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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
6.8 Edema
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Table 20.Differential diagnosis of edema – continued
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Diagnosis Sonographic signs
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Rare
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Myxedema (p. 118)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Acute glomerulonephritis (p. 119)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyy
Atrophic thyroid gland
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyy
Enlarged kidneys, echogenic parenchyma, prominent hypoechoic
medullary pyramids, indistinct boundary between the renal pelvis
and parenchyma
Conditions that cannot be diagnosed with ultrasound
Common: Idiopathic edema, premenstrual symptoms
Less common: Nephrotic syndrome, medications
Rare: Quincke edema, exudative enteropathy, intestinal lymphangiectasia, Whipple disease,
Menetrier syndrome, Cushing syndrome, malabsorption syndrome, beriberi, nutritional
edema, mehlnährschaden, neonatal hemolytic disease
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Localized
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Common
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Lower-extremity or
pelvic venous
thrombosis (p. 120)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Deep lower extremity
varicose veins (p. 121)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Left heart failure (p. 119)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Rare
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Phlegmasia cerulea
dolens (p. 123)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Superior or inferior vena
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyy
Veins are markedly dilated and may contain high-level echoes;
incompressible
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyy
Dilated, compressible veins with abnormal flow patterns
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyy
Pleural effusion; echocardiography: enlarged left ventricle with
diminished output
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyy
Maximally dilated veins, thrombotic material, absence of flow,
incompressible veins
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyy
Dilated vena cava; causative tumor may be visualized
cava syndrome (p. 122)
Conditions that cannot be diagnosed with ultrasound
Common: Post-thrombotic syndrome
Less common Lymphatic forms of edema (elephantiasis nostras [recurrent erysipelas with
obliterative lymphangitis] ), thermal, mechanical, chemical or bacterial capillary damage
Rare: Obliterative lymphangiopathy, lymphedema praecox (Meige disease), congenital
lymphedema (Milroy disease), osteomyelitis, scleronychia syndrome
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
Right Heart Failure
..............................................................................................................
n
See also Ascites, p. 155; Renal Failure, Shock Kidney, p. 124, 136.
n
Scanning tip: During scanning of the upper abdomen, the probe can be angled
cephalad in the mid-upper abdominal transverse plane to display the enlarged
right atrium and the terminal part of the congested inferior vena cava. Generally
the enlarged right ventricle can also be visualized.
117
6.8 Edema
Schmidt, Ultrasound © 2007 Thieme
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6
6
Hepatic Diseases
..............................................................................................................
n
See also Renal Failure, Hepatorenal Syndrome, p. 135; Ascites, Hepatic Cirrhosis,
p. 156, 239; Liver, Hepatic Cirrhosis, pp. 236.
n
Scanning tip: A CDS or power Doppler examination is important for detecting
vascular abnormalities such as venous occlusions, portal vein thrombosis, and
flow reversal due to portal hypertension.
Edema of Pregnancy
..............................................................................................................
n
Clinical manifestations: generalized edema and excessive weight gain during
pregnancy
n
Diagnosis: Exclude other causes such as congestive heart failure, drug effects, deep
lower extremity venous thrombosis, and renal disease. It is particularly important
to recognize impending preeclampsia (proteinuria, blood pressure elevation).
Principal Signs and Symptoms
Principal Signs and Symptoms
n
Sonographic findings :
x
Normal-appearing venous system with good compressibility
x
No fluid collection in anatomical cavities (pleura, intraperitoneal)
x
Normal-appearing kidneys
x
Normal echocardiogram
n
Accuracy of sonographic diagnosis: Simple edema of pregnancy is not accessible
to sonography. Other causes of edema during pregnancy should be excluded, however, and therefore the role of ultrasound is to facilitate a diagnosis by exclusion.
Myxedema (Fig. 161)
..............................................................................................................
n
Clinical manifestations: edema, deepening of the voice, bradycardia, hypothyroid-
ism
n
Diagnosis: elevated TSH, T
n
Sonographic findings :
x
Small, hypoechoic thyroid gland
x
Possible scars and calcification
and T4values, TPO antibodies
3
Fig. 161 Myxedema due to complete
atrophy of the thyroid gland (TG) with
microcalcifications and an acoustic
shadow (S)
118
6.8 Edema
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Acute Glomerulonephritis
..............................................................................................................
n
See also Kidney, p. 269.
n
Clinical manifestations: generalized edema, starting in the periorbital region;
possible ascites and pleural effusion; hematuria, proteinuria (ask about foamy
urine); hypertension
n
Diagnosis:
x
Urinalysis: proteinuria, hematuria, possible erythrocyte and leukocyte casts;
24 hour urine: proteinuria may exceed 3 g/day, blood chemistry, hypalbuminemia (I 2.5 g/dL)
x
Abdominal sonography
x
Chest radiograph: Pulmonary congestion without cardiomegaly, no dyspnea
x
Renal biopsy: Not mandatory, but helpful in establishing the cause
n
Sonographic findings :
x
Bilateral renal enlargement
x
Thickened echogenic parenchyma; may appear less echogenic in other acute
forms of nephritis, depending on the extent of inflammatory edema
x
Prominent hypoechoic medullary pyramids
x
Narrowing of the central echo complex
x
Possible local tenderness to probe pressure
x
Indistinct boundary between the renal pelvis and parenchyma
x
Possible posterior acoustic shadow, depending on edema
x
Possible perirenal fluid
n
Accuracy of sonographic diagnosis: The sonographic changes in acute nephritis
are clearly defined. Ultrasound cannot establish the cause of an episode of acute
nephritis, however.
Left Heart Failure (Figs. 162 and 163)
..............................................................................................................
n
See also Pleura, Transudative Effusion, p. 405.
n
Clinical manifestations : dyspnea, poor exercise tolerance, possible angina pec-
toris. Other clinical signs depend on the cause: hypertension, valvular disease, etc.
n
Diagnosis:
x
History, physical examination: Acute event? Pulmonary edema, dullness? Blood
pressure
x
Laboratory tests: simple blood count, CK, CKMB, GOT, AP, electrolytes, creatinine, ESR
x
ECG; chest radiograph
x
Abdominal sonography; echocardiography
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
Fig. 162 Left heart failure, CDS: apical
left ventricular aneurysm following a
myocardial infarction with a mural
thrombus (arrow)
119
6.8 Edema
Schmidt, Ultrasound © 2007 Thieme
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6
6
ab
Fig. 163 a, b Pleural effusion. a Pleural effusion (PE) on the left side with
pulmonary atelectasis (PA) due to compression. S = spleen. b Pleural effusion (PE)
on the right side with a fibrin strand (arrow). L = liver
Principal Signs and Symptoms
Principal Signs and Symptoms
n
Sonographic findings :
x
Pleural sonography: anechoic mass above the diaphragm, often more on the
right side than on the left, as a sign of pleural effusion
– Occasional floating echogenic bands (fibrin strands) in long-standing effu-
sions
– Echogenic, less mobile, denser-appearing structures (lung tissue) may sig-
nify areas of pulmonary atelectasis
x
Signs of right heart failure in patients who already have long-standing left heart
failure
x
Echocardiography: enlarged left ventricle with impaired pumping action; a
valvular defect may be detectable as the cause; possible signs of hypertensive
heart disease (impaired diastolic pumping action, left ventricular hypertrophy)
n
Accuracy of sonographic diagnosis: Left heart failure can be diagnosed sonogra-
phically with 100 % accuracy on the basis of pleural sonography and echocardiography. Further studies are needed to establish the cause.
Venous Thrombosis of the Pelvis and Lower Extremity
(Figs. 164 and 165)
..............................................................................................................
n
See also Vena Cava and Peripheral Veins, p. 210.
n
Clinical manifestations: lower extremity swelling, usually confined to one leg;
more common on the left side than on the right (the left iliac vein passes below
the iliac artery and is compressed); usually painful; minimally pitting edema
n
Diagnosis:
x
History: mobility, underlying diseases; ask about symptoms of possible sequelae (e.g., persistent mild cough due to pulmonary embolism, chest pain on
respiration)
x
Laboratory tests: simple blood count with HCT, coagulation parameters and
D-dimers; serum and EDTA blood may be frozen for later coagulation studies
x
Lower extremity venous sonography: more details with CDS; the veins of the
lower leg are examined in the sitting position
x
Abdominal sonography
x
Conventional venography of the lower extremity may be necessary in equivocal
cases.
!
Caution: It is also important to look for an unknown tumor that may have
120
caused the thrombosis.
6.8 Edema
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Fig. 165 Partially occlusive thrombus
(T) in the popliteal vein. The popliteal
artery is posterior to the popliteal vein
Fig. 164 Thrombosis of the common
femoral vein, CDS: partially occlusive
thrombus (TH) in the dilated femoral
vein (FV) located at the termination of
the long saphenous vein (LSV)
n
Sonographic findings :
n
Markedly dilated veins; the venous caliber is twice that of the accompanying
artery (with a fresh thrombosis)
n
High-level internal echoes (thrombus) may be noted:
– Floating or adherent to the vessel wall
– Appears as an intraluminal flow void or distributed along the wall
x
Affected veins show little or no compressibility.
n
Accuracy of sonographic diagnosis:
x
Venous sonography is easy to learn, and the upper leg veins can be accurately
evaluated by an experienced examiner. Thrombosis in this region can be
detected or excluded with a high degree of confidence. Thrombosis in the abdomen, lesser pelvis, and lower leg can be clearly visualized, but it is difficult to
distinguish between acute and chronic thrombosis below the knee.
x
If there is a high index of clinical suspicion for thrombosis but ultrasound findings are equivocal, conventional venography is indicated (see p. 213). This
study may also be inconclusive, however, especially at the pelvic level because
of insufficient opacification of the veins.
Deep Varicose Veins of the Leg (Fig. 166)
..............................................................................................................
n
Clinical manifestations: increased superficial venous markings; feeling of tension
or aching tightness rather than actual pain; swelling of the legs, aggravated by
prolonged standing and worse at night
n
Diagnosis:
x
History, clinical examination
x
Venous sonography; Doppler sonography of the veins (to detect saphenofemoral incompetence)
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
121
6.8 Edema
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6
6
b
Fig. 166a, b Varicose veins. a Dilated
popliteal vein (PV) and short saphenous
Principal Signs and Symptoms
Principal Signs and Symptoms
a
vein (SSV) with high-level internal
echoes; termination of the short saphenous vein at the popliteal vein (arrow).
b Testing of valvular competence and
measurement of reflux time
n
Sonographic findings :
x
Dilated veins
x
Good compressibility
x
Abnormal flow characteristics
n
Accuracy of sonographic diagnosis: same as in the diagnosis of deep venous
thrombosis of the lower extremity
Superior or Inferior Vena Cava Syndrome (Figs. 167 and 168)
..............................................................................................................
n
See also Liver, Chronic Portal Vein Thrombosis, p. 246; Search for Occult Tumors,
displacement, fixation, infiltration, p. 449.
n
Clinical manifestations: signs of global heart failure due to decreased venous
return to the heart: dyspnea, tachycardia, hypotension; edema distal to the
caval obstruction
ab
Fig. 167a, b Inferior vena cava syndrome: retroperitoneal sarcoma (T)
compressing the vena cava (VC)
122
6.8 Edema
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Fig. 168 Compression of the inferior
vena cava by hepatic metastases
n
Diagnosis:
n
Note: It is essential to consider the possibility of this diagnosis.
x
Abdominal sonography
x
Search for an occult tumor
n
Sonographic findings :
x
Dilated vena cava
x
A tumor can usually be detected as the cause of the obstruction:
– Metastasis or primary tumor causing extrinsic compression
– Intraluminal tumor extension
n
Accuracy of sonographic diagnosis: Generally this syndrome is easy to diagnose
with ultrasound. CT and FNAB should also be carried out to evaluate treatment
options (chemotherapy, radiotherapy, etc.).
Phlegmasia cerulea dolens
..............................................................................................................
n
Clinical manifestations: fulminating form of deep venous thrombosis marked by
extremely painful swelling of the extremity (all veins obstructed). The limb is cold
and livid as a result of arterial compression.
n
Diagnosis:
x
Clinical examination
x
Venous sonography to define the outflow tract and locate the cause of the
obstruction
n
Sonographic findings :
x
Maximally dilated veins
x
CDS: absence of detectable flow
x
Incompressible veins
n
Accuracy of sonographic diagnosis: The diagnosis is based on the combination of
sonographic and clinical findings.
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
123
6.9 Renal Insufficiency and Acute Renal Failure
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6
6
6.9 Renal Insufficiency and Acute Renal Failure
Basic Principles
..............................................................................................................
n
Principal signs and symptoms: decrease or absence of urinary excretion,
increased solute retention in the blood, possible edema
n
Classification: Renal failure is classified as prerenal, due to diminished renal blood
flow; intrinsic (renal), caused by renal parenchymal damage; and postrenal, due to
blockage of urine flow.
x
Prerenal: fluid deficit
x
Renal: glomerulonephritis (Tables 21 and 22) or interstitial nephritis (Table 23)
x
Postrenal: Can be positively confirmed or excluded by sonography
x
Acquired
x
Congenital
Principal Signs and Symptoms
Principal Signs and Symptoms
Table 21.Classification of glomerulonephritis
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Acute glomerulonephritis
Rapidly progressive glomerulonephritis
Chronic glomerulonephritis (membranous, membranoproliferative, mesangioproliferative)
Thrombotic microangiopathy
Minimal-change nephritis
Table 22.Occurrence of glomerulonephritis
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
In systemic diseases In metabolic diseases
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Wegener granulomatosis
Panarteritis Amyloidosis
Lupus erythematosus
Antiglomerular basement membrane disease
yyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyy
Diabetes mellitus
(Kimmelstiel–Wilson glomerulosclerosis)
Table 23.Classification of interstitial nephritis
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Form of nephritis Causes
yyyyyyyyyyyyyyyyyyyyyyyyy
Bacterial nephritis
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Bacterial infection
Abacterial nephritis Drug-induced
Metabolic
Obstruction
Autoimmune
Other causes: polycystic kidneys, multiple myeloma, sickle
cell anemia, Balkan nephritis, radiation nephritis
124
6.9 Renal Insufficiency and Acute Renal Failure
Schmidt, Ultrasound © 2007 Thieme
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n
Differential diagnoses: Listed in Table 24 according to their frequency in the gen-
eral hospital setting.
Table 24.Differential diagnosis of renal insufficiency
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Diagnosis Sonographic signs
yyyyyyyyyyyyyyyyyyyyyyyyyyyy
Common
yyyyyyyyyyyyyyyyyyyyyyyyyyyy
Fluid deficit (p. 126)
Kimmelstiel–Wilson
glomerulosclerosis
(p. 128)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Collapsed vena cava, empty bladder, normal-appearing kidneys
Kidneys initially enlarged; signs of chronic glomerulonephritis
appear as the disease progresses (see below), followed by signs of
chronic pyelonephritis (see below)
Heart failure (p. 127) Hypoechoic kidney with a thickened parenchymal rim, congested
yyyyyyyyyyyyyyyyyyyyyyyyyyyy
Less common
yyyyyyyyyyyyyyyyyyyyyyyyyyyy
Chronic pyelonephritis
(p. 130)
Chronic glomerulonephritis (p. 128)
Hydronephrosis
(p. 131)
Ureteral obstruction
renal vein
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Small kidney with contour irregularities due to scarring; thin,
echogenic parenchyma; calyces are cystic or ectatic
Diffusely increased echogenicity, loss of corticomedullary differentiation, prominent hypoechoic medullary pyramids
Full bladder, obstructed ureter, dilated pyelocalyceal system,
displaced renal sinus, loss of renal parenchyma
Dilated ureter, possible dilatation of the pyelocalyceal system
(p. 131)
Pyonephrosis (p. 132) Dilated renal collecting system, occasional high-level internal
echoes
Analgesic nephropathy
(p. 133)
Atrophic kidney
(p. 134)
yyyyyyyyyyyyyyyyyyyyyyyyyyyy
Rare
yyyyyyyyyyyyyyyyyyyyyyyyyyyy
Bladder tamponade
(p. 134)
Acute glomerulonephritis (p. 135)
Hepatorenal syndrome
(p. 135)
Poor delineation, irregular increase in parenchymal sonodensity,
papillary tip calcification
Disproportionately small kidney, parenchymal thinning, increased
parenchymal echogenicity
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Full bladder, often with high-level internal echoes (blood, debris,
stone)
Thickened renal cortex, hyperechoic to the prominent medullary
pyramids
Normal-appearing kidneys, ascites, signs of hepatic cirrhosis or
injury
Shock kidney (p. 136) Enlarged kidneys, markedly hypoechoic parenchyma, swollen
medullary pyramids, narrow renal sinus
Renal lithiasis (p. 137) Features vary depending on the location of the stone and duration
of the disease:
– echogenic renal pelvis with an acoustic shadow
– obstructed renal pelvis, shadowing ureteral stone
Antiglomerular
basement membrane
Enlarged, rounded kidney; ill-defined medullary pyramids;
nonhomogeneous echogenic parenchyma
disease (p. 129)
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
125
6.9 Renal Insufficiency and Acute Renal Failure
Schmidt, Ultrasound © 2007 Thieme
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6
6
Table 24.Differential diagnosis of renal insufficiency – continued
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Diagnosis Sonographic signs
yyyyyyyyyyyyyyyyyyyyyyyyyyyy
Renal artery embolism
(p. 129)
Urethral obstruction
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Wedge-shaped echogenic area in the renal parenchyma due to loss
of perfusion
Full bladder; extrinsic compression is usually seen
(p. 131)
Polycystic kidney
Multiple anechoic masses displacing the renal parenchyma
(p. 137)
Renal amyloidosis
Both kidneys enlarged with decreased parenchymal echogenicity
(p. 137)
Medullary nephro-
Principal Signs and Symptoms
Principal Signs and Symptoms
calcinosis (p. 138)
Gouty nephropathy
Markedly echogenic medullary pyramids, possible acoustic shadowing
Small, bulging surface with parenchymal thinning, calculi
(p. 136)
Conditions that cannot be diagnosed with ultrasound
Rare: Calcium oxalate nephritis, Fanconi syndrome (congenital defect of tubular transport),
amino acid diabetes, renal hypochloremic acidosis, renal hypercalcemia (Fanconi syndrome),
potassium loss syndrome (of Albright–Hadorn), salt-losing nephritis (Thorn syndrome), and
many others
Fluid Deficit
..............................................................................................................
n
Classification: prerenal renal failure, due either to a decrease in total fluid volume
or to decreased fluid delivery to the kidneys (perfusion deficit)
n
Clinical manifestations: decrease or absence of urinary excretion, possible somno-
lence, possible fever; signs of low-output syndrome due to heart failure
n
Diagnosis:
x
History: Pay particular attention to the cause of the fluid deficit (decreased
intake, increased losses)
x
Laboratory tests: simple blood count with hematocrit
x
Sonography
x
Echocardiography to investigate a cardiac etiology
x
A central venous catheter may be used to measure CVP for assessing the fluid
deficit. The CVP measurement should be interpreted within the context of
the echocardiography findings. Usually there is no need for right heart catheterization to measure the left ventricular filling pressure.
n
Sonographic findings :
n
Note: Scanning conditions are usually poor because of tissue dryness.
x
Collapsed vena cava with decreased filling of other veins
x
Empty urinary bladder
Renal morphology appears normal on ultrasound.
x
Echocardiography: empty, hyperactive cardiac ventricle due to volume deficit.
Pumping action may be impaired even with a dilated ventricle (forward failure;
in this case the veins are generally congested and the renal parenchyma is
swollen).
n
Accuracy of sonographic diagnosis: The sonographic signs of the fluid deficit are
unmistakable. The resumption of diuresis after fluid loading is confirmatory.
126