RENAL ULTRASOUND

Pre-test
Write what you have known so far( It
will contain 2.5 point)
1. What is an ultrasound?
2. What is a transducer/probe? What is
the functional unite of a probe?
3. Write the difference b/n TGC and over
all gain?
4. What is an acoustic window?
5. Explain what A mode, B mode and M
mode are?

2 Done by: Tesfaye Mtz,MRT 10/24/2024

 Abdominal Cavity
 The abdominal cavity is divided into two
major compartments, the peritoneal cavity
and retroperitoneal cavity.
 Peritoneal cavity is a potential space
between the parietal peritoneum lining the
abdominal wall and the visceral peritoneum
enveloping the abdominal organs.
Peritoneum is a large complex serous
membrane which forms a closed sac within the
abdominal cavity.
It has two layers parietal and visceral
layers.
3 Done by: Tesfaye Mtz,MRT 10/24/2024
4 Done by: Tesfaye Mtz,MRT 10/24/2024
  Retroperitoneal Cavity is the part of
the abdominal cavity that lies between the
posterior parietal peritoneum and anterior
to the transversalis fascia.
• It is divided into three spaces by the perirenal
fascia
 anterior pararenal space/ GI space/
 perirenal space/ renal space/
 posterior pararenal space/ fat space/

5 Done by: Tesfaye Mtz,MRT 10/24/2024

  The perirenal fascia is a dense, elastic
connective tissue sheath that envelops
each kidney and adrenal gland together with a
layer of surrounding perirenal fat forming the
perirenal space.
 Grote fascia (anterior perirenal fascia): a thin
lamina that passes around the front of the kidney
and variably interleaves with the opposite anterior
fascia
 Zuckerkandl fascia (posterior perirenal
fascia): a thicker posterior fascia which continues
anterolaterally as the lateroconal fascia and fuses
with the parietal peritoneum
6 Done by: Tesfaye Mtz,MRT 10/24/2024
7 Done by: Tesfaye Mtz,MRT 10/24/2024
8 Done by: Tesfaye Mtz,MRT 10/24/2024
 Gross Renal Anatomy
 Kidneys are a retroperitoneal organs.

 Located with in the abdominal cavity.

 Are at T12 to L3, at the costal margin; the ribs protect

them a little bit.

9 Done by: Tesfaye Mtz,MRT 10/24/2024

10 Done by: Tesfaye Mtz,MRT 10/24/2024
 A) Outer: Fibrous cortex
o Contains renal corpuscle & proximal and distal
convoluted tubules of juxtamedullary nephrons and
almost all cortical nephrons.
o Filtration takes place

Cortical thickness(young adults): is distance between the

capsule and the margin of the medullary

pyramid.

 2.5-3cm at the poles & 1.5- 2cm elsewhere

 May ↓ with age

11 Done by: Tesfaye Mtz,MRT 10/24/2024
 B) Middle: pyramids (medulla) with surrounding cortex
o Contains renal loops
Loop of Henle
o 8-18 medullary pyramids
o Pyramids are triangular
Apex-narrow tip
Base-broad
o Reabsorption takes place

12 Done by: Tesfaye Mtz,MRT 10/24/2024

 C) Inner: renal sinus that contains calyces and renal pelvis

with larger blood vessels, lymphatics and fatty tissue

 Renal sinus contains blood vessels and

collecting system surrounded by fat

13 Done by: Tesfaye Mtz,MRT 10/24/2024

14 Done by: Tesfaye Mtz,MRT 10/24/2024
15 Done by: Tesfaye Mtz,MRT 10/24/2024
 Common Indications For Renal US

16 Done by: Tesfaye Mtz,MRT 10/24/2024

  What we look for when scanning kidney?

 Renal size

 Cortical thickness(not <1cm)

 Cortico-medullary differentiation
 For hydronephrosis

 Renal scarring(beware mistaking prominent

lobulations as scars)
 Nephrolithiasis

 Masses

17 Done by: Tesfaye Mtz,MRT 10/24/2024

 How Reporting Looks Like
Rt.Kidney: is normal in size(9.0cm x4.0cm),
shape, and contour.
: It has normal cortico-medulary
differentiation.
:No hydronephrosis or stone.

Lt.Kidney: is normal in size(10.0cm x4.5cm),

shape, and contour.
: It has normal cortico-medulary
differentiation.
:No hydronephrosis or stone.
18 Done by: Tesfaye Mtz,MRT 10/24/2024
 Preparation
A) Preparation of patient

No special preparation unless bladder is wanted

B) Positioning a patient

First examined on supine position then decibutus.

C) Choice of transducer: 3.5MHz for adults &

5MHz for children

19 Done by: Tesfaye Mtz,MRT 10/24/2024

 Scanning Technique
 Patient supine

 Apply coupling agent

 Use liver as acoustic window to scan right

kidney

Scanning-longitudinal and Transverse

coronal- Lt or Rt lateral decubitus

20 Done by: Tesfaye Mtz,MRT 10/24/2024
 Deep inspiration can be used to move the kidney
relative to the ribs and any overlying bowel gas

The left kidney is not usually demonstrable

sagittally because it lies posterior to the stomach
and splenic flexure.

The spleen can be used as an acoustic

window to the upper pole by scanning
coronally, from the patients left side with the
patient supine or decubitus( left side raised).

21 Done by: Tesfaye Mtz,MRT 10/24/2024

 But unless the spleen is enlarged. The
lower pole must usually be imaged
from the left side posteriorly.

Coronal sections of both kidneys are

particularly useful as they display the
renal pelvicalyceal system(PCS) and its
relation ship to the renal hilum.

22 Done by: Tesfaye Mtz,MRT 10/24/2024

 The kidneys must be examined in both
longitudinal and transverse planes.
This usually requires a combination of
sbucostal and intercostal scanning with
anterior ,posterior and lateral approaches.

23 Done by: Tesfaye Mtz,MRT 10/24/2024

 Upper abdominal longitudinal
scan, Rt side

24 Done by: Tesfaye Mtz,MRT 10/24/2024

 Longitudinal Rt Kidney

25 Done by: Tesfaye Mtz,MRT 10/24/2024

 Upper abdominal transverse scan, Rt
side

26 Done by: Tesfaye Mtz,MRT 10/24/2024

27 Done by: Tesfaye Mtz,MRT 10/24/2024
 Lateral Decubitus

28 Done by: Tesfaye Mtz,MRT 10/24/2024

 Longitudinal flank scan, left
side

29 Done by: Tesfaye Mtz,MRT 10/24/2024

30 Done by: Tesfaye Mtz,MRT 10/24/2024
 Left Coronal View

31 Done by: Tesfaye Mtz,MRT 10/24/2024

 Normal Renal Sonographic
Appearances
 The 3 main components identified easily on U/S

 Renal Cortex,

 Medulla and

 Renal Sinus

32 Done by: Tesfaye Mtz,MRT 10/24/2024

  Renal Capsule- echogenic, surrounds cortex

 Cortex- less echogenic than liver and spleen, homogeneous echo

pattern

 Medulla- pyramids found here, hypo echoic to anechoic

 Arcuate Arteries- echogenic dots found at the cortico-medullary

junction

 Sinus- hyperechoic

 Renal pelvis- may appear as a central slit of anechoic fluid at the

hilum

33 Done by: Tesfaye Mtz,MRT 10/24/2024

34 Done by: Tesfaye Mtz,MRT 10/24/2024
 Cortical Thickness

35 Done by: Tesfaye Mtz,MRT 10/24/2024

 Renal sinus and collecting
system
Renal sinus contains collecting system , renal vessels

and fat

 Seen as echogenic due to fat.

 Amount of fat can vary; tend to increase in obesity and

steroid therapy.

NB; There is increase in size of central echocomplex

with age due to atrophy of parenchyma.

36 Done by: Tesfaye Mtz,MRT 10/24/2024

37 Done by: Tesfaye Mtz,MRT 10/24/2024
 Measuring the size of
kidney
 Pole-to-pole length( 9-12cm) - most widely used

measurement.

 This is a quick, easily obtained measurement,

 But accurate reproducibility requires careful

technique.

 The main problem is underestimation of the size by

misinterpreting an oblique plane as the true length.

 Width of kidney=4cm-6cm

38 Done by: Tesfaye Mtz,MRT 10/24/2024

 Normal Variants
 Fetal Lobulation

 Dromedulary Hump/splenic hump

 Hypertrophied Column of Bertin

 Double Collecting System

39 Done by: Tesfaye Mtz,MRT 10/24/2024

 Fetal Lobulation
 Renal margins is normally a smooth curved shape

 some normal variants should be recognized and

should not be mistaken for pathologic changes.

 Fetal lobulation: produces parenchymal

irregularities

40 Done by: Tesfaye Mtz,MRT 10/24/2024

 Fetal Lobulation

41 Done by: Tesfaye Mtz,MRT 10/24/2024

 Splenic Hump
 Due to pressure from spleen on LK.

 Humps are basically a variation in the shape of the

kidney rather than an area of hypertrophied tissue.

 Mimics tumor

 Parenchymal thickness not increased.

42 Done by: Tesfaye Mtz,MRT 10/24/2024

43 Done by: Tesfaye Mtz,MRT 10/24/2024
 Hyperthropied Column of
Bertin

 Produced by the fusion of adjacent portion

of cortex as renal lobules fuse.

 Parenchymal surface is not distorted.

 No change of echogenecity

44 Done by: Tesfaye Mtz,MRT 10/24/2024

45 Done by: Tesfaye Mtz,MRT 10/24/2024
 Duplex kidneys/Double
collecting system

 These occur in a spectrum of degrees, from

two separate organs with separate collecting

systems and duplex ureters, to a mild degree

of separation of the PCS at the renal hilum

 The latter is more difficult to recognize on

46 Done by: Tesfaye Mtz,MRT 10/24/2024
 Double collecting System

47 Done by: Tesfaye Mtz,MRT 10/24/2024

 Extra-renal pelvis

 Renal pelvis projects outside the kidney.

 Transverse section_ ‘baggy’ containing anechoic

Urine.

 DDx -dilatation of the PCS or

parapelvic cyst or collection.

48 Done by: Tesfaye Mtz,MRT 10/24/2024
  Ultrasound images
TS through the RK
demonstrating a
baggy extrarenal
pelvis. The PCS
remains undilated,
and this should not
be confused with
hydronephrosis

49 Done by: Tesfaye Mtz,MRT 10/24/2024

 Assignment
Write and explain the normal variants of liver,
GB, spleen, pancreas and kidney.
Write the normal adult and pediatric size range
each of the above organs.
List and explain Types of renal ectopia / renal
ectopic kidneys.
Explain what renal hypoplasia, renal agenesis
and renal atrophy are.
Note: only hand written assignment is
acceptable!!!
Submission date: Tuesday Jan. 18; 2022 GC.
at 3:oo o’clock in the morning local time
50 Done by: Tesfaye Mtz,MRT 10/24/2024
 Renal cysts and cystic disease
 The most common renal mass is a simple cyst

- can be found in up to 50% of the population

-The incidence increasing with age.

 Most cysts are asymptomatic and may be solitary or

multiple.

 Generally they are peripheral but may occur within the

kidney adjacent to the renal pelvis.

51 Done by: Tesfaye Mtz,MRT 10/24/2024
 Ultrasound appearances
 Renal cysts display three basic characteristics:

o Anechoic, Have a thin, Well-defined capsule and

exhibit posterior enhancement.

 It can be difficult to appreciate the posterior enhancement

if the hyper echoic perirenal fat lies distal to the cyst;

scanning from a different angle may be helpful.

52 Done by: Tesfaye Mtz,MRT 10/24/2024

 Hemorrhage or infection can give rise to
low-level echoes within a cyst and in
some cases the capsule may display
calcification.

53 Done by: Tesfaye Mtz,MRT 10/24/2024

 Renal cysts and cystic disease
 Simple Cysts

 Autosomal dominant (adult) polycystic kidney

disease

 Autosomal recessive (infantile) disease

 Acquired cystic disease(due to dialiysis)

 Multicystic dysplastic kidney (MCDK)

54 Done by: Tesfaye Mtz,MRT 10/24/2024
 Simple renal cysts
 The most common renal mass

 Found in up to 50% of the population,

 The incidence increasing with age.

 Most cysts are asymptomatic

 May be solitary or multiple.

 Generally they are peripheral but may occur within the

kidney adjacent to the renal pelvis.

55 Done by: Tesfaye Mtz,MRT 10/24/2024
  A simple renal cyst forms about 65-70% of

focal changes of the kidney.

 With ageing, the cysts usually grow.

 Up to 40% of adult patient show at least one

simple kidney cyst.

56 Done by: Tesfaye Mtz,MRT 10/24/2024

 Sonographic criteria for simple renal
cysts
I. Anechoic

II. Sharply marginated

III. Smooth walls

IV. Good through transmision

NB; Presence of a thin single septation or a minor

indentation of wall, do not significantly affect the Dx.

Cysts arising near renal pelvis may some times

simulate a dilated Collecting system.

57 Done by: Tesfaye Mtz,MRT 10/24/2024

 Thin walled,
smoothly outlined
structures with
anechoic contents

58 Done by: Tesfaye Mtz,MRT 10/24/2024

 Para-pelvic Cysts
Para-pelvic cysts lie adjacent to the renal pelvis at

the hilum.
They are histologically different from cortical cysts.

Their nature may be inferred from their position, but

since cortical cysts also may lie centrally, the

distinction cannot be made with certainty.
Such distinction is academic since both entities are

innocent and require no treatment.

59 Done by: Tesfaye Mtz,MRT 10/24/2024

 Parapelvic cyst;This
is similar in
appearance to a
cortical cyst. The
diagnosis is
suggested only by
the position

60 Done by: Tesfaye Mtz,MRT 10/24/2024

 Complex Renal Cysts
Simple cortical and para-pelvic cysts are

thin-walled spherical structures with

anechoic contents.

Anything other than these features

makes them a complex cyst, which may

61
be caused by a number of pathologic
Done by: Tesfaye Mtz,MRT 10/24/2024
  Complex cysts are characterized by
septations,hemorrhage,infection and
calcifications
 Septations: thicker septations(>1mm)
 Hemorhage :internal echoes within cysts area
usually either infection or hemorrhage

62 Done by: Tesfaye Mtz,MRT 10/24/2024

 Complicated Polycystic Kidney
Cysts

63 Done by: Tesfaye Mtz,MRT 10/24/2024

  Infection: indistinguishable from simple renal

cysts.

• infected cysts are likely to show complex echo

pattern

• There may be fluid-fluid level,dependent

debris,contained gas.
64 Done by: Tesfaye Mtz,MRT 10/24/2024
• Wall of cyst may becomes thicker and may
 Complex renal cyst: with echogenic
debris

65 Done by: Tesfaye Mtz,MRT 10/24/2024

 Autosomal dominant (Adult)polycystic
kidney
disease
ADPKD is the third most common systemic
hereditary condition
 Accounts for 10% to 15% of all patients on
dialysis .
Renal failure develops in 50% of patients
Usually present by 60 years of age
Early signs of the disease include
hypertension and flank or back pain.
Extra-renal manifestations of ADPKD
include hepatic, pancreatic, ovarian, splenic
cysts
66 Done by: Tesfaye Mtz,MRT 10/24/2024
 Ultrasound appearances
 The disease is always bilateral,

 multiple cysts of various sizes, many having

irregular margins

 There is often little or no demonstrable normal

renal tissue and the kidneys may become so

large that they visibly distend the abdomen.

67 Done by: Tesfaye Mtz,MRT 10/24/2024
68 Done by: Tesfaye Mtz,MRT 10/24/2024
 Autosomal recessive (infantile) polycystic
kidney disease (PCKD)

 often be diagnosed prenatally on

ultrasound. The disease carries a high

mortality rate in early childhood, and is
therefore rarely seen on ultrasound in
children.
 Tiny cysts replace both kidneys, giving

them a hyper echogenic appearance

69
due to the multiple reflections .
Done by: Tesfaye Mtz,MRT 10/24/2024
 Newborn who has
bilaterally enlarged,
echogenic kidneys
consistent with
ARPKD. The right
kidney
measures 10 cm in
length and the left
kidney measures 9.8
cm in length.

70 Done by: Tesfaye Mtz,MRT 10/24/2024

 Multicystic Dysplastic Kidney Disease
(MCDKD

 This is a congenital malformation of the kidney, in which

the renal tissue is completely replaced by cysts.

 It is frequently diagnosed prenatally (although it is

naturally a lethal condition if bilateral).

 The MCDK may shrink with age and by adult hood

may be mistaken for an absent kidney.

 Contralateral renal hypertrophy is often present.

71 Done by: Tesfaye Mtz,MRT 10/24/2024

  MCDK occurs as a result of severe

early renal obstruction during

development in utero.

 Obstructed calyces become blocked off,

forming numerous cysts which do not

72
connect.
Done by: Tesfaye Mtz,MRT 10/24/2024
73 Done by: Tesfaye Mtz,MRT 10/24/2024
 Acquired Cystic Disease of
Kidney
This affects patients on long term dialysis.

Its frequency increases with duration of

dialysis.

Through time the cysts has a potential of

developing a malignant mass.

 Sonographically, we will notice bilateral

multiple different size cysts, as of adult
PCKD.
74 Done by: Tesfaye Mtz,MRT 10/24/2024
 Renal Masses
 Role of ultrasound is to determine whether these
masses are simple cortical cysts, the most
common masses, or solid lesions.

 Ultrasound cannot reliably d/t b/n benign and

malignant renal tumours(other than renal cysts)

 Ultrasound cannot always accurately differentiate

malignant tumours from renal abscesses

75 Done by: Tesfaye Mtz,MRT 10/24/2024

 Solid Renal Masses In Adults
Iso-echoic Renal Lesions

Renal cell carcinoma

Column of bertin (pseudomass)

Dromedary hump( Pseudomass)

76 Done by: Tesfaye Mtz,MRT 10/24/2024

 Hypo echoic Lesions
 Renal cell carcinomas also may be predominantly

hypo echoic

 The presence of a relatively small, smooth hypo echoic

lesion should raise the possibility of an oncocytoma.

 However, oncocytoma often is indistinguishable

from carcinoma on imaging, the diagnosis being

made only on the post-nephrectomy specimen.

77 Done by: Tesfaye Mtz,MRT 10/24/2024

 Hyper echoic And Mixed Hyper
echoic Lesions
Renal cell carcinomas also may display a
mixed pattern, predominantly hyper echoic.
 Angiomyolipoma/AML/
 Adenoma
 A Small well-defined hyper echoic lesion similar in appearance to
that of AML.
 It is felt that adenomas are early manifestations of RCC.
 Renal Adenomas may be found in association with a RCC in the
same or contralateral kidney.

78 Done by: Tesfaye Mtz,MRT 10/24/2024

 Calcification In Renal
Masses
 Such calcifications are predominantly characteristic

of renal cell carcinomas

- calcification is often seen on CT images than on

ultrasound

 Peripheral or rim calcification may occur in renal cell

carcinomas or benign conditions.

79 Done by: Tesfaye Mtz,MRT 10/24/2024
  A smooth, thin calcific rim typically occurs in benign

conditions

 A rim with irregular thick areas suggests a malignant

lesion.

 Dense shadowing calcifications are suggestive of

malignant. lesions
80 Done by: Tesfaye Mtz,MRT 10/24/2024
 Renal cell
carcinoma with
calcification. Dense
hyper echoic areas
of calcification are
seen with in the
tumor

81 Done by: Tesfaye Mtz,MRT 10/24/2024

 Benign Focal Tumours
Angiomyolipoma

 Homogeneous, highly echogenic, usually rounded lesion

 usually solitary,

 Asymptomatic lesions, found incidentally on the scan.

 Tend to be smaller and more echogenic than RCC, and

may demonstrate shadowing.

 CT -identify the fat content of the lesion

82 Done by: Tesfaye Mtz,MRT 10/24/2024

83 Done by: Tesfaye Mtz,MRT 10/24/2024
 Oncocytoma
 This is a benign tumor which usually

shows more echo than the kidney cortex

and is of a mostly homogenuous
structure.
 The occurance of scars located at the

centre is quite common

84 Done by: Tesfaye Mtz,MRT 10/24/2024

85 Done by: Tesfaye Mtz,MRT 10/24/2024
 Malignant Renal Masses

 Ultrasound highly sensitive in detecting large

renal masses above 2.5 cm in diameter.

 Smaller masses may be missed as they are iso-

echoic (in 86% of cases).

 CT is more sensitive in detecting small lesions.

86 Done by: Tesfaye Mtz,MRT 10/24/2024
 Renal cell carcinoma (RCC)
(Adenocarcinoma)
 Most common type of renal malignancy

 Are frequently large at clinical presentation.

 Triads of RCC: Hematuria, Flank mass, Flank pain

 Usually large, heterogeneous mass which enlarges

and deforms the shape of the kidney.

 May contain areas of cystic degeneration and/or

calcification.
 Color Doppler usually reveals a disorganized and increased

blood flow

87 Done by: Tesfaye Mtz,MRT 10/24/2024

88 Done by: Tesfaye Mtz,MRT 10/24/2024
 Metastasis
 Primary malignancies which commonly metastasize
to the kidney are lung, breast, gastrointestinal
tumors and melanoma.
 usually occur late in the course of a known
malignancy as part of widespread disease.
 In rare cases a renal metastasis may manifest as a
solitary lesion and may be hard to differentiate from
a renal cell carcinoma.

-CT scan used in this case.

89 Done by: Tesfaye Mtz,MRT 10/24/2024
90 Done by: Tesfaye Mtz,MRT 10/24/2024
 Pelvicalyceal System Dilatation And Obstructive
Uropathy
Physiological dilatation

 Mild dilatation of PCS

 Seen on over-distended bladder.

 An external renal pelvis.

 Pregnancy related physiological dilation -more frequently

seen on the Right kidney.

 If symptomatic, the suspicion of obstruction in a

dilated system is increased

91 Done by: Tesfaye Mtz,MRT 10/24/2024
 Obstructive Uropathy
 US plays a prominent role in diagnosing obstruction.

 Dilatation of the Collecting system occurs

proximal to the site of obstruction called

HYDRONEPHROSIS.
 If the obstruction is long-standing the renal cortex may

atrophy, becoming thin.

 Normal thickness of cortex is a good prognostic

indicator.
 May cause renal failure

92 Done by: Tesfaye Mtz,MRT 10/24/2024

 Hydronephrosis/HN

93 Done by: Tesfaye Mtz,MRT 10/24/2024

 Mild(grade I )
hydronephrosis

 Calyceal dilatation (anechoic area within

renal sinus)

 Maintains normal anatomic structure

N.B Normal finding in overhaydrated

patient, or over distended bladder

94 Done by: Tesfaye Mtz,MRT 10/24/2024
95 Done by: Tesfaye Mtz,MRT 10/24/2024
 Moderate(grade II) hydro

Pelvi-Calyceal
system becomes
distended

96 Done by: Tesfaye Mtz,MRT 10/24/2024

 Severe (grade III) hydro

Effacement of renal
medulla & cortex

97 Done by: Tesfaye Mtz,MRT 10/24/2024

98 Done by: Tesfaye Mtz,MRT 10/24/2024
 Renal Tract Calcificaton
 Calcification within the kidney usually occurs in the

form of stones.

 Smaller foci of calcium, which do not shadow on

ultrasound, are associated with conditions such as

tuberculosis, xanthogranulomatous pyelonephritis,

nephrocalcinosis or some neoplastic tumours.

99 Done by: Tesfaye Mtz,MRT 10/24/2024

 Renal calculi

 Renal calculi may be present in patients with

acute renal colic and complete or partial

obstruction of the ipsilateral renal tract.

 May cause haematuria or UTI.

10 Done by: Tesfaye Mtz,MRT 10/24/2024

0
 Types
 Calcium stones are the most common

 Struvite (triple phosphate) are associated with UTI .

They may form large, staghorn calculi.

 Uric acid stones associated with gout.

 Cystine stones are the rarest of all and result from

cystinuria/ a disorder of amino acid metabolism/.

10 Done by: Tesfaye Mtz,MRT 10/24/2024

1
 Sonographic appearance
 Highly reflective and displays distal shadowing.

 Small stones may be missed on ultrasound.

 Differentiation of small stones from sinus fat and

reflective vessel wall is dependent on careful

ultrasound scanning technique and optimal use of

equipment.
10 Done by: Tesfaye Mtz,MRT 10/24/2024
2
 A calculus
within the PCS
of the RK. Distal
acoustic
shadowing is
easily seen.

10 Done by: Tesfaye Mtz,MRT 10/24/2024

3
 A staghorn
calculus fills the
entire PCS of the
kidney. this is, in
fact, a single
calculus

10 Done by: Tesfaye Mtz,MRT 10/24/2024

4
 Nephrocalcinosis
It is deposition of calcium in the renal
parenchyma.
It is MOST often related to medullary
pyramids.
It is common in patients with disorders
of calcium metabolism, e.g.
hyperparathyroidism.
It may affect some or all the pyramids.
A regular arrangement of
hyperechoic pyramids seen on
10
ultrasound
Done by: Tesfaye Mtz,MRT 10/24/2024
5

 Renal Parenchymal
Disease
A) Renal size and overall appearance

In acute
 some swelling and edema of kidney may seen
 In most cases size remain normal

In chronic
 Contract in size, but variable
 Small and echogenic may be difficult to
distinguish within retroperitoneal fat

10 Done by: Tesfaye Mtz,MRT 10/24/2024

6
 B. Cortex

 Appearance the cortex of may be within normal limits

or show decrease or increase echogenecity

 Normal renal echogenecity is less than the adjacent

liver or spleen(assuming these are normal)

 In some acute condition swelling of cortex may seen.

 Cortical scaring or calcification may occur.

10 Done by: Tesfaye Mtz,MRT 10/24/2024

7
 C. Medulla/pyramids
 Normal pyramids have lower echopattern than
adjacent cortex
 In some acute disorders pyramids may be more
visible

-due to increased cortical echogenecity

 In some cases there may be decreased
corticomedullary differentiation
10 Done by: Tesfaye Mtz,MRT 10/24/2024
8
 D) Renal sinus

 Usually does not involved in diffuse renal

disease

 May reduced in size in severe parenchyma

edema

 Show increased size in parenchymal

10 Done by: Tesfaye Mtz,MRT 10/24/2024
9
atrophy
 Cortical disorders

Glomerulonephritis

Acute interstitial nephritis

Acute cortical necrosis

 Cortical nephrocalcinosis

11 Done by: Tesfaye Mtz,MRT 10/24/2024

0
 Loss of CMD in
glomerulonephritis

11 Done by: Tesfaye Mtz,MRT 10/24/2024

1
 Renal Tract Inflammation and
Infection

 The most common UTI are bacterial in origin, with

viral and fungal infections being comparatively rare.

 Infection may be via the blood stream

(haematogenous) or the urethra (ascending).

 Also infection is associated with

obstruction ,calculi,diabetes,catheters

11 Done by: Tesfaye Mtz,MRT 10/24/2024

2
 Pyelonephritis
 Acute bacterial pyelonephritis is the most common

 Most common in females

 Respond to antibiotics

 Ultrasound only in those do not respond to treatment

 May appear normal even in severe infection

11 Done by: Tesfaye Mtz,MRT 10/24/2024

3
 Acute pyelonephritis
Rarely results in any Sonographic abnormality.

Enlarged hypoechoic kidney

Loss of corticomedullary differentiation

Compressed renal sinus

11 Done by: Tesfaye Mtz,MRT 10/24/2024

4
 Chronic pyelonephritis

 Usually the result of frequent previous

inflammatory/infective episodes.

 The kidney may be small and often has focal

scarring present; hyperechoic, linear lesion.

 The renal cortex is frequently thin.

11 Done by: Tesfaye Mtz,MRT 10/24/2024

5
 Chronic
pyelonephritis
with irregular
destructed
kidney

11 Done by: Tesfaye Mtz,MRT 10/24/2024

6
 Renal abscess
 Is a progression of focal inflammation in kidney

 Form a complex mass with distal acoustic

enhancement.

 Low-level echoes from pus or debris may fill the

abscess cavity

 Capsule ill-defined at first but later may develop

identifiable thick rim.

11 Done by: Tesfaye Mtz,MRT 10/24/2024
7
  Gradual resolution of the abscess can be

monitored with ultrasound.

 May be single or multiple

11 Done by: Tesfaye Mtz,MRT 10/24/2024

8
  Abscess in the LK
containing low-levell
echoes from pus. The
abscess capsule is
irregular and
thickened
DDX: infected
renal cyst

11 Done by: Tesfaye Mtz,MRT 10/24/2024

9
 Diffuse renal disease and renal
failure

Acute renal failure/AKD

 Increase in overall renal size

 Diffuse alteration in the renal cortical

echogenicity :Hypo-or hyperechoic compared with the

normal.

 Either increased or decreased corticomedullary

differentiation
12 Done by: Tesfaye Mtz,MRT 10/24/2024
0
  Acute renal failure
demonstrating an
enlarged, diffusely
hyperechoic kidney
with loss of
corticomedullary
differentiation.

12 Done by: Tesfaye Mtz,MRT 10/24/2024

1
 Acute renal failure
in paracetamol
overdose. The
kidney is large
(16 cm) and
hyperechoic with
increased
corticomedullary
differentiation.
12 Done by: Tesfaye Mtz,MRT 10/24/2024
2
 In chronic renal failure/CKD

The kidneys shrink and the cortex thins

 The end-stage kidney can be quite tiny and

hyperechoic and may be difficult to

differentiate from the surrounding tissues.

 Both of the kidneys are affected usually.

12 Done by: Tesfaye Mtz,MRT 10/24/2024
3
 Chronic renal
failure. The
kidney is
shrunken with
only a thin rim of
cortical tissue
remaining. The
cortical rim may
be of normal
echogenicity (i) or
hyperechoic (ii).
12
4
Done by: Tesfaye Mtz,MRT The latter 10/24/2024
 Solid Renal Masses In
Children
 GENERAL CONSIDERATIONS

Determining the nature of pediatric renal

masses depends as much on the age of the

patient as the appearance

 It is also useful to distinguish between

common and uncommon masses.

12 Done by: Tesfaye Mtz,MRT 10/24/2024
5
  Age: 0-1yr.
 Most Common Tumor: Mesoblastic nephroma
 Appearance
 Well-circumscribed homogeneous sometimes necrotic
center; occasional concentric rings
 Age:1-5yrs.
 Most Common Tumor: Wilm's tumor
 Appearance
 Well-defined capsule of compressed renal tissue;
homogeneous or heterogeneous
 Age : >5yrs.
 Most Common Tumor: Renal cell carcinoma
 Appearance
 Poorly defined; hyperechoic isoechoic, hypoechoic, or mixed

12 Done by: Tesfaye Mtz,MRT 10/24/2024

6
 First Year of Life: Mesoblastic
Nephroma
 Appear as well-circumscribed homogeneous

hypoechoic masses,
 Rarely with an irregular area of hypoechoic or

anechoic necrosis at the center

 They occasionally contain concentric hyperechoic

and hypoechoic rings.

 They may be locally invasive, although they do not

invade the hilar vessels and do not metastasize.

12 Done by: Tesfaye Mtz,MRT 10/24/2024

7
 Mesoblasticnephr
oma.
An 8-week-old
infant presented
with a palpable
renal mass.
The lesion is
typically a well
circumscribed
mostly
homogeneous with
12
8
Done by: Tesfaye Mtz,MRT hypoechoic 10/24/2024
 Older Than 1 Year of Age:
Wilms’ Tumor
 Is the most common pediatric renal malignancy in

children older than 1 year of age, with most presenting

before 5 years of age.

 They usually are large by the time they present

 Appear ultrasonically as well-circumscribed mass

with a well-defined hyperechoic or hypoechoic rim

of compressed renal tissue .

12 Done by: Tesfaye Mtz,MRT 10/24/2024

9
  They may be homogeneous or heterogeneous

because of areas of necrosis, hemorrhage, fat, and

calcification.

 They may invade locally through the renal capsule,

spread along the renal vein and vena cava, and

metastasize to local lymph nodes, liver, and lung.

 They metastasize.

13 Done by: Tesfaye Mtz,MRT 10/24/2024

0
13 Done by: Tesfaye Mtz,MRT 10/24/2024
1
ULTRASOUND OF BLADDER
AND PROSTATE
 Anatomy of Bladder
Centrally lie in the pelvis

Is infra peritoneal although peritoneum reflects over superior

surface

Bladder base or trigone lies inferior

Ureter enters trigone approximately 2cm either side of

midline

13 Done by: Tesfaye Mtz,MRT 10/24/2024

3
 Technique

Preparation-full-bladder

Position- supine, decubitus

Transducer-3.5-5MHz

Method –image in both longitudinal and trasverse

13 Done by: Tesfaye Mtz,MRT 10/24/2024

4
 Ultrasound Appearances of
Normal Bladder
Bladder wall

Normal bladder wall is smooth

3-5mm when distended

Bladder base

Smooth in outline

The intramural ureters seen as linear ‘corrugation’ along the bladder base

Not eleveated when prostate is normal

13 Done by: Tesfaye Mtz,MRT 10/24/2024
5
13 Done by: Tesfaye Mtz,MRT 10/24/2024
6
 Ultrasound of The Abnormal
Bladder
Congenital Anomalies

Bladder agenesis is rare

Duplication is more common

-present with an incomplete septum

-complete septum is unusual

13 Done by: Tesfaye Mtz,MRT 10/24/2024

7
 Acquired Diverticula

Usually Associated With Bladder-wall Thickening

Have narrow neck and may be large

Carefully Examined For Calculi, and Primary Bladder

Tumors

13 Done by: Tesfaye Mtz,MRT 10/24/2024

8
 Thickened irregular bladder wall(short arrow) with small
diverticulum (long arrow)

13 Done by: Tesfaye Mtz,MRT 10/24/2024

9
 Filling Defects or Intravesical
Masses
Intravesical mass is an uncommon

Calculi are more common-mobile high reflective

and posterior shadowing

Hematoma may be mobile or form a layer in the

dependent area and subsequently adhere to bladder

walls.

When hematoma is adhered to bladder wall –

indistinguishable from bladder tumor

14 Done by: Tesfaye Mtz,MRT 10/24/2024
0
14 Done by: Tesfaye Mtz,MRT 10/24/2024
1
 Diffuse Bladder-wall
Abnormalities

Diffuse bladder wall thickening seen

-usually due to muscular hypertrophy

-secondary to enlarged prostate or urethral stricture

N.B calculi,diverticula may be found associated

with this finding

14 Done by: Tesfaye Mtz,MRT 10/24/2024

2
 Infective cystitis may not cause any

abnormalities on ultrasound

Severe infection-thickened bladder

walls with internal low level echo debris.

14 Done by: Tesfaye Mtz,MRT 10/24/2024

3
 Focal Bladder-wall
Abnormalities
Over 95% of focal bladder-wall lesions
are due to TCC

Vast majority of TCC appears with

macroscopic hematuria

TCC are seen as polyp

TCC rarely calcify

14 Done by: Tesfaye Mtz,MRT 10/24/2024

4
 TCC

14 Done by: Tesfaye Mtz,MRT 10/24/2024

5
Ultrasound of the
prostate
 Gross Anatomy of The Prostate
Post puberty the gland has a volume of 25ml

Prostate gland measures: H=3.5

W=4cm and

Antero-posterior diameter= 2.5cm

Lies anterior to rectum and posterior to bladder

Has the shape of inverted cone or pyramids

14 Done by: Tesfaye Mtz,MRT 10/24/2024

7
14 Done by: Tesfaye Mtz,MRT 10/24/2024
8
 Zonal Anatomy of The Prostate
 Three glandular zones:

-Central Zone

- Peripheral Zone and

- Periurethral or Transitional Zone

 The peripheral zone accounts for 75% of the prostate mass in

young men

 With increased age the transitional zone increases in

size due to benign prostatic hyperplasia(BPH) while the

central zone atrophies and peripheral zone remain static

14 Done by: Tesfaye Mtz,MRT 10/24/2024

9
15 Done by: Tesfaye Mtz,MRT 10/24/2024
0
 Ultrasound Appearance of
Normal Prostate

In young it appears homogenous with indistinguishable

zones

Peripheral zone is normally hyper-reflective

Central zone and transitional zone are not separated from

each other
15 Done by: Tesfaye Mtz,MRT 10/24/2024
1
15 Done by: Tesfaye Mtz,MRT 10/24/2024
2
 Benign Prostate Hypertrophy

Over the age of 40 prostate will enlarge

Exact cause is unknown but hormones

play a great role

Hypertrophy may be diffuse or grow

15 Done by: Tesfaye Mtz,MRT 10/24/2024
3
 Ultrasound Appearance Of BPH

Gland enlargement(>25ml)

Thinning of the peripheral zones observed

Heterogeneous

Cystic degeneration in some cases

15 Done by: Tesfaye Mtz,MRT 10/24/2024

4
 Enlarged Prostate/BPH

15 Done by: Tesfaye Mtz,MRT 10/24/2024

5