Placenta previa
If the placental edge is >2 cm away from internal os, it is considered normal. Only two terminologies prefereed.
Acute abdomen in pregnancy
Differentials
Single umbilical artery
Two vessel cord One umbilical artery and one umbilical vein In isolation, no adverse clinical outcome When accompanied by other anomalies, 50% chance for trisomy 13 and 18 IUGR in 15% cases Imaging Free loop of cord with 2 vessels 70% absent left umbilical artery Single umbilical artery is larger in size than 3 vessel…
7th edition AJCC TNM staging of adrenocortical carcinoma
TX Primary tumor cannot be assessed T0 No evidence of primary tumor T1 Tumor 5 cm or less in greatest dimension, no extra-adrenal invasion T2 Tumor greater than 5 cm, no extra-adrenal invasion T3 Tumor of any size with local invasion, but not invading adjacent organs T4 Tumor of any size with invasion of adjacent…
Goldman and Sandler classification of urethral injuries
Grade I Posterior urethra stretched but intact Grade II Partial or complete posterior urethral tear above intact urogenital diaphragm Grade III Partial or complete tear of combined anterior and posterior urethra with torn urogenital diaphragm Grade IV Bladder neck injury with extension to the urethra Grade IVa Injury to bladder base with extravasation simulating type…
Colapinto and McCallum classification of urethral injuries
Grade I Posterior urethra stretched but intact Grade II Posterior urethral tear above intact urogenital diaphragm Grade III Posterior urethral tear with extravasation through torn urogenital diaphragm
AAST renal injury scale
Grade Parenchyma Collecting system Vascular Grade I Sub capsular hematoma and/or contusion No injury No injury Grade II Laceration < 1 cm in depth and into cortex, small perirenal hematoma contained within Gerota fascia No injury No injury Grade III Laceration > 1 cm in depth and into medulla, hematoma contained within Gerota fascia No…
FIGO staging of ovarian carcinoma
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Risk stratification in prostate cancer by European Association of Urology
Low risk PSA < 10 ng/ml Gleason score < 7 Clinical stage T1 – T2a Intermediate risk PSA 10-20 ng/ml Gleason score 7 Clinical stage T2b High risk PSA > 20 ng/ml Gleason score > 7 Clinical stage > T2c or N+
Risk stratification in prostate cancer by American Urological Association
Very low risk PSA < 10 ng/ml Grade group I Clinical stage T1 – T2a < 34% biopsy cores positive No core >50% involved PSA density < 0.15 ng/ml/cc Low risk PSA < 10 ng/ml Grade group I Clinical stage T1 – T2a Intermediate risk PSA 10-20 ng/ml Grade group 2 or 3 Clinical stage …
Bladder cancer staging
Tx Primary tumor cannot be assessed T0 No evidence of residual tumor Ta Superficial non invasive papillary carcinoma Tis Superficial flat tumor (carcinoma in situ) T1 Invasion of subepithelial connective tissue (lamina propria) T2a Superficial invasion of muscularis mucosa (into inner half) T2b Deep invasion of muscularis mucosa (into outer half) T3a Microscopic perivesical spread…
Upper tract urothelial carcinoma staging
T0 No evidence of primary tumor Ta Non-invasive papillary carcinoma Tis Carcinoma in situ T1 Tumor invades sub epithelium T2 Tumor invades muscularis T3 Tumor invades beyond muscularis into perirenal or periureteric fat or into renal parenchyma T4 Tumor invades adjacent organs or through the kidney into perinephric fat N0 No regional lymph nodes N1…
2017 modification TNM renal cell carcinoma staging
T1a Tumor confined to kidney, small, < 4 cm T1b Tumor confined to kidney > 4 cm, < 7 cm T2a Tumor confined to kidney > 7 cm, < 10 cm T2b Tumor confined to kidney > 10 cm T3a Tumor spread to perinephric fat, renal vein or pelvicalyceal system T3b Tumor spread to cava…
Differentials for right iliac fossa pain
Appendicitis Ectopic pregnancy Ovarian cyst with or without torsion Salpingitis Endometriosis Diverticulitis Infectious ileocecitis Crohn’s disease Malignancy Intussusception Meckel’s diverticulum Cholecystitis Urolithiasis Mesenteric adenitis
O-RADS MRI risk stratification and management system
O-RADS MRI score Risk category Positive predictive value for malignancy Remarks 0 Incomplete evaluation – – 1 Normal ovaries – No ovarian lesion Simple cyst < or equal to 3 cm in premenopausal women Hemorrhagic cyst < or equal to 3 cm in premenopausal women Corpus luteum with or without hemorrhage < or equal to…
Emphysematous disease of the urinary tract
Emphysematous pyelonephritis gas in renal parenchyma focal or diffuse may involve collecting system and perinephric space high mortality may require nephrectomy Emphysematous pyelitis gas in pelvicalyceal system and ureter alone low mortality percutaneous drainage and antibiotics helps Emphysematous cystitis gas in urinary bladder and bladder wall typically in diabetics
Testicular torsion
Peripubertal boys, and in infancy Normally tunica vaginalis converges posterior to fix testis to scrotal wall This convergence is deficient or patulous leading to ‘bell clapper’ deformity and torsion Afebrile boy with acute scrotal pain and vomiting Acute torsion – 24 hrs to 10 days Testicular salvage rates: 80% first 6 hours, 20% if beyond…
Testicular atrophy
Previous epididymo-orchitis, testicular torsion, cryptorchidism, varicocele, mumps, estrogen therapy Part of normal aging Imaging US: iso- or hyporeflective compared with normal side. Homogeneous or mixed parenchymal reflectivity Read more Lipshultz, Larry I., and Joseph N. Corriere Jr. “Progressive testicular atrophy in the varicocele patient.” The Journal of urology 117.2 (1977): 175-176.
Testicular microlithiasis
Calcium deposits in lumina of seminiferous tubules Associated with cryptorchidism, infertility, Klinefelter syndrome, testicular infarction, testicular dysgenesis, infertility, testicular torsion and atrophy Association with malignancy is controversial and not established In isolation, microlithiasis needs no follow up When associated with previous malignancy, maldescent, atrophy (<12 ml), orchidopexy or history of testicular malignancy in first-degree relative,…
Benign prostatic hyperplasia
Arises in transition zone Hyperplasia of prostatic tissue Variable degrees of glandular, muscular and fibrous components Imaging Heterogeneity of hypertrophy seen as varying signals in T2 and variable diffusivity Nodules may grow exophytically to protrude into peripheral zone Dynamic contrast enhanced MRI shows rich vascular areas interspersed with variable vascular areas. Read more Kahn,…
Post-transplant renal artery stenosis
Late complication Occurs at anastomosis site – between donor and recipient artery Presents with severe hypertension or renal dysfunction Imaging US: renal artery velocity >200 cm/s, gradient of 2:1 between stenotic and pre-stenotic segment and spectral broadening. Downstream turbulence, tardus parvus waveform distal to stenotic segment False positive: kinking or tortuosity of vessels. If USG…
Nephrocalcinosis
Deposition of calcium in renal parenchyma Deposition of calcium phosphate and calcium oxalate Due to conditions that cause hypercalcemia, hyperphosphatemia and increased excretion of calcium, phosphate or oxalate Can be medullary or cortical Medullary nephrocalcinosis Due to metabolic dysfunction More common form Hyperparathyroidism Sarcoidosis Medullary sponge kidney disease Renal tubular acidosis Loop diuretics Beta thalassemia …
Ureteropelvic junction obstruction
Congenital seen in 1 in 500 live births Intrinsic narrowing of proximal ureter as it joins pelvis Congenital disruption of muscle development In 10% cases, aberrant or accessory renal artery crosses and obstructs proximal ureter Antenatal hydronephrosis detection Abdominal mass Intermittent flank pain Imaging Voiding cystourethrogram is used to rule out reflux disease Diuretic renography…
Ovarian hyperstimulation syndrome
Potential life-threatening complication Occurs during luteal phase or early pregnancy following IVF ovarian stimulation Caused by vasoactive substances that increase vascular permeability, ascitic fluid shift into abdomen Abdominal distension, nausea, vomiting, weight gain Pleural effusion, intravascular fluid depletion, hemoconcentration, thromboses, renal failure, shock Imaging USG – technique of choice Bilateral symmetrical enlarged ovaries (≥6 cm)…
Polycystic ovaries
Polycystic ovarian syndrome (2003 definition based on joint meeting of American society of reproductive medicine and European society for human reproduction and embryology) requires 2 out of the 3 following criteria Oligo and or anovulation Hyperandrogenism (clinical and/or biochemical) Polycystic ovaries 6-15% women have polycystic ovaries. 80% have infertility, menstrual irregularity or hirsuitism Imaging Transvaginal…
Angiomyolipoma
Benign Composed of variable amounts of fat, smooth muscle and abnormal blood vessel Occur spontaneously Women in 50s Younger age, multiple in patients with tuberous sclerosis Rare in neurofibromatosis and in adult polycystic kidney disease Consists of thick-walled inelastic blood vessels Risk of hemorrhage higher in lesions larger than 4 cm in diameter Imaging USG…
Parapelvic and peripelvic cysts
Occur in renal sinus Causes sinus distortion but no obstruction Peripelvic: lymphatic origin Parapelvic: serous cysts arising from renal parenchyma present in the sinus Important to distinguish from hydronephrosis – dilated infundibula are not seen to connect to a dilated renal pelvis Read more Hidalgo, H., et al. “Parapelvic cysts: appearance on CT and sonography.” American…
Radiographic grading of Vesicoureteric Reflux
Grade Finding I ureter and upper collecting system without dilatation II mild dilatation of ureter and renal pelvis with minimal blunting of fornices III moderate dilatation of ureter and renal pelvis with minimal blunting of fornices IV moderate dilatation and tortuosity of ureter with moderate dilatation of renal pelvis and calyces, obliteration of sharp angle…
Ultrasound classification of pelvicalyceal dilatation
Type Finding 0 collecting system hardly visible, normal I just renal pelvis visible, calyces not seen. pelvic diameter <7 mm, considered normal II axial renal pelvis diameter <10 mm, some calyces visible but with normal forniceal and papillar shape / configuration III marked dilatation of calyces and pelvis, pelvic axial width >10 mm with flattened…
Adrenal dysfunction
Diagnosed clinically and biochemically Imaging to identify causal lesion, unilateral or bilateral, plan surgical or medical management Types Cortical hyperfunction Cushing’s syndrome Conn’s syndrome Adrenogenital syndrome Medullary hyperfunction Adrenal medullary hyperplasia Pheochromocytoma Cortical hypofunction Addison’s disease Secondary cortical insufficiency (due to decreased ACTH)
Adrenal myelolipoma
Rare Benign, non-functioning Adrenocortical dysfunction in 10% <5 cm, solitary Hematopoietic precursor cells and mature adipose tissue May have fibromyxoid degeneration, hemorrhage, necrosis, calcification Asymptomatic Large lesions sometimes cause abdominal pain or retroperitoneal bleeding Imaging Recognizable capsule May have calcification Varying amounts of fat Myeloid soft tissue component enhances with contrast Fat attenuation < -30…
Adrenal cysts
Endothelial cyst Vascular cyst Endothelial lining 45% of adrenal cysts 2/3 in females 8% bilateral May have residual adrenocortical tissue in wall Hemorrhagic cyst Pseudocyst 39% of adrenal cysts Middle-aged women Seen in Beckwith-Wiedemann syndrome Originally would have been an endothelial cyst, that underwent hemorrhage, and secondary fibrosis or hemosiderin deposition Parasitic cyst Echinococcal Asymptomatic…
Imaging an adrenal mass
Incidental masses in 5% of abdominal scans 6% of people >60 years carry an adrenal adenoma. 70-80% of these are non-functioning Prevalence of 9-13% in patients with an extra-adrenal malignancy In a patient with known carcinoma, only 26 – 36% are metastatic European Society of Endocrinology Clinical Practice Guidelines for adrenal masses Unenhanced CT should…
Adenomyosis
endometrial tissue in myometrium secondary smooth muscle hypertrophy and hyperplasia diffuse or focal clinical presentation dysmenorrhea dysfunctional uterine bleeding ultrasound enlarged, globular uterus myometrial heterogeneity echogenic myometrial nodules subendometrial echogenic linear striations 2-6 mm subendometrial cysts endometrial pseudowidening: poor definition of endomyometrial junction rain shower appearance: multiple fine areas of attenuation throughout the lesion doppler:…
Acute epididymo orchitis
Clinical presentation 40 year old gentleman with fever, hemiscrotal heaviness and pain. Ultrasound Findings Hypoechoic enlarged right testis and epididymis with diffusely increased vascularity demonstrated in power doppler setting. Learning points Most common differential for acute onset scrotal pain. It is often accompanied by febrile illness. The worrisome differential is testicular torsion. Read more Acute…
Transitional cell carcinoma – urinary bladder
Clinical presentation Hematuria in an otherwise healthy fit young 25 year old gentleman. MRI https://www.youtube.com/watch?v=1oK2CgczpjM https://www.youtube.com/watch?v=ZHY8FpIXE5w https://www.youtube.com/watch?v=WY-zZM9AyQM https://www.youtube.com/watch?v=6eWoyvmPOB8 https://www.youtube.com/watch?v=rsWHMhYSrmQ https://www.youtube.com/watch?v=G4kjt-r3Aq0 https://www.youtube.com/watch?v=FjEcEP02zpI https://www.youtube.com/watch?v=sP5n_mYcSgg https://www.youtube.com/watch?v=yTAOsBF_lZc https://www.youtube.com/watch?v=-TE8u_PDDFs Findings and Discussion Focal exophytic growth with signal intensity similar to urinary bladder wall is seen arising from right posterolateral wall approximately 2cm cranial to right vesicoureteric junction. It shows diffusion restriction…
Duplex renal collecting system
Clinical presentation Health check up incidental pick up in a 35 year old lady. USG Findings and Discussion Duplex collecting system is a common developmental variant seen most often in children, but incidentally in adults. They need to be documented due to their association with vesicuoureteric reflux or ureteroceles. The easiest clue is the disruption o…
Hydrocele
Clinical presentation Long standing scrotal swelling for assessment. USG Findings Approximately 75ml of fluid with fine internal echoes is seen in right tunica vaginalis. No fluid fluid levels. Both testes and epididymis are normal. No varicocele. A 10mm simple cyst is seen in the body of left epididymis. Discussion This is an example of uncomplicated…
Indirect inguinal hernia
Clinical presentation 50 year old gentleman with a 2 year history of inguinoscrotal swelling presented with acute severe pain at the site of swelling since one day. USG CT https://www.youtube.com/watch?v=1fk5P72mIGk https://www.youtube.com/watch?v=5Iv5htVCOaw https://www.youtube.com/watch?v=-Q_9k_su8_A Findings Indirect left inguinal hernia with an afferent and efferent loop of distal descending colon / proximal sigmoid colon as content with associated…
Bicornuate unicollis uterus
Clinical presentation 40 year old lady presented for evaluation of abdominal pain. MRI https://www.youtube.com/watch?v=QMpeC_XJ-y4 https://www.youtube.com/watch?v=xPUfkxLzsOE https://www.youtube.com/watch?v=ceSaXJCX-s4 Findings Two separate horns of uterus with independent endometrial canals fusing to a common cervical canal. Small submucosal fibroid in fundal left horn. Discussion Documenting variants of uterine anatomy is imperative especially in cases of repeated abortions and infertility…
Hydrocele of canal of Nuck
Clinical presentation 35 year old multiparous lady presented with a relatively painless right inguinolabial swelling. Ultrasound identified a fluid filled inguinal lesion raising suscpicion of indirect inguinal vs femoral hernia. A contrast enhanced CT study was done. CT Oral postivie contrast followed by i.v. iodinated contrast administration and portovenous phase acquisition. https://www.youtube.com/watch?v=P47AWVzpS0M https://www.youtube.com/watch?v=Q8nDrKNMjuA https://www.youtube.com/watch?v=_bwoQsPKXFI Annotated…