In a female patient presenting
with lower abdominal pain, abnormal ovarian (cyst) location, that is, in
midline above the uterus and adjacent to urinary bladder on transabdominal scan
suggests ovarian
torsion. As both bladder and the cyst are anechoic structures, it appears
as if there are two bladders next to each other. In addition, watch for free
fluid in the pouch of Douglas.
Why talking about cyst? Note that torsion is usually associated with an ovarian cyst that twists along the infundibulopelvic ligament and pedicle, subsequently compressing the ovarian vein and artery leading to stromal edema and ovarian enlargement. Presence of the cyst is a clue to ovarian location as the ovarian tissue itself is not clearly visualized on abdominal scans.
Stone-In-Neck or the ‘SIN’ sign is when you see an immobile stone lodged in the gallbladder neck, without any anechoic space between the neck and the stone. It is suggestive of cholecystitis even in the absence of other sonographic signs such as thickened gall bladder wall, Pericholecystic fluid, sonographic Murphy’s sign etc. One small study found that the sensitivity of this sign is 56.5% and the specificity 97% for cholecystitis.
In clinical practice, a cut off
of 3mm is commonly used to define the upper limit of normal gall bladder wall
thickness and acute cholecystitis is one thing that comes to our mind when we
see increased wall thickness. Along with a compatible clinical picture, ultrasonographic features
that suggest acute cholecystitis are a distended gallbladder, thickened walls,
biliary sludge and lithiasis, pericholecystic fluid and the sonographic
Murphy’s sign, which is defined as maximal abdominal tenderness from pressure
of the ultrasound probe over the visualized gallbladder.
However, this is not the only condition that causes gall bladder wall thickening. As POCUS is not necessarily performed in a fasting patient, we must be aware that the gall bladder wall is thick in non-fasting state. In addition, any systemic disease associated with generalized hypervolemia such as congestive heart failure can lead to gall bladder wall thickening. In these patients, think of alternate etiology if the clinical picture does not fit. The presence of gall stones also does not mean much if there are no symptoms. Following image shows thickened gall bladder wall and ascites in a patient with congestive heart failure exacerbation. Note that the liver floating in ascites appears like a fish with gall bladder as its mouth. Though the wall diameter is measured in transverse plane in this example, it is generally recommended to be measured in long axis, and of the anterior wall (the one on the top).
This is one of the commonest artefacts encountered in NephroPOCUS. It is generated by the false assumption that an echo returns to the transducer after a single reflection. In this scenario, the primary beam encounters a highly reflective interface, the reflected echoes then encounter the “back side” of the structure and are reflected back toward the reflective interface before being reflected to the transducer for detection. The display shows a duplicated structure equidistant from but deep to the strongly reflective interface. Remember, time = distance in the ultrasound world, which means if the echoes take longer time to reach back to the probe, that structure is displayed farther from the top of the screen and vice versa. In other words, structures closer to the probe are displayed at the top of the image.
In this example, the diaphragm sitting next to the air-filled lung that is reflective acts as a mirror, and the mirror image artefact appears as hepatic parenchyma (or spleen on the left) in the expected location of lung. However, when there is pleural effusion, this artefact disappears (fluid is an excellent transmitter of ultrasound waves unlike air) and you’ll see an anechoic area above the diaphragm representing the effusion. In these cases, identification of thoracic spine sign confirms the diagnosis of pleural effusion.
You can watch my video 10 ~7:58 for more examples and better understanding of the mechanism of this artefact.
This image demonstrates hepatic hemangioma incidentally found while imaging the kidney. On ultrasound, hepatic hemangiomas appear as well-defined, hyperechoic, homogeneous lesions. Some of them may have posterior acoustic enhancement. The hyperechogenicity probably results from multiple fibrous interfaces between vascular spaces. If the lesion is in a fibrotic liver, that is background echogenicity, it may appear hypoechoic. Lesions >5 cm can have mixed echogenicity because of intratumoral thrombosis and fibrosis.
Ultrasound has a good accuracy in differentiating hepatic hemangioma from malignant hyperechoic masses (sensitivity of 94.1% and specificity of 80.0% for lesions less than 3 cm diameter). The absence of blood flow on Doppler exam is also a reliable sign to differentiate hemangioma from hepatocellular carcinoma, which frequently has intra- or peri-tumoral vascularity. Though the lesion is vascular, the blood flow is too slow to be picked up by Doppler usually. In hypoechoic lesions, a peripheral echogenicrim favors hemangioma, while a perilesional hypoechoic rim, known as the ‘target sign’, strongly suggests malignancy.
Asymptomatic patients with lesions <1.5 cm, but also including those with lesions ≤5 cm, can be reassured and observed without follow-up imaging. On the other hand, close radiologic follow-up of should be considered in patients with lesions >5 cm (e.g. CT scan yearly), particularly those in a subcapsular location. In the absence of symptoms, prophylactic resection is usually not recommended [UpToDate].
This image demonstrates a lesion of mixed echogenicity in a non homogeneous liver (cirrhosis) and ascites. It was diagnosed as HCC.
Accessory spleen or a splenule is a congenital focus of healthy splenic tissue, that is separate from the main body of the spleen. The reported incidence is as high as 16% in patients undergoing contrast-enhanced abdominal CT. The most frequent location (22%) is posteromedial to the spleen; anterolateral to the upper pole of the left kidney; and lateral, posterior, and superior to the tail of the pancreas.
Why should we care about it?
For nephrology-related POCUS, it is important to be familiar with this entity because it may be confused with neoplastic growth of the kidney. Other important things to note about accessory spleen are: It can undergo hypertrophy after splenectomy, and can be responsible for the recurrence of hematological disorders for which the splenectomy has been performed if not removed during surgery. Occasionally, an accessory spleen may become symptomatic because of torsion, spontaneous rupture, hemorrhage or cyst formation and can cause an acute abdomen.
What does the image show?
The renal sonogram shown here demonstrates an approximately 1.5 cm hypoechoic well-circumscribed lesion outside the left kidney (not anchored to the kidney), which is an accessory spleen. It was confirmed by MRI.
The surgical image shown here is an example of hilar accessory spleen.
