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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
10.2 Diffuse Renal Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
10
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b
a
cd
Fig. 382a–d Increased renal echogenicity. a Diabetic nephropathy: Large kidney
(12.5 cm) with prominent hypoechoic medullary pyramids (arrow). b Subacute
glomerulonephritis: Increased cortical echogenicity with very hypoechoic medullary pyramids (arrows). c Renal myeloma, renal insufficiency: Basically the same
features as in a, with an echogenic parenchyma and hypoechoic medullary pyramids (arrows; K = kidney). d Gouty nephropathy: Increased echogenicity of the
medullary pyramids reflects the precipitation of uric acid in the tubules (arrows;
S = acoustic shadows). Patient presented with ubiquitous gouty tophi, hyperuricemia, and mild renal function impairment. Differential diagnosis: medullary
nephrocalcinosis, medullary sponge kidney (tuberulosis)
n
Diabetic nephropathy, early stage (Mogensen stage I–IV; Fig. 382a):
x
Increase in renal volume
x
Hyperechoic parenchyma
x
Prominent hypoechoic medullary pyramids
n
Acute glomerulonephritis (Fig. 382b): Clinical signs include fever, somnolence,
weakness, oliguria, and hypertension.
x
Laboratory findings : elevated creatinine, erythrocyturia, proteinuria
x
Sonographic findings:
– Marked renal enlargement due to parenchymal swelling
– Consequent narrowing of the CEC
– Increased echogenicity
– Prominent hypoechoic medullary pyramids
n
Renal myeloma, renal amyloidosis, gouty nephropathy (Fig. 382c):
x
Significant increase in echogenicity
x
Prominent hypoechoic medullary pyramids
Small Kidneys with Normal Echogenicity
..............................................................................................................
n
Hypoplastic kidney (see Fig. 374a, p. 263) : small kidney with normal parenchy-
mal echogenicity
269
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
10.2 Diffuse Renal Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
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Fig. 383 Hypoplastic kidney (K) due to
renal artery stenosis: Small kidney with
parenchymal thinning. Patient presented clinically with severe hyperten-
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
n
Renal atrophy due to vascular occlusive disease (Fig. 383): Small kidney, usually
showing loss of parenchyma p CDS with determination of RI values (see p. 193)
Small Kidneys with Increased Echogenicity
..............................................................................................................
n
Chronic glomerulonephritis (predialysis, dialysis; Fig. 384): Kidneys are not
decreased in size until the dialysis stage.
x
Increased echogenicity
x
Loss of corticomedullary differentiation
x
Hypoechoic cystic or ill-defined medullary pyramids
sion. S = faint ac oustic shadow
Fig. 384 Chronic glomerulonephritis
(IgA nephropathy requiring dialysis):
Small kidney (cursors) showing
increased echogenicity, loss of corticomedullary differentiation, and a hazy
internal echo pattern
n
Diabetic nephropathy (Fig. 385):
x
Renal size is not decreased until the dialysis stage
x
Parenchymal thinning
x
Increased parenchymal echogenicity
x
Hazy parenchyma with irregular contours
x
Loss of corticomedullary differentiation
x
Loss or cystic transformation of the medullary pyramids
x
CDS: Loss of regional vascularity
x
End stage: Calcification (optional), secondary cysts (optional),
loss of parenchyma
270
10.2 Diffuse Renal Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
ab
Fig. 385a, b Diabetic nephropathy at the dialysis stage. a Small kidney
(K, 91.8 mm long) shows increased echogenicity. Arrow: Medullary pyramid with a
patchy echo pattern. L = liver b CDS prior to dialysis shows very little vascularity
n
Chronic pyelonephritis (Fig. 386):
x
Kidneys often remain normal in size for years and do not shrink until the
advanced stage.
x
Focal echogenic scarring and thinning of the parenchyma accompanied by
hypoechoic areas of hypertrophy
x
Possible calyceal cysts, renal pelvic abscess
n
Analgesic nephropathy (Fig. 387):
x
Irregular, ill-defined contours, poor delineation, irregular parenchymal echogenicity
x
Echogenic papillary microcalcifications
x
Possible secondary retention cysts due to inflammation and scarring
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Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Fig. 386 Decreased renal size in pyelonephritis (83.9 mm, cursors): Foci of
parenchymal thinning due to scarring,
producing a wavy surface contour.
C = flat cyst. Fine-needle aspiration of
a suspected abscess p adrrenal
epithelium
Fig. 387 Analgesic nephropathy (K).
Harmonic imaging shows marked
parenchymal thinning with a hazy
internal echo pattern and fine calcifications projected over the papillary tip
(arrows). Secondary cyst (C)
271
10.3 Circumscribed Changes in the Renal Parenchyma
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
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10.3 Circumscribed Changes in the
Renal Parenchyma
Overview (Table 48):
..............................................................................................................
Table 48.Circumscribed changes in the renal parenchyma
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Anechoic Hypoechoic Isoechoic Echogenic, hyperechoic
yyyyyyyyyyyyyyyyyyyyyyyyyy yyy
Simple cysts (p. 272)
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Polycystic kidneys
(p. 273)
Secondary cysts (p. 274) Renal adenoma
Atypical or complicated
cysts (p. 274)
Obstructive pyelocalyceal ectasia (p. 275)
Cystic renal cell
carcinoma (p. 276)
Benign cystic lymphangioma (p. 275)
Lymphocele (p. 275)
Tuberculosis (p. 275)
Intracystic hemorrhage
(p. 275)
Hematoma (p. 275)
yyyyyyyyyyyyyyyyyyyyyyyyyy
Metastases (p. 276)
Malignant
lymphoma
(see p. 276)
(see p. 277)
Abscess, carbuncle
(p. 277)
Oncocytoma
(p. 278)
yyyyyyyyyyyyyyyyyyyyyyy
Bulge, lobulation
(see p. 278)
Parenchymal
bands (p. 278)
Hematoma
(p. 279)
Renal cell carcinoma (p. 279)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Renal cell carcinoma
(p. 279)
Angiomyolipoma
(p. 279)
Scars (p. 280)
Renal infarction (p. 281)
Medullary nephrocalcinosis (p. 281)
Cortical nephrocalcinosis (see p. 282)
Vascular calcification,
parenchymal calcification (p. 283)
Anechoic Changes in the Renal Parenchyma
..............................................................................................................
n
Simple cysts (Bosniak type I, Fig. 388): dysontogenetic cysts = tubular retention
cysts
x
Classification by location:
– Subcapsular (perirenal) cysts
– Cortical cysts
– Parapelvic cysts of the renal sinus (generally lymphatic cysts, but occasion-
ally tubular retention cysts projecting into the central echo complex)
x
Classification by number:
– Solitary
– Multiple
x
Sonographic criteria:
– Anechoic
– Smooth margins with a thin wall and lateral edge shadowing
– Round shape; parapelvic cysts may also have a flattened or oval shape
272
– Distal acoustic enhancement
10.3 Circumscribed Changes in the Renal Parenchyma
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
10
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ab
cd
Fig. 388a–d Simple renal cysts (C). a Perirenal (subcapsular, “extrarenal”) cyst.
b Cortical cyst. Arrow: orthograde projection of the renal capsule. c Parapelvic cyst.
d CDS of parapelvic cysts shows absence of internal vascularity (this excludes a
tumor). K = kidney
– A fine, echogenic capsule can often be identified in an orthograde projection
(entry and exit echoes).
n
Polycystic kidneys (adult type polycystic kidney disease, see Fig. 389):
x
Clinical features: autosomal dominant mode of inheritance. Renal swelling,
hypertension, and slowly progressive renal failure starting at about 40 years
of age. Often accompanied by a cystic liver. The pediatric form becomes symptomatic at an early age.
ab
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Fig. 389a, b Differentiation of polycystic kidney from multiple renal cysts.
a Multiple renal cysts: The kidney is normal-sized with definable parenchyma.
Arrow: parapelvic cysts. b Polycystic kidney: The kidney is enlarged and poorly
defined with little evidence of residual parenchyma. A central echo complex is
not visualized
273
10.3 Circumscribed Changes in the Renal Parenchyma
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
10
10
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x
Sonographic criteria:
– Small or large cystic masses, or a combination of both, permeating both kid-
neys
– Significant renal enlargement
– Little identifiable parenchyma
– Absence of the CEC and loss of corticomedullary differentiation
n
Secondary cysts (Fig. 390):
x
Occurrence: secondary to an underlying renal disease such as nephritis, renal
abscess, parenchymal scarring, diabetic nephropathy, or renal tuberculosis
x
Sonographic criteria:
– Usually have a noncircular shape
– Often located near scar tissue
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
– Cystic degeneration of medullary pyramids
– Evidence of inflammatory renal disease
ab
Fig. 390a, b Secondary cysts. a Secondary cysts (C) in analgesic nephropathy
(decreased renal size, cursors). b Cavernous cysts (C) in renal tuberculosis with
calcifications (arrows) and acoustic shadows (S). K = kidney
n
Atypical or complicated cysts (Bosniak types II and III): Figs. 391, 392, 393c.
x
Atypical: extrarenal extension
x
Septation, calcification, intracystic hemorrhage; echinococcal cyst: single or
septated cyst, hyperechoic wall
x
Vascularized septa: cystic renal carcinoma (Bosniak type IV)
b
Fig. 391a, b Atypical cysts. a Septated
cyst with a well-defined outer wall
a
(echinococcal cyst? tubercular cavity?
cystic carcinoma?). CDS: complete
absence of vascularity and a well-defined echogenic wall. b Atypical cysts (C)
with septa-like internal structures and bulging contours (arrow) p requires
cytohistologic evaluation!
274
10.3 Circumscribed Changes in the Renal Parenchyma
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
ab
Fig. 392a, b Complicated cyst with internal hemorrhage. a Anechoic clotted
blood (arrows in b) within the cyst (C), which is still identifiable. SP = spleen,
K = kidney. b CDS : no detectable vascularity. This excludes a cystic tumor
ab
Fig. 393a, b Cystic renal cell carcinoma. a Renal cell carcinoma (T) with cystic
regressive changes and areas of intralesional hemorrhage (H). K = kidney b Cystic
renal cell carcinoma (T, H). CDS: predominantly cystic mass. Only the peripheral
vascular rim marks the outlines of a solid tumor
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Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
n
Obstructive pyelocalyceal ectasia (see Fig. 408, p. 285):
x
Multiple oval or triangular anechoic masses
x
Dilatation of the renal pelvis
x
Dilatation of the ureteropelvic junction
n
Multiple parapelvic cysts (“benign cystic lymphangioma”): see Fig. 407, p. 284:
x
Hypoechoic
x
Complex internal echo pattern.
n
Lymphocele:
x
Atypical round or angular anechoic mass
x
Frequently, past history of urologic surgery
n
Tuberculosis (see Fig. 390b; Fig. 405c, p. 282) :
x
Area of parenchymal cavitation
x
Cystic renal pelvic mass (dilated calyces, clean cavities)
x
Late changes include atrophy or calcification
n
Intracystic hemorrhage (see Fig. 392):
x
Cystic shape can still be recognized
x
Echogenic or complex internal echo pattern
x
Possible moving echoes
275
10.3 Circumscribed Changes in the Renal Parenchyma
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
10
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n
Cystic renal cell carcinoma (cystic RCC, Fig. 393):
x
Clinical features: cystic component i 50 % (note: never oncocytoma)
x
Histology: carcinoma that has undergone small-cell or papillary pseudocystic
transformation
x
Differential diagnosis: intratumoral hemorrhage, tumor liquefaction, cyst-ass ociated carcinoma, and intracystic hemorrhage
x
Sonographic criteria:
– Round or oval masses, anechoic or hypoechoic (intratumoral hemorrhage or
necrosis)
– Tumor can still be recognized in many cases
– Tumor occurrence in cysts is controversial.
n
Hematoma (Fig. 394):
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
x
Heterogeneous hyper- or hypoechoic mass with indistinct margins
x
Anechoic or complex perirenal mass
x
Hypoechoic parenchymal area with a normal organ contour, suggesting a
contusion (= hypoperfused area)
x
CDS: absence of color flow signals
ab
Fig. 394a, b Traumatic renal hematoma. a Mixed hypoechoic–hyperechoic echo
pattern with a bulging contour (C) and a thin fluid rim surrounding the kidney (K).
b Parenchymal contusion (hypoechoic to anechoic area of intraparenchymal
hemorrhage, arrows). K = kidney. Patient had a history of ladder-related and riding
injuries
Hypoechoic or Isoechoic Renal Parenchymal Changes
..............................................................................................................
n
Metastases (see Fig. 416, p. 287) : The primary tumor may be in the breast,
bronchi, stomach, bowel, or kidney.
x
Sonographic appearance: Round or oval mass of low echogenicity
n
Malignant lymphoma (Fig. 395):
x
Round or oval hypoechoic mass (low-grade lymphoma)
x
Large mass with a complex pattern of low-level internal echoes (high-grade
lymphoma)
276
10.3 Circumscribed Changes in the Renal Parenchyma
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Fig. 395 High-grade non-Hodgkin
lymphoma (T) of the kidney: extensive
hypoechoic to complex mass with tumor
nodules, also a branched anechoic pattern signifying pyelectasis (P)
n
Renal adenoma (Fig. 396):
x
Round, hypoechoic mass with smooth margins
x
Complex internal echo pattern due to regressive changes
x
Occasionally hyperechoic
x
CDS: internal vascularity
b
a
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Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Fig. 396a, b Renal adenoma. a Intensely hypoechoic mass with smooth margins.
The fine echogenic wall (arrows) closely resembles a hemorrhagic cyst. b CDS:
subtle but constant vascularity excludes a cyst or abscess in favor of a solid mass
n
Abscess (due to suppurative pyelonephritis); carbuncle (due to hematogenous
spread of staphylococci):
x
Nonhomogeneous hypoechoic mass
x
Possible gas bubbles (empyematous pyelonephritis, Fig. 397)
277
10.3 Circumscribed Changes in the Renal Parenchyma
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
10
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Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
ab
Fig. 397a, b Suppurative, empyematous pyelonephritis. a Extensive gas bubbles
(arrows). The kidney (K) is partially obscured by reverberations (R). b Scan 2 weeks
later shows a demarcated abscess (arrows), still accompanied by gas bubbles
(young, poorly managed diabetic patient; changes resolved in response to intensive conservative therapy). L = liver
n
Oncocytoma (adenoma): no reliable sonographic criteria
x
Usually hypoechoic
x
Smooth margins
x
CDS: internal vascularity
Isoechoic Changes in the Renal Parenchyma
..............................................................................................................
n
Lateral bulge in the renal contour, fetal lobulation (Fig. 398):
x
Bulge in the lateral renal contour not associated with thinning of the parenchyma
n
Parenchymal bands (parenchymatous extensions or hypertrophic renal columns):
399; see also Fig. 375a, p. 264:
Fig.
x
Tissue band passing from parenchyma to parenchyma through the central echo
complex, often multiple
x
Tumor-like parenchymal thickening (often creates a hypoechoic appearance)
x
Signs of duplex kidney are common (surface notching, long narrow or enlarged
kidney, duplicated renal pelvis)
ab
Fig. 398a, b Isoechoic bulges in the renal contour (arrows). a Lateral bulge,
b Fetal lobulation. Note the concomitant thickening of the parenchymal border
in the direction of the renal sinus. K = kidney
278