disease. Sonograms A dual screen (TV) sonogram of the right ovary in longitudinal and transverse orientations. The ovarian volume is 15.44 ml which is above the normal of 10 ml in a premenopausal woman A dual screen (TV) sonogram of the left ovary in longitudinal and transverse orientations. The ovarian volume is 13.19 ml which is above the normal of 10 ml in a premenopausal woman A TV longitudinal sonogram of the normal retroverted uterus showing the homogeneous myometrium and endometrium
Obstetrics and Gynaecology Articles Uterine/Uterus Endometrial/Endometrium Ovarian/Ovaries Tubal/Fallopian Tubes Early Pregnancy (4/40 - 12/40) Foetal Anomaly Placental Uterine/Uterus Septate Uterus Müllerian Duct Abnormality 2-D Ultrasound Clinical History A 45-year old female presented with lower abdominal pain. Transabdominal and Transvaginal ultrasound of the pelvis was requested for further assessment. Case Description Mullerian duct abnormality was seen incidentally during a pelvic ultrasound of a 45-year old due to lower abdominal pain. These features can be better confirmed with a more definitive diagnosis using 3-D ultrasound of the pelvis. HyCoSy can also be used if infertility is an indication. However, these were not carried out at the time of the patient’s visit. Diagnosis/ Discussion/ Treatment/ Follow up No treatment was required at the time. Sonograms Bicornuate uterus transvaginal USS Bicornuate uterus TVUSS Bicornuate uterus Bicornuate uterus anterior horn Bicornuate uterus posterior horn Bicornuate uterus transverse view Haematometra Haematometra Presenting as Pelvic Pain Clinical History A 47-year old lady presented with an acute onset of pelvic pain towards the left iliac fossa. The patient was known to be on long-term contraception and had a history of multiple caesarean sections. An ultrasound of the pelvis was requested for an initial assessment. Case Description Ultrasound revealed a distended endometrial cavity containing a localised hypoechoic collection measuring 39 x 23 x 28 mm which suggests haematometra with no cervical or vaginal involvement. Diagnosis/ Discussion/ Treatment/ Follow up The patient had an MRI of the pelvis which confirmed the haematometra to be caused by a scar. The collection was drained surgically. Sonograms Transabdominal sonogram of the uterus showing the hypoechoic structure in the endometrial cavity Transvaginal sonogram of the uterus showing the hypoechoic structure in the endometrial cavity Transvaginal sonogram in an axial orientation showing the hypoechoic structure in the endometrial cavity The distended endometrial cavity with its measurements Sagittal MRI of the uterus showing the distended endometrial cavity with a possible adhesion towards the internal Os Endometrial/Endometrium Endometrial polyp Endometrial Polyp in an 80-Year Old Clinical History An 80-year old lady presented with abdominal bloating and discomfort. Case Description An ultrasound of the abdomen and pelvis revealed a 17 mm oval-shaped lesion sitting within the fluid-filled endometrial cavity with evidence of a feeder vessel seen within it. Appearances are in keeping with an endometrial polyp. Diagnosis/ Discussion/ Treatment/ Follow up The polyp was surgically removed and the specimen was histologically examined which confirmed the ultrasound findings. Sonograms 2-D, B-mode transvaginal ultrasound showing the large endometrial polyp with some fluid within the endometrial cavity Endometrial polyp with measurement callipers Endometrial polyp with colour Doppler showing a tiny ‘feeder vessel’ Endometrial polyp with power Doppler showing a tiny ‘feeder vessel’ Post-op appearance of the normal endometrium Endometrial Polyp Presenting as Painful Heavy Menstrual Bleeding Clinical History A 48-year old lady presented with a history of heavy and painful menstrual bleeding with the presence of clots. Gynaecological ultrasound was requested to assess for uterine fibroids or any related causes. Case Description Transvaginal ultrasound revealed a 2 cm polyp within the endometrial cavity of the retroverted uterus with a feeder vessel seen extending from the adjacent myometrium. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to gynaecology where she had hysteroscopy to confirm the polyp prior to its removal (polypectomy) Sonograms Transvaginal B-mode sonogram of the endometrium showing the oval-shaped polyp PDI image of the endometrial polyp showing the feeder vessel Endometrium Endometrial Carcinoma A Large Adnexal Mass in a Patient with Endometrial Cancer Clinical History A 74-year old lady presented with abdominal distension and discomfort. Case Description Ultrasound of the abdomen and pelvis (TA and TV) revealed a grossly thickened endometrium measuring 27 mm in AP calibre with heterogeneous echotexture. In addition there was a 131 mm complex non-vascular cystic mass (endometrial cancer) in the left adnexa/ left hemipelvis. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a whole body contrast CT which confirmed the ultrasound findings (endometrial cancer) in addition to the diagnosis of some omental cake with nodal peritoneal deposits and ascites in keeping with gynaecological malignancy. The adnexal cyst appeared to herniate through the left inguinal canal. The tumour markers (Ca125 and Ca19.9) were significantly elevated. Subsequently, the patient had an omental biopsy which confirmed metastatic high grade carcinoma. Sonograms Transabdominal view of the pelvis showing a 131 mm x 68 mm (L x AP) heterogeneous cystic mass in the left adnexa Transvaginal longitudinal view of the uterus showing an abnormally thickened endometrium of 26 mm (AP) Power Doppler imaging of the left adnexal complex cyst showing no evidence of internal vascularity PDI of the left adnexal cystic mass Free fluid in the right upper quadrant in keeping with ascites Ascites in the left upper abdominal quadrant adjacent to the spleen; subphrenic and within the splenorenal recess Ascites in the LUQ Axial CT showing the cyst in the LIF Sagittal CT showing the left adnexal cystic mass herniating into the left inguinal canal Cervical Mass A Large Cervical Mass Presenting as PMB Clinical History A 64-year old lady presented with a 2-week history of postmenopausal vaginal bleeding. A gynaecology ultrasound was requested to assess for endometrial thickening. Case Description Transabdominal and transvaginal ultrasound were performed to assess the uterus, endometrium and ovaries. Ultrasound revealed a 3.3 cm echogenic oval-shaped lesion in the cervical cavity (cervical mass) with some fluid around it. The endometrium measured 0.7 cm and contained some echogenic materials that could be seen to migrate towards the cervical canal. Diagnosis/ Discussion/ Treatment/ Follow up Based on the ultrasound appearances and the patient’s symptoms, the features of the cervical lesion are suggestive of a cervical mass or polyp. A low-lying intracavitary fibroid could be a possible differential diagnosis. Sonograms Cervical lesion in longitudinal view with callipers Cervical lesion in axial view with callipers Endometrial cavity fluid CDI showing no flow in the cervical lesion Echogenic content in the endometrium about to migrate into the cervix Echogenic content of the endometrium migrating into the cervix Keywords Ovarian/Ovaries Right Ovarian Hemorrhagic Cyst Haemorrhagic Cyst in a 26-year old Female Presenting as Pelvic Pain Patient History A 26-year old female presented with pelvic pain. The patient had a history of cystectomy. Case Description Ultrasound of the pelvis (transabdominal and transvaginal) revealed a 51 mm haemorrhagic cyst within the right ovary with a mild trace of free fluid in the adnexa. Diagnosis/ Discussion/ Treatment/ Follow Up The patient was managed conservatively and the cyst resolved over time as it was no longer present on subsequent scans a year later. Sonograms Transabdominal view of the right ovarian cyst Transvaginal view of the right ovarian haemorrhagic cyst Transvaginal view of the right ovarian hemorrhagic cyst with some normal right ovarian tissues in view Power Doppler imaging of the right ovarian hemorrhagic cyst viewed transvaginally Right ovarian hemorrhagic cyst on transvaginal view showing the cyst (CC), ovarian tissue with normal follicles (OV) and a mild trace of free fluid (FF) adjacent to the right ovary Polycystic Ovaries Ultrasound Appearances of Polycystic Ovaries Clinical History A 34-year old lady with primary infertility was referred to have an ultrasound of the pelvis (TA and TV) to examine the ovaries. The clinician had suspected PCOS from the patient’s recent blood results. Case Description Ultrasound (TA and TV) revealed bulky ovaries; right measuring 15 ml and left 13 ml in volume. There were also multiple peripherally arranged follicles all less than 10 mm in diameter within both ovaries. These features are suggestive of polycystic ovarian morphology (polycystic ovaries). Diagnosis/ Discussion/ Treatment/ Follow up Although ultrasound is not definitive in diagnosing Polycystic Ovarian Syndrome (PCOS), hormonal analysis of the haematological samples are more accurate for this. However, some ultrasound features like bulky ovaries (> 10 ml volume), multiple peripherally arranged follicles less than 10 mm can raise sonographic suspicion of the disease. Sonograms A dual screen (TV) sonogram of the right ovary in longitudinal and transverse orientations. The ovarian volume is 15.44 ml which is above the normal of 10 ml in a premenopausal woman A dual screen (TV) sonogram of the left ovary in longitudinal and transverse orientations. The ovarian volume is 13.19 ml which is above the normal of 10 ml in a premenopausal woman A TV longitudinal sonogram of the normal retroverted uterus showing the homogeneous myometrium and endometrium Ovarian Cancer An Ovarian Tumour with an Initial Presentation of RIF Pain Clinical History A 76-year old lady presented with a few weeks history of right sided abdominal pain, tenderness, and bloating. Although the blood results were normal, the patient was referred to have an ultrasound of the abdomen and pelvis to rule out cholelithiasis or ovarian abnormality. Case Description Ultrasound (TA and TV) revealed a large heterogeneous mass in the right adnexa with cystic and solid components and some internal vascularity. The right renal pelvis was also mildly dilated at 10 mm in AP calibre, suggesting mass effect on the right ureter by the mass. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have a pelvic MRI then whole body CT scan for staging prior to surgery. Subsequently, the patient had a total abdominal hysterectomy with bilateral salpingo oophorectomy. Future MRI scans revealed no evidence of disease recurrence. The post-operative histology analysis of the right ovary revealed a low grade serous carcinoma (Ovarian Tumour) arising in a borderline serous tumour. Sonograms TVUSS showing a cystic mass in the right adnexa with some solid components PDI of the right adnexal complex cystic mass showing some internal vascularity B Mode showing the right adnexal mass with its cystic component Axial CT image of the right adnexal complex cystic mass T1 axial MRI of the right adnexal mass Complex Ovarian Cyst A Large Complex Ovarian Cyst Mimicking a Fibroid Clinical History A 54-year old lady presented with a large mass in the centre of the lower abdomen mimicking a fibroid. Case Description Ultrasound performed (TA and TV) revealed a large 21 cm complex cystic mass (complex ovarian cyst) emanating from the pelvis into the abdomen with multiple septations within it. A subsequent MRI pelvis confirmed the large multicystic pelvic lesion to be a possible neoplasm arising from the left ovary. The patient had a whole body contrast staging CT that revealed no extra-ovarian disease presence. Diagnosis/ Discussion/ Treatment/ Follow up Total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed and the cyst was analysed histologically. Histology revealed the lesion to be a benign mucinous cystadenoma. Sonograms Transabdominal ultrasound showing the large complex cyst in the pelvis Transvaginal ultrasound showing the complex cyst in the pelvis Transvaginal ultrasound showing the complex cyst in the pelvis Colour Doppler imaging of the complex cyst in the pelvis Sagittal MRI of the complex cyst in the pelvis Coronal CT of the large pelvic complex cyst Ovarian Dermoid Right Ovarian Dermoid Cyst Clinical History A 30-year old female presented with recent onset of lower abdominal pain with raised inflammatory markers. Ultrasound was requested to rule out appendicitis or ovarian cyst causing the pain. Case Description On ultrasound, the appendix was normal. However, there was a 37 mm heterogeneous, non-vascular, echogenic lesion (ovarian dermoid cyst) in the right adnexa attached to the right ovary suggestive of an ovarian dermoid. The lesion was seen to be attached to a normal right ovarian tissue. The otherwise normal left ovary contained a small collapsing corpus luteum with some associated mild free fluid in the pouch of Douglas, secondary to this. Diagnosis/ Discussion/ Treatment/ Follow up The patient was managed conservatively with the lesion being monitored six-monthly for 2 years, with follow up ultrasound scans (TA and TV) showing stable appearances. Sonograms Transabdominal sonogram of the dermoid in the right ovary Transvaginal sonogram of the dermoid in the right ovary Transvaginal sonogram of the dermoid in the right ovary Colour Doppler imaging showing no vascularity in the right ovarian dermoid cyst The normal left ovary showing a collapsing follicle Free fluid in the pouch of Douglas Dermoid Cyst Clinical History A 50-year old lady presented with a recent onset of lower abdominal pain. Ultrasound was requested to assess the pelvic organs as the cause for pain. Case Description Transabdominal pelvic ultrasound revealed a 6 cm dermoid cyst in the right adnexa. The normal right ovarian tissue was not visualised separate from this cyst. Diagnosis/ Discussion/ Treatment/ Follow up A few months later, the patient had a follow up CT scan of the abdomen and pelvis for a different assessment which also confirmed the presence of the fat-containing right ovarian dermoid cyst. Sonograms Axial B-mode dermoid cyst in the right adnexa. Longitudinal view of the right adnexal dermoid cyst CDI showing no colour flow within the cyst Coronal CT image of the right adnexal dermoid cyst Axial CT of the dermoid cyst Tubal/Fallopian Tubes Cancer of the Fallopian Tube Fallopian Tube Cancer Clinical History A 67-year old lady presented with severe lower abdominal pain with some change in bowel habit and loose stool. Case Description The patient was initially referred to have a CT scan of the whole body with contrast. This revealed a large predominantly cystic structure in the pelvis centrally. The mass was further investigated using a pelvic ultrasound (TA and TV). Ultrasound revealed a 13 cm mass with solid and cystic components in the central pelvis. The mass showed some evidence of internal vascularity within its solid component. There was also free fluid in the anterior and posterior cul-de-sac. Ultrasound features were suggestive of malignancy (fallopian tube cancer). Diagnosis/ Discussion/ Treatment/ Follow up The patient had laparotomy which revealed the mass to be a stage II HGS cancer of the fallopian tube. Sonograms TVUSS showing a mass with cystic and solid component in the mid pelvis. The mass is a Stage II HGS cancer of the left fallopian tube Colour Doppler imaging of the mass showing some active flow within the solid component Triplex studies evaluation of the pelvic mass using b-mode, CDI, and spectral Doppler Free fluid in the rectouterine pouch of Douglas Early Pregnancy (4/40 - 12/40) Foetal Anomaly Placental
Intramuscular Abscess Articles Forearm Inflammatory Intramuscular Collection Forearm Inflammatory Intramuscular Collection Clinical History A 51-year old man presented with an acute large swelling on the left forearm with erythema and tenderness. Case Description Ultrasound performed using a linear transducer at 14 MHz revealed a large hypervascular collection within the intramuscular layer of the affected forearm suggestive of an abscess. Diagnosis/ Discussion/ Treatment/ Follow up A further ultrasound performed 3 months later revealed a significant reduction in the said collection, still some internal vascularity, and a tract to the skin surface suggestive of a resolving collection. Sonograms Panoramic view of the forearm showing the 8 cm abscess in B-mode Intramuscular abscess of the forearm longitudinal view Intramuscular abscess of the forearm transverse view CDI showing hypervascularity in axial view CDI showing hypervascularity in longitudinal view B-mode longitudinal view of the forearm abscess Forearm collection Ultrasound 3 months later revealing a significant reduction in the abscess
Bladder Mass with Liver Metastasis Clinical History A 91-year old man with sudden health deterioration and in critical condition presented with haematuria, anaemia, thrombocytopaenia, and abnormal LFT. An abdominal ultrasound was requested as a first line of imaging. Case Description Ultrasound revealed a 7 cm heterogeneous mass in the urinary bladder with an irregular outline. The liver appeared enlarged with heterogeneous parenchymal echotexture and multiple hypoechoic lesions throughout, suggestive of metastases. Diagnosis/ Discussion/ Treatment/ Follow-up Unfortunately, the patient passed away. Sonograms Articles Bladder Tumour Bladder Tumour Clinical History A 91-year old man with sudden health deterioration and in critical condition presented with haematuria, anaemia, thrombocytopaenia, and abnormal LFT. An abdominal ultrasound was requested as a first line of imaging. Case Description Ultrasound revealed a 7 cm heterogeneous mass (bladder tumour) in the urinary bladder with an irregular outline. The liver appeared enlarged with heterogeneous parenchymal echotexture and multiple hypoechoic lesions throughout, suggestive of metastases. Diagnosis/ Discussion/ Treatment/ Follow up Unfortunately, the patient passed away. Sonograms Left lobe of the liver in a longitudinal orientation with multiple hypoechoic lesions Left lobe of the liver in a transverse orientation showing multiple hypoechoic lesions Right lobe of the liver containing multiple lesions, and showing the portal vein The portal vein on colour Doppler imaging showing normal hepatopetal flow Sonogram of the partly filled urinary bladder showing a bladder wall mass
Perforated Appendicitis Articles Complicated Appendicitis with Perforations Complicated Appendicitis with Perforations Clinical History A 19-year old male presented with a 4-day history of abdominal pain radiating to the right iliac fossa, some fever, diarrhoea, and vomiting. Blood tests revealed elevated inflammatory markers. Case Description Ultrasound revealed a 98 x 43 x 58 mm heterogeneous hypoechoic area in the right iliac fossa posterolateral to the caecum and anterior to the psoas muscle fibres. Also, there was mesenteric fat stranding around it. These were all at the site of the patient’s maximum tenderness. The normal appendix tissue was not seen leading the sonographer to raise the suspicion of appendiceal perforation. Diagnosis/ Discussion/ Treatment/ Follow up The patient had an emergency appendectomy and the surgical specimen analysed histologically confirmed the diagnosis of perforated appendicitis. Sonograms Sonogram acquired using a high frequency linear probe showing a heterogeneous hypoechoic structure in the RIF Sonogram acquired using a curvilinear probe showing a heterogeneous hypoechoic structure in the RIF Sonogram acquired using a curvilinear probe showing a heterogeneous hypoechoic structure in the RIF Power Doppler showing no evidence of vascularity Sonogram acquired using a high frequency linear probe showing a heterogeneous hypoechoic structure in the RIF Panoramic view of the RIF
Testicular Seminoma Clinical History A 29-year old male presented symptoms of a hard palpable lump in the right testis. Ultrasound was requested as the first line of imaging to assess for any lesions within the scrotum. Case Description Ultrasound revealed a 4 cm mass within the right testis with an irregular outline, a hypoechoic echotexture, and a significantly increased vascularity within the mass. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a right orchidectomy. Histology revealed features of testicular seminoma. Sonograms B-mode showing the right testicular mass next to the normal left testis Right testicular mass Right testicular mass with measurement callipers longitudinal and axial views CDI showing hypervascularity of the right testicular mass Dual screen image of the right and left testes on CDI Keywords
Pancreas Articles Intraductal Papillary Mucinous Neoplasm (IPMN) Acute Pancreatitis Intraductal Papillary Mucinous Neoplasm (IPMN) Cystic Pancreatic Mass in an 81-Year Old Lady Presenting with an Abnormal LFT Clinical History An 81-year old lady presented with acute deterioration of her recent liver function tests which progressively worsened. ALP – 890, Bilirubin 28, ALT 195. Case Description Abdominal ultrasound performed revealed the presence of a 42 mm complex cystic lesion (cystic pancreatic mass) at the pancreatic head. The gallbladder was also distended with a thickened and oedematous wall morphology. Also, there was sludge seen within the gallbladder lumen. The common bile duct was dilated at 9 mm in AP calibre. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have an MRCP which confirmed the ultrasound findings including the complex cystic lesion at the pancreatic head which was suggested to be due an IPMN. IPMNs are commonly benign tumours, however, some have been reported to progress into being cancerous. In this case, the cystic pancreatic lesion was causing some biliary obstruction. Sonograms Dilated CBD measuring 9 mm in AP calibre A distended thin-walled gallbladder containing some sludge within its lumen A cystic lesion at the head of the pancreas (HOP) adjacent to the thick-walled gallbladder Cystic lesion at the head of pancreas (HOP) with some normal pancreatic tissues seen around it Acute Pancreatitis A Case of Acute Pancreatitis Mimicking Pancreatic Malignancy Clinical History A 62-year old man presented with symptoms of right upper quadrant abdominal pain, vomiting, raised inflammatory markers, and deranged LFT. An abdominal ultrasound was requested as a first line of imaging to assess for features of cholecystitis. Case Description Ultrasound revealed a large heterogeneous cystic structure within the epigastrium posterior to the duodenum, with no internal vascularity seen in the structure. Although the pancreas was not clearly visualised on this examination, the said cystic structure was suggested to be related to the pancreas, due to its proximity. In addition, there was also a mild trace of ascites in the hepatorenal pouch of Morrison, right and left iliac fossae, with the thin-walled gallbladder containing some sludge within its lumen. Due to these findings, an urgent review was advised. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have a contrast-enhanced CT scan of the whole body which confirmed the presence of a large heterogeneous mass replacing the head and body of pancreas. The mass was seen to have a cystic/ necrotic component. Suggestive of a pancreatic tumour (Acute Pancreatitis). However, the patient’s blood results and clinical evaluation were more inflammatory than tumoral. The patient had ERCP, cytology, and endoscopic ultrasound (EUS), which aided the diagnosis of acute pancreatitis. A follow up whole body CT scan 3 months post treatment confirmed resolution of the pancreatic collection in keeping with chronic (acute Pancreatitis) pancreatitis. Sonograms A heterogeneous cystic mass at the head of pancreas (HOP) CDI of the HOP mass Free fluid in the hepatorenal pouch of Morrison Sludge in the lumen of the thin-walled gallbladder An initial CT (coronal slice) of the abdomen showing the mass in the region of the pancreatic head One year later CT showed the inflammatory mass (pancreatitis confirmed on EUS) in the pancreatic area has reduced post treatment
Ovarian/Ovaries Articles Right Ovarian Hemorrhagic Cyst Polycystic Ovaries Ovarian Cancer Complex Ovarian Cyst Ovarian Dermoid Right Ovarian Hemorrhagic Cyst Haemorrhagic Cyst in a 26-year old Female Presenting as Pelvic Pain Patient History A 26-year old female presented with pelvic pain. The patient had a history of cystectomy. Case Description Ultrasound of the pelvis (transabdominal and transvaginal) revealed a 51 mm haemorrhagic cyst within the right ovary with a mild trace of free fluid in the adnexa. Diagnosis/ Discussion/ Treatment/ Follow Up The patient was managed conservatively and the cyst resolved over time as it was no longer present on subsequent scans a year later. Sonograms Transabdominal view of the right ovarian cyst Transvaginal view of the right ovarian haemorrhagic cyst Transvaginal view of the right ovarian hemorrhagic cyst with some normal right ovarian tissues in view Power Doppler imaging of the right ovarian hemorrhagic cyst viewed transvaginally Right ovarian hemorrhagic cyst on transvaginal view showing the cyst (CC), ovarian tissue with normal follicles (OV) and a mild trace of free fluid (FF) adjacent to the right ovary Polycystic Ovaries Ultrasound Appearances of Polycystic Ovaries Clinical History A 34-year old lady with primary infertility was referred to have an ultrasound of the pelvis (TA and TV) to examine the ovaries. The clinician had suspected PCOS from the patient’s recent blood results. Case Description Ultrasound (TA and TV) revealed bulky ovaries; right measuring 15 ml and left 13 ml in volume. There were also multiple peripherally arranged follicles all less than 10 mm in diameter within both ovaries. These features are suggestive of polycystic ovarian morphology (polycystic ovaries). Diagnosis/ Discussion/ Treatment/ Follow up Although ultrasound is not definitive in diagnosing Polycystic Ovarian Syndrome (PCOS), hormonal analysis of the haematological samples are more accurate for this. However, some ultrasound features like bulky ovaries (> 10 ml volume), multiple peripherally arranged follicles less than 10 mm can raise sonographic suspicion of the disease. Sonograms A dual screen (TV) sonogram of the right ovary in longitudinal and transverse orientations. The ovarian volume is 15.44 ml which is above the normal of 10 ml in a premenopausal woman A dual screen (TV) sonogram of the left ovary in longitudinal and transverse orientations. The ovarian volume is 13.19 ml which is above the normal of 10 ml in a premenopausal woman A TV longitudinal sonogram of the normal retroverted uterus showing the homogeneous myometrium and endometrium Ovarian Cancer An Ovarian Tumour with an Initial Presentation of RIF Pain Clinical History A 76-year old lady presented with a few weeks history of right sided abdominal pain, tenderness, and bloating. Although the blood results were normal, the patient was referred to have an ultrasound of the abdomen and pelvis to rule out cholelithiasis or ovarian abnormality. Case Description Ultrasound (TA and TV) revealed a large heterogeneous mass in the right adnexa with cystic and solid components and some internal vascularity. The right renal pelvis was also mildly dilated at 10 mm in AP calibre, suggesting mass effect on the right ureter by the mass. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have a pelvic MRI then whole body CT scan for staging prior to surgery. Subsequently, the patient had a total abdominal hysterectomy with bilateral salpingo oophorectomy. Future MRI scans revealed no evidence of disease recurrence. The post-operative histology analysis of the right ovary revealed a low grade serous carcinoma (Ovarian Tumour) arising in a borderline serous tumour. Sonograms TVUSS showing a cystic mass in the right adnexa with some solid components PDI of the right adnexal complex cystic mass showing some internal vascularity B Mode showing the right adnexal mass with its cystic component Axial CT image of the right adnexal complex cystic mass T1 axial MRI of the right adnexal mass Complex Ovarian Cyst A Large Complex Ovarian Cyst Mimicking a Fibroid Clinical History A 54-year old lady presented with a large mass in the centre of the lower abdomen mimicking a fibroid. Case Description Ultrasound performed (TA and TV) revealed a large 21 cm complex cystic mass (complex ovarian cyst) emanating from the pelvis into the abdomen with multiple septations within it. A subsequent MRI pelvis confirmed the large multicystic pelvic lesion to be a possible neoplasm arising from the left ovary. The patient had a whole body contrast staging CT that revealed no extra-ovarian disease presence. Diagnosis/ Discussion/ Treatment/ Follow up Total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed and the cyst was analysed histologically. Histology revealed the lesion to be a benign mucinous cystadenoma. Sonograms Transabdominal ultrasound showing the large complex cyst in the pelvis Transvaginal ultrasound showing the complex cyst in the pelvis Transvaginal ultrasound showing the complex cyst in the pelvis Colour Doppler imaging of the complex cyst in the pelvis Sagittal MRI of the complex cyst in the pelvis Coronal CT of the large pelvic complex cyst Ovarian Dermoid Right Ovarian Dermoid Cyst Clinical History A 30-year old female presented with recent onset of lower abdominal pain with raised inflammatory markers. Ultrasound was requested to rule out appendicitis or ovarian cyst causing the pain. Case Description On ultrasound, the appendix was normal. However, there was a 37 mm heterogeneous, non-vascular, echogenic lesion (ovarian dermoid cyst) in the right adnexa attached to the right ovary suggestive of an ovarian dermoid. The lesion was seen to be attached to a normal right ovarian tissue. The otherwise normal left ovary contained a small collapsing corpus luteum with some associated mild free fluid in the pouch of Douglas, secondary to this. Diagnosis/ Discussion/ Treatment/ Follow up The patient was managed conservatively with the lesion being monitored six-monthly for 2 years, with follow up ultrasound scans (TA and TV) showing stable appearances. Sonograms Transabdominal sonogram of the dermoid in the right ovary Transvaginal sonogram of the dermoid in the right ovary Transvaginal sonogram of the dermoid in the right ovary Colour Doppler imaging showing no vascularity in the right ovarian dermoid cyst The normal left ovary showing a collapsing follicle Free fluid in the pouch of Douglas Dermoid Cyst Clinical History A 50-year old lady presented with a recent onset of lower abdominal pain. Ultrasound was requested to assess the pelvic organs as the cause for pain. Case Description Transabdominal pelvic ultrasound revealed a 6 cm dermoid cyst in the right adnexa. The normal right ovarian tissue was not visualised separate from this cyst. Diagnosis/ Discussion/ Treatment/ Follow up A few months later, the patient had a follow up CT scan of the abdomen and pelvis for a different assessment which also confirmed the presence of the fat-containing right ovarian dermoid cyst. Sonograms Axial B-mode dermoid cyst in the right adnexa. Longitudinal view of the right adnexal dermoid cyst CDI showing no colour flow within the cyst Coronal CT image of the right adnexal dermoid cyst Axial CT of the dermoid cyst
Testes Articles Orchitis Epidermoid Cyst Calcified Ductus Deferens Testicular Cancer (Malignancy) Orchitis Right Orchitis in a 30-year Old Male with a Coexisting Left Varicocoele Patient History A 30-year old male presented with an acute onset of right testicular pain. Case Description An ultrasound of the testes was performed using a 15 MHz linear transducer. Ultrasound revealed a hypoechoic and striated right testicle with evidence of hypervascularity on colour Doppler imaging. Appearances were in keeping with right orchitis. There was also evidence of dilatation of the left pampiniform plexus with a flow reversal of more than 2 seconds on spectral Doppler imaging. Appearances were suggestive of left varicocoele. Diagnosis/ Discussion/ Treatment/ Follow up The patient’s symptoms resolved after antibiotic therapy. Sonograms Grayscale image of the inflamed right testicle showing some hypoechoic striations across the testicular parenchyma in keeping with blood vessels Colour Doppler Imaging of the inflamed right testicle showing hypervascularity A dual-screen image of the right and left testes in colour Doppler mode. A normal left testicular vascularity can be seen Dilatation of the left pampiniform plexus veins Flow reversal on Valsalva manoeuvre for more than 2 seconds in the dilated left pampiniform plexus veins confirming varicocoele Epididymo-orchitis Presenting as Painful Hemiscrotal Swelling Clinical History A 25-year old man presented with symptoms of swelling and pain in the left hemiscrotum. The patient was referred to have an inpatient ultrasound on the same day. Case Description Ultrasound revealed a bulky and heterogeneous left epididymis (epididymo-orchitis). The left testis and epididymis both showed evidence of a significantly increased vascularity within them. There was also some reactive hydrocoele in the left hemiscrotum with a heterogeneous collection adjacent to the left epididymis. Diagnosis/ Discussion/ Treatment/ Follow up The patient’s symptoms resolved after completing antibiotic therapy. A subsequent ultrasound post-treatment confirmed the resolution of symptoms. Sonograms A panoramic image of the left hemiscrotum, in B-mode, showing an inflamed left epididymis B-mode image of the inflamed left testis and left epididymis Heterogeneous (complex) fluid collection in the left hemiscrotum adjacent to the left epididymis. No internal vascularity seen in the collection, as it is not a lesion B-mode left hemiscrotum showing the bulky and inflamed left epididymis Colour Doppler imaging showing hypervascularity of the left testis and epididymis in a ‘christmas tree’ fashion Epidermoid Cyst An Extratesticular Intrascrotal Right Epidermoid Cyst Clinical History A 60-year old man presented to the hospital after he had noticed a swollen structure posterior to his right testicle. Upon clinical evaluation, the structure felt to be outside the testis, suggestive of an epididymal cyst. The tumour markers were negative. An ultrasound of the testes was requested for further evaluation. Case Description Using a high frequency (15MHz) linear transducer, ultrasound revealed a roundish lesion within the right hemiscrotum with concentric morphology and no internal vascularity. The lesion appears as a concentric ring of alternating echogenicity with a well-defined outline and no internal vascularity. Ultrasound features were in keeping with an intrascrotal extratesticular epidermoid cyst and this corresponded with the site of concern the patient pointed at during the ultrasound encounter. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound report was sent to the referring clinician. At the time of compiling this report, the patient was known to have been managed conservatively as surgery is not clinically indicated. Epidermoid cysts are uncommon benign intratesticular or intrascrotal lesions encountered sonographically. They present as painless swelling or lump within the scrotum. Intrascrotal extratesticular epidermoid cysts are reportedly rare in the current literature. Ultrasound is the ideal imaging modality of choice in examining the scrotum for masses or lumps felt. Sonogram B-mode sonogram of the extratesticular right hemiscrotal lesion. B-mode sonogram of the extratesticular right hemiscrotal lesion. CDI sonogram of the extratesticular right hemiscrotal lesion. B-mode sonogram showing the lesion adjacent to the inferior pole of the unremarkable right testicle A Large Extratesticular Epidermoid Cyst Clinical History A 74-year old man presented with a fast-growing painful swelling next to the left testicle. Case Description Ultrasound performed, using a 15 MHz linear transducer, revealed a 7 cm heterogeneous mass adjacent to the left testis. The mass contained numerous anechoic patches with no evidence of internal vascularity. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have an MRI to help characterise the scrotal mass. The MRI revealed the left paratesticular mass to have appearances as the adjacent testis and was unable to provide detailed characteristics of the mass. The patient had left orchiectomy and the samples were examined histologically. Histology confirmed the paratesticular mass to contain keratinised stratified squamous epithelium with a diagnosis of an epidermoid cyst. Sonograms Right and left testes (T) with the mass (M) laterally Left hemiscrotal heterogeneous mass Axial view of the left hemiscrotal mass PDI showing no flow signal in the mass B-mode shoeing the left hemiscrotal mass lateral to the left testis Coronal MRI showing the left hemiscrotal mass (double arrows) next to the left testis (single arrow) Keywords Calcified Ductus Deferens Incidental Calcifications within the Ductus Deferens Clinical History A 65-year old man presented with the feeling of some palpable lumps within the scrotum, lateral to the testis. Case Description Ultrasound performed using a 15 MHz linear transducer revealed some focal calcifications within the left spermatic cord. Furthermore, the left epididymal head contained two tiny simple cysts. Diagnosis/ Discussion/ Treatment/ Follow up The patient was managed conservatively. Calcifications within the ductus deferens are benign findings that are incidentally detected on imaging of the region. It can occur with increasing age, in patients with diabetes mellitus, or in men with a history of chronic infection. Sonograms B-mode sonogram showing the calcification within the left spermatic cord B-mode sonogram showing multiple calcifications within the left spermatic cord Calcifications within the left spermatic cord and a normal left testis inferiorly Calcification adjacent to the normal left testis Testicular Cancer (Malignancy) Mixed Germ Cell Tumour of the Testis Clinical History A 21-year old male presented with a 3-week history of increased swelling in the left hemiscrotum. The patient was referred urgently to urology. An ultrasound of the scrotum was requested as an initial diagnostic approach. Case Description Ultrasound performed, using a 15 MHz linear transducer, revealed 7.5 cm heterogeneous mass occupying the entire left hemiscrotum. The mass showed strong evidence of internal vascularity on power Doppler imaging (PDI). Diagnosis/ Discussion/ Treatment/ Follow up The tumour markers (HCG, AFP, and LDH) were significantly raised, further confirming the ultrasound findings. CT scan of the chest, abdomen and pelvis with contrast was performed to adequately stage the disease. The patient had radical left orchiectomy and histology analysis of the tumour samples confirmed a diagnosis of a mixed germ cell testicular tumour (50 % yolk sac and 50 % embryonal carcinoma). Sonograms B-mode of the left testicular mass next to the normal right testis CDI comparing the vascularity of the testes Left testicular mass with measurement callipers in longitudinal and axial views PDI of the left testicular mass showing some internal vascularity Axial CT showing the left testicular mass Keywords Testicular cancer, Yolk sac carcinoma, Embryonal carcinoma Testicular Seminoma Clinical History A 29-year old male presented symptoms of a hard palpable lump in the right testis. Ultrasound was requested as the first line of imaging to assess for any lesions within the scrotum. Case Description Ultrasound revealed a 4 cm mass within the right testis with an irregular outline, a hypoechoic echotexture, and a significantly increased vascularity within the mass. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a right orchidectomy. Histology revealed features of testicular seminoma. Sonograms B-mode showing the right testicular mass next to the normal left testis Right testicular mass Right testicular mass with measurement callipers longitudinal and axial views CDI showing hypervascularity of the right testicular mass Dual screen image of the right and left testes on CDI Keywords
Horseshoe Kidney Articles Horseshoe Kidney in a Patient with UTI Symptoms Horseshoe Kidney in a Patient with UTI Symptoms Clinical History A 48-year old man presented with UTI symptoms. Case Description Ultrasound performed on the patient’s abdomen revealed a horseshoe kidney with the isthmus anterior to the IVC and abdominal aorta inferiorly. The patient had no prior imaging of his abdomen, therefore, this was the first time the variant was found. Diagnosis/ Discussion/ Treatment/ Follow up The patient’s symptoms were managed with the appropriate antibiotic therapy. Sonograms Sonogram acquired above the umbilicus using a transverse probe orientation showing the isthmus of the horseshoe kidney with the abdominal aorta (red), IVC (blue), and spine posteriorly Left moiety of the horseshoe kidney Right moiety of the horseshoe kidney CT scan of the horseshoe kidney
Peripheral Veins Articles Jugular Subclavian DVT Upper Limb DVT Jugular Jugular Vein Thrombus Caused by a Supraclavicular Mass Clinical History A 69-year old male presented with a sudden onset of pain and swelling of his left upper limb after a recent insertion of a pacemaker device. A vascular ultrasound was requested to examine his upper limb veins for deep venous thrombosis (DVT). Case Description Ultrasound using a multifrequency linear transducer set at 8 MHz revealed an occlusive thrombus in the entire left subclavian vein adjacent to the pacemaker (jugular vein thrombus). Diagnosis/ Discussion/ Treatment/ Follow up The result was urgently sent to the referring clinician who commenced the patient on the appropriate anticoagulation therapy. Sonograms B-mode of the internal jugular vein showing an occlusive thrombus Colour Doppler showing the occluded IJV Colour Doppler showing the occluded IJV Axial segment of the IJV showing the occlusive thrombus A heterogeneous left supraclavicular mass CDI showing evidence of internal vascularity in the left supraclavicular mass Subclavian DVT An Occlusive Thrombus in the Subclavian Vein Clinical History A 69-year old male presented with a sudden onset of pain and swelling of his left upper limb after a recent insertion of a pacemaker device. A vascular ultrasound was requested to examine his upper limb veins for deep venous thrombosis (DVT). Case Description Ultrasound using a multifrequency linear transducer set at 8 MHz revealed an occlusive thrombus in the entire left subclavian vein adjacent to the pacemaker. Diagnosis/ Discussion/ Treatment/ Follow Up The result was urgently sent to the referring clinician who commenced the patient on the appropriate anticoagulation therapy. Sonograms B-mode ultrasound showing an occlusive thrombus in the left subclavian vein Colour Doppler imaging showing an absence of flow signal in the subclavian vein Colour Doppler imaging showing an absence of flow signal in the subclavian vein Colour Doppler imaging showing an absence of flow signal in the subclavian vein Subclavian DVT Clinical History A 30-year old male presented with an acute onset of right arm swelling and pain. Recent blood tests revealed an elevated D dimer value. Case Description Ultrasound revealed an occlusive thrombus within the proximal subclavian vein. The remaining veins of the left upper limb were patent and free of thrombus. Diagnosis/ Discussion/ Treatment/ Follow up Due to the patient’s medical history, arterial Doppler studies of the upper limbs were performed which showed no abnormality. Sonograms Colour Doppler imaging of the occluded right subclavian vein CDI axial view of the occluded right subclavian vein B-mode axial right subclavian DVT An Occlusive Thrombus within the Subclavian Vein Clinical History A 19-year old male patient presented with symptoms of swelling, erythema, and numbness to the left arm. Case Description Vascular ultrasound revealed an occlusive thrombus visualised within the entire left subclavian vein. However, the left jugular vein, axillary vein, brachial vein, basilic, vein, cephalic vein, and median cubital veins were patent and unaffected by the thrombus. Diagnosis/ Discussion/ Treatment/ Follow up The patient was placed on the appropriate anticoagulation therapy. Sonograms CDI occluded left subclavian vein proximal CDI occluded subclavian vein distal Occluded subclavian vein Patent left jugular vein Upper Limb DVT Extensive Occlusive Venous Thrombosis of the Left Upper Limb Clinical History A 64-year old lady with a peripherally inserted central catheter (PICC line) through her left upper limb, presented with a sudden onset of swelling in her left arm. A vascular ultrasound was requested to rule out thrombosis. Case Description Ultrasound revealed an extensive occlusive thrombus in the basilic vein, axillary vein, subclavian vein, and jugular vein of the left side. The PICC line was also visualised within the lumen of the thrombosed vein. Diagnosis/ Discussion/ Treatment/ Follow up The insertion of PICC lines can sometimes be for administering certain treatments. Patients who develop any adverse symptom (swelling, pain, redness) post PICC line insertion are prime candidates for an upper limb venous Doppler ultrasound. It is vital to rule out an onset of thrombosis in these patients to avoid dangerous outcomes. Sonograms CDI occluded left jugular vein CDI occluded left jugular vein CDI occluded left subclavian vein with PICC line in situ B-mode occluded left axillary vein with PICC line in situ B-mode occluded left basilic vein with PICC line in situ
Epidermoid Cyst Articles An Extratesticular Intrascrotal Right Epidermoid Cyst A Large Extratesticular Epidermoid Cyst An Extratesticular Intrascrotal Right Epidermoid Cyst Clinical History A 60-year old man presented to the hospital after he had noticed a swollen structure posterior to his right testicle. Upon clinical evaluation, the structure felt to be outside the testis, suggestive of an epididymal cyst. The tumour markers were negative. An ultrasound of the testes was requested for further evaluation. Case Description Using a high frequency (15MHz) linear transducer, ultrasound revealed a roundish lesion within the right hemiscrotum with concentric morphology and no internal vascularity. The lesion appears as a concentric ring of alternating echogenicity with a well-defined outline and no internal vascularity. Ultrasound features were in keeping with an intrascrotal extratesticular epidermoid cyst and this corresponded with the site of concern the patient pointed at during the ultrasound encounter. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound report was sent to the referring clinician. At the time of compiling this report, the patient was known to have been managed conservatively as surgery is not clinically indicated. Epidermoid cysts are uncommon benign intratesticular or intrascrotal lesions encountered sonographically. They present as painless swelling or lump within the scrotum. Intrascrotal extratesticular epidermoid cysts are reportedly rare in the current literature. Ultrasound is the ideal imaging modality of choice in examining the scrotum for masses or lumps felt. Sonogram B-mode sonogram of the extratesticular right hemiscrotal lesion. B-mode sonogram of the extratesticular right hemiscrotal lesion. CDI sonogram of the extratesticular right hemiscrotal lesion. B-mode sonogram showing the lesion adjacent to the inferior pole of the unremarkable right testicle A Large Extratesticular Epidermoid Cyst Clinical History A 74-year old man presented with a fast-growing painful swelling next to the left testicle. Case Description Ultrasound performed, using a 15 MHz linear transducer, revealed a 7 cm heterogeneous mass adjacent to the left testis. The mass contained numerous anechoic patches with no evidence of internal vascularity. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have an MRI to help characterise the scrotal mass. The MRI revealed the left paratesticular mass to have appearances as the adjacent testis and was unable to provide detailed characteristics of the mass. The patient had left orchiectomy and the samples were examined histologically. Histology confirmed the paratesticular mass to contain keratinised stratified squamous epithelium with a diagnosis of an epidermoid cyst. Sonograms Right and left testes (T) with the mass (M) laterally Left hemiscrotal heterogeneous mass Axial view of the left hemiscrotal mass PDI showing no flow signal in the mass B-mode shoeing the left hemiscrotal mass lateral to the left testis Coronal MRI showing the left hemiscrotal mass (double arrows) next to the left testis (single arrow) Keywords
Popliteal Artery Occlusion Co-existing with Popliteal Vein DVT Clinical History A 92-year old lady presented with pain and swelling in the right leg. The WELLS score was 2 upon an initial specialist clinical assessment. Doppler ultrasound of the lower limb veins was requested to rule out deep venous thrombosis (DVT). Case Description Ultrasound revealed the presence of an occlusive thrombus in the popliteal vein. There was also an occluded superficial femoral artery (SFA). However, the popliteal artery was patent. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred urgently to vascular surgery for further management. Unfortunately, the patient passed away Sonograms Patent right common femoral artery Partially occluded right superficial femoral artery (proximal) Partially occluded right superficial femoral artery (mid) Partially occluded right superficial femoral artery (distal) Colour Doppler imaging of the distal right superficial femoral artery showing some distal patency towards the popliteal artery Patent right popliteal artery Occluded right popliteal vein containing thrombus (blood clot), in keeping with deep venous thrombosis (DVT) Axial orientation of the right popliteal vein showing occlusion, and the patent artery posteriorly
Subclavian DVT Clinical History A 30-year old male presented with an acute onset of right arm swelling and pain. Recent blood tests revealed an elevated D dimer value. Case Description Ultrasound revealed an occlusive thrombus within the proximal subclavian vein. The remaining veins of the left upper limb were patent and free of thrombus. Diagnosis/ Discussion/ Treatment/ Follow up Due to the patient’s medical history, arterial Doppler studies of the upper limbs were performed which showed no abnormality. Sonograms Colour Doppler imaging of the occluded right subclavian vein CDI axial view of the occluded right subclavian vein B-mode axial right subclavian DVT
Soft Tissue Mass Articles Lower Leg Soft Tissue Lesion with Concerning Ultrasound Features Lower Leg Soft Tissue Lesion with Concerning Ultrasound Features Clinical History A 72-year old mass presented with pain and swelling to the left calf. An initial Doppler ultrasound was requested to assess for DVT. Case Description Ultrasound ruled out DVT. However, during the examination, the sonographer could palpate a lump below the patient’s calf. This corresponded to a 3 cm oval-shaped well-defined heterogeneous vascular lesion in the deep subcutaneous compartment. Further evaluation with MRI was recommended. Diagnosis/ Discussion/ Treatment/ Follow up The patient declined having an MRI or any other studies in relation to this. Sonograms B-mode sonogram of an oval-shaped mass in the deep subcutaneous layer of the right lower leg Colour Doppler imaging of the oval-shaped deep subcutaneous mass showing a significant amount of internal vascularity B-mode virtual convex view of the deep subcutaneous mass showing some compression effect on the adjacent muscle fibres B-mode sonogram of the mass with measurement callipers Power Doppler imaging of the mass again showing a significant amount of vascularity within the mass
Bilateral Calcification at the Vesicoureteric Junctions Articles Bilateral Calcification at the Vesicoureteric Junctions Bilateral Calcification at the Vesicoureteric Junctions Clinical History A 5-year old female was referred to have an ultrasound of the urinary tract due to dysfunctional voiding. Case Description Ultrasound revealed some calcifications within the right and left vesicoureteric junctions measuring 0.9 cm in the right and 1.1 cm in the left VUJ respectively. There was no hydronephrosis present, and the urinary bladder emptied completely. Diagnosis/ Discussion/ Treatment/ Follow up Bilateral calcifications of the vesicoureteric junctions. Sonograms B-mode bladder showing calcifications within the VUJ bilaterally CDI showing twinkle artefacts of the VUJ calcifications Normal kidney
IVC Thrombus Articles Tumour Thrombus in the IVC Tumour Thrombus in the IVC Clinical History A 60-year old man presented with pain in the right upper quadrant and in the epigastrium. Abdominal ultrasound was requested to examine the liver and biliary tree for a possible cause. Case Description Ultrasound revealed an occluded IVC containing thrombus-like material. The occlusion (tumour thrombus) extends a few millimetres into the proximal portion of one of the hepatic veins. Mild ascites in the RUQ and pleural effusion seen in the right lung. The gallbladder was empty with an oedematous wall appearance, which might have been secondary to the irritation caused by the ascites. An urgent CT pulmonary angiogram was recommended to further examine the occluded IVC and to assess the extent of the thrombus. Diagnosis/ Discussion/ Treatment/ Follow up An urgent CTPA revealed the IVC thrombus to be extending into the right atrium of the heart. A further CT contrast abdomen and pelvis suggested the thrombus might be a tumour as it was also seen to encase the right renal vessels and beyond the IVC. Overall, appearances were suggestive of either a thrombus due to hyperviscosity syndrome or a malignant tumour, possibly leiomyosarcoma. Sonograms Right upper quadrant showing the liver and the occluded IVC posteriorly Colour Doppler Imaging showing the occluded IVC Colour Doppler Imaging showing the occluded IVC Empty oedematous gallbladder, probably due to the ascites A tiny trace of free fluid in the hepatorenal (Morrison’s) pouch Colour Doppler showing patent hepatic veins. The right hepatic vein might be occluded B-mode showing an occlusive thrombus in the right branch of the hepatic vein Sagittal CT showing the occlusive thrombus in the IVC
Duodenal Tumour Articles Obstructive Duodenal Tumour in a 76 year Old Patient Obstructive Duodenal Tumour in a 76 year Old Patient Clinical History A 76-year old man presented with epigastric pain and haematemesis. Case Description The patient was referred to have an abdominal ultrasound which reveals a large heterogeneous mass in the duodenum (duodenal tumour). There was also intrahepatic biliary dilatation and raised portal vein flow velocity, all secondary to the obstructive nature of the duodenal mass. Diagnosis/ Discussion/ Treatment/ Follow Up The patient also had Oesophagoduodenoscopy (OGD) which revealed the mass to be causing a gastric outflow obstruction. The patient also has a CT scan of the chest abdomen and pelvis (with contrast) which revealed the obstructive mass (duodenal tumour) to be at D2/3 with an abnormal D3 and an abrupt calibre of D4. The patient was referred to the Upper GI specialists for further management. Sonograms Sonogram of the abdomen at the level of the epigastrium, showing the duodenal mass Sonogram at the level of the epigastrium showing the long segment of the duodenal mass Power Doppler imaging of the duodenal mass. No internal vascularity seen. However, there is evidence of peripheral vascularity Sonogram of the pancreas (P) with the duodenal mass (M) seen adjacent and medial to the pancreatic head Right hepatic lobe showing evidence of intrahepatic biliary dilatation secondary to the obstructive duodenal mass Patent portal vein with a slightly elevated velocity measurement of 44.6 cm/s due to the duodenal mass-effect on the proxima portal vein Dilated common bile duct (CBD) secondary to the obstructive duodenal mass
An Incidental Finding of an Asymptomatic Renal Mass Clinical History A 48-year old man presented with left flank pain and overall discomfort. An ultrasound of the abdomen was requested to assess for left renal calculi that might explain the symptoms. Case Description Ultrasound revealed a 5 cm heterogeneous echogenic mass in the right kidney with some evidence of vascularity within it. Diagnosis/ Discussion/ Treatment/ Follow up A subsequent whole body CT scan confirmed the presence of the 5 cm mass arising from the midpole of the right kidney and showing heterogeneous contrast enhancement. The patient had a right nephrectomy. The histology analysis of the surgical samples confirmed the lesion to he renal cell carcinoma (RCC). Sonograms Right renal mass with callipers Right renal mass longitudinal view CDI right renal mass with some internal vascularity Normal left kidney Coronal CT showing the right renal mass
Obstructive Duodenal Tumour in a 76 year Old Patient Clinical History A 76-year old man presented with epigastric pain and haematemesis. Case Description The patient was referred to have an abdominal ultrasound which reveals a large heterogeneous mass in the duodenum (duodenal tumour). There was also intrahepatic biliary dilatation and raised portal vein flow velocity, all secondary to the obstructive nature of the duodenal mass. Diagnosis/ Discussion/ Treatment/ Follow Up The patient also had Oesophagoduodenoscopy (OGD) which revealed the mass to be causing a gastric outflow obstruction. The patient also has a CT scan of the chest abdomen and pelvis (with contrast) which revealed the obstructive mass (duodenal tumour) to be at D2/3 with an abnormal D3 and an abrupt calibre of D4. The patient was referred to the Upper GI specialists for further management. Sonograms Sonogram of the abdomen at the level of the epigastrium, showing the duodenal mass Sonogram at the level of the epigastrium showing the long segment of the duodenal mass Power Doppler imaging of the duodenal mass. No internal vascularity seen. However, there is evidence of peripheral vascularity Sonogram of the pancreas (P) with the duodenal mass (M) seen adjacent and medial to the pancreatic head Right hepatic lobe showing evidence of intrahepatic biliary dilatation secondary to the obstructive duodenal mass Patent portal vein with a slightly elevated velocity measurement of 44.6 cm/s due to the duodenal mass-effect on the proxima portal vein Dilated common bile duct (CBD) secondary to the obstructive duodenal mass
Subclavian DVT Articles An Occlusive Thrombus in the Subclavian Vein Subclavian DVT An Occlusive Thrombus within the Subclavian Vein An Occlusive Thrombus in the Subclavian Vein Clinical History A 69-year old male presented with a sudden onset of pain and swelling of his left upper limb after a recent insertion of a pacemaker device. A vascular ultrasound was requested to examine his upper limb veins for deep venous thrombosis (DVT). Case Description Ultrasound using a multifrequency linear transducer set at 8 MHz revealed an occlusive thrombus in the entire left subclavian vein adjacent to the pacemaker. Diagnosis/ Discussion/ Treatment/ Follow Up The result was urgently sent to the referring clinician who commenced the patient on the appropriate anticoagulation therapy. Sonograms B-mode ultrasound showing an occlusive thrombus in the left subclavian vein Colour Doppler imaging showing an absence of flow signal in the subclavian vein Colour Doppler imaging showing an absence of flow signal in the subclavian vein Colour Doppler imaging showing an absence of flow signal in the subclavian vein Subclavian DVT Clinical History A 30-year old male presented with an acute onset of right arm swelling and pain. Recent blood tests revealed an elevated D dimer value. Case Description Ultrasound revealed an occlusive thrombus within the proximal subclavian vein. The remaining veins of the left upper limb were patent and free of thrombus. Diagnosis/ Discussion/ Treatment/ Follow up Due to the patient’s medical history, arterial Doppler studies of the upper limbs were performed which showed no abnormality. Sonograms Colour Doppler imaging of the occluded right subclavian vein CDI axial view of the occluded right subclavian vein B-mode axial right subclavian DVT An Occlusive Thrombus within the Subclavian Vein Clinical History A 19-year old male patient presented with symptoms of swelling, erythema, and numbness to the left arm. Case Description Vascular ultrasound revealed an occlusive thrombus visualised within the entire left subclavian vein. However, the left jugular vein, axillary vein, brachial vein, basilic, vein, cephalic vein, and median cubital veins were patent and unaffected by the thrombus. Diagnosis/ Discussion/ Treatment/ Follow up The patient was placed on the appropriate anticoagulation therapy. Sonograms CDI occluded left subclavian vein proximal CDI occluded subclavian vein distal Occluded subclavian vein Patent left jugular vein
Popliteal Artery Aneurysm Articles Incidental Finding of a Popliteal Artery Aneurysm during a DVT Ultrasound Incidental Finding of a Popliteal Artery Aneurysm during a DVT Ultrasound Clinical History An 83-year old man presented with left leg swelling, erythema, and shortness of breath. Case Description Ultrasound revealed a 27 mm popliteal artery aneurysm in the left popliteal fossa. The patient also had a positive extensive DVT in the deep veins of the left lower limb. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to the vascular specialist for further management. Sonograms B-Mode longitudinal view of the left popliteal artery aneurysm B-Mode axial view of the left popliteal artery aneurysm Colour Doppler imaging of the left popliteal artery aneurysm in longitudinal orientation Colour Doppler imaging of the left popliteal artery aneurysm in transverse orientation
Epididymo-orchitis Presenting as Painful Hemiscrotal Swelling Clinical History A 25-year old man presented with symptoms of swelling and pain in the left hemiscrotum. The patient was referred to have an inpatient ultrasound on the same day. Case Description Ultrasound revealed a bulky and heterogeneous left epididymis (epididymo-orchitis). The left testis and epididymis both showed evidence of a significantly increased vascularity within them. There was also some reactive hydrocoele in the left hemiscrotum with a heterogeneous collection adjacent to the left epididymis. Diagnosis/ Discussion/ Treatment/ Follow up The patient’s symptoms resolved after completing antibiotic therapy. A subsequent ultrasound post-treatment confirmed the resolution of symptoms. Sonograms A panoramic image of the left hemiscrotum, in B-mode, showing an inflamed left epididymis B-mode image of the inflamed left testis and left epididymis Heterogeneous (complex) fluid collection in the left hemiscrotum adjacent to the left epididymis. No internal vascularity seen in the collection, as it is not a lesion B-mode left hemiscrotum showing the bulky and inflamed left epididymis Colour Doppler imaging showing hypervascularity of the left testis and epididymis in a ‘christmas tree’ fashion
Dermoid Cyst Clinical History A 50-year old lady presented with a recent onset of lower abdominal pain. Ultrasound was requested to assess the pelvic organs as the cause for pain. Case Description Transabdominal pelvic ultrasound revealed a 6 cm dermoid cyst in the right adnexa. The normal right ovarian tissue was not visualised separate from this cyst. Diagnosis/ Discussion/ Treatment/ Follow up A few months later, the patient had a follow up CT scan of the abdomen and pelvis for a different assessment which also confirmed the presence of the fat-containing right ovarian dermoid cyst. Sonograms Axial B-mode dermoid cyst in the right adnexa. Longitudinal view of the right adnexal dermoid cyst CDI showing no colour flow within the cyst Coronal CT image of the right adnexal dermoid cyst Axial CT of the dermoid cyst
Parapelvic Simple Renal Cyst Mimicking Hydronephrosis on MRI Clinical History A 74-year old man had an MRI of his spine which revealed an area of possible hydronephrosis in his right kidney. An ultrasound of his kidneys was requested to confirm this. Case Description Ultrasound revealed a 6 cm parapelvic simple cyst (renal cyst) in the lower pole. There was also another 2 cm simple cyst adjacent to the former. Diagnosis/ Discussion/ Treatment/ Follow up These findings were confirmed by an outpatient contrast CT scan of the urinary tract carried out months later. Sonograms A right parapelvic renal cyst B-Mode A right parapelvic renal cyst colour Doppler Imaging An axial CT scan post-ultrasound confirming the right parapelvic cyst to be a Bosniak 1 category A coronal CT scan post-ultrasound confirming the right parapelvic cyst to be a Bosniak 1 category
Endometrial Carcinoma Articles A Large Adnexal Mass in a Patient with Endometrial Cancer A Large Adnexal Mass in a Patient with Endometrial Cancer Clinical History A 74-year old lady presented with abdominal distension and discomfort. Case Description Ultrasound of the abdomen and pelvis (TA and TV) revealed a grossly thickened endometrium measuring 27 mm in AP calibre with heterogeneous echotexture. In addition there was a 131 mm complex non-vascular cystic mass (endometrial cancer) in the left adnexa/ left hemipelvis. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a whole body contrast CT which confirmed the ultrasound findings (endometrial cancer) in addition to the diagnosis of some omental cake with nodal peritoneal deposits and ascites in keeping with gynaecological malignancy. The adnexal cyst appeared to herniate through the left inguinal canal. The tumour markers (Ca125 and Ca19.9) were significantly elevated. Subsequently, the patient had an omental biopsy which confirmed metastatic high grade carcinoma. Sonograms Transabdominal view of the pelvis showing a 131 mm x 68 mm (L x AP) heterogeneous cystic mass in the left adnexa Transvaginal longitudinal view of the uterus showing an abnormally thickened endometrium of 26 mm (AP) Power Doppler imaging of the left adnexal complex cyst showing no evidence of internal vascularity PDI of the left adnexal cystic mass Free fluid in the right upper quadrant in keeping with ascites Ascites in the left upper abdominal quadrant adjacent to the spleen; subphrenic and within the splenorenal recess Ascites in the LUQ Axial CT showing the cyst in the LIF Sagittal CT showing the left adnexal cystic mass herniating into the left inguinal canal
Calcified Ductus Deferens Articles Incidental Calcifications within the Ductus Deferens Incidental Calcifications within the Ductus Deferens Clinical History A 65-year old man presented with the feeling of some palpable lumps within the scrotum, lateral to the testis. Case Description Ultrasound performed using a 15 MHz linear transducer revealed some focal calcifications within the left spermatic cord. Furthermore, the left epididymal head contained two tiny simple cysts. Diagnosis/ Discussion/ Treatment/ Follow up The patient was managed conservatively. Calcifications within the ductus deferens are benign findings that are incidentally detected on imaging of the region. It can occur with increasing age, in patients with diabetes mellitus, or in men with a history of chronic infection. Sonograms B-mode sonogram showing the calcification within the left spermatic cord B-mode sonogram showing multiple calcifications within the left spermatic cord Calcifications within the left spermatic cord and a normal left testis inferiorly Calcification adjacent to the normal left testis
Intramuscular Haematoma of the Thigh Following Anticoagulation Clinical History A 39-year old man presented with an acute onset of tense swelling of the right lateral thigh region. The patient was on anticoagulation therapy, at the time of this occurrence, for a different condition. Ultrasound of the thigh was requested to assess for haematoma or other collections. Case Description Ultrasound revealed an 8 cm heterogeneous non-vascular haematoma within the intramuscular layer of the right lateral thigh region. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a CT angiogram of the lower limbs to assess the potential source of an acute bleed within the vessels. The ultrasound findings were confirmed on CT. However, there was no evidence of contrast extravasation to the pool of haematoma seen on CT. Sonograms B-mode showing the right thigh haematoma in longitudinal view Distal end of the right thigh haematoma Transverse view of the right thigh haematoma Right thigh haematoma in transverse view Transverse view of the distal portion of the right thigh haematoma Longitudinal view right thigh haematoma Panoramic view of the right thigh intramuscular haematoma PDI showing no flow signal in the haematoma Coronal view of the thigh haematoma on CT scan
Biliary tree Articles Choledocholithiasis Choledocholithiasis Multiple Biliary Calculi Clinical History A 76-year old man presented with abdominal pain, vomiting, and jaundice. His blood test showed raised infection markers and deranged LFTs. Abdominal ultrasound was requested as the first line of imaging. Case Description Ultrasound revealed multiple large calculi within the lumen of the dilated common bile duct (multiple biliary calculi) measuring 12 mm in AP dimension. The gallbladder was thick-walled and contained some tiny calculi within its lumen. Diagnosis/ Discussion/ Treatment/ Follow up The patient had magnetic resonance cholangiopancreaticography (MRCP) which confirmed the ultrasound findings. Sonograms Thick-walled gallbladder Axial sonogram of the thick-walled gallbladder Dilated common bile duct containing multiple oval-shaped echogenic structures Dilated common bile duct containing multiple oval-shaped echogenic structures MRCP; coronal image showing the dilated CBD containing multiple filling-defects Multiple oval-shaped structures within the lumen of the CBD Calculus Within the Common Bile Duct Causing Biliary Obstruction Clinical History A 49-year old man presented with abdominal pain. Case Description An abdominal ultrasound was done using a 2 – 5 MHz curvilinear transducer. This revealed multiple calculus within the common bile duct and another calculus within the lumen of the collapsed gallbladder. These findings were also confirmed on MRCP done afterwards. Diagnosis/ Discussion/ Treatment/ Follow up The patient had ERCP and cholecystectomy. Sonograms Sonogram of the pancreas showing the head, body, and uncinate process of the pancreas. The pancreatic tail is partly obscured by bowel gas shadowing. A short segment of the left hepatic lobe and duodenum are displayed anterior to the pancreas. No pancreatic duct dilatation An obstructive calculus in the common bile duct. The calculus measures 11 mm and the common bile duct measures 10 mm in AP calibre A 10 mm immoble calculus at the neck of the nearly empty gallbladder An Obstructive Calculus in the Common Bile Duct Clinical History A 61 year old lady presented with an acute onset of epigastric pain and loss of appetite. The patient is known to have uncomplicated cholelithiasis which was diagnosed 2 decades ago. Presently, the bloods revealed raised alkaline phosphatase of 200. Case Description Abdominal ultrasound revealed a distended gallbladder with multiple calculi. There was also intra and extrahepatic biliary dilatation present. The common bile duct measured 15 mm in AP calibre with a calculus (obstructive calculus) seen towards the distal end of the lumen. However, the pancreatic duct was not dilated. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound findings were confirmed on a subsequent MRCP. Sonograms The right hepatic lobe showing dilatation of the IHD and CBD Longitudinal section of the gallbladder containing multiple tiny calculi An obstructive calculus in the distal CBD
Tubal/Fallopian Tubes Articles Cancer of the Fallopian Tube Cancer of the Fallopian Tube Fallopian Tube Cancer Clinical History A 67-year old lady presented with severe lower abdominal pain with some change in bowel habit and loose stool. Case Description The patient was initially referred to have a CT scan of the whole body with contrast. This revealed a large predominantly cystic structure in the pelvis centrally. The mass was further investigated using a pelvic ultrasound (TA and TV). Ultrasound revealed a 13 cm mass with solid and cystic components in the central pelvis. The mass showed some evidence of internal vascularity within its solid component. There was also free fluid in the anterior and posterior cul-de-sac. Ultrasound features were suggestive of malignancy (fallopian tube cancer). Diagnosis/ Discussion/ Treatment/ Follow up The patient had laparotomy which revealed the mass to be a stage II HGS cancer of the fallopian tube. Sonograms TVUSS showing a mass with cystic and solid component in the mid pelvis. The mass is a Stage II HGS cancer of the left fallopian tube Colour Doppler imaging of the mass showing some active flow within the solid component Triplex studies evaluation of the pelvic mass using b-mode, CDI, and spectral Doppler Free fluid in the rectouterine pouch of Douglas
Penile Articles Penile Doppler Assessment Penile Doppler Assessment Penile Doppler Assessment Clinical information A 27-year old man presented with problems maintaining erections. A Doppler ultrasound of the penis was requested to provide an insight to the situation while assessing the penile blood vessels for a vasculogenic aetiology. Case Description Ultrasound was performed using a high frequency linear transducer of up to 16 MHz after administering 20 mcg of Caverject IM. The assessment was carried out every 5 minutes post injection. The corporal bodies were initially examined in B-mode to assess for any (Peyronie’s) plaques. Afterwhich, the right and left cavernosal arteries were interrogated using colour and spectral Doppler ultrasound to evaluate the flow velocities. Both peak systolic and end diastolic velocity parameters are the most useful in determining arterial or venous insufficiency causes of erectile dysfunction. Diagnosis/ Discussion/ Treatment/ Follow up Venous Insufficiency Sonographs Right corpus cavernosum 5 minutes after caverject administration. Left corpus cavernosum 5 minutes after caverject administration. Spectral Doppler of the left cavernosal artery during tumescence phase of erection. Spectral Doppler of the right cavernosal artery during tumescence phase of erection. Spectral imaging of the left cavernosal artery showing in axial orientation. Spectral imaging of the right cavernosal artery showing in axial orientation.
The Great Vessels Articles Abdominal Aortic Aneurysm IVC Thrombus Abdominal Aortic Aneurysm Severe case of Abdominal Aortic Aneurysm (AAA) Clinical History A 90-year old lady presented with a palpable lump towards the left side of the abdomen. Case Description Ultrasound revealed an 83 mm abdominal aortic aneurysm which corresponds to the palpable mass pointed by the patient. Diagnosis/ Discussion/ Treatment/ Follow up A subsequent contrast-enhanced CT scan of the thorax abdomen and pelvis confirmed this diagnosis. The patient was managed conservatively as surgery was contraindicated based on other comorbidities. Sonograms Longitudinal section of the AAA colour Doppler imaging Transverse section of the AAA colour Doppler imaging B-Mode of the AAA Sagittal contrast CT showing large AAA in arterial phase IVC Thrombus Tumour Thrombus in the IVC Clinical History A 60-year old man presented with pain in the right upper quadrant and in the epigastrium. Abdominal ultrasound was requested to examine the liver and biliary tree for a possible cause. Case Description Ultrasound revealed an occluded IVC containing thrombus-like material. The occlusion (tumour thrombus) extends a few millimetres into the proximal portion of one of the hepatic veins. Mild ascites in the RUQ and pleural effusion seen in the right lung. The gallbladder was empty with an oedematous wall appearance, which might have been secondary to the irritation caused by the ascites. An urgent CT pulmonary angiogram was recommended to further examine the occluded IVC and to assess the extent of the thrombus. Diagnosis/ Discussion/ Treatment/ Follow up An urgent CTPA revealed the IVC thrombus to be extending into the right atrium of the heart. A further CT contrast abdomen and pelvis suggested the thrombus might be a tumour as it was also seen to encase the right renal vessels and beyond the IVC. Overall, appearances were suggestive of either a thrombus due to hyperviscosity syndrome or a malignant tumour, possibly leiomyosarcoma. Sonograms Right upper quadrant showing the liver and the occluded IVC posteriorly Colour Doppler Imaging showing the occluded IVC Colour Doppler Imaging showing the occluded IVC Empty oedematous gallbladder, probably due to the ascites A tiny trace of free fluid in the hepatorenal (Morrison’s) pouch Colour Doppler showing patent hepatic veins. The right hepatic vein might be occluded B-mode showing an occlusive thrombus in the right branch of the hepatic vein Sagittal CT showing the occlusive thrombus in the IVC
Ovarian Cancer Articles An Ovarian Tumour with an Initial Presentation of RIF Pain An Ovarian Tumour with an Initial Presentation of RIF Pain Clinical History A 76-year old lady presented with a few weeks history of right sided abdominal pain, tenderness, and bloating. Although the blood results were normal, the patient was referred to have an ultrasound of the abdomen and pelvis to rule out cholelithiasis or ovarian abnormality. Case Description Ultrasound (TA and TV) revealed a large heterogeneous mass in the right adnexa with cystic and solid components and some internal vascularity. The right renal pelvis was also mildly dilated at 10 mm in AP calibre, suggesting mass effect on the right ureter by the mass. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have a pelvic MRI then whole body CT scan for staging prior to surgery. Subsequently, the patient had a total abdominal hysterectomy with bilateral salpingo oophorectomy. Future MRI scans revealed no evidence of disease recurrence. The post-operative histology analysis of the right ovary revealed a low grade serous carcinoma (Ovarian Tumour) arising in a borderline serous tumour. Sonograms TVUSS showing a cystic mass in the right adnexa with some solid components PDI of the right adnexal complex cystic mass showing some internal vascularity B Mode showing the right adnexal mass with its cystic component Axial CT image of the right adnexal complex cystic mass T1 axial MRI of the right adnexal mass
Small Intestine Articles Duodenal Tumour Duodenal Tumour Obstructive Duodenal Tumour in a 76 year Old Patient Clinical History A 76-year old man presented with epigastric pain and haematemesis. Case Description The patient was referred to have an abdominal ultrasound which reveals a large heterogeneous mass in the duodenum (duodenal tumour). There was also intrahepatic biliary dilatation and raised portal vein flow velocity, all secondary to the obstructive nature of the duodenal mass. Diagnosis/ Discussion/ Treatment/ Follow Up The patient also had Oesophagoduodenoscopy (OGD) which revealed the mass to be causing a gastric outflow obstruction. The patient also has a CT scan of the chest abdomen and pelvis (with contrast) which revealed the obstructive mass (duodenal tumour) to be at D2/3 with an abnormal D3 and an abrupt calibre of D4. The patient was referred to the Upper GI specialists for further management. Sonograms Sonogram of the abdomen at the level of the epigastrium, showing the duodenal mass Sonogram at the level of the epigastrium showing the long segment of the duodenal mass Power Doppler imaging of the duodenal mass. No internal vascularity seen. However, there is evidence of peripheral vascularity Sonogram of the pancreas (P) with the duodenal mass (M) seen adjacent and medial to the pancreatic head Right hepatic lobe showing evidence of intrahepatic biliary dilatation secondary to the obstructive duodenal mass Patent portal vein with a slightly elevated velocity measurement of 44.6 cm/s due to the duodenal mass-effect on the proxima portal vein Dilated common bile duct (CBD) secondary to the obstructive duodenal mass
Hip, Groin & Buttock Articles Abscess and Collection Abscess and Collection Left Groin Abscess Clinical History A 35-year old female presented with an onset of painful and tender swelling in the left groin. The patient has a history of intravenous drug injection into the groin. An ultrasound of the groin was requested to examine the swelling for further management. Case Description The left groin swelling was initially examined using a curvilinear ultrasound transducer to assess any mass or collection deep within the groin while limiting compromise on the image resolution. This revealed a 9 cm heterogeneous collection within the left groin (Left Groin Abscess) at the site of concern pointed by the patient. The collection was seen deep in the intramuscular compartment with a regular outline, some cystic internal component, and air bubbles floating in the dependent areas of the collection, appearing as echogenic rim with some comet tail artefacts at the anterior surface of the collection. The overall ultrasound features are congruent with an abscess in the deep muscle compartment of the left groin/ upper thigh. Using a high frequency linear transducer did not provide any tangible information as the collection was too deep to be fully examined by the high frequency transducer. Therefore, in this case, the curvilinear evaluation of the mass on ultrasound was sufficient. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound findings were congruent with the patient’s overall clinical picture. However, an MRI of the groin was requested for confirmation prior to a consideration of drainage. MRI confirmed a 9 cm collection in the right adductor compartment with air-fluid levels present, some lymphedema, and reactive lymph nodes. Sonograms Power Doppler imaging showing no evidence of vascularity within the groin abscess B-mode image of the left groin abscess B-mode ultrasound showing the left groin abscess with evidence of comet tail artefact from the gas pockets within its anterior surface A coronal MRI image of the groin showing the large collection in the upper and medial aspect of the left thigh
Normal Transplant Liver Articles Normal Doppler Ultrasound Assessment of a Transplant Liver Normal Doppler Ultrasound Assessment of a Transplant Liver Clinical History A 45-year old with a history of chronic polycystic liver and kidney disease had a recent liver transplant. Doppler ultrasound was requested to assess the blood flow in and out of the transplant liver. Case Description Ultrasound was performed using a 3 MHz curvilinear transducer. The examination started on B-mode to visualise the entire hepatic outline and parenchyma. Colour Doppler was used to evaluate patency of the hepatic veins, common hepatic artery, and the main portal veins and its branches. Spectral Doppler was further used to examine the flow pattern and velocity in the hepatic vessels. Diagnosis/ Discussion/ Treatment/ Follow-up The vessels examined in transplant liver assessment include: The right hepatic vein. The middle hepatic veins. The left hepatic vein. The main portal vein. The right portal vein. Middle portal vein. Left portal vein. The common hepatic artery. The parameters deduced from the haemodynamic spectral Doppler studies include: peak systolic velocity (PSV), end diastolic velocity (EDV), pulsatility index (PI), resistivity index (RI), and the wave pattern. Sonograms Longitudinal view of the left hepatic lobe showing the caudate lobe Spectral Doppler of the right hepatic vein Transverse view of the transplant liver showing the hepatic veins in B-mode Middle hepatic vein Left hepatic vein Main portal vein Hepatic artery Hepatic artery showing the Doppler ultrasound values
Normal Doppler Ultrasound Assessment of a Transplant Liver Clinical History A 45-year old with a history of chronic polycystic liver and kidney disease had a recent liver transplant. Doppler ultrasound was requested to assess the blood flow in and out of the transplant liver. Case Description Ultrasound was performed using a 3 MHz curvilinear transducer. The examination started on B-mode to visualise the entire hepatic outline and parenchyma. Colour Doppler was used to evaluate patency of the hepatic veins, common hepatic artery, and the main portal veins and its branches. Spectral Doppler was further used to examine the flow pattern and velocity in the hepatic vessels. Diagnosis/ Discussion/ Treatment/ Follow-up The vessels examined in transplant liver assessment include: The right hepatic vein. The middle hepatic veins. The left hepatic vein. The main portal vein. The right portal vein. Middle portal vein. Left portal vein. The common hepatic artery. The parameters deduced from the haemodynamic spectral Doppler studies include: peak systolic velocity (PSV), end diastolic velocity (EDV), pulsatility index (PI), resistivity index (RI), and the wave pattern. Sonograms Longitudinal view of the left hepatic lobe showing the caudate lobe Spectral Doppler of the right hepatic vein Transverse view of the transplant liver showing the hepatic veins in B-mode Middle hepatic vein Left hepatic vein Main portal vein Hepatic artery Hepatic artery showing the Doppler ultrasound values
An Occlusive Thrombus within the Subclavian Vein Clinical History A 19-year old male patient presented with symptoms of swelling, erythema, and numbness to the left arm. Case Description Vascular ultrasound revealed an occlusive thrombus visualised within the entire left subclavian vein. However, the left jugular vein, axillary vein, brachial vein, basilic, vein, cephalic vein, and median cubital veins were patent and unaffected by the thrombus. Diagnosis/ Discussion/ Treatment/ Follow up The patient was placed on the appropriate anticoagulation therapy. Sonograms CDI occluded left subclavian vein proximal CDI occluded subclavian vein distal Occluded subclavian vein Patent left jugular vein
Upper Limb DVT Articles Extensive Occlusive Venous Thrombosis of the Left Upper Limb Extensive Occlusive Venous Thrombosis of the Left Upper Limb Clinical History A 64-year old lady with a peripherally inserted central catheter (PICC line) through her left upper limb, presented with a sudden onset of swelling in her left arm. A vascular ultrasound was requested to rule out thrombosis. Case Description Ultrasound revealed an extensive occlusive thrombus in the basilic vein, axillary vein, subclavian vein, and jugular vein of the left side. The PICC line was also visualised within the lumen of the thrombosed vein. Diagnosis/ Discussion/ Treatment/ Follow up The insertion of PICC lines can sometimes be for administering certain treatments. Patients who develop any adverse symptom (swelling, pain, redness) post PICC line insertion are prime candidates for an upper limb venous Doppler ultrasound. It is vital to rule out an onset of thrombosis in these patients to avoid dangerous outcomes. Sonograms CDI occluded left jugular vein CDI occluded left jugular vein CDI occluded left subclavian vein with PICC line in situ B-mode occluded left axillary vein with PICC line in situ B-mode occluded left basilic vein with PICC line in situ
Bladder Cancer Articles Transitional Cell Carcinoma of the Urinary Bladder Transitional Cell Carcinoma of the Urinary Bladder Clinical History A 74-year old man presented with painless frank haematuria. Case Description Ultrasound revealed a 17 mm hypoechoic mass (carcinoma) in the posterolateral wall of the urinary bladder lateral to the right ureteral orifice. The mass showed some evidence of vascularity within it. The kidneys appear unremarkable. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a whole body CT to further characterise the mass. CT revealed the lesion in the bladder with no evidence of extravesical involvement. The patient had transurethral resection of the bladder tumour (TURBT). A subsequent histology analysis of the specimen sample confirmed a Grade 3 bladder cancer. No disease recurrence recorded on follow-up evaluations. Sonograms B-Mode ultrasound showing the mass in the posterolateral wall Longitudinal view of the bladder mass in the posterior bladder wall Colour Doppler Imaging of the bladder mass showing some internal vascularity CDI showing evidence of right ureteric jets adjacent to the bladder mass. Evidently, no ureteric obstruction caused by the bladder mass CDI showing ureteric jets bilaterally Normal right kidney Normal left kidney
Bilateral Calcification at the Vesicoureteric Junctions Clinical History A 5-year old female was referred to have an ultrasound of the urinary tract due to dysfunctional voiding. Case Description Ultrasound revealed some calcifications within the right and left vesicoureteric junctions measuring 0.9 cm in the right and 1.1 cm in the left VUJ respectively. There was no hydronephrosis present, and the urinary bladder emptied completely. Diagnosis/ Discussion/ Treatment/ Follow up Bilateral calcifications of the vesicoureteric junctions. Sonograms B-mode bladder showing calcifications within the VUJ bilaterally CDI showing twinkle artefacts of the VUJ calcifications Normal kidney
Normal Transplant Kidney Articles Normal Ultrasound Assessment of the Renal Allograft Normal Ultrasound Assessment of the Renal Allograft Clinical History A 43-year old man with a recent history of renal transplant surgery was referred to have an ultrasound assessment of the new renal allograft. Case Description The renal allograft appeared normal in size, outline, echotexture, and perfusion with no evidence of renal artery stenosis encountered. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound report was sent to the referring nephrologist. During ultrasound assessment of the renal allografts, it is important to use a high frequency curvilinear transducer (6 – 7 MHz). This provides a reasonable balance between the acquisition of great image resolution, and having enough depth to visualise the graft and structures deep to and surrounding the graft. Sonograms B-Mode sonogram of the normal transplant kidney in the left iliac fossa (LIF) Colour Doppler imaging of the normal transplant kidney showing excellent perfusion of the graft Power Doppler imaging of the normal transplant kidney showing excellent perfusion of the graft Colour Doppler imaging of the transplant renal artery showing the point of anastomosis with the left external iliac artery Spectral Doppler imaging of the left external iliac artery measuring the peak systolic velocity (PSV) prior to the anastomosis Spectral Doppler imaging of the left external iliac artery measuring the peak systolic velocity (PSV) at the level of the anastomosis Spectral Doppler imaging of the transplant renal artery Spectral Doppler of the segmental artery within the transplant kidney Spectral Doppler of the intrarenal artery at the lower pole Spectral Doppler of the intrarenal artery at the interpolar region of the graft Spectral Doppler of the intrarenal artery at the upper pole
Cervical Mass Articles A Large Cervical Mass Presenting as PMB A Large Cervical Mass Presenting as PMB Clinical History A 64-year old lady presented with a 2-week history of postmenopausal vaginal bleeding. A gynaecology ultrasound was requested to assess for endometrial thickening. Case Description Transabdominal and transvaginal ultrasound were performed to assess the uterus, endometrium and ovaries. Ultrasound revealed a 3.3 cm echogenic oval-shaped lesion in the cervical cavity (cervical mass) with some fluid around it. The endometrium measured 0.7 cm and contained some echogenic materials that could be seen to migrate towards the cervical canal. Diagnosis/ Discussion/ Treatment/ Follow up Based on the ultrasound appearances and the patient’s symptoms, the features of the cervical lesion are suggestive of a cervical mass or polyp. A low-lying intracavitary fibroid could be a possible differential diagnosis. Sonograms Cervical lesion in longitudinal view with callipers Cervical lesion in axial view with callipers Endometrial cavity fluid CDI showing no flow in the cervical lesion Echogenic content in the endometrium about to migrate into the cervix Echogenic content of the endometrium migrating into the cervix Keywords
Intramuscular Haematoma Articles A Large Intramuscular Haematoma Coexisting with Lesser Trochanter Osteochondroma A Large Intramuscular Haematoma Coexisting with Lesser Trochanter Osteochondroma Clinical History A 35-year old man presented with a medial right thigh mass that he had felt for two weeks. An ultrasound was requested to assess the nature of the mass. Case Description Ultrasound was performed using linear and curvilinear transducers. This revealed a large area of intramuscular haematoma with some linear calcific component within the medial upper thigh compartment. Diagnosis/ Discussion/ Treatment/ Follow up A subsequent MRI revealed a sessile osteochondroma at the right lesser trochanter with no significant cartilage and an adjacent haemorrhagic fluid extending from the right ischiofemoral interval to the adductor compartment caudally. Sonograms B-mode right thigh haematoma Axial view right thigh haematoma CDI showing no flow in the right thigh haematoma Right thigh haematoma with a curvilinear transducer CDI right thigh haematoma Right thigh haematoma with measurement callipers Right and left comparison image of the upper thigh at the level of the haematoma Coronal MRI showing the right thigh haematoma
Bladder Diverticulum Articles Bladder Diverticulum Coexisting with Bladder Wall Thickening and a Small Prostatic Cyst Bladder Diverticulum Coexisting with Bladder Wall Thickening and a Small Prostatic Cyst Clinical History A 78-year old gentleman presented with a recent history of urinary incontinence with some microscopic haematuria and pain in the lower abdomen. An ultrasound of the renal tract was requested to further investigate. Case Description Ultrasound revealed a 3 mm defect in the posterolateral wall of the urinary bladder with a small diverticulum. The bladder wall was irregular in outline and has an increased thickness of up to 7 mm in AP calibre. Posterior to the bladder, the prostate contained a 20 mm simple cyst. Diagnosis/ Discussion/ Treatment/ Follow up Bladder diverticulum occurs when there is a breach in the bladder wall due to a loss of wall integrity and weakness of the bladder muscles. Bladder diverticulum can be single or multiple and are commonly age-related. The term microscopic haematuria, also called non-visible haematuria, is commonly used when the presence of blood cells within the urine is only detectable via laboratory testing. Sonograms B-mode of the urinary bladder showing the tiny defect (top arrow) and the diverticulum (bottom arrow) Bladder wall thickening measuring 7 mm in AP calibre Longitudinal view of the bladder showing the diverticulum (three arrows) and a small simple cyst in the prostate (single arrow) CDI showing no flow in the prostate simple cyst
Complex Ovarian Cyst Articles A Large Complex Ovarian Cyst Mimicking a Fibroid A Large Complex Ovarian Cyst Mimicking a Fibroid Clinical History A 54-year old lady presented with a large mass in the centre of the lower abdomen mimicking a fibroid. Case Description Ultrasound performed (TA and TV) revealed a large 21 cm complex cystic mass (complex ovarian cyst) emanating from the pelvis into the abdomen with multiple septations within it. A subsequent MRI pelvis confirmed the large multicystic pelvic lesion to be a possible neoplasm arising from the left ovary. The patient had a whole body contrast staging CT that revealed no extra-ovarian disease presence. Diagnosis/ Discussion/ Treatment/ Follow up Total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed and the cyst was analysed histologically. Histology revealed the lesion to be a benign mucinous cystadenoma. Sonograms Transabdominal ultrasound showing the large complex cyst in the pelvis Transvaginal ultrasound showing the complex cyst in the pelvis Transvaginal ultrasound showing the complex cyst in the pelvis Colour Doppler imaging of the complex cyst in the pelvis Sagittal MRI of the complex cyst in the pelvis Coronal CT of the large pelvic complex cyst
Urology Articles Kidneys Urinary Bladder Testes Penile Kidneys Parapelvic Renal Cyst Parapelvic Simple Renal Cyst Mimicking Hydronephrosis on MRI Clinical History A 74-year old man had an MRI of his spine which revealed an area of possible hydronephrosis in his right kidney. An ultrasound of his kidneys was requested to confirm this. Case Description Ultrasound revealed a 6 cm parapelvic simple cyst (renal cyst) in the lower pole. There was also another 2 cm simple cyst adjacent to the former. Diagnosis/ Discussion/ Treatment/ Follow up These findings were confirmed by an outpatient contrast CT scan of the urinary tract carried out months later. Sonograms A right parapelvic renal cyst B-Mode A right parapelvic renal cyst colour Doppler Imaging An axial CT scan post-ultrasound confirming the right parapelvic cyst to be a Bosniak 1 category A coronal CT scan post-ultrasound confirming the right parapelvic cyst to be a Bosniak 1 category Horseshoe Kidney Horseshoe Kidney in a Patient with UTI Symptoms Clinical History A 48-year old man presented with UTI symptoms. Case Description Ultrasound performed on the patient’s abdomen revealed a horseshoe kidney with the isthmus anterior to the IVC and abdominal aorta inferiorly. The patient had no prior imaging of his abdomen, therefore, this was the first time the variant was found. Diagnosis/ Discussion/ Treatment/ Follow up The patient’s symptoms were managed with the appropriate antibiotic therapy. Sonograms Sonogram acquired above the umbilicus using a transverse probe orientation showing the isthmus of the horseshoe kidney with the abdominal aorta (red), IVC (blue), and spine posteriorly Left moiety of the horseshoe kidney Right moiety of the horseshoe kidney CT scan of the horseshoe kidney Normal Transplant Kidney Normal Ultrasound Assessment of the Renal Allograft Clinical History A 43-year old man with a recent history of renal transplant surgery was referred to have an ultrasound assessment of the new renal allograft. Case Description The renal allograft appeared normal in size, outline, echotexture, and perfusion with no evidence of renal artery stenosis encountered. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound report was sent to the referring nephrologist. During ultrasound assessment of the renal allografts, it is important to use a high frequency curvilinear transducer (6 – 7 MHz). This provides a reasonable balance between the acquisition of great image resolution, and having enough depth to visualise the graft and structures deep to and surrounding the graft. Sonograms B-Mode sonogram of the normal transplant kidney in the left iliac fossa (LIF) Colour Doppler imaging of the normal transplant kidney showing excellent perfusion of the graft Power Doppler imaging of the normal transplant kidney showing excellent perfusion of the graft Colour Doppler imaging of the transplant renal artery showing the point of anastomosis with the left external iliac artery Spectral Doppler imaging of the left external iliac artery measuring the peak systolic velocity (PSV) prior to the anastomosis Spectral Doppler imaging of the left external iliac artery measuring the peak systolic velocity (PSV) at the level of the anastomosis Spectral Doppler imaging of the transplant renal artery Spectral Doppler of the segmental artery within the transplant kidney Spectral Doppler of the intrarenal artery at the lower pole Spectral Doppler of the intrarenal artery at the interpolar region of the graft Spectral Doppler of the intrarenal artery at the upper pole Renal Cell Carcinoma Renal Cell Carcinoma Clinical History A 55-year old man presented with symptoms of frank haematuria. Case Description Renal ultrasound revealed a 5.4 cm heterogeneous vascular lesion in the midpole of the right kidney. Diagnosis/Discussion/Treatment/ Follow up The lesion was confirmed on CT with subtle evidence of invasion of the tumour into the a branch of the right renal vein. The patient had a right nephrectomy. Histology confirmed the diagnosis of clear cell renal cell carcinoma. Subsequent CT showed no evidence of disease recurrence. Sonograms B-mode longitudinal view of the right renal mass Right renal mass in b-mode Right renal mass in axial orientation CDI right renal mass showing some internal vascularity Axial CT scan of the right renal mass Post right nephrectomy coronal CT scan Post right nephrectomy axial CT An Incidental Finding of an Asymptomatic Renal Mass Clinical History A 48-year old man presented with left flank pain and overall discomfort. An ultrasound of the abdomen was requested to assess for left renal calculi that might explain the symptoms. Case Description Ultrasound revealed a 5 cm heterogeneous echogenic mass in the right kidney with some evidence of vascularity within it. Diagnosis/ Discussion/ Treatment/ Follow up A subsequent whole body CT scan confirmed the presence of the 5 cm mass arising from the midpole of the right kidney and showing heterogeneous contrast enhancement. The patient had a right nephrectomy. The histology analysis of the surgical samples confirmed the lesion to he renal cell carcinoma (RCC). Sonograms Right renal mass with callipers Right renal mass longitudinal view CDI right renal mass with some internal vascularity Normal left kidney Coronal CT showing the right renal mass Renal Subcapsular Haematoma Subcapsular Haematoma Clinical History A 74-year old man presented with a recent history of fall and an acute kidney injury (AKI) was referred to have a renal ultrasound as an initial imaging assessment. Case Description Ultrasound revealed a 12 cm heterogeneous structure within the subcapsular layer of the left kidney with no internal vascularity seen within the abnormality. Appearances were suggestive of a subcapsular haematoma. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a subsequent contrast CT which confirmed the ultrasound findings. A followup ultrasound months later revealed the haematoma to have mostly resolved. Subcapsular haematoma can mimic renal masses on ultrasound. However, the absence of internal vascularity and the location of the abnormality within the renal capsule are two features that can help improve the diagnostic confidence of ultrasound practitioners in clinical settings Sonograms B-mode left kidney with a subcapsular haematoma Left renal subcapsular haematoma with measurement callipers CDI showing some normal intrarenal vessels but no flow in the haematoma Coronal CT scan showing the left renal subcapsular haematoma Follow up ultrasound of the left kidney showing resolved haematoma after 4 months B-mode ultrasound showing what is left of the resolved left renal subcapsular haematoma Urinary Bladder Bladder and Renal Calculus Urolithiasis in the Bladder and Kidney of a 75-year Old Man Patient History A 75-year old man presented with macroscopic haematuria Case Description The patient was referred to have an ultrasound examination of his kidneys and bladder as part of the (NICE guideline) diagnostic workup for haematuria in individuals above 45-years old. The bladder contained a 13 mm intraluminal mobile calculus (Urolithiasis). The right kidney contained an 8 mm non-obstructing calculus within its lower pole. Diagnosis/ Discussion/ Treatment/ Follow Up The patient had a follow up CT scan which confirmed the findings. The bladder calculus was removed transurethral. Sonograms Transverse section of the well-filled urinary bladder containing a calculus A dual-screen image of the urinary bladder with the patient initially in supine position, then asked to roll on to the left lateral decubitus position. This manoeuvre shows evidence of calculus movement which confirms that the calculus is within the bladder lumen A longitudinal image of the right kidney showing a 6 mm calculus at its lower pole A transverse image of the right renal lower pole showing the calculus A transverse image of the right renal lower pole with colour Doppler imaging, showing twinkling artefact Bladder Mass with Liver Metastasis Clinical History A 91-year old man with sudden health deterioration and in critical condition presented with haematuria, anaemia, thrombocytopaenia, and abnormal LFT. An abdominal ultrasound was requested as a first line of imaging. Case Description Ultrasound revealed a 7 cm heterogeneous mass in the urinary bladder with an irregular outline. The liver appeared enlarged with heterogeneous parenchymal echotexture and multiple hypoechoic lesions throughout, suggestive of metastases. Diagnosis/ Discussion/ Treatment/ Follow-up Unfortunately, the patient passed away. Sonograms Bladder Tumour Clinical History A 91-year old man with sudden health deterioration and in critical condition presented with haematuria, anaemia, thrombocytopaenia, and abnormal LFT. An abdominal ultrasound was requested as a first line of imaging. Case Description Ultrasound revealed a 7 cm heterogeneous mass (bladder tumour) in the urinary bladder with an irregular outline. The liver appeared enlarged with heterogeneous parenchymal echotexture and multiple hypoechoic lesions throughout, suggestive of metastases. Diagnosis/ Discussion/ Treatment/ Follow up Unfortunately, the patient passed away. Sonograms Left lobe of the liver in a longitudinal orientation with multiple hypoechoic lesions Left lobe of the liver in a transverse orientation showing multiple hypoechoic lesions Right lobe of the liver containing multiple lesions, and showing the portal vein The portal vein on colour Doppler imaging showing normal hepatopetal flow Sonogram of the partly filled urinary bladder showing a bladder wall mass Bladder Cancer Transitional Cell Carcinoma of the Urinary Bladder Clinical History A 74-year old man presented with painless frank haematuria. Case Description Ultrasound revealed a 17 mm hypoechoic mass (carcinoma) in the posterolateral wall of the urinary bladder lateral to the right ureteral orifice. The mass showed some evidence of vascularity within it. The kidneys appear unremarkable. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a whole body CT to further characterise the mass. CT revealed the lesion in the bladder with no evidence of extravesical involvement. The patient had transurethral resection of the bladder tumour (TURBT). A subsequent histology analysis of the specimen sample confirmed a Grade 3 bladder cancer. No disease recurrence recorded on follow-up evaluations. Sonograms B-Mode ultrasound showing the mass in the posterolateral wall Longitudinal view of the bladder mass in the posterior bladder wall Colour Doppler Imaging of the bladder mass showing some internal vascularity CDI showing evidence of right ureteric jets adjacent to the bladder mass. Evidently, no ureteric obstruction caused by the bladder mass CDI showing ureteric jets bilaterally Normal right kidney Normal left kidney Bladder Diverticulum Bladder Diverticulum Coexisting with Bladder Wall Thickening and a Small Prostatic Cyst Clinical History A 78-year old gentleman presented with a recent history of urinary incontinence with some microscopic haematuria and pain in the lower abdomen. An ultrasound of the renal tract was requested to further investigate. Case Description Ultrasound revealed a 3 mm defect in the posterolateral wall of the urinary bladder with a small diverticulum. The bladder wall was irregular in outline and has an increased thickness of up to 7 mm in AP calibre. Posterior to the bladder, the prostate contained a 20 mm simple cyst. Diagnosis/ Discussion/ Treatment/ Follow up Bladder diverticulum occurs when there is a breach in the bladder wall due to a loss of wall integrity and weakness of the bladder muscles. Bladder diverticulum can be single or multiple and are commonly age-related. The term microscopic haematuria, also called non-visible haematuria, is commonly used when the presence of blood cells within the urine is only detectable via laboratory testing. Sonograms B-mode of the urinary bladder showing the tiny defect (top arrow) and the diverticulum (bottom arrow) Bladder wall thickening measuring 7 mm in AP calibre Longitudinal view of the bladder showing the diverticulum (three arrows) and a small simple cyst in the prostate (single arrow) CDI showing no flow in the prostate simple cyst Testes Orchitis Right Orchitis in a 30-year Old Male with a Coexisting Left Varicocoele Patient History A 30-year old male presented with an acute onset of right testicular pain. Case Description An ultrasound of the testes was performed using a 15 MHz linear transducer. Ultrasound revealed a hypoechoic and striated right testicle with evidence of hypervascularity on colour Doppler imaging. Appearances were in keeping with right orchitis. There was also evidence of dilatation of the left pampiniform plexus with a flow reversal of more than 2 seconds on spectral Doppler imaging. Appearances were suggestive of left varicocoele. Diagnosis/ Discussion/ Treatment/ Follow up The patient’s symptoms resolved after antibiotic therapy. Sonograms Grayscale image of the inflamed right testicle showing some hypoechoic striations across the testicular parenchyma in keeping with blood vessels Colour Doppler Imaging of the inflamed right testicle showing hypervascularity A dual-screen image of the right and left testes in colour Doppler mode. A normal left testicular vascularity can be seen Dilatation of the left pampiniform plexus veins Flow reversal on Valsalva manoeuvre for more than 2 seconds in the dilated left pampiniform plexus veins confirming varicocoele Epididymo-orchitis Presenting as Painful Hemiscrotal Swelling Clinical History A 25-year old man presented with symptoms of swelling and pain in the left hemiscrotum. The patient was referred to have an inpatient ultrasound on the same day. Case Description Ultrasound revealed a bulky and heterogeneous left epididymis (epididymo-orchitis). The left testis and epididymis both showed evidence of a significantly increased vascularity within them. There was also some reactive hydrocoele in the left hemiscrotum with a heterogeneous collection adjacent to the left epididymis. Diagnosis/ Discussion/ Treatment/ Follow up The patient’s symptoms resolved after completing antibiotic therapy. A subsequent ultrasound post-treatment confirmed the resolution of symptoms. Sonograms A panoramic image of the left hemiscrotum, in B-mode, showing an inflamed left epididymis B-mode image of the inflamed left testis and left epididymis Heterogeneous (complex) fluid collection in the left hemiscrotum adjacent to the left epididymis. No internal vascularity seen in the collection, as it is not a lesion B-mode left hemiscrotum showing the bulky and inflamed left epididymis Colour Doppler imaging showing hypervascularity of the left testis and epididymis in a ‘christmas tree’ fashion Epidermoid Cyst An Extratesticular Intrascrotal Right Epidermoid Cyst Clinical History A 60-year old man presented to the hospital after he had noticed a swollen structure posterior to his right testicle. Upon clinical evaluation, the structure felt to be outside the testis, suggestive of an epididymal cyst. The tumour markers were negative. An ultrasound of the testes was requested for further evaluation. Case Description Using a high frequency (15MHz) linear transducer, ultrasound revealed a roundish lesion within the right hemiscrotum with concentric morphology and no internal vascularity. The lesion appears as a concentric ring of alternating echogenicity with a well-defined outline and no internal vascularity. Ultrasound features were in keeping with an intrascrotal extratesticular epidermoid cyst and this corresponded with the site of concern the patient pointed at during the ultrasound encounter. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound report was sent to the referring clinician. At the time of compiling this report, the patient was known to have been managed conservatively as surgery is not clinically indicated. Epidermoid cysts are uncommon benign intratesticular or intrascrotal lesions encountered sonographically. They present as painless swelling or lump within the scrotum. Intrascrotal extratesticular epidermoid cysts are reportedly rare in the current literature. Ultrasound is the ideal imaging modality of choice in examining the scrotum for masses or lumps felt. Sonogram B-mode sonogram of the extratesticular right hemiscrotal lesion. B-mode sonogram of the extratesticular right hemiscrotal lesion. CDI sonogram of the extratesticular right hemiscrotal lesion. B-mode sonogram showing the lesion adjacent to the inferior pole of the unremarkable right testicle A Large Extratesticular Epidermoid Cyst Clinical History A 74-year old man presented with a fast-growing painful swelling next to the left testicle. Case Description Ultrasound performed, using a 15 MHz linear transducer, revealed a 7 cm heterogeneous mass adjacent to the left testis. The mass contained numerous anechoic patches with no evidence of internal vascularity. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have an MRI to help characterise the scrotal mass. The MRI revealed the left paratesticular mass to have appearances as the adjacent testis and was unable to provide detailed characteristics of the mass. The patient had left orchiectomy and the samples were examined histologically. Histology confirmed the paratesticular mass to contain keratinised stratified squamous epithelium with a diagnosis of an epidermoid cyst. Sonograms Right and left testes (T) with the mass (M) laterally Left hemiscrotal heterogeneous mass Axial view of the left hemiscrotal mass PDI showing no flow signal in the mass B-mode shoeing the left hemiscrotal mass lateral to the left testis Coronal MRI showing the left hemiscrotal mass (double arrows) next to the left testis (single arrow) Keywords Calcified Ductus Deferens Incidental Calcifications within the Ductus Deferens Clinical History A 65-year old man presented with the feeling of some palpable lumps within the scrotum, lateral to the testis. Case Description Ultrasound performed using a 15 MHz linear transducer revealed some focal calcifications within the left spermatic cord. Furthermore, the left epididymal head contained two tiny simple cysts. Diagnosis/ Discussion/ Treatment/ Follow up The patient was managed conservatively. Calcifications within the ductus deferens are benign findings that are incidentally detected on imaging of the region. It can occur with increasing age, in patients with diabetes mellitus, or in men with a history of chronic infection. Sonograms B-mode sonogram showing the calcification within the left spermatic cord B-mode sonogram showing multiple calcifications within the left spermatic cord Calcifications within the left spermatic cord and a normal left testis inferiorly Calcification adjacent to the normal left testis Testicular Cancer (Malignancy) Mixed Germ Cell Tumour of the Testis Clinical History A 21-year old male presented with a 3-week history of increased swelling in the left hemiscrotum. The patient was referred urgently to urology. An ultrasound of the scrotum was requested as an initial diagnostic approach. Case Description Ultrasound performed, using a 15 MHz linear transducer, revealed 7.5 cm heterogeneous mass occupying the entire left hemiscrotum. The mass showed strong evidence of internal vascularity on power Doppler imaging (PDI). Diagnosis/ Discussion/ Treatment/ Follow up The tumour markers (HCG, AFP, and LDH) were significantly raised, further confirming the ultrasound findings. CT scan of the chest, abdomen and pelvis with contrast was performed to adequately stage the disease. The patient had radical left orchiectomy and histology analysis of the tumour samples confirmed a diagnosis of a mixed germ cell testicular tumour (50 % yolk sac and 50 % embryonal carcinoma). Sonograms B-mode of the left testicular mass next to the normal right testis CDI comparing the vascularity of the testes Left testicular mass with measurement callipers in longitudinal and axial views PDI of the left testicular mass showing some internal vascularity Axial CT showing the left testicular mass Keywords Testicular cancer, Yolk sac carcinoma, Embryonal carcinoma Testicular Seminoma Clinical History A 29-year old male presented symptoms of a hard palpable lump in the right testis. Ultrasound was requested as the first line of imaging to assess for any lesions within the scrotum. Case Description Ultrasound revealed a 4 cm mass within the right testis with an irregular outline, a hypoechoic echotexture, and a significantly increased vascularity within the mass. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a right orchidectomy. Histology revealed features of testicular seminoma. Sonograms B-mode showing the right testicular mass next to the normal left testis Right testicular mass Right testicular mass with measurement callipers longitudinal and axial views CDI showing hypervascularity of the right testicular mass Dual screen image of the right and left testes on CDI Keywords Penile Penile Doppler Assessment Penile Doppler Assessment Clinical information A 27-year old man presented with problems maintaining erections. A Doppler ultrasound of the penis was requested to provide an insight to the situation while assessing the penile blood vessels for a vasculogenic aetiology. Case Description Ultrasound was performed using a high frequency linear transducer of up to 16 MHz after administering 20 mcg of Caverject IM. The assessment was carried out every 5 minutes post injection. The corporal bodies were initially examined in B-mode to assess for any (Peyronie’s) plaques. Afterwhich, the right and left cavernosal arteries were interrogated using colour and spectral Doppler ultrasound to evaluate the flow velocities. Both peak systolic and end diastolic velocity parameters are the most useful in determining arterial or venous insufficiency causes of erectile dysfunction. Diagnosis/ Discussion/ Treatment/ Follow up Venous Insufficiency Sonographs Right corpus cavernosum 5 minutes after caverject administration. Left corpus cavernosum 5 minutes after caverject administration. Spectral Doppler of the left cavernosal artery during tumescence phase of erection. Spectral Doppler of the right cavernosal artery during tumescence phase of erection. Spectral imaging of the left cavernosal artery showing in axial orientation. Spectral imaging of the right cavernosal artery showing in axial orientation.
Spleen Articles Splenic Haemangioma Splenic Haemangioma An Incidental Diagnosis of Splenic Haemangioma Clinical History A 75-year old lady was referred to have an ultrasound of the urinary tract due to some evidence of frank haematuria. Case Description Although ultrasound did not reveal any renal or bladder lesion, while examining the left kidney, a 16 mm hypoechoic lesion was discovered within the spleen. The lesion had a uniformly roundish outline with some evidence of internal vascularity. Ultrasound features were suggestive of a splenic haemangioma. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound findings were confirmed on a subsequent CT. Splenic haemangiomas are some of the most commonly encountered splenic lesions on ultrasound. They are benign slow-growing tumours of the spleen. Due to their nature, they contain evidence of vascular enhancement on imaging. Sonograms Splenic haemangioma B-mode Splenic haemangioma showing the measurement callipers CDI showing the splenic haemangioma with some evidence of internal vascularity Axial CT scan showing the splenic haemangioma with evidence of enhancement Keywords
Renal Cell Carcinoma Articles Renal Cell Carcinoma An Incidental Finding of an Asymptomatic Renal Mass Renal Cell Carcinoma Clinical History A 55-year old man presented with symptoms of frank haematuria. Case Description Renal ultrasound revealed a 5.4 cm heterogeneous vascular lesion in the midpole of the right kidney. Diagnosis/Discussion/Treatment/ Follow up The lesion was confirmed on CT with subtle evidence of invasion of the tumour into the a branch of the right renal vein. The patient had a right nephrectomy. Histology confirmed the diagnosis of clear cell renal cell carcinoma. Subsequent CT showed no evidence of disease recurrence. Sonograms B-mode longitudinal view of the right renal mass Right renal mass in b-mode Right renal mass in axial orientation CDI right renal mass showing some internal vascularity Axial CT scan of the right renal mass Post right nephrectomy coronal CT scan Post right nephrectomy axial CT An Incidental Finding of an Asymptomatic Renal Mass Clinical History A 48-year old man presented with left flank pain and overall discomfort. An ultrasound of the abdomen was requested to assess for left renal calculi that might explain the symptoms. Case Description Ultrasound revealed a 5 cm heterogeneous echogenic mass in the right kidney with some evidence of vascularity within it. Diagnosis/ Discussion/ Treatment/ Follow up A subsequent whole body CT scan confirmed the presence of the 5 cm mass arising from the midpole of the right kidney and showing heterogeneous contrast enhancement. The patient had a right nephrectomy. The histology analysis of the surgical samples confirmed the lesion to he renal cell carcinoma (RCC). Sonograms Right renal mass with callipers Right renal mass longitudinal view CDI right renal mass with some internal vascularity Normal left kidney Coronal CT showing the right renal mass
Transplant Liver Collection Articles Abnormal Intrahepatic Collection of a Liver Transplant Abnormal Intrahepatic Collection of a Liver Transplant Clinical History A 50-year old man with recurrent history of liver transplantations presented with delirium, diarrhoea, and vomiting. Liver function test was abnormal. Ultrasound was requested as a first line of imaging to assess the biliary tree or other possible cause for symptoms. Case Description Ultrasound revealed a large tubular and tortuous heterogeneous hypoechoic area within the liver suggestive of intrahepatic collection. No internal vascularity was observed within the area of abnormality. The hepatic vessels were patent on Doppler interrogation. Diagnosis/ Discussion/ Treatment/ Follow-up Triple-phase liver CT confirmed the presence of branching fluid attenuation in the right hepatic lobe in keeping with collections. The hepatic collection was drained. Sonograms Right lobe liver with a heterogeneous collection CDI right lobe liver showing the collection adjacent to the hepatic veins CDI right lobe liver showing the hepatic collection adjacent to the hepatic veins CDI RLL showing the hepatic collection adjacent to the main portal vein Spectral Doppler of the patent hepatic vein Microvascular imaging (MVI) showing the patent hepatic veins adjacent to the hepatic collection Axial CT showing the hepatic collection Coronal CT showing the hepatic collection Axial CT post pigtail drain insertion Intrahepatic collection in the transplant liver Keywords
Abnormal Intrahepatic Collection of a Liver Transplant Clinical History A 50-year old man with recurrent history of liver transplantations presented with delirium, diarrhoea, and vomiting. Liver function test was abnormal. Ultrasound was requested as a first line of imaging to assess the biliary tree or other possible cause for symptoms. Case Description Ultrasound revealed a large tubular and tortuous heterogeneous hypoechoic area within the liver suggestive of intrahepatic collection. No internal vascularity was observed within the area of abnormality. The hepatic vessels were patent on Doppler interrogation. Diagnosis/ Discussion/ Treatment/ Follow-up Triple-phase liver CT confirmed the presence of branching fluid attenuation in the right hepatic lobe in keeping with collections. The hepatic collection was drained. Sonograms Right lobe liver with a heterogeneous collection CDI right lobe liver showing the collection adjacent to the hepatic veins CDI right lobe liver showing the hepatic collection adjacent to the hepatic veins CDI RLL showing the hepatic collection adjacent to the main portal vein Spectral Doppler of the patent hepatic vein Microvascular imaging (MVI) showing the patent hepatic veins adjacent to the hepatic collection Axial CT showing the hepatic collection Coronal CT showing the hepatic collection Axial CT post pigtail drain insertion Intrahepatic collection in the transplant liver Keywords
Testicular Cancer (Malignancy) Articles Mixed Germ Cell Tumour of the Testis Testicular Seminoma Mixed Germ Cell Tumour of the Testis Clinical History A 21-year old male presented with a 3-week history of increased swelling in the left hemiscrotum. The patient was referred urgently to urology. An ultrasound of the scrotum was requested as an initial diagnostic approach. Case Description Ultrasound performed, using a 15 MHz linear transducer, revealed 7.5 cm heterogeneous mass occupying the entire left hemiscrotum. The mass showed strong evidence of internal vascularity on power Doppler imaging (PDI). Diagnosis/ Discussion/ Treatment/ Follow up The tumour markers (HCG, AFP, and LDH) were significantly raised, further confirming the ultrasound findings. CT scan of the chest, abdomen and pelvis with contrast was performed to adequately stage the disease. The patient had radical left orchiectomy and histology analysis of the tumour samples confirmed a diagnosis of a mixed germ cell testicular tumour (50 % yolk sac and 50 % embryonal carcinoma). Sonograms B-mode of the left testicular mass next to the normal right testis CDI comparing the vascularity of the testes Left testicular mass with measurement callipers in longitudinal and axial views PDI of the left testicular mass showing some internal vascularity Axial CT showing the left testicular mass Keywords Testicular cancer, Yolk sac carcinoma, Embryonal carcinoma Testicular Seminoma Clinical History A 29-year old male presented symptoms of a hard palpable lump in the right testis. Ultrasound was requested as the first line of imaging to assess for any lesions within the scrotum. Case Description Ultrasound revealed a 4 cm mass within the right testis with an irregular outline, a hypoechoic echotexture, and a significantly increased vascularity within the mass. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a right orchidectomy. Histology revealed features of testicular seminoma. Sonograms B-mode showing the right testicular mass next to the normal left testis Right testicular mass Right testicular mass with measurement callipers longitudinal and axial views CDI showing hypervascularity of the right testicular mass Dual screen image of the right and left testes on CDI Keywords
Renal Subcapsular Haematoma Articles Subcapsular Haematoma Subcapsular Haematoma Clinical History A 74-year old man presented with a recent history of fall and an acute kidney injury (AKI) was referred to have a renal ultrasound as an initial imaging assessment. Case Description Ultrasound revealed a 12 cm heterogeneous structure within the subcapsular layer of the left kidney with no internal vascularity seen within the abnormality. Appearances were suggestive of a subcapsular haematoma. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a subsequent contrast CT which confirmed the ultrasound findings. A followup ultrasound months later revealed the haematoma to have mostly resolved. Subcapsular haematoma can mimic renal masses on ultrasound. However, the absence of internal vascularity and the location of the abnormality within the renal capsule are two features that can help improve the diagnostic confidence of ultrasound practitioners in clinical settings Sonograms B-mode left kidney with a subcapsular haematoma Left renal subcapsular haematoma with measurement callipers CDI showing some normal intrarenal vessels but no flow in the haematoma Coronal CT scan showing the left renal subcapsular haematoma Follow up ultrasound of the left kidney showing resolved haematoma after 4 months B-mode ultrasound showing what is left of the resolved left renal subcapsular haematoma
Vascular & Thorax Articles Lungs and Pleura Peripheral Arteries Peripheral Veins The Great Vessels Thoracic Wall Lungs and Pleura Peripheral Arteries Popliteal Artery Occlusion Occluded Popliteal Artery Clinical History An 80-year old man with metastatic bowel cancer presented with a sudden onset of right leg swelling. Case description An 80-year old man with metastatic bowel cancer presented with a sudden onset of right leg swelling. The patient was referred to have an ultrasound Doppler of the veins of his right lower limb to rule out deep venous thrombosis (DVT). Although DVT was ruled out, however, the popliteal artery appeared occluded. The patient was referred to the vascular team for further management of the occluded popliteal artery. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to the vascular team for further management. Sonograms Occluded popliteal artery with arrow Color Doppler showing the absence of flow in the popliteal artery. Patent popliteal vein (in blue) Color Doppler showing no flow in the popliteal artery Popliteal Artery Occlusion Co-existing with Popliteal Vein DVT Clinical History A 92-year old lady presented with pain and swelling in the right leg. The WELLS score was 2 upon an initial specialist clinical assessment. Doppler ultrasound of the lower limb veins was requested to rule out deep venous thrombosis (DVT). Case Description Ultrasound revealed the presence of an occlusive thrombus in the popliteal vein. There was also an occluded superficial femoral artery (SFA). However, the popliteal artery was patent. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred urgently to vascular surgery for further management. Unfortunately, the patient passed away Sonograms Patent right common femoral artery Partially occluded right superficial femoral artery (proximal) Partially occluded right superficial femoral artery (mid) Partially occluded right superficial femoral artery (distal) Colour Doppler imaging of the distal right superficial femoral artery showing some distal patency towards the popliteal artery Patent right popliteal artery Occluded right popliteal vein containing thrombus (blood clot), in keeping with deep venous thrombosis (DVT) Axial orientation of the right popliteal vein showing occlusion, and the patent artery posteriorly Popliteal Artery Aneurysm Incidental Finding of a Popliteal Artery Aneurysm during a DVT Ultrasound Clinical History An 83-year old man presented with left leg swelling, erythema, and shortness of breath. Case Description Ultrasound revealed a 27 mm popliteal artery aneurysm in the left popliteal fossa. The patient also had a positive extensive DVT in the deep veins of the left lower limb. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to the vascular specialist for further management. Sonograms B-Mode longitudinal view of the left popliteal artery aneurysm B-Mode axial view of the left popliteal artery aneurysm Colour Doppler imaging of the left popliteal artery aneurysm in longitudinal orientation Colour Doppler imaging of the left popliteal artery aneurysm in transverse orientation Peripheral Veins Jugular Jugular Vein Thrombus Caused by a Supraclavicular Mass Clinical History A 69-year old male presented with a sudden onset of pain and swelling of his left upper limb after a recent insertion of a pacemaker device. A vascular ultrasound was requested to examine his upper limb veins for deep venous thrombosis (DVT). Case Description Ultrasound using a multifrequency linear transducer set at 8 MHz revealed an occlusive thrombus in the entire left subclavian vein adjacent to the pacemaker (jugular vein thrombus). Diagnosis/ Discussion/ Treatment/ Follow up The result was urgently sent to the referring clinician who commenced the patient on the appropriate anticoagulation therapy. Sonograms B-mode of the internal jugular vein showing an occlusive thrombus Colour Doppler showing the occluded IJV Colour Doppler showing the occluded IJV Axial segment of the IJV showing the occlusive thrombus A heterogeneous left supraclavicular mass CDI showing evidence of internal vascularity in the left supraclavicular mass Subclavian DVT An Occlusive Thrombus in the Subclavian Vein Clinical History A 69-year old male presented with a sudden onset of pain and swelling of his left upper limb after a recent insertion of a pacemaker device. A vascular ultrasound was requested to examine his upper limb veins for deep venous thrombosis (DVT). Case Description Ultrasound using a multifrequency linear transducer set at 8 MHz revealed an occlusive thrombus in the entire left subclavian vein adjacent to the pacemaker. Diagnosis/ Discussion/ Treatment/ Follow Up The result was urgently sent to the referring clinician who commenced the patient on the appropriate anticoagulation therapy. Sonograms B-mode ultrasound showing an occlusive thrombus in the left subclavian vein Colour Doppler imaging showing an absence of flow signal in the subclavian vein Colour Doppler imaging showing an absence of flow signal in the subclavian vein Colour Doppler imaging showing an absence of flow signal in the subclavian vein Subclavian DVT Clinical History A 30-year old male presented with an acute onset of right arm swelling and pain. Recent blood tests revealed an elevated D dimer value. Case Description Ultrasound revealed an occlusive thrombus within the proximal subclavian vein. The remaining veins of the left upper limb were patent and free of thrombus. Diagnosis/ Discussion/ Treatment/ Follow up Due to the patient’s medical history, arterial Doppler studies of the upper limbs were performed which showed no abnormality. Sonograms Colour Doppler imaging of the occluded right subclavian vein CDI axial view of the occluded right subclavian vein B-mode axial right subclavian DVT An Occlusive Thrombus within the Subclavian Vein Clinical History A 19-year old male patient presented with symptoms of swelling, erythema, and numbness to the left arm. Case Description Vascular ultrasound revealed an occlusive thrombus visualised within the entire left subclavian vein. However, the left jugular vein, axillary vein, brachial vein, basilic, vein, cephalic vein, and median cubital veins were patent and unaffected by the thrombus. Diagnosis/ Discussion/ Treatment/ Follow up The patient was placed on the appropriate anticoagulation therapy. Sonograms CDI occluded left subclavian vein proximal CDI occluded subclavian vein distal Occluded subclavian vein Patent left jugular vein Upper Limb DVT Extensive Occlusive Venous Thrombosis of the Left Upper Limb Clinical History A 64-year old lady with a peripherally inserted central catheter (PICC line) through her left upper limb, presented with a sudden onset of swelling in her left arm. A vascular ultrasound was requested to rule out thrombosis. Case Description Ultrasound revealed an extensive occlusive thrombus in the basilic vein, axillary vein, subclavian vein, and jugular vein of the left side. The PICC line was also visualised within the lumen of the thrombosed vein. Diagnosis/ Discussion/ Treatment/ Follow up The insertion of PICC lines can sometimes be for administering certain treatments. Patients who develop any adverse symptom (swelling, pain, redness) post PICC line insertion are prime candidates for an upper limb venous Doppler ultrasound. It is vital to rule out an onset of thrombosis in these patients to avoid dangerous outcomes. Sonograms CDI occluded left jugular vein CDI occluded left jugular vein CDI occluded left subclavian vein with PICC line in situ B-mode occluded left axillary vein with PICC line in situ B-mode occluded left basilic vein with PICC line in situ The Great Vessels Abdominal Aortic Aneurysm Severe case of Abdominal Aortic Aneurysm (AAA) Clinical History A 90-year old lady presented with a palpable lump towards the left side of the abdomen. Case Description Ultrasound revealed an 83 mm abdominal aortic aneurysm which corresponds to the palpable mass pointed by the patient. Diagnosis/ Discussion/ Treatment/ Follow up A subsequent contrast-enhanced CT scan of the thorax abdomen and pelvis confirmed this diagnosis. The patient was managed conservatively as surgery was contraindicated based on other comorbidities. Sonograms Longitudinal section of the AAA colour Doppler imaging Transverse section of the AAA colour Doppler imaging B-Mode of the AAA Sagittal contrast CT showing large AAA in arterial phase IVC Thrombus Tumour Thrombus in the IVC Clinical History A 60-year old man presented with pain in the right upper quadrant and in the epigastrium. Abdominal ultrasound was requested to examine the liver and biliary tree for a possible cause. Case Description Ultrasound revealed an occluded IVC containing thrombus-like material. The occlusion (tumour thrombus) extends a few millimetres into the proximal portion of one of the hepatic veins. Mild ascites in the RUQ and pleural effusion seen in the right lung. The gallbladder was empty with an oedematous wall appearance, which might have been secondary to the irritation caused by the ascites. An urgent CT pulmonary angiogram was recommended to further examine the occluded IVC and to assess the extent of the thrombus. Diagnosis/ Discussion/ Treatment/ Follow up An urgent CTPA revealed the IVC thrombus to be extending into the right atrium of the heart. A further CT contrast abdomen and pelvis suggested the thrombus might be a tumour as it was also seen to encase the right renal vessels and beyond the IVC. Overall, appearances were suggestive of either a thrombus due to hyperviscosity syndrome or a malignant tumour, possibly leiomyosarcoma. Sonograms Right upper quadrant showing the liver and the occluded IVC posteriorly Colour Doppler Imaging showing the occluded IVC Colour Doppler Imaging showing the occluded IVC Empty oedematous gallbladder, probably due to the ascites A tiny trace of free fluid in the hepatorenal (Morrison’s) pouch Colour Doppler showing patent hepatic veins. The right hepatic vein might be occluded B-mode showing an occlusive thrombus in the right branch of the hepatic vein Sagittal CT showing the occlusive thrombus in the IVC Thoracic Wall
Ovarian Dermoid Articles Right Ovarian Dermoid Cyst Dermoid Cyst Right Ovarian Dermoid Cyst Clinical History A 30-year old female presented with recent onset of lower abdominal pain with raised inflammatory markers. Ultrasound was requested to rule out appendicitis or ovarian cyst causing the pain. Case Description On ultrasound, the appendix was normal. However, there was a 37 mm heterogeneous, non-vascular, echogenic lesion (ovarian dermoid cyst) in the right adnexa attached to the right ovary suggestive of an ovarian dermoid. The lesion was seen to be attached to a normal right ovarian tissue. The otherwise normal left ovary contained a small collapsing corpus luteum with some associated mild free fluid in the pouch of Douglas, secondary to this. Diagnosis/ Discussion/ Treatment/ Follow up The patient was managed conservatively with the lesion being monitored six-monthly for 2 years, with follow up ultrasound scans (TA and TV) showing stable appearances. Sonograms Transabdominal sonogram of the dermoid in the right ovary Transvaginal sonogram of the dermoid in the right ovary Transvaginal sonogram of the dermoid in the right ovary Colour Doppler imaging showing no vascularity in the right ovarian dermoid cyst The normal left ovary showing a collapsing follicle Free fluid in the pouch of Douglas Dermoid Cyst Clinical History A 50-year old lady presented with a recent onset of lower abdominal pain. Ultrasound was requested to assess the pelvic organs as the cause for pain. Case Description Transabdominal pelvic ultrasound revealed a 6 cm dermoid cyst in the right adnexa. The normal right ovarian tissue was not visualised separate from this cyst. Diagnosis/ Discussion/ Treatment/ Follow up A few months later, the patient had a follow up CT scan of the abdomen and pelvis for a different assessment which also confirmed the presence of the fat-containing right ovarian dermoid cyst. Sonograms Axial B-mode dermoid cyst in the right adnexa. Longitudinal view of the right adnexal dermoid cyst CDI showing no colour flow within the cyst Coronal CT image of the right adnexal dermoid cyst Axial CT of the dermoid cyst
Calculus Cholecystitis Articles Ultrasound Diagnosed Gallstones that were Radiolucent on a Recent CT Scan A Gallbladder Filled with Numerous Radiolucent Calculi Ultrasound Diagnosed Gallstones that were Radiolucent on a Recent CT Scan Clinical History A 55-year old lady presented with abdominal pain and tenderness in the right upper quadrant. Case Description A contrast CT scan of the abdomen and pelvis was performed which revealed an inflamed gallbladder wall with no radio-opaque gallstone seen. However, ultrasound was recommended to rule out gallstones. Diagnosis/ Discussion/ Treatment/ Follow up The patient had an uneventful laparoscopic cholecystectomy. Ultrasound is more sensitive in the diagnosis of cholelithiasis than CT scan. Some gallbladder calculi (cholelithiasis) can be radioluscent, therefore missed on CT. This is why abdominal ultrasound is the recommended first line of imaging, when it is available, for cases with clinically suspected cholelithiasis. Sonograms B-mode image showing the gallbladder containing some calculi B-mode image of the gallbladder calculus impacted in the gallbladder neck Longitudinal view of the normal common bile duct B-mode image of the gallbladder showing an increased wall thickness of 5.5 mm in AP calibre Axial CT of the gallbladder performed just prior to ultrasound showing some wall inflammation, however, no radiopaque calculus was seen A Gallbladder Filled with Numerous Radiolucent Calculi Clinical History A 56-year old lady presented with abdominal pain and some bowel symptoms. Case Description CT abdomen and pelvis with contrast revealed mild thickening of the gallbladder wall, however, no radiopaque calculus (radiolucent calculi) was seen. Ultrasound was advised. An ultrasound of the abdomen after adequate fasting (>6 hours) revealed a mildly thick-walled gallbladder filled with numerous calculi (radiolucent calculi). Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to the surgical team to discuss plans for cholecystectomy if clinically indicative. Sonograms Longitudinal image of the gallbladder containing numerous calculi within its lumen Axial Image of the gallbladder containing numerous calculi Gallbladder wall showing some increased thickness of 5 mm in AP calibre (normal = up to 3 mm) Longitudinal view of the gallbladder filled with numerous calculi Normal calibre of the common bile duct Axial CT of the gallbladder , performed recently, showing wall inflammation with no radiopaque calculi within the lumen
Ultrasound Diagnosed Gallstones that were Radiolucent on a Recent CT Scan Clinical History A 55-year old lady presented with abdominal pain and tenderness in the right upper quadrant. Case Description A contrast CT scan of the abdomen and pelvis was performed which revealed an inflamed gallbladder wall with no radio-opaque gallstone seen. However, ultrasound was recommended to rule out gallstones. Diagnosis/ Discussion/ Treatment/ Follow up The patient had an uneventful laparoscopic cholecystectomy. Ultrasound is more sensitive in the diagnosis of cholelithiasis than CT scan. Some gallbladder calculi (cholelithiasis) can be radioluscent, therefore missed on CT. This is why abdominal ultrasound is the recommended first line of imaging, when it is available, for cases with clinically suspected cholelithiasis. Sonograms B-mode image showing the gallbladder containing some calculi B-mode image of the gallbladder calculus impacted in the gallbladder neck Longitudinal view of the normal common bile duct B-mode image of the gallbladder showing an increased wall thickness of 5.5 mm in AP calibre Axial CT of the gallbladder performed just prior to ultrasound showing some wall inflammation, however, no radiopaque calculus was seen
A Gallbladder Filled with Numerous Radiolucent Calculi Clinical History A 56-year old lady presented with abdominal pain and some bowel symptoms. Case Description CT abdomen and pelvis with contrast revealed mild thickening of the gallbladder wall, however, no radiopaque calculus (radiolucent calculi) was seen. Ultrasound was advised. An ultrasound of the abdomen after adequate fasting (>6 hours) revealed a mildly thick-walled gallbladder filled with numerous calculi (radiolucent calculi). Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to the surgical team to discuss plans for cholecystectomy if clinically indicative. Sonograms Longitudinal image of the gallbladder containing numerous calculi within its lumen Axial Image of the gallbladder containing numerous calculi Gallbladder wall showing some increased thickness of 5 mm in AP calibre (normal = up to 3 mm) Longitudinal view of the gallbladder filled with numerous calculi Normal calibre of the common bile duct Axial CT of the gallbladder , performed recently, showing wall inflammation with no radiopaque calculi within the lumen
Pediatrics Articles Paediatric Scrotum Paediatric Abdomen & Retroperitoneum Paediatric Head & Neck Paediatric Gynaecology Neonatal Brain & Spine Infant Hip & Knee Paediatric Thorax Paediatric Urinary Tract Paediatric Urology Paediatric Scrotum Paediatric Abdomen & Retroperitoneum Paediatric Head & Neck Paediatric Gynaecology Neonatal Brain & Spine Infant Hip & Knee Paediatric Thorax Paediatric Urinary Tract Paediatric Urology Urinary Tract Infection UTI in a Paediatric Patient Clinical History A 14-year old boy presented with long-standing recurrent UTI symptoms with some fever. Case Description Ultrasound revealed a thick and irregular urinary bladder wall outline. There was some debris seen within the bladder lumen. The pre void bladder volume was 182 ml, while the post void bladder volume was 105 ml (incomplete bladder emptying). In addition, there was also an area of focal thickening seen in the left ureteric orifice measuring 16 mm x 11 mm (L x AP). Although the ureters were not obstructed as there was no hydroureter, and the bladder jets were within optimal limits. There was no hydronephrosis either, however, the left urothelium was mildly thickened as seen in the left renal pelvis indicating a UTI. Diagnosis/ Discussion/ Treatment/ Follow up The patient was placed on antibiotics therapy which helped resolve the symptoms. Sonograms A distended urinary bladder showing an increased wall thickness. Note the numerous debris within the bladder lumen A dual-screen image of the bladder volume measurement Thickening of the left ureteric orifice (transverse orientation) appearing as an echogenic protrusion into the bladder lumen Thickening of the left ureteric orifice (longitudinal orientation) appearing as an echogenic protrusion into the bladder lumen Bladder jet from the left ureteric orifice indicating a lack of obstruction in the bladder inlet A dual-screen image of the bladder showing b-mode and colour Doppler simultaneously. Good bladder jets were recorded from both right and left ureteric orifices Left kidney transverse view showing thickness of the urothelium Axial left kidney showing urothelial thickening Post void with a significant amount of post void residual bladder volume of 105 ml Paediatric UTI Clinical History A 7-year old female presented with recurrent UTI symptoms. Ultrasound or the renal tract was requested. Case Description Ultrasound revealed some floating debris in the urinary bladder. There was also evidence of focal hypertrophy of the bladder base surrounding the right and left ureteric orifices measuring 10 mm and 13 mm respectively. Multiple bladder jets were observed in the right ureteric orifice while none was seen in the left within a minute of close evaluation. Diagnosis/ Discussion/ Treatment/ Follow up The patient was commenced on antibiotic therapy in light of the ultrasound findings (UTI) and clinical manifestations. Sonograms Axial sonogram of the urinary bladder showing two echogenic protrusions at the bladder base in the region of the ureteric orifices Power Doppler imaging showing no evidence of vascularity within the protrusions Power Doppler imaging showing evidence of good bladder jets on the right ureteric orifice, ruling out right inlet obstruction A dilated left distal ureter at 12 mm (AP) posterior to the urinary bladder No right ureteric dilatation Post void examination showing a completely emptied urinary bladder Normal right kidney with no hydronephrosis Hydronephrotic left kidney Bilateral Calcification at the Vesicoureteric Junctions Bilateral Calcification at the Vesicoureteric Junctions Clinical History A 5-year old female was referred to have an ultrasound of the urinary tract due to dysfunctional voiding. Case Description Ultrasound revealed some calcifications within the right and left vesicoureteric junctions measuring 0.9 cm in the right and 1.1 cm in the left VUJ respectively. There was no hydronephrosis present, and the urinary bladder emptied completely. Diagnosis/ Discussion/ Treatment/ Follow up Bilateral calcifications of the vesicoureteric junctions. Sonograms B-mode bladder showing calcifications within the VUJ bilaterally CDI showing twinkle artefacts of the VUJ calcifications Normal kidney
Gallbladder Adenomyomatosis Articles Figure of 8 Gallbladder with a Focal Fundal Thickening Gallbladder Polyps Coexisting with Adenomyomatosis Figure of 8 Gallbladder with a Focal Fundal Thickening Clinical History A 56-year old lady presented with an acute onset of epigastric tenderness and pain radiating to the right upper abdominal quadrant. Ultrasound of the abdomen was requested for an initial assessment. Case Description Ultrasound revealed a ‘figure of 8’ gallbladder morphology with mild focal thickening at the fundal half (focal fundal thickening). There were also two tiny flecks of interstitial gas pockets within the gallbladder wall that appeared as reverberation artefacts and twinkling on colour Doppler imaging. Diagnosis/ Discussion/ Treatment/ Follow up The patient had magnetic resonance cholangiopancreaticography (MRCP) which further confirmed the ultrasound findings of adenomyomatosis. Gallbladder adenomyomatosis is a benign condition in which there is hypertrophy of the gallbladder mucosal epithelium with an invagination into its interstices. This leads to the formation of gas pockets within the gallbladder wall known as Rokitansky-Aschoff sinuses. Sonograms Figure 8 gallbladder B-mode gallbladder showing a focal thickening of the folded fundus with gas pocket in the wall Twinkle artefact from the gallbladder interstitial gas pocket Figure 8 gallbladder Axial MRI of the gallbladder Gallbladder Polyps Coexisting with Adenomyomatosis Clinical History A 48-year old lady presented with a long-term history of right upper quadrant abdominal pain. The patient was referred to have an ultrasound of the abdomen to check for possible gallbladder calculi (gallstones). Case Description An abdominal ultrasound was performed using a 6 MHz curvilinear transducer. Ultrasound revealed multiple tiny gallbladder polyps. The largest polyp measured up to 4 mm x 4 mm in length and AP diameter. The gallbladder was thin-walled and contained no calculus within its lumen. However, there were multiple gas pockets within the gallbladder wall that appeared as ‘comet tail’ artefacts in keeping with Rokintansky Aschoff sinuses. These ultrasound appearances of the gallbladder have been known to be related to gallbladder adenomyomatosis. Diagnosis/ Discussion/ Treatment/ Follow up The patient was placed on an ultrasound pathway where the gallbladder would be monitored every six months to check for any abrupt change in appearances. Sonograms B-mode of the gallbladder showing a comet-tail artefact Arrows pointing at the comet-tail artefact Longitudinal view of the gallbladder on B-mode Two tiny gallbladder polyps Axial view of the gallbladder showing two polyps Normal common bile duct
Figure of 8 Gallbladder with a Focal Fundal Thickening Clinical History A 56-year old lady presented with an acute onset of epigastric tenderness and pain radiating to the right upper abdominal quadrant. Ultrasound of the abdomen was requested for an initial assessment. Case Description Ultrasound revealed a ‘figure of 8’ gallbladder morphology with mild focal thickening at the fundal half (focal fundal thickening). There were also two tiny flecks of interstitial gas pockets within the gallbladder wall that appeared as reverberation artefacts and twinkling on colour Doppler imaging. Diagnosis/ Discussion/ Treatment/ Follow up The patient had magnetic resonance cholangiopancreaticography (MRCP) which further confirmed the ultrasound findings of adenomyomatosis. Gallbladder adenomyomatosis is a benign condition in which there is hypertrophy of the gallbladder mucosal epithelium with an invagination into its interstices. This leads to the formation of gas pockets within the gallbladder wall known as Rokitansky-Aschoff sinuses. Sonograms Figure 8 gallbladder B-mode gallbladder showing a focal thickening of the folded fundus with gas pocket in the wall Twinkle artefact from the gallbladder interstitial gas pocket Figure 8 gallbladder Axial MRI of the gallbladder
Musculoskeletal Articles Shoulder Elbow Hip, Groin & Buttock Fingers Wrist & Carpus Knee Ankle Foot Bone Muscle Peripheral Nerves Lymph Nodes Soft Tissue Shoulder Elbow Hip, Groin & Buttock Abscess and Collection Left Groin Abscess Clinical History A 35-year old female presented with an onset of painful and tender swelling in the left groin. The patient has a history of intravenous drug injection into the groin. An ultrasound of the groin was requested to examine the swelling for further management. Case Description The left groin swelling was initially examined using a curvilinear ultrasound transducer to assess any mass or collection deep within the groin while limiting compromise on the image resolution. This revealed a 9 cm heterogeneous collection within the left groin (Left Groin Abscess) at the site of concern pointed by the patient. The collection was seen deep in the intramuscular compartment with a regular outline, some cystic internal component, and air bubbles floating in the dependent areas of the collection, appearing as echogenic rim with some comet tail artefacts at the anterior surface of the collection. The overall ultrasound features are congruent with an abscess in the deep muscle compartment of the left groin/ upper thigh. Using a high frequency linear transducer did not provide any tangible information as the collection was too deep to be fully examined by the high frequency transducer. Therefore, in this case, the curvilinear evaluation of the mass on ultrasound was sufficient. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound findings were congruent with the patient’s overall clinical picture. However, an MRI of the groin was requested for confirmation prior to a consideration of drainage. MRI confirmed a 9 cm collection in the right adductor compartment with air-fluid levels present, some lymphedema, and reactive lymph nodes. Sonograms Power Doppler imaging showing no evidence of vascularity within the groin abscess B-mode image of the left groin abscess B-mode ultrasound showing the left groin abscess with evidence of comet tail artefact from the gas pockets within its anterior surface A coronal MRI image of the groin showing the large collection in the upper and medial aspect of the left thigh Fingers Wrist & Carpus Knee Ankle Foot Bone Muscle Haematoma Calf Haematoma Clinical History A 62-year old lady presented with left sided calf tenderness (Calf Haematoma) and swelling. Her recent D-Dimer test value was elevated, raising the suspicion of DVT. The patient was referred to have a venous Doppler ultrasound of her affected lower limb to rule out DVT. Case Description Ultrasound revealed no DVT. However, there was a 20 cm heterogeneous non-vascular complex area of fluid collection in the medial aspect of the left popliteal fossa, extending to the mid-lower leg region. The distal compartment of the collection contained hypoechoic contents. Appearances were in keeping with a Morel-Lavallee type of injury with a collection of blood products of varying chronology in the region demonstrated. This was seen to cause a slight displacement of the medial gastrocnemius muscle fibres. Diagnosis/ Discussion/ Treatment/ Follow up Morel-Lavellee also called ‘degloving’ injury, is a rare injury that occurs from the separation or tear of the skin and subcutaneous tissues away from the rest of the underlying muscle fibres. In this case, it led to an accumulation of blood products and some fluid collection within the affected region. Sonograms A panoramic view of the left medial calf showing the heterogeneous fluid collection in the intramuscular layer Power Doppler imaging showing no evidence of flow within the collection B-mode axial sonogram of the calf collection B-mode longitudinal sonogram of the calf collection PDI of the calf collection, again showing no vascularity Intramuscular Haematoma in the Upper Arm Clinical History A 42-year old lady with a recent history of a peripherally inserted central catheter (PICC line) insertion in her left upper arm developed an acute onset of pain and swelling around the PICC line insertion. Ultrasound of the arm was requested to rule out venous thrombosis or soft tissue haematoma or collection. Case Description Ultrasound revealed a 7 cm hypoechoic, heterogeneous, and non-vascular structure within the intramuscular layer of the brachium deep to the site of the line insertion. Appearances were suggestive of an intramuscular haematoma. In addition to the recent PICC line insertion, the patient had other preexisting conditions that supports the ultrasound findings Diagnosis/ Discussion/ Treatment/ Follow up The patient was continually managed for her comorbidities while the arm haematoma was managed conservatively. However, prior anticoagulation therapy (for other comorbidities) was discontinued. Sonograms CDI showing flow in the left subclavian vein B-mode showing the PICC line in the subclavian vein (arrow) Left arm intramuscular haematoma on B-mode Panoramic view of the intramuscular haematoma Haematoma measuring 7 cm x 2 cm Axial image of the intramuscular haematoma PDI showing no evidence of vascularity within the haematoma Intramuscular Haematoma of the Thigh Following Anticoagulation Clinical History A 39-year old man presented with an acute onset of tense swelling of the right lateral thigh region. The patient was on anticoagulation therapy, at the time of this occurrence, for a different condition. Ultrasound of the thigh was requested to assess for haematoma or other collections. Case Description Ultrasound revealed an 8 cm heterogeneous non-vascular haematoma within the intramuscular layer of the right lateral thigh region. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a CT angiogram of the lower limbs to assess the potential source of an acute bleed within the vessels. The ultrasound findings were confirmed on CT. However, there was no evidence of contrast extravasation to the pool of haematoma seen on CT. Sonograms B-mode showing the right thigh haematoma in longitudinal view Distal end of the right thigh haematoma Transverse view of the right thigh haematoma Right thigh haematoma in transverse view Transverse view of the distal portion of the right thigh haematoma Longitudinal view right thigh haematoma Panoramic view of the right thigh intramuscular haematoma PDI showing no flow signal in the haematoma Coronal view of the thigh haematoma on CT scan Intramuscular Abscess Forearm Inflammatory Intramuscular Collection Clinical History A 51-year old man presented with an acute large swelling on the left forearm with erythema and tenderness. Case Description Ultrasound performed using a linear transducer at 14 MHz revealed a large hypervascular collection within the intramuscular layer of the affected forearm suggestive of an abscess. Diagnosis/ Discussion/ Treatment/ Follow up A further ultrasound performed 3 months later revealed a significant reduction in the said collection, still some internal vascularity, and a tract to the skin surface suggestive of a resolving collection. Sonograms Panoramic view of the forearm showing the 8 cm abscess in B-mode Intramuscular abscess of the forearm longitudinal view Intramuscular abscess of the forearm transverse view CDI showing hypervascularity in axial view CDI showing hypervascularity in longitudinal view B-mode longitudinal view of the forearm abscess Forearm collection Ultrasound 3 months later revealing a significant reduction in the abscess Intramuscular Haematoma A Large Intramuscular Haematoma Coexisting with Lesser Trochanter Osteochondroma Clinical History A 35-year old man presented with a medial right thigh mass that he had felt for two weeks. An ultrasound was requested to assess the nature of the mass. Case Description Ultrasound was performed using linear and curvilinear transducers. This revealed a large area of intramuscular haematoma with some linear calcific component within the medial upper thigh compartment. Diagnosis/ Discussion/ Treatment/ Follow up A subsequent MRI revealed a sessile osteochondroma at the right lesser trochanter with no significant cartilage and an adjacent haemorrhagic fluid extending from the right ischiofemoral interval to the adductor compartment caudally. Sonograms B-mode right thigh haematoma Axial view right thigh haematoma CDI showing no flow in the right thigh haematoma Right thigh haematoma with a curvilinear transducer CDI right thigh haematoma Right thigh haematoma with measurement callipers Right and left comparison image of the upper thigh at the level of the haematoma Coronal MRI showing the right thigh haematoma Peripheral Nerves Lymph Nodes Soft Tissue Haematoma Subpectoral Haematoma Clinical History A 78-year old lady presented with swelling and bruising on her left arm secondary to a recent fall. Patient is on Apixaban for an underlying heart condition, however, the recent blood results revealed a sudden drop in haemoglobin, which led the clinicians to withhold the apixaban medication. Also a cardiac pacemaker was recently inserted. Case Description Ultrasound revealed an 8 cm heterogeneous hypoechoic non-vascular area in the intramuscular layer of the anterior chest region, posterior to the pectoralis muscle. Appearances suggested an intramuscular (subpectoral haematoma) haematoma. Diagnosis/ Discussion/ Treatment/ Follow up The patient had CT which confirmed the findings. Sonograms B-mode sonogram, acquired using a 9 MHz linear transducer, showing the subpectoral haematoma B-mode sonogram showing the subpectoral haematoma B-mode sonogram, acquired using a 12 MHz linear transducer, showing the subpectoral haematoma Axial CT of the chest showing the subpectoral haematoma Soft Tissue Mass Lower Leg Soft Tissue Lesion with Concerning Ultrasound Features Clinical History A 72-year old mass presented with pain and swelling to the left calf. An initial Doppler ultrasound was requested to assess for DVT. Case Description Ultrasound ruled out DVT. However, during the examination, the sonographer could palpate a lump below the patient’s calf. This corresponded to a 3 cm oval-shaped well-defined heterogeneous vascular lesion in the deep subcutaneous compartment. Further evaluation with MRI was recommended. Diagnosis/ Discussion/ Treatment/ Follow up The patient declined having an MRI or any other studies in relation to this. Sonograms B-mode sonogram of an oval-shaped mass in the deep subcutaneous layer of the right lower leg Colour Doppler imaging of the oval-shaped deep subcutaneous mass showing a significant amount of internal vascularity B-mode virtual convex view of the deep subcutaneous mass showing some compression effect on the adjacent muscle fibres B-mode sonogram of the mass with measurement callipers Power Doppler imaging of the mass again showing a significant amount of vascularity within the mass
Intraductal Papillary Mucinous Neoplasm (IPMN) Articles Cystic Pancreatic Mass in an 81-Year Old Lady Presenting with an Abnormal LFT Cystic Pancreatic Mass in an 81-Year Old Lady Presenting with an Abnormal LFT Clinical History An 81-year old lady presented with acute deterioration of her recent liver function tests which progressively worsened. ALP – 890, Bilirubin 28, ALT 195. Case Description Abdominal ultrasound performed revealed the presence of a 42 mm complex cystic lesion (cystic pancreatic mass) at the pancreatic head. The gallbladder was also distended with a thickened and oedematous wall morphology. Also, there was sludge seen within the gallbladder lumen. The common bile duct was dilated at 9 mm in AP calibre. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have an MRCP which confirmed the ultrasound findings including the complex cystic lesion at the pancreatic head which was suggested to be due an IPMN. IPMNs are commonly benign tumours, however, some have been reported to progress into being cancerous. In this case, the cystic pancreatic lesion was causing some biliary obstruction. Sonograms Dilated CBD measuring 9 mm in AP calibre A distended thin-walled gallbladder containing some sludge within its lumen A cystic lesion at the head of the pancreas (HOP) adjacent to the thick-walled gallbladder Cystic lesion at the head of pancreas (HOP) with some normal pancreatic tissues seen around it
Head & Neck Articles Thyroid Gland Parathyroid Glands Salivary Glands Lymph Nodes Others Thyroid Gland Parathyroid Glands Salivary Glands Lymph Nodes Others
Acute Pancreatitis Articles A Case of Acute Pancreatitis Mimicking Pancreatic Malignancy A Case of Acute Pancreatitis Mimicking Pancreatic Malignancy Clinical History A 62-year old man presented with symptoms of right upper quadrant abdominal pain, vomiting, raised inflammatory markers, and deranged LFT. An abdominal ultrasound was requested as a first line of imaging to assess for features of cholecystitis. Case Description Ultrasound revealed a large heterogeneous cystic structure within the epigastrium posterior to the duodenum, with no internal vascularity seen in the structure. Although the pancreas was not clearly visualised on this examination, the said cystic structure was suggested to be related to the pancreas, due to its proximity. In addition, there was also a mild trace of ascites in the hepatorenal pouch of Morrison, right and left iliac fossae, with the thin-walled gallbladder containing some sludge within its lumen. Due to these findings, an urgent review was advised. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have a contrast-enhanced CT scan of the whole body which confirmed the presence of a large heterogeneous mass replacing the head and body of pancreas. The mass was seen to have a cystic/ necrotic component. Suggestive of a pancreatic tumour (Acute Pancreatitis). However, the patient’s blood results and clinical evaluation were more inflammatory than tumoral. The patient had ERCP, cytology, and endoscopic ultrasound (EUS), which aided the diagnosis of acute pancreatitis. A follow up whole body CT scan 3 months post treatment confirmed resolution of the pancreatic collection in keeping with chronic (acute Pancreatitis) pancreatitis. Sonograms A heterogeneous cystic mass at the head of pancreas (HOP) CDI of the HOP mass Free fluid in the hepatorenal pouch of Morrison Sludge in the lumen of the thin-walled gallbladder An initial CT (coronal slice) of the abdomen showing the mass in the region of the pancreatic head One year later CT showed the inflammatory mass (pancreatitis confirmed on EUS) in the pancreatic area has reduced post treatment
Paediatric Urology Articles Urinary Tract Infection Bilateral Calcification at the Vesicoureteric Junctions Urinary Tract Infection UTI in a Paediatric Patient Clinical History A 14-year old boy presented with long-standing recurrent UTI symptoms with some fever. Case Description Ultrasound revealed a thick and irregular urinary bladder wall outline. There was some debris seen within the bladder lumen. The pre void bladder volume was 182 ml, while the post void bladder volume was 105 ml (incomplete bladder emptying). In addition, there was also an area of focal thickening seen in the left ureteric orifice measuring 16 mm x 11 mm (L x AP). Although the ureters were not obstructed as there was no hydroureter, and the bladder jets were within optimal limits. There was no hydronephrosis either, however, the left urothelium was mildly thickened as seen in the left renal pelvis indicating a UTI. Diagnosis/ Discussion/ Treatment/ Follow up The patient was placed on antibiotics therapy which helped resolve the symptoms. Sonograms A distended urinary bladder showing an increased wall thickness. Note the numerous debris within the bladder lumen A dual-screen image of the bladder volume measurement Thickening of the left ureteric orifice (transverse orientation) appearing as an echogenic protrusion into the bladder lumen Thickening of the left ureteric orifice (longitudinal orientation) appearing as an echogenic protrusion into the bladder lumen Bladder jet from the left ureteric orifice indicating a lack of obstruction in the bladder inlet A dual-screen image of the bladder showing b-mode and colour Doppler simultaneously. Good bladder jets were recorded from both right and left ureteric orifices Left kidney transverse view showing thickness of the urothelium Axial left kidney showing urothelial thickening Post void with a significant amount of post void residual bladder volume of 105 ml Paediatric UTI Clinical History A 7-year old female presented with recurrent UTI symptoms. Ultrasound or the renal tract was requested. Case Description Ultrasound revealed some floating debris in the urinary bladder. There was also evidence of focal hypertrophy of the bladder base surrounding the right and left ureteric orifices measuring 10 mm and 13 mm respectively. Multiple bladder jets were observed in the right ureteric orifice while none was seen in the left within a minute of close evaluation. Diagnosis/ Discussion/ Treatment/ Follow up The patient was commenced on antibiotic therapy in light of the ultrasound findings (UTI) and clinical manifestations. Sonograms Axial sonogram of the urinary bladder showing two echogenic protrusions at the bladder base in the region of the ureteric orifices Power Doppler imaging showing no evidence of vascularity within the protrusions Power Doppler imaging showing evidence of good bladder jets on the right ureteric orifice, ruling out right inlet obstruction A dilated left distal ureter at 12 mm (AP) posterior to the urinary bladder No right ureteric dilatation Post void examination showing a completely emptied urinary bladder Normal right kidney with no hydronephrosis Hydronephrotic left kidney Bilateral Calcification at the Vesicoureteric Junctions Bilateral Calcification at the Vesicoureteric Junctions Clinical History A 5-year old female was referred to have an ultrasound of the urinary tract due to dysfunctional voiding. Case Description Ultrasound revealed some calcifications within the right and left vesicoureteric junctions measuring 0.9 cm in the right and 1.1 cm in the left VUJ respectively. There was no hydronephrosis present, and the urinary bladder emptied completely. Diagnosis/ Discussion/ Treatment/ Follow up Bilateral calcifications of the vesicoureteric junctions. Sonograms B-mode bladder showing calcifications within the VUJ bilaterally CDI showing twinkle artefacts of the VUJ calcifications Normal kidney
Gallbladder Polyps Coexisting with Adenomyomatosis Clinical History A 48-year old lady presented with a long-term history of right upper quadrant abdominal pain. The patient was referred to have an ultrasound of the abdomen to check for possible gallbladder calculi (gallstones). Case Description An abdominal ultrasound was performed using a 6 MHz curvilinear transducer. Ultrasound revealed multiple tiny gallbladder polyps. The largest polyp measured up to 4 mm x 4 mm in length and AP diameter. The gallbladder was thin-walled and contained no calculus within its lumen. However, there were multiple gas pockets within the gallbladder wall that appeared as ‘comet tail’ artefacts in keeping with Rokintansky Aschoff sinuses. These ultrasound appearances of the gallbladder have been known to be related to gallbladder adenomyomatosis. Diagnosis/ Discussion/ Treatment/ Follow up The patient was placed on an ultrasound pathway where the gallbladder would be monitored every six months to check for any abrupt change in appearances. Sonograms B-mode of the gallbladder showing a comet-tail artefact Arrows pointing at the comet-tail artefact Longitudinal view of the gallbladder on B-mode Two tiny gallbladder polyps Axial view of the gallbladder showing two polyps Normal common bile duct
Gastrointestinal Articles Appendix Hernia Large Intestine Small Intestine Appendix Complicated Appendicitis Acute Complicated Appendicitis in a 31-year Old Male Clinical History A 31-year old presented with 1 day history of central abdominal pain radiating to the right iliac fossa. Raised WCC and CRP. Case Description The patient was referred to have an ultrasound of the abdomen and pelvis to include the appendix. Ultrasound revealed an abnormal appendix in the RIF measuring 14 mm in AP calibre with significant probe tenderness observed while scanning the area. There was also evidence of mesenteric fat stranding around the inflamed appendix with hypervascularity within the appendix wall. An echogenic focus was seen within the appendix suggestive of a small appendicolith. Diagnosis/ Discussion/ Treatment/ Follow Up The patient had laparoscopic appendectomy and the appendix specimen was sent for histology analysis. Histology revealed an inflamed appendix with focal mucosal ulceration in keeping with complicated appendicitis. Sonograms Longitudinal section of the inflamed appendix in the RIF Transverse section of the inflamed appendix in the RIF Power Doppler imaging showing evidence of vascularity within the wall of the inflamed appendix Power Doppler imaging 2 A tiny calcific focus within the inflamed appendix, suggestive of an appendicolith Perforated Appendicitis Complicated Appendicitis with Perforations Clinical History A 19-year old male presented with a 4-day history of abdominal pain radiating to the right iliac fossa, some fever, diarrhoea, and vomiting. Blood tests revealed elevated inflammatory markers. Case Description Ultrasound revealed a 98 x 43 x 58 mm heterogeneous hypoechoic area in the right iliac fossa posterolateral to the caecum and anterior to the psoas muscle fibres. Also, there was mesenteric fat stranding around it. These were all at the site of the patient’s maximum tenderness. The normal appendix tissue was not seen leading the sonographer to raise the suspicion of appendiceal perforation. Diagnosis/ Discussion/ Treatment/ Follow up The patient had an emergency appendectomy and the surgical specimen analysed histologically confirmed the diagnosis of perforated appendicitis. Sonograms Sonogram acquired using a high frequency linear probe showing a heterogeneous hypoechoic structure in the RIF Sonogram acquired using a curvilinear probe showing a heterogeneous hypoechoic structure in the RIF Sonogram acquired using a curvilinear probe showing a heterogeneous hypoechoic structure in the RIF Power Doppler showing no evidence of vascularity Sonogram acquired using a high frequency linear probe showing a heterogeneous hypoechoic structure in the RIF Panoramic view of the RIF Hernia Port Site Hernia Post-laparoscopic Port site or Incisional Hernia Clinical History A 25-year old woman who recently had laparoscopic appendectomy presented with abdominal pain and swelling post op, with a palpable mass that was felt under the port site. Case Description An abdominal ultrasound done with a 2 – 5 MHz curvilinear transducer and a 10 MHz (high frequency transducer) revealed a 24 mm breech in the abdominal wall at the port site containing omental fat and some surrounding fluid. Ultrasound findings are in keeping with port site hernia. Diagnosis/ Discussion/ Treatment/ Follow-up Patient had the hernia repaired. Sonograms Port site hernia, image acquired using a low frequency curvilinear transducer Port site hernia showing the protrusion of the mesenteric fat content with a tiny trace of adjacent fluid within the herniated sac. No bowel loop seen within the sac. image acquired using a high frequency linear transducer Port site hernia Power Doppler showing no evidence of vascularity within the protruding mesenteric fat, as would be expected Large Intestine Small Intestine Duodenal Tumour Obstructive Duodenal Tumour in a 76 year Old Patient Clinical History A 76-year old man presented with epigastric pain and haematemesis. Case Description The patient was referred to have an abdominal ultrasound which reveals a large heterogeneous mass in the duodenum (duodenal tumour). There was also intrahepatic biliary dilatation and raised portal vein flow velocity, all secondary to the obstructive nature of the duodenal mass. Diagnosis/ Discussion/ Treatment/ Follow Up The patient also had Oesophagoduodenoscopy (OGD) which revealed the mass to be causing a gastric outflow obstruction. The patient also has a CT scan of the chest abdomen and pelvis (with contrast) which revealed the obstructive mass (duodenal tumour) to be at D2/3 with an abnormal D3 and an abrupt calibre of D4. The patient was referred to the Upper GI specialists for further management. Sonograms Sonogram of the abdomen at the level of the epigastrium, showing the duodenal mass Sonogram at the level of the epigastrium showing the long segment of the duodenal mass Power Doppler imaging of the duodenal mass. No internal vascularity seen. However, there is evidence of peripheral vascularity Sonogram of the pancreas (P) with the duodenal mass (M) seen adjacent and medial to the pancreatic head Right hepatic lobe showing evidence of intrahepatic biliary dilatation secondary to the obstructive duodenal mass Patent portal vein with a slightly elevated velocity measurement of 44.6 cm/s due to the duodenal mass-effect on the proxima portal vein Dilated common bile duct (CBD) secondary to the obstructive duodenal mass
Cystic Pancreatic Mass in an 81-Year Old Lady Presenting with an Abnormal LFT Clinical History An 81-year old lady presented with acute deterioration of her recent liver function tests which progressively worsened. ALP – 890, Bilirubin 28, ALT 195. Case Description Abdominal ultrasound performed revealed the presence of a 42 mm complex cystic lesion (cystic pancreatic mass) at the pancreatic head. The gallbladder was also distended with a thickened and oedematous wall morphology. Also, there was sludge seen within the gallbladder lumen. The common bile duct was dilated at 9 mm in AP calibre. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have an MRCP which confirmed the ultrasound findings including the complex cystic lesion at the pancreatic head which was suggested to be due an IPMN. IPMNs are commonly benign tumours, however, some have been reported to progress into being cancerous. In this case, the cystic pancreatic lesion was causing some biliary obstruction. Sonograms Dilated CBD measuring 9 mm in AP calibre A distended thin-walled gallbladder containing some sludge within its lumen A cystic lesion at the head of the pancreas (HOP) adjacent to the thick-walled gallbladder Cystic lesion at the head of pancreas (HOP) with some normal pancreatic tissues seen around it
Choledocholithiasis Articles Multiple Biliary Calculi Calculus Within the Common Bile Duct Causing Biliary Obstruction An Obstructive Calculus in the Common Bile Duct Multiple Biliary Calculi Clinical History A 76-year old man presented with abdominal pain, vomiting, and jaundice. His blood test showed raised infection markers and deranged LFTs. Abdominal ultrasound was requested as the first line of imaging. Case Description Ultrasound revealed multiple large calculi within the lumen of the dilated common bile duct (multiple biliary calculi) measuring 12 mm in AP dimension. The gallbladder was thick-walled and contained some tiny calculi within its lumen. Diagnosis/ Discussion/ Treatment/ Follow up The patient had magnetic resonance cholangiopancreaticography (MRCP) which confirmed the ultrasound findings. Sonograms Thick-walled gallbladder Axial sonogram of the thick-walled gallbladder Dilated common bile duct containing multiple oval-shaped echogenic structures Dilated common bile duct containing multiple oval-shaped echogenic structures MRCP; coronal image showing the dilated CBD containing multiple filling-defects Multiple oval-shaped structures within the lumen of the CBD Calculus Within the Common Bile Duct Causing Biliary Obstruction Clinical History A 49-year old man presented with abdominal pain. Case Description An abdominal ultrasound was done using a 2 – 5 MHz curvilinear transducer. This revealed multiple calculus within the common bile duct and another calculus within the lumen of the collapsed gallbladder. These findings were also confirmed on MRCP done afterwards. Diagnosis/ Discussion/ Treatment/ Follow up The patient had ERCP and cholecystectomy. Sonograms Sonogram of the pancreas showing the head, body, and uncinate process of the pancreas. The pancreatic tail is partly obscured by bowel gas shadowing. A short segment of the left hepatic lobe and duodenum are displayed anterior to the pancreas. No pancreatic duct dilatation An obstructive calculus in the common bile duct. The calculus measures 11 mm and the common bile duct measures 10 mm in AP calibre A 10 mm immoble calculus at the neck of the nearly empty gallbladder An Obstructive Calculus in the Common Bile Duct Clinical History A 61 year old lady presented with an acute onset of epigastric pain and loss of appetite. The patient is known to have uncomplicated cholelithiasis which was diagnosed 2 decades ago. Presently, the bloods revealed raised alkaline phosphatase of 200. Case Description Abdominal ultrasound revealed a distended gallbladder with multiple calculi. There was also intra and extrahepatic biliary dilatation present. The common bile duct measured 15 mm in AP calibre with a calculus (obstructive calculus) seen towards the distal end of the lumen. However, the pancreatic duct was not dilated. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound findings were confirmed on a subsequent MRCP. Sonograms The right hepatic lobe showing dilatation of the IHD and CBD Longitudinal section of the gallbladder containing multiple tiny calculi An obstructive calculus in the distal CBD
Others Articles Ocular Skin Echocardiography Interventional Verterinary Breast Ocular Skin Echocardiography Interventional Verterinary Breast
Muscle Articles Haematoma Intramuscular Abscess Intramuscular Haematoma Haematoma Calf Haematoma Clinical History A 62-year old lady presented with left sided calf tenderness (Calf Haematoma) and swelling. Her recent D-Dimer test value was elevated, raising the suspicion of DVT. The patient was referred to have a venous Doppler ultrasound of her affected lower limb to rule out DVT. Case Description Ultrasound revealed no DVT. However, there was a 20 cm heterogeneous non-vascular complex area of fluid collection in the medial aspect of the left popliteal fossa, extending to the mid-lower leg region. The distal compartment of the collection contained hypoechoic contents. Appearances were in keeping with a Morel-Lavallee type of injury with a collection of blood products of varying chronology in the region demonstrated. This was seen to cause a slight displacement of the medial gastrocnemius muscle fibres. Diagnosis/ Discussion/ Treatment/ Follow up Morel-Lavellee also called ‘degloving’ injury, is a rare injury that occurs from the separation or tear of the skin and subcutaneous tissues away from the rest of the underlying muscle fibres. In this case, it led to an accumulation of blood products and some fluid collection within the affected region. Sonograms A panoramic view of the left medial calf showing the heterogeneous fluid collection in the intramuscular layer Power Doppler imaging showing no evidence of flow within the collection B-mode axial sonogram of the calf collection B-mode longitudinal sonogram of the calf collection PDI of the calf collection, again showing no vascularity Intramuscular Haematoma in the Upper Arm Clinical History A 42-year old lady with a recent history of a peripherally inserted central catheter (PICC line) insertion in her left upper arm developed an acute onset of pain and swelling around the PICC line insertion. Ultrasound of the arm was requested to rule out venous thrombosis or soft tissue haematoma or collection. Case Description Ultrasound revealed a 7 cm hypoechoic, heterogeneous, and non-vascular structure within the intramuscular layer of the brachium deep to the site of the line insertion. Appearances were suggestive of an intramuscular haematoma. In addition to the recent PICC line insertion, the patient had other preexisting conditions that supports the ultrasound findings Diagnosis/ Discussion/ Treatment/ Follow up The patient was continually managed for her comorbidities while the arm haematoma was managed conservatively. However, prior anticoagulation therapy (for other comorbidities) was discontinued. Sonograms CDI showing flow in the left subclavian vein B-mode showing the PICC line in the subclavian vein (arrow) Left arm intramuscular haematoma on B-mode Panoramic view of the intramuscular haematoma Haematoma measuring 7 cm x 2 cm Axial image of the intramuscular haematoma PDI showing no evidence of vascularity within the haematoma Intramuscular Haematoma of the Thigh Following Anticoagulation Clinical History A 39-year old man presented with an acute onset of tense swelling of the right lateral thigh region. The patient was on anticoagulation therapy, at the time of this occurrence, for a different condition. Ultrasound of the thigh was requested to assess for haematoma or other collections. Case Description Ultrasound revealed an 8 cm heterogeneous non-vascular haematoma within the intramuscular layer of the right lateral thigh region. Diagnosis/ Discussion/ Treatment/ Follow up The patient had a CT angiogram of the lower limbs to assess the potential source of an acute bleed within the vessels. The ultrasound findings were confirmed on CT. However, there was no evidence of contrast extravasation to the pool of haematoma seen on CT. Sonograms B-mode showing the right thigh haematoma in longitudinal view Distal end of the right thigh haematoma Transverse view of the right thigh haematoma Right thigh haematoma in transverse view Transverse view of the distal portion of the right thigh haematoma Longitudinal view right thigh haematoma Panoramic view of the right thigh intramuscular haematoma PDI showing no flow signal in the haematoma Coronal view of the thigh haematoma on CT scan Intramuscular Abscess Forearm Inflammatory Intramuscular Collection Clinical History A 51-year old man presented with an acute large swelling on the left forearm with erythema and tenderness. Case Description Ultrasound performed using a linear transducer at 14 MHz revealed a large hypervascular collection within the intramuscular layer of the affected forearm suggestive of an abscess. Diagnosis/ Discussion/ Treatment/ Follow up A further ultrasound performed 3 months later revealed a significant reduction in the said collection, still some internal vascularity, and a tract to the skin surface suggestive of a resolving collection. Sonograms Panoramic view of the forearm showing the 8 cm abscess in B-mode Intramuscular abscess of the forearm longitudinal view Intramuscular abscess of the forearm transverse view CDI showing hypervascularity in axial view CDI showing hypervascularity in longitudinal view B-mode longitudinal view of the forearm abscess Forearm collection Ultrasound 3 months later revealing a significant reduction in the abscess Intramuscular Haematoma A Large Intramuscular Haematoma Coexisting with Lesser Trochanter Osteochondroma Clinical History A 35-year old man presented with a medial right thigh mass that he had felt for two weeks. An ultrasound was requested to assess the nature of the mass. Case Description Ultrasound was performed using linear and curvilinear transducers. This revealed a large area of intramuscular haematoma with some linear calcific component within the medial upper thigh compartment. Diagnosis/ Discussion/ Treatment/ Follow up A subsequent MRI revealed a sessile osteochondroma at the right lesser trochanter with no significant cartilage and an adjacent haemorrhagic fluid extending from the right ischiofemoral interval to the adductor compartment caudally. Sonograms B-mode right thigh haematoma Axial view right thigh haematoma CDI showing no flow in the right thigh haematoma Right thigh haematoma with a curvilinear transducer CDI right thigh haematoma Right thigh haematoma with measurement callipers Right and left comparison image of the upper thigh at the level of the haematoma Coronal MRI showing the right thigh haematoma
Splenic Haemangioma Articles An Incidental Diagnosis of Splenic Haemangioma An Incidental Diagnosis of Splenic Haemangioma Clinical History A 75-year old lady was referred to have an ultrasound of the urinary tract due to some evidence of frank haematuria. Case Description Although ultrasound did not reveal any renal or bladder lesion, while examining the left kidney, a 16 mm hypoechoic lesion was discovered within the spleen. The lesion had a uniformly roundish outline with some evidence of internal vascularity. Ultrasound features were suggestive of a splenic haemangioma. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound findings were confirmed on a subsequent CT. Splenic haemangiomas are some of the most commonly encountered splenic lesions on ultrasound. They are benign slow-growing tumours of the spleen. Due to their nature, they contain evidence of vascular enhancement on imaging. Sonograms Splenic haemangioma B-mode Splenic haemangioma showing the measurement callipers CDI showing the splenic haemangioma with some evidence of internal vascularity Axial CT scan showing the splenic haemangioma with evidence of enhancement Keywords
A Case of Acute Pancreatitis Mimicking Pancreatic Malignancy Clinical History A 62-year old man presented with symptoms of right upper quadrant abdominal pain, vomiting, raised inflammatory markers, and deranged LFT. An abdominal ultrasound was requested as a first line of imaging to assess for features of cholecystitis. Case Description Ultrasound revealed a large heterogeneous cystic structure within the epigastrium posterior to the duodenum, with no internal vascularity seen in the structure. Although the pancreas was not clearly visualised on this examination, the said cystic structure was suggested to be related to the pancreas, due to its proximity. In addition, there was also a mild trace of ascites in the hepatorenal pouch of Morrison, right and left iliac fossae, with the thin-walled gallbladder containing some sludge within its lumen. Due to these findings, an urgent review was advised. Diagnosis/ Discussion/ Treatment/ Follow up The patient was referred to have a contrast-enhanced CT scan of the whole body which confirmed the presence of a large heterogeneous mass replacing the head and body of pancreas. The mass was seen to have a cystic/ necrotic component. Suggestive of a pancreatic tumour (Acute Pancreatitis). However, the patient’s blood results and clinical evaluation were more inflammatory than tumoral. The patient had ERCP, cytology, and endoscopic ultrasound (EUS), which aided the diagnosis of acute pancreatitis. A follow up whole body CT scan 3 months post treatment confirmed resolution of the pancreatic collection in keeping with chronic (acute Pancreatitis) pancreatitis. Sonograms A heterogeneous cystic mass at the head of pancreas (HOP) CDI of the HOP mass Free fluid in the hepatorenal pouch of Morrison Sludge in the lumen of the thin-walled gallbladder An initial CT (coronal slice) of the abdomen showing the mass in the region of the pancreatic head One year later CT showed the inflammatory mass (pancreatitis confirmed on EUS) in the pancreatic area has reduced post treatment
Multiple Biliary Calculi Clinical History A 76-year old man presented with abdominal pain, vomiting, and jaundice. His blood test showed raised infection markers and deranged LFTs. Abdominal ultrasound was requested as the first line of imaging. Case Description Ultrasound revealed multiple large calculi within the lumen of the dilated common bile duct (multiple biliary calculi) measuring 12 mm in AP dimension. The gallbladder was thick-walled and contained some tiny calculi within its lumen. Diagnosis/ Discussion/ Treatment/ Follow up The patient had magnetic resonance cholangiopancreaticography (MRCP) which confirmed the ultrasound findings. Sonograms Thick-walled gallbladder Axial sonogram of the thick-walled gallbladder Dilated common bile duct containing multiple oval-shaped echogenic structures Dilated common bile duct containing multiple oval-shaped echogenic structures MRCP; coronal image showing the dilated CBD containing multiple filling-defects Multiple oval-shaped structures within the lumen of the CBD
Calculus Within the Common Bile Duct Causing Biliary Obstruction Clinical History A 49-year old man presented with abdominal pain. Case Description An abdominal ultrasound was done using a 2 – 5 MHz curvilinear transducer. This revealed multiple calculus within the common bile duct and another calculus within the lumen of the collapsed gallbladder. These findings were also confirmed on MRCP done afterwards. Diagnosis/ Discussion/ Treatment/ Follow up The patient had ERCP and cholecystectomy. Sonograms Sonogram of the pancreas showing the head, body, and uncinate process of the pancreas. The pancreatic tail is partly obscured by bowel gas shadowing. A short segment of the left hepatic lobe and duodenum are displayed anterior to the pancreas. No pancreatic duct dilatation An obstructive calculus in the common bile duct. The calculus measures 11 mm and the common bile duct measures 10 mm in AP calibre A 10 mm immoble calculus at the neck of the nearly empty gallbladder
Soft Tissue Articles Haematoma Soft Tissue Mass Haematoma Subpectoral Haematoma Clinical History A 78-year old lady presented with swelling and bruising on her left arm secondary to a recent fall. Patient is on Apixaban for an underlying heart condition, however, the recent blood results revealed a sudden drop in haemoglobin, which led the clinicians to withhold the apixaban medication. Also a cardiac pacemaker was recently inserted. Case Description Ultrasound revealed an 8 cm heterogeneous hypoechoic non-vascular area in the intramuscular layer of the anterior chest region, posterior to the pectoralis muscle. Appearances suggested an intramuscular (subpectoral haematoma) haematoma. Diagnosis/ Discussion/ Treatment/ Follow up The patient had CT which confirmed the findings. Sonograms B-mode sonogram, acquired using a 9 MHz linear transducer, showing the subpectoral haematoma B-mode sonogram showing the subpectoral haematoma B-mode sonogram, acquired using a 12 MHz linear transducer, showing the subpectoral haematoma Axial CT of the chest showing the subpectoral haematoma Soft Tissue Mass Lower Leg Soft Tissue Lesion with Concerning Ultrasound Features Clinical History A 72-year old mass presented with pain and swelling to the left calf. An initial Doppler ultrasound was requested to assess for DVT. Case Description Ultrasound ruled out DVT. However, during the examination, the sonographer could palpate a lump below the patient’s calf. This corresponded to a 3 cm oval-shaped well-defined heterogeneous vascular lesion in the deep subcutaneous compartment. Further evaluation with MRI was recommended. Diagnosis/ Discussion/ Treatment/ Follow up The patient declined having an MRI or any other studies in relation to this. Sonograms B-mode sonogram of an oval-shaped mass in the deep subcutaneous layer of the right lower leg Colour Doppler imaging of the oval-shaped deep subcutaneous mass showing a significant amount of internal vascularity B-mode virtual convex view of the deep subcutaneous mass showing some compression effect on the adjacent muscle fibres B-mode sonogram of the mass with measurement callipers Power Doppler imaging of the mass again showing a significant amount of vascularity within the mass
An Obstructive Calculus in the Common Bile Duct Clinical History A 61 year old lady presented with an acute onset of epigastric pain and loss of appetite. The patient is known to have uncomplicated cholelithiasis which was diagnosed 2 decades ago. Presently, the bloods revealed raised alkaline phosphatase of 200. Case Description Abdominal ultrasound revealed a distended gallbladder with multiple calculi. There was also intra and extrahepatic biliary dilatation present. The common bile duct measured 15 mm in AP calibre with a calculus (obstructive calculus) seen towards the distal end of the lumen. However, the pancreatic duct was not dilated. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound findings were confirmed on a subsequent MRCP. Sonograms The right hepatic lobe showing dilatation of the IHD and CBD Longitudinal section of the gallbladder containing multiple tiny calculi An obstructive calculus in the distal CBD
An Incidental Diagnosis of Splenic Haemangioma Clinical History A 75-year old lady was referred to have an ultrasound of the urinary tract due to some evidence of frank haematuria. Case Description Although ultrasound did not reveal any renal or bladder lesion, while examining the left kidney, a 16 mm hypoechoic lesion was discovered within the spleen. The lesion had a uniformly roundish outline with some evidence of internal vascularity. Ultrasound features were suggestive of a splenic haemangioma. Diagnosis/ Discussion/ Treatment/ Follow up The ultrasound findings were confirmed on a subsequent CT. Splenic haemangiomas are some of the most commonly encountered splenic lesions on ultrasound. They are benign slow-growing tumours of the spleen. Due to their nature, they contain evidence of vascular enhancement on imaging. Sonograms Splenic haemangioma B-mode Splenic haemangioma showing the measurement callipers CDI showing the splenic haemangioma with some evidence of internal vascularity Axial CT scan showing the splenic haemangioma with evidence of enhancement Keywords
