Renal ultrasound: Difference between revisions
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**Cysts are typically single, circular, and arise in the periphery of the kidney | **Cysts are typically single, circular, and arise in the periphery of the kidney | ||
**They can be multiple as in polycystic kidney disease | **They can be multiple as in polycystic kidney disease | ||
***cyst classification: | |||
****Bosniak I :Benign simple cyst with thin wall without septa, calcifications, or solid components. | |||
****Bosniak II: Benign cyst with a few thin septa, which may contain fine calcifications or a small segment of mildly thickened calcification. Hyperdense cysts must be exophytic with at least 75 percent of its wall outside the kidney to allow for appropriate assessment of margins, otherwise they are categorized as IIF. | |||
****Bosniak IIF: Includes renal cysts with multiple thin septa, a septum thicker than hairline, slightly thick wall, or with calcification, which may be thick. It also includes intrarenal cysts larger than 3 centimetres (1.2 inches). Category IIF cysts have a 5-10% risk of being kidney cancer, and therefore follow-up is recommended every 6 months. | |||
****Bosniak III: Indeterminate cystic masses with thickened irregular septa with enhancement. 50 percent of these lesions are ultimately found to be malignant. | |||
****Bosniak IV: Malignant cystic masses with all the characteristics of category III lesions but also with enhancing soft tissue components on CT independent of but adjacent to the septa. 100 percent of these lesions are malignant. | |||
*Patients that are overhydrated, pregnant, or with a full-bladder may have mild hydronephrosis bilaterally without obstruction | *Patients that are overhydrated, pregnant, or with a full-bladder may have mild hydronephrosis bilaterally without obstruction | ||
*Underhydrated patients may not have hydronephrosis on initial renal scanning, despite obstruction | *Underhydrated patients may not have hydronephrosis on initial renal scanning, despite obstruction | ||
Revision as of 16:40, 5 November 2017
Background
- Bedside renal ultrasound has accepted use in the diagnosis of nephrolithiasis
- In comparison of diagnosis by CT vs. U/S (by EP) vs. U/S (by radiologist):[1]
- No difference in rate of missed high-risk diagnoses that resulted in complications (pyelo/sepsis/diverticular abscess)
- No difference in rate of serious adverse events, pain scores, return emergency department visits, or hospitalizations
Indications
- Flank pain
- Suspected nephrolithiasis
Technique
- Select probe
- Curvilinear/large convex probe (phased array probe may substitute)
- Location
- Right kidney
- Patient supine
- Probe in the right lower intercostal space in the midaxillary line
- Left kidney
- Patient supine or right lateral decubitus
- Probe in the lower intercostal space on the posterior axillary line
- More cephalad and posterior than when visualizing the right kidney
- Right kidney
- Scan entire kidney (through liver)
- Longitudinal (long axis) and transverse (short axis) views
- Scan the bladder
Findings
- Hydronephrosis
- Mild: Distention of collecting system
- Moderate: Dilation of collecting system, rounding of calyces
- Severe: Dilated renal calyces and cortical thinning[2]
- “Bear claw” appearance
- Represents severe obstructive uropathy
Images
Normal
No hydronephrosis
Abnormal
Mild hydro
Moderate hydro
Severe hydro
Pearls and Pitfalls
- Renal cysts can sometimes be mistaken for hydronephrosis
- Cysts are typically single, circular, and arise in the periphery of the kidney
- They can be multiple as in polycystic kidney disease
- cyst classification:
- Bosniak I :Benign simple cyst with thin wall without septa, calcifications, or solid components.
- Bosniak II: Benign cyst with a few thin septa, which may contain fine calcifications or a small segment of mildly thickened calcification. Hyperdense cysts must be exophytic with at least 75 percent of its wall outside the kidney to allow for appropriate assessment of margins, otherwise they are categorized as IIF.
- Bosniak IIF: Includes renal cysts with multiple thin septa, a septum thicker than hairline, slightly thick wall, or with calcification, which may be thick. It also includes intrarenal cysts larger than 3 centimetres (1.2 inches). Category IIF cysts have a 5-10% risk of being kidney cancer, and therefore follow-up is recommended every 6 months.
- Bosniak III: Indeterminate cystic masses with thickened irregular septa with enhancement. 50 percent of these lesions are ultimately found to be malignant.
- Bosniak IV: Malignant cystic masses with all the characteristics of category III lesions but also with enhancing soft tissue components on CT independent of but adjacent to the septa. 100 percent of these lesions are malignant.
- cyst classification:
- Patients that are overhydrated, pregnant, or with a full-bladder may have mild hydronephrosis bilaterally without obstruction
- Underhydrated patients may not have hydronephrosis on initial renal scanning, despite obstruction
Documentation
Normal Exam
A bedside ultrasound was conducted to assess for hydronephrosis with clinical indication of left/right flank pain. The left kidney, right kidney, and bladder were identified in the transverse and sagittal plane. There was no hydronephrosis identified.
Abnormal Exam
A bedside ultrasound was conducted to assess for hydronephrosis with clinical indication of left/right flank pain. The left kidney, right kidney, and bladder were identified in the transverse and sagittal plane. There was mild/moderate/severe hydronephrosis identified on the left/right.
Clips
Normal
Abnormal
Mild hydro
Moderate hydro
Severe hydro
Pitfall
Nonobstructing stone
Using color flow to determine vasculature vs hydro
