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10.5 Evaluation and Further Testing
Schmidt, Ultrasound © 2007 Thieme
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10.5 Evaluation and Further Testing
Ultrasound Evaluation
..............................................................................................................
n
Diffuse changes: e.g., renal failure, undetermined renal disease. Ultrasound is
usually the primary imaging modality for evaluating these cases. Generally the
process can immediately be classified as interstitial, glomerular, or atrophic on
the basis of sonographic findings.
n
Circumscribed changes: These changes are often detected incidentally in routine
examinations. Table
confidence with which they can be identified with ultrasound.
Table 50.Circumscribed lesions that can be identified with ultrasound
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Can be positively identified Can be classified, but further testing is recommended
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Cysts
Kidney stone Calcification
Renal cell carcinoma Abscess
Angiomyolipoma Tumor mass in the renal pelvis or renal sinus
Further Testing
..............................................................................................................
n
Indeterminate chronic renal disease : Besides routine medical and serologic tests,
special nephrologic procedures are used that include ultrasound-guided percutaneous renal biopsy.
x
The most common cause of renal failure in a general hospital setting is diabetic
nephropathy.
!
Caution: Renal pelvic abscesses are often mistaken for cysts. This diagnosis
should be considered in patients with unexplained fever and diabetes, and if
necessary the lesions should be evacuated by fine-needle aspiration or retrograde drainage.
n
Indeterminate masses in the parenchyma or renal pelvis :
x
CDS: Peripheral vascularity and multiple intratumoral vessels detected by contrast-enhanced duplex sonography are considered proof of a renal malignancy.
The confirmation of RCC is an indication for surgery. CDS is a proven adjunct
that can narrow the differential diagnosis in many other types of investigation
(Fig.
420).
x
Further tests: FNAB or CT (for the differentiation of tumor, parenchymal band,
sinus lipomatosis, and hemorrhagic cyst)
50 reviews the various changes that may be found and the
yyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyy
Lipomatosis
10
10
10
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
289
10.5 Evaluation and Further Testing
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
10
10
10
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
ab
Fig. 420a, b CDS of the kidney. a Normal-appearing segmental and interlobar
arteries alongside the medullary pyramids (MP). b CDS: avascular area caused by a
traumatic hematoma (H), causing the displacement of other vascular structures
n
Parapelvic cysts, obstruction: excretory urography. Peripheral vascularity and
multiple intratumoral vessels detected by contrast-enhanced duplex scanning
establish the diagnosis of a malignant renal tumor.
n
Suspected ectopic kidney or atrophic kidney: excretory urography, isotope
nephrography, or both
n
Small kidney and hypertension: Suspicion of renal artery stenosis should be
investigated by CDS with the determination of Doppler indices (see also Table
30, p. 193).
x
Renal artery (Fig. 421a, b): examine in the lateral decubitus position (more
favorable angle). With stenosis: V
x
Intrarenal parameters (Fig. 421c, d): RI I 0.5 is a significant decrease and indi-
cates stenosis in i 75 % of cases with 95 % sensitivity and 97 % specificity. Accuracy is further increased by comparing the sides (DRI pathologic if i 0.05).
i 150 cm/s, aliasing (see p. 8)
max
290
10.5 Evaluation and Further Testing
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
ab
cd
Fig. 421a–d Examination to confirm or exclude renal artery stenosis (CDS and
spectral analysis). a Scan plane for defining the renal arteries (left oblique position,
flank scan from right to left). The scan displays the right and left renal arteries (RRA,
LRA) at a favorable angle for duplex sonography (“banana peel” view; AO = aorta).
b Normal spectral analysis of the LRA. c Normal intrarenal vascular architecture.
d RI determined from an interlobar artery = 0.63 (normal)
10
10
10
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
291
10.6 Perirenal Masses and Adrenal Tumors
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
10
10
10
10.6 Perirenal Masses and Adrenal Tumors
Perirenal Masses (Fig. 422a, b)
..............................................................................................................
n
Perirenal abscess or hematoma: complex mass. An abscess may contain gas
bubbles.
n
Perirenal cyst (Fig. 284, p. 209) : anechoic mass
n
Adrenal tumors : Hypoechoic mass:
x
Adrenal adenoma (“incidentaloma”)
x
Primary adrenal carcinoma
x
Pheochromocytoma (may also show a diffuse pattern)
x
Adrenal metastases.
Kidney and Adrenal Gland
Kidney and Adrenal Gland
Kidney and Adrenal Gland
ab
cd
Fig. 422a–d Perirenal mass. a Perirenal fat (F). Arrows : Gerota fascia enclosing the
perirenal fat capsule, K = kidney. b Incidentaloma of the right adrenal gland
(arrows), detected incidentally as a complex mass. DD: pheochromocytoma,
metastasis, primary carcinoma. Hormone tests were negative. c Adrenal metastasis
from bronchial carcinoma (cursors), located between the upper pole of the kidney
(K) and the vena cava (VC). d Perirenal fluid collection, showing a bar-shaped
connection to the kidney at the pericapsular level. Differential diagnosis: abscess,
hematoma, urinoma
292
11 Pancreas
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
11.1 Examination
11
11
11
11.1 Examination
Scan Planes
..............................................................................................................
n
Upper abdominal transverse scan (see p. 22).
n
Upper abdominal longitudinal scan (see p. 29).
Sonographic Anatomy and Normal Findings
..............................................................................................................
n
Sonographic anatomy (Fig. 423): narrow, elongated, S-shaped organ that extends
upward and to the left from the duodenal C loop to the hilum of the spleen.
Fig. 423 Topographic anatomy
of the pancreas
n
Normal findings (Fig. 424) : The normal pancreas has a homogeneous, finely gran-
ular internal echo texture. It may be isoechoic or slightly hyperechoic to the liver.
The pancreas often shows increased echogenicity in elderly patients and diabetics
(lipomatosis).
Pancreas
Pancreas
Pancreas
a b
Fig. 424a, b Upper abdominal transverse scan displays the pancreas as a
hypoechoic organ arching over the spinal column, aorta, and inferior vena cava and
containing a double-walled echogenic duct. AO = aorta, GB = gallbladder, IVC =
inferior vena cava, L = liver, P = pancreas, U = uncinate process, SV = splenic vein.
PD = pancreatic duct
293
11.1 Examination
Schmidt, Ultrasound © 2007 Thieme
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11
11
11
n
Normal dimensions: head 25–30 mm, body I 18 mm, tail 25–30 mm, duct
I 2 mm.
Scanning Protocol
..............................................................................................................
Pancreas
Pancreas
Pancreas
n
The patient is scanned early in the morning in a fasting state.
n
Upper abdominal transverse scan, placing the probe at the level of the xiphoid.
n
Angle the probe to locate the celiac trunk. A key landmark is the splenic vein,
which is located by angling the probe further and sliding it in the caudal direction.
n
The scanning technique is adapted to the organ: The head of the pancreas is directed downward and to the right; the tail is directed upward and to the left (Fig.
see also Fig.
423).
a b
Fig. 425a, b Tail of the pancreas is demonstrated by placing the transducer
obliquely and scanning upward to the left. P = pancreas, AO = aorta, SV = splenic
vein (cursors mark the width of the pancreatic tail), VC = vena cava
n
Transsplenic scanning is occasionally necessary to evaluate the tail region
426).
(Fig.
425,
a b
Fig. 426a, b Transsplenic scan of the pancreatic tail. P = pancreas, S = spleen,
SV = splenic vein
n
The healthy pancreas is elastic and compliant, contrasting with its “en bloc” movement in chronic pancreatitis.
n
Scanning tips :
x
Note any tenderness in response to digital or probe palpation.
x
If the pancreas is poorly visualized, the following measures may be helpful:
– Scan during inspiration with the lower abdomen protruding (this moves the
acoustic window of the liver downward and displaces bowel loops laterally
294
downward).
11.2 Diffuse Changes
Schmidt, Ultrasound © 2007 Thieme
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– Fill the stomach with 500–1000 mL of water or tea (ingested through a
straw).
– Scan at full expiration in athletic or heavy-set patients (stomach cranial to
the pancreas).
Overview and Classification of Findings
..............................................................................................................
n
Note: Pancreatic diseases appear sonographically as circumscribed or diffuse
architectural changes in the organ. There may be associated focal changes in
some cases.
n
Diffuse changes (see Table 51, p. 295) : Diffuse changes are seen mainly in fibro-
lipomatosis and in the various forms of pancreatitis (as defined in the Marseille
classification of 1984):
x
Acute pancreatitis: mild or severe course
x
Chronic pancreatitis: pancreatitis characterized by
– focal necrosis,
– segmental or diffuse fibrosis,
– calcification or stones,
– obstruction
n
Circumscribed changes (see Table 52, p. 301): The findings of greatest signifi-
cance are pancreatic pseudocysts and pancreatic carcinoma.
11.2 Diffuse Changes
Definition and Overview
..............................................................................................................
n
Definition: Diffuse changes are characterized by a disturbanc e in the overall echo
pattern (“echo texture”) of the organ, with associated changes in size and structure. There may also be changes in the duct system as well as circumscribed complications.
n
Overview: See Table 51.
11
11
11
Pancreas
Pancreas
Pancreas
Table 51.Diffuse changes in the pancreas
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Hypoechoic Hyperechoic Small pancreas Large pancreas
yyyyyyyyyyyyyyyyyyyyyyyyy
Acute pancreatitis
(p. 295)
Early chronic
pancreatitis (p. 296)
Hypoechoic Changes
..............................................................................................................
n
Acute pancreatitis (Fig. 427, see also Figs. 87–89, p. 66):
x
Enlarged pancreas
x
Hazy, hypoechoic organ structure
x
Circumscribed anechoic (rarely hyperechoic) lesions representing necrotic or
yyyyyyyyyyyyyyyyyyyyyyyyyyy
Lipomatosis (p. 297)
Pancreatic fibrosis
(p. 297)
Chronic pancreatitis
(p. 297)
yyyyyyyyyyyyyyyyyyyyyyyyyyy
Age-related changes
(p. 298)
Pancreatic atrophy
(p. 298)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Annular pancreas
(p. 298)
Acute pancreatitis
(p. 298)
Tumor infiltration
(p. 298)
hemorrhagic areas
295
11.2 Diffuse Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
11
11
11
Pancreas
Pancreas
Pancreas
ab
Fig. 427a, b Hypoechoic pancreas. a Mild, acute pancreatitis (P): slightly enlarged
pancreas with a very hypoechoic structure. The slightly wavy structure is typical of
the resolution phase. A = gastric antrum, DB = duodenal bulb, SV = splenic vein.
b Normal pancreas of a 21-year-old woman (P, cursors show a normal size).
Note that the pancreas is less echogenic than the liver. VC = vena cava, AO = aorta,
GB = gallbladder, MS = mesenteric artery
Fig. 428 Severe pancreatitis: pancreas
also contains anechoic masses (necrotic
and hemorrhagic areas). The anteroposterior diameter (cursors) is increased
to 43 mm. S = anteriorly displaced
stomach
x
Possible ductal dilatation (biliary?)
x
Associated signs: peripancreatic fluid, ascites, left-sided pleural effusion
x
Complications: abscess formation along pathways of inflammatory spread
(mesenteric, pararenal, subphrenic, see p. 72); pseudocysts (p. 302)
n
Early form of chronic pancreatitis (Fig. 429):
x
Decreased echogenicity in a normal-sized pancreas
x
Irregular borders
x
Possible undulation and dilatation of the pancreatic duct
Fig. 429 Early form of chronic pancreatitis (P): hypoechoic structure with
irregular borders. The pancreatic duct is
wavy and slightly dilated at 3.2 mm
296
(cursors). SV = splenic vein
11.2 Diffuse Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Hyperechoic Changes
..............................................................................................................
n
Lipomatosis (Fig. 430): occurs in older patients, especially elderly diabetics
x
Increased echogenicity
x
Usually normal size
x
No significant induration
Fig. 430 Pancreatic lipomatosis.
The pancreas (P) is more echogenic
than the liver (L)
n
Pancreatic fibrosis (Fig. 431): may occur in chronic pancreatitis, cystic fibrosis,
and primary siderophilia (iron storage disease, “bronze diabetes”)
x
Increased echogenicity
x
Indurated organ
x
Usually normal size
Fig. 431 Pancreatic fibrosis (P) in a
patient with hemochromatosis (“bronze
diabetes”): hyperechoic structure with
incipient atrophy. L = liver, SV = splenic
vein, AO = aorta
n
Chronic pancreatitis (Fig. 432):
x
Irregular hyperechoic structure (fibrosis after acute inflammatory episodes)
x
Irregular borders
11
11
11
Pancreas
Pancreas
Pancreas
ab
Fig. 432a, b Chronic pancreatitis. a Pancreatic fibrosis in a patient with chronic
alcohol-related pancreatitis. The pancreas (cursors) is poorly delineated and shows
a coarse echogenic structure. b The above changes plus calcifications with acoustic
shadows (S) that obscure the deeper vascular landmarks. SV = splenic vein
297
11.2 Diffuse Changes
Schmidt, Ultrasound © 2007 Thieme
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11
11
11
x
Usually normal size
x
Possible micro- and macrocysts, calcifications (note acoustic shadows), ductectasia
Pancreas
Pancreas
Pancreas
Small Pancreas
..............................................................................................................
n
Age-related changes (Fig. 433a) : small pancreas that may show decreased,
normal, or increased echogenicity
n
Pancreatic atrophy (Fig. 433b)
n
Surgical resection or old pancreatic necrosis
ab
Fig. 433a, b Small pancreas, pancreatic atrophy. a Small, hypoechoic pancreas (P)
in an elderly cachexic woman. The organ is barely detectable but contains a normal-sized duct (cursors). b Autoimmune chronic pancreatitis: complete atrophy
with no discernible pancreas. The patient presented clinically with diabetes and
maldigestion. SV = splenic vein. A = mesenteric artery
Large Pancreas
..............................................................................................................
n
Annular pancreas (Fig. 434a): enlargement due to extension around the duode-
num
n
Acute pancreatitis or an acute exacerbation of chronic pancreatitis (Fig. 427 and
p. 296)
n
Tumor infiltration (Fig. 434b)
ab
Fig. 434a, b Large pancreas. a Annular pancreas (P). A = antrum of stomach,
AO = aorta, DB = duodenal bulb, SV = splenic vein. b Matted intra- and peripancreatic lymph nodes (cursors) causing enlargement of the pancreas (P) anterior
and posterior to the splenic vein (SV). AO = aorta, RV = renal vein
298