Normal Appearances Articles Normal Abdominal Ultrasound Normal Abdominal UltrasoundClinical HistoryA 30-year old female presented with an acute onset of abdominal pain on the right.Case DescriptionAn abdominal ultrasound was requested.Diagnosis/ Discussion/ Treatment/ Follow-upThe patient was managed conservatively, and the symptoms resolved spontaneously over time.SonogramsPancreasAbdominal aortaLeft lobe liver in longitudinal orientationLeft lobe liver in transverse orientationRight lobe liver in transverse orientationRight lobe liver in longitudinal orientation Patent portal vein showing hepatopetal (antegrade) flowRight kidneyA thin-walled gallbladderCommon bile ductLeft kidneySpleen
Complicated Appendicitis Articles Acute Complicated Appendicitis in a 31-year Old Male Acute Complicated Appendicitis in a 31-year Old MaleClinical HistoryA 31-year old presented with 1 day history of central abdominal pain radiating to the right iliac fossa. Raised WCC and CRP.Case DescriptionThe 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 UpThe 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.SonogramsLongitudinal section of the inflamed appendix in the RIFTransverse section of the inflamed appendix in the RIFPower Doppler imaging showing evidence of vascularity within the wall of the inflamed appendixPower Doppler imaging 2A tiny calcific focus within the inflamed appendix, suggestive of an appendicolith
UTI in a Paediatric PatientClinical HistoryA 14-year old boy presented with long-standing recurrent UTI symptoms with some fever.Case DescriptionUltrasound 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 upThe patient was placed on antibiotics therapy which helped resolve the symptoms.SonogramsA distended urinary bladder showing an increased wall thickness. Note the numerous debris within the bladder lumenA dual-screen image of the bladder volume measurementThickening of the left ureteric orifice (transverse orientation) appearing as an echogenic protrusion into the bladder lumenThickening of the left ureteric orifice (longitudinal orientation) appearing as an echogenic protrusion into the bladder lumenBladder jet from the left ureteric orifice indicating a lack of obstruction in the bladder inletA dual-screen image of the bladder showing b-mode and colour Doppler simultaneously. Good bladder jets were recorded from both right and left ureteric orificesLeft kidney transverse view showing thickness of the urotheliumAxial left kidney showing urothelial thickeningPost void with a significant amount of post void residual bladder volume of 105 ml
Appendix Articles Complicated Appendicitis Perforated Appendicitis Complicated Appendicitis Acute Complicated Appendicitis in a 31-year Old MaleClinical HistoryA 31-year old presented with 1 day history of central abdominal pain radiating to the right iliac fossa. Raised WCC and CRP.Case DescriptionThe 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 UpThe 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.SonogramsLongitudinal section of the inflamed appendix in the RIFTransverse section of the inflamed appendix in the RIFPower Doppler imaging showing evidence of vascularity within the wall of the inflamed appendixPower Doppler imaging 2A tiny calcific focus within the inflamed appendix, suggestive of an appendicolith Perforated Appendicitis Complicated Appendicitis with PerforationsClinical HistoryA 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 DescriptionUltrasound 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 upThe patient had an emergency appendectomy and the surgical specimen analysed histologically confirmed the diagnosis of perforated appendicitis.SonogramsSonogram acquired using a high frequency linear probe showing a heterogeneous hypoechoic structure in the RIFSonogram acquired using a curvilinear probe showing a heterogeneous hypoechoic structure in the RIFSonogram acquired using a curvilinear probe showing a heterogeneous hypoechoic structure in the RIFPower Doppler showing no evidence of vascularitySonogram acquired using a high frequency linear probe showing a heterogeneous hypoechoic structure in the RIFPanoramic view of the RIF
Uterine/Uterus Articles Septate Uterus Haematometra Septate Uterus Müllerian Duct Abnormality 2-D UltrasoundClinical HistoryA 45-year old female presented with lower abdominal pain. Transabdominal and Transvaginal ultrasound of the pelvis was requested for further assessment. Case DescriptionMullerian 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 upNo treatment was required at the time.SonogramsBicornuate uterus transvaginal USSBicornuate uterus TVUSSBicornuate uterusBicornuate uterus anterior hornBicornuate uterus posterior hornBicornuate uterus transverse view Haematometra Haematometra Presenting as Pelvic PainClinical HistoryA 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 DescriptionUltrasound 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 upThe patient had an MRI of the pelvis which confirmed the haematometra to be caused by a scar. The collection was drained surgically.SonogramsTransabdominal sonogram of the uterus showing the hypoechoic structure in the endometrial cavityTransvaginal sonogram of the uterus showing the hypoechoic structure in the endometrial cavityTransvaginal sonogram in an axial orientation showing the hypoechoic structure in the endometrial cavityThe distended endometrial cavity with its measurementsSagittal MRI of the uterus showing the distended endometrial cavity with a possible adhesion towards the internal Os
Occluded Popliteal ArteryClinical HistoryAn 80-year old man with metastatic bowel cancer presented with a sudden onset of right leg swelling.Case descriptionAn 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 upThe patient was referred to the vascular team for further management.SonogramsOccluded popliteal artery with arrowColor 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 Articles Occluded Popliteal Artery Popliteal Artery Occlusion Co-existing with Popliteal Vein DVT Occluded Popliteal ArteryClinical HistoryAn 80-year old man with metastatic bowel cancer presented with a sudden onset of right leg swelling.Case descriptionAn 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 upThe patient was referred to the vascular team for further management.SonogramsOccluded popliteal artery with arrowColor 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 DVTClinical HistoryA 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 DescriptionUltrasound 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 upThe patient was referred urgently to vascular surgery for further management. Unfortunately, the patient passed awaySonogramsPatent right common femoral arteryPartially 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 arteryPatent right popliteal arteryOccluded 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
Acute Complicated Appendicitis in a 31-year Old MaleClinical HistoryA 31-year old presented with 1 day history of central abdominal pain radiating to the right iliac fossa. Raised WCC and CRP.Case DescriptionThe 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 UpThe 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.SonogramsLongitudinal section of the inflamed appendix in the RIFTransverse section of the inflamed appendix in the RIFPower Doppler imaging showing evidence of vascularity within the wall of the inflamed appendixPower Doppler imaging 2A tiny calcific focus within the inflamed appendix, suggestive of an appendicolith
Hepatic/Liver Articles Normal Appearances Bladder Mass with Liver Metastasis Hepatic Haemangioma Normal Transplant Liver Transplant Liver Collection Normal Appearances Normal Abdominal UltrasoundClinical HistoryA 30-year old female presented with an acute onset of abdominal pain on the right.Case DescriptionAn abdominal ultrasound was requested.Diagnosis/ Discussion/ Treatment/ Follow-upThe patient was managed conservatively, and the symptoms resolved spontaneously over time.SonogramsPancreasAbdominal aortaLeft lobe liver in longitudinal orientationLeft lobe liver in transverse orientationRight lobe liver in transverse orientationRight lobe liver in longitudinal orientation Patent portal vein showing hepatopetal (antegrade) flowRight kidneyA thin-walled gallbladderCommon bile ductLeft kidneySpleen Bladder Mass with Liver Metastasis Bladder TumourClinical HistoryA 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 DescriptionUltrasound 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-upUnfortunately, the patient passed away.SonogramsLeft lobe of the liver in a longitudinal orientation with multiple hypoechoic lesionsLeft lobe of the liver in a transverse orientation showing multiple hypoechoic lesionsRight lobe of the liver containing multiple lesions, and showing the portal veinThe portal vein on colour Doppler imaging showing normal hepatopetal flowSonogram of the partly filled urinary bladder showing a bladder wall mass Hepatic Haemangioma Focal Hepatic LesionClinical HistoryA 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 calculiCase DescriptionUltrasound 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-upSince 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.SonogramsLeft hepatic lobe showing a 2.5 cm echogenic lesionColour Doppler imaging showing no evidence of flow within the lesion in the left hepatic lobeB-mode ultrasound showing the echogenic lesion in the left hepatic lobeAxial 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 LiverClinical HistoryA 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 DescriptionUltrasound 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-upThe 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.SonogramsLongitudinal view of the left hepatic lobe showing the caudate lobe Spectral Doppler of the right hepatic veinTransverse view of the transplant liver showing the hepatic veins in B-modeMiddle hepatic veinLeft hepatic veinMain portal veinHepatic arteryHepatic artery showing the Doppler ultrasound values Transplant Liver Collection Abnormal Intrahepatic Collection of a Liver TransplantClinical HistoryA 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 DescriptionUltrasound 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-upTriple-phase liver CT confirmed the presence of branching fluid attenuation in the right hepatic lobe in keeping with collections.The hepatic collection was drained.SonogramsRight lobe liver with a heterogeneous collectionCDI right lobe liver showing the collection adjacent to the hepatic veinsCDI right lobe liver showing the hepatic collection adjacent to the hepatic veinsCDI RLL showing the hepatic collection adjacent to the main portal veinSpectral Doppler of the patent hepatic veinMicrovascular imaging (MVI) showing the patent hepatic veins adjacent to the hepatic collectionAxial CT showing the hepatic collectionCoronal CT showing the hepatic collectionAxial CT post pigtail drain insertionIntrahepatic collection in the transplant liverKeywords
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 ManPatient HistoryA 75-year old man presented with macroscopic haematuriaCase DescriptionThe 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 UpThe patient had a follow up CT scan which confirmed the findings. The bladder calculus was removed transurethral.SonogramsTransverse section of the well-filled urinary bladder containing a calculusA 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 lumenA longitudinal image of the right kidney showing a 6 mm calculus at its lower poleA transverse image of the right renal lower pole showing the calculusA 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 ManPatient HistoryA 75-year old man presented with macroscopic haematuriaCase DescriptionThe 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 UpThe patient had a follow up CT scan which confirmed the findings. The bladder calculus was removed transurethral.SonogramsTransverse section of the well-filled urinary bladder containing a calculusA 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 lumenA longitudinal image of the right kidney showing a 6 mm calculus at its lower poleA transverse image of the right renal lower pole showing the calculusA transverse image of the right renal lower pole with colour Doppler imaging, showing twinkling artefact
Normal Abdominal UltrasoundClinical HistoryA 30-year old female presented with an acute onset of abdominal pain on the right.Case DescriptionAn abdominal ultrasound was requested.Diagnosis/ Discussion/ Treatment/ Follow-upThe patient was managed conservatively, and the symptoms resolved spontaneously over time.SonogramsPancreasAbdominal aortaLeft lobe liver in longitudinal orientationLeft lobe liver in transverse orientationRight lobe liver in transverse orientationRight lobe liver in longitudinal orientation Patent portal vein showing hepatopetal (antegrade) flowRight kidneyA thin-walled gallbladderCommon bile ductLeft kidneySpleen
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 MRIClinical HistoryA 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 DescriptionUltrasound 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 upThese findings were confirmed by an outpatient contrast CT scan of the urinary tract carried out months later.SonogramsA right parapelvic renal cyst B-ModeA right parapelvic renal cyst colour Doppler ImagingAn axial CT scan post-ultrasound confirming the right parapelvic cyst to be a Bosniak 1 categoryA 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 SymptomsClinical HistoryA 48-year old man presented with UTI symptoms.Case DescriptionUltrasound 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 upThe patient’s symptoms were managed with the appropriate antibiotic therapy.SonogramsSonogram 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 posteriorlyLeft moiety of the horseshoe kidneyRight moiety of the horseshoe kidneyCT scan of the horseshoe kidney Normal Transplant Kidney Normal Ultrasound Assessment of the Renal AllograftClinical HistoryA 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 DescriptionThe renal allograft appeared normal in size, outline, echotexture, and perfusion with no evidence of renal artery stenosis encountered.Diagnosis/ Discussion/ Treatment/ Follow upThe 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.SonogramsB-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 graftPower Doppler imaging of the normal transplant kidney showing excellent perfusion of the graftColour Doppler imaging of the transplant renal artery showing the point of anastomosis with the left external iliac arterySpectral 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 anastomosisSpectral Doppler imaging of the transplant renal arterySpectral Doppler of the segmental artery within the transplant kidney Spectral Doppler of the intrarenal artery at the lower poleSpectral Doppler of the intrarenal artery at the interpolar region of the graftSpectral Doppler of the intrarenal artery at the upper pole Renal Cell Carcinoma Renal Cell CarcinomaClinical HistoryA 55-year old man presented with symptoms of frank haematuria.Case DescriptionRenal ultrasound revealed a 5.4 cm heterogeneous vascular lesion in the midpole of the right kidney.Diagnosis/Discussion/Treatment/ Follow upThe 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.SonogramsB-mode longitudinal view of the right renal massRight renal mass in b-modeRight renal mass in axial orientationCDI right renal mass showing some internal vascularityAxial CT scan of the right renal massPost right nephrectomy coronal CT scanPost right nephrectomy axial CT An Incidental Finding of an Asymptomatic Renal MassClinical HistoryA 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 DescriptionUltrasound revealed a 5 cm heterogeneous echogenic mass in the right kidney with some evidence of vascularity within it.Diagnosis/ Discussion/ Treatment/ Follow upA 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).SonogramsRight renal mass with callipersRight renal mass longitudinal viewCDI right renal mass with some internal vascularityNormal left kidneyCoronal CT showing the right renal mass Renal Subcapsular Haematoma Subcapsular HaematomaClinical HistoryA 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 DescriptionUltrasound 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 upThe 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 settingsSonogramsB-mode left kidney with a subcapsular haematomaLeft renal subcapsular haematoma with measurement callipersCDI showing some normal intrarenal vessels but no flow in the haematomaCoronal CT scan showing the left renal subcapsular haematomaFollow up ultrasound of the left kidney showing resolved haematoma after 4 monthsB-mode ultrasound showing what is left of the resolved left renal subcapsular haematoma
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 PainPatient HistoryA 26-year old female presented with pelvic pain. The patient had a history of cystectomy.Case DescriptionUltrasound 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 UpThe patient was managed conservatively and the cyst resolved over time as it was no longer present on subsequent scans a year later.SonogramsTransabdominal view of the right ovarian cystTransvaginal view of the right ovarian haemorrhagic cystTransvaginal 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 transvaginallyRight 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 PainPatient HistoryA 26-year old female presented with pelvic pain. The patient had a history of cystectomy.Case DescriptionUltrasound 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 UpThe patient was managed conservatively and the cyst resolved over time as it was no longer present on subsequent scans a year later.SonogramsTransabdominal view of the right ovarian cystTransvaginal view of the right ovarian haemorrhagic cystTransvaginal 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 transvaginallyRight 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
A Large Complex Ovarian Cyst Mimicking a FibroidClinical HistoryA 54-year old lady presented with a large mass in the centre of the lower abdomen mimicking a fibroid.Case DescriptionUltrasound 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 upTotal abdominal hysterectomy and bilateral salpingo-oophorectomy was performed and the cyst was analysed histologically. Histology revealed the lesion to be a benign mucinous cystadenoma.SonogramsTransabdominal ultrasound showing the large complex cyst in the pelvisTransvaginal ultrasound showing the complex cyst in the pelvisTransvaginal ultrasound showing the complex cyst in the pelvisColour Doppler imaging of the complex cyst in the pelvisSagittal MRI of the complex cyst in the pelvisCoronal CT of the large pelvic complex cyst
Müllerian Duct Abnormality 2-D UltrasoundClinical HistoryA 45-year old female presented with lower abdominal pain. Transabdominal and Transvaginal ultrasound of the pelvis was requested for further assessment. Case DescriptionMullerian 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 upNo treatment was required at the time.SonogramsBicornuate uterus transvaginal USSBicornuate uterus TVUSSBicornuate uterusBicornuate uterus anterior hornBicornuate uterus posterior hornBicornuate uterus transverse view
Abscess and Collection Articles Left Groin Abscess Left Groin AbscessClinical HistoryA 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 DescriptionThe 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 upThe 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.SonogramsPower Doppler imaging showing no evidence of vascularity within the groin abscessB-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 surfaceA coronal MRI image of the groin showing the large collection in the upper and medial aspect of the left thigh
Subpectoral HaematomaClinical HistoryA 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 DescriptionUltrasound 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 upThe patient had CT which confirmed the findings.SonogramsB-mode sonogram, acquired using a 9 MHz linear transducer, showing the subpectoral haematomaB-mode sonogram showing the subpectoral haematomaB-mode sonogram, acquired using a 12 MHz linear transducer, showing the subpectoral haematomaAxial CT of the chest showing the subpectoral haematoma
Haematoma Articles Subpectoral Haematoma Subpectoral HaematomaClinical HistoryA 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 DescriptionUltrasound 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 upThe patient had CT which confirmed the findings.SonogramsB-mode sonogram, acquired using a 9 MHz linear transducer, showing the subpectoral haematomaB-mode sonogram showing the subpectoral haematomaB-mode sonogram, acquired using a 12 MHz linear transducer, showing the subpectoral haematomaAxial CT of the chest showing the subpectoral haematoma
An Extratesticular Intrascrotal Right Epidermoid CystClinical HistoryA 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 DescriptionUsing 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 upThe 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.SonogramB-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
Post-laparoscopic Port site or Incisional HerniaClinical HistoryA 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 DescriptionAn 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-upPatient had the hernia repaired.SonogramsPort site hernia, image acquired using a low frequency curvilinear transducerPort 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 transducerPort site herniaPower Doppler showing no evidence of vascularity within the protruding mesenteric fat, as would be expected
Endometrial polyp Articles Endometrial Polyp in an 80-Year Old Endometrial Polyp Presenting as Painful Heavy Menstrual Bleeding Endometrial Polyp in an 80-Year OldClinical HistoryAn 80-year old lady presented with abdominal bloating and discomfort. Case DescriptionAn 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 upThe polyp was surgically removed and the specimen was histologically examined which confirmed the ultrasound findings.Sonograms2-D, B-mode transvaginal ultrasound showing the large endometrial polyp with some fluid within the endometrial cavityEndometrial polyp with measurement callipersEndometrial 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 BleedingClinical HistoryA 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 DescriptionTransvaginal 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 upThe patient was referred to gynaecology where she had hysteroscopy to confirm the polyp prior to its removal (polypectomy)SonogramsTransvaginal B-mode sonogram of the endometrium showing the oval-shaped polypPDI image of the endometrial polyp showing the feeder vesselEndometrium
Endometrial Polyp in an 80-Year OldClinical HistoryAn 80-year old lady presented with abdominal bloating and discomfort. Case DescriptionAn 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 upThe polyp was surgically removed and the specimen was histologically examined which confirmed the ultrasound findings.Sonograms2-D, B-mode transvaginal ultrasound showing the large endometrial polyp with some fluid within the endometrial cavityEndometrial polyp with measurement callipersEndometrial 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
Septate Uterus Articles Müllerian Duct Abnormality 2-D Ultrasound Müllerian Duct Abnormality 2-D UltrasoundClinical HistoryA 45-year old female presented with lower abdominal pain. Transabdominal and Transvaginal ultrasound of the pelvis was requested for further assessment. Case DescriptionMullerian 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 upNo treatment was required at the time.SonogramsBicornuate uterus transvaginal USSBicornuate uterus TVUSSBicornuate uterusBicornuate uterus anterior hornBicornuate uterus posterior hornBicornuate uterus transverse view
Left Groin AbscessClinical HistoryA 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 DescriptionThe 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 upThe 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.SonogramsPower Doppler imaging showing no evidence of vascularity within the groin abscessB-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 surfaceA coronal MRI image of the groin showing the large collection in the upper and medial aspect of the left thigh
A Large Adnexal Mass in a Patient with Endometrial CancerClinical HistoryA 74-year old lady presented with abdominal distension and discomfort.Case DescriptionUltrasound 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 upThe 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.SonogramsTransabdominal view of the pelvis showing a 131 mm x 68 mm (L x AP) heterogeneous cystic mass in the left adnexaTransvaginal 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 vascularityPDI of the left adnexal cystic massFree fluid in the right upper quadrant in keeping with ascitesAscites in the left upper abdominal quadrant adjacent to the spleen; subphrenic and within the splenorenal recessAscites in the LUQAxial CT showing the cyst in the LIFSagittal CT showing the left adnexal cystic mass herniating into the left inguinal canal
Transitional Cell Carcinoma of the Urinary BladderClinical HistoryA 74-year old man presented with painless frank haematuria.Case DescriptionUltrasound 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 upThe 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.SonogramsB-Mode ultrasound showing the mass in the posterolateral wallLongitudinal view of the bladder mass in the posterior bladder wallColour Doppler Imaging of the bladder mass showing some internal vascularityCDI showing evidence of right ureteric jets adjacent to the bladder mass. Evidently, no ureteric obstruction caused by the bladder massCDI showing ureteric jets bilaterallyNormal right kidneyNormal left kidney
Cancer of the Fallopian Tube Articles Fallopian Tube Cancer Fallopian Tube CancerClinical HistoryA 67-year old lady presented with severe lower abdominal pain with some change in bowel habit and loose stool.Case DescriptionThe 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 upThe patient had laparotomy which revealed the mass to be a stage II HGS cancer of the fallopian tube.SonogramsTVUSS showing a mass with cystic and solid component in the mid pelvis. The mass is a Stage II HGS cancer of the left fallopian tubeColour Doppler imaging of the mass showing some active flow within the solid componentTriplex studies evaluation of the pelvic mass using b-mode, CDI, and spectral DopplerFree fluid in the rectouterine pouch of Douglas
Fallopian Tube CancerClinical HistoryA 67-year old lady presented with severe lower abdominal pain with some change in bowel habit and loose stool.Case DescriptionThe 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 upThe patient had laparotomy which revealed the mass to be a stage II HGS cancer of the fallopian tube.SonogramsTVUSS showing a mass with cystic and solid component in the mid pelvis. The mass is a Stage II HGS cancer of the left fallopian tubeColour Doppler imaging of the mass showing some active flow within the solid componentTriplex studies evaluation of the pelvic mass using b-mode, CDI, and spectral DopplerFree fluid in the rectouterine pouch of Douglas
An Ovarian Tumour with an Initial Presentation of RIF PainClinical HistoryA 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 DescriptionUltrasound (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 upThe 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.SonogramsTVUSS showing a cystic mass in the right adnexa with some solid componentsPDI of the right adnexal complex cystic mass showing some internal vascularityB Mode showing the right adnexal mass with its cystic componentAxial CT image of the right adnexal complex cystic massT1 axial MRI of the right adnexal mass
Ultrasound Appearances of Polycystic OvariesClinical HistoryA 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 DescriptionUltrasound (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 upAlthough 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 womanA 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
