ABDOMINAL ULTRASOUND LECTURE 4

By: Joseph Arkorful, Msc, RDMS

Deptof Imaging Tech & Sonography
University of Cape Coast
 RENAL ULTRASOUND

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URINARY SYSTEM
• Kidneys

• Renal Artery & vein

• Ureters

• Urinary Bladder

• Urethra

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 KIDNEY - anatomy

• Cortex
• Medullary pyramids
• Renal Pelvis
• Renal hilum à Renal sinus
• Renal capsule
• Ureters

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Indications for renal usg

• Lumbar / back pains / colicky pains

• Abnormal RFTs
• Trauma
• Hematuria (either microscopic or gross)
• Infections
• Initial survey / evaluation for renal insufficiency
• Differentiate between solid and cystic masses

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Relevant imaging markers
• Parenchymal echogenicty
• Renal length, size or volume
• ? Dilatation of collecting systems
• ?calculi or masses

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Correlating lab tests

• Creatinine
• Most direct measure of renal function
• Very high levels may indicate renal failure
• eGFR (est Glomerular Filtration Rate)
• BUN (blood urea nitrogen)
• Extremely high levels may indicate impaired renal function
• Urinalysis
• ? Presence of WBC’s (indicative of infection)
• ? Presence of RBC’s (hematuria)

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Imaging of the adult kidney
• Normal renal cortex is more hypoechoic than liver

• Medullary pyramids are more hypoechoic than neighboring cortex

• Echogenic center of kidney is caused by the prominent renal sinus fat

• Collecting system not usually visible unless dilated

• Normal adult kidney length : 8-12 cm

• Normal adult kidney volume : 110 – 190cc in males; 90 – 150 cc in females

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Scanning tips

• Kidneys may be scanned from the anterior surface of the body

through the liver or spleen
• Combination of Subcostal and intercostal scanning approaches
• May be more easily seen in the lateral decubitus position
(particularly the left kidney)
• Ribs may obscure parts of the kidney - Deep inspiration while
scanning may reduce this problem
• May need to scan from coronal or posterior approach (especially
left kidney)

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 Renal variants

• Dromedary humps are bulges on the lateral borders (usually on the left)
• Double collecting system (two ureters)
• Parenchymal junctional defect (usually seen anteriorly and superiorly.
Commonly seen on right kid in sag view)
• Hypertrophied column of Bertin (HCB)
• Horseshoe kidneys - connected by isthmus at the lower poles (90% of
cases).
• Cross-fused kidneys
• Ectopic kidney - located outside the normal renal fossa (usually in pelvis)
• Absent kidney (renal agenesis)
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Renal dromedary hump

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Double ureters

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Junctional parenchymal defect

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Hypertrophied column of Bertin

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 Horseshoe kidneys

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 Horseshoe kidneys

RK LK

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 Horseshoe kidneys

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Horseshoe kidneys

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 Cross-fused kidneys

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Cross-fused kidneys

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 ECTOPIC KIDNEY

UT

KID

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ECTOPIC KIDNEY

UT

KID

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 ECTOPIC KIDNEY

UB
KID

KID

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 Renal pathology

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cysts

• A solitary encapsulated collection of fluid of unknown origin. Often

found accidentally
• Common in the aged population
• May be multiple, and can be very large.
• Asymptomatic unless they obstruct the collecting system.
• May contain a few septations (complex cyst)
• Complex cyst may need follow-up and aspiration

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 Ultrasound characteristics of simple cysts

• Smooth edges / sharp borders

• Circular/ rounded
• Good through transmission with enhancement of the posterior
wall
• Anechoic or echo-free or no internal septations

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 Simple renal cyst

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Complex renalcyst

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Reading assignment
• Read on Bosniak classification of renal cysts

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POLYCYSTIC KIDNEY DISEASE (PKD)

• Inherited disorders characterized by many bilateral renal cysts

that increase renal size and reduce functioning renal tissue

• Two types
• Autosomal dominant (adult form)
• Autosomal recessive (infantile form)

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ADPKD (cont’d)

• Symptoms usually related to effects of the many large cysts

(pain, hematuria, UTI, loss of renal function, hypertension)
• Some association with cerebral aneurysms - risk of rupture
• Some association with cardiac valve abnormalities

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Ultrasound features of adpkd

• Bilaterally enlarged kidneys

• Numerous large and small cysts scattered through out the cortex
and medulla.
• Cysts differ greatly in size
• Cysts may also be found in the liver, and less commonly in the
pancreas or spleen.

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 Ultrasound in the evaluation of renal failure

• Chronic renal disease

• Small kidneys
• Diffusely echogenic
• No well-differentiated cortex, medulla and fatty sinus

• Obstruction
• Is evidenced by hydronephrosis
• May be at ureter, bladder, or urethra level

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Hydronephrosis (RENAL OBSTRUCTION)

• Dilatation of the calyces due to an obstruction of the flow of

urine after it leaves the kidneys
• If unilateral, then obstruction is in the kidney (pelvis or UPJ) or
ureter
• If bilateral, than obstruction must be either in the bladder or
urethra
• The longer the duration of hydro, the more risk there is of
permanent renal damage, resulting in renal failure

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CAUSES OF HYDRONEPHROSIS

• Kidney stones (calculi)

• Masses, blood clots or tumors in or pressing on the ureters
• Congenital anomalies (UPJ- Ureteropelvic jxn)
• Prostate enlargement in males (results in bilateral hydro)
• Pregnancy (usually on the right)
• Transient cause - Overly distended urinary bladder!!!

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UsG appearance of hydronephrosis
• Must be able to demonstrate communication between fluid
collections (dilated calyces) and renal pelvis
• Visualized as a “bear claw” appearance in moderate hydronephrosis
• Severe hydronephrosis will result in parenchymal thinning due to
compression of the tissues

• Always do post-void check !!

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 hydronephrosis - grading

• Grade I (mild) - pelviectasis

• Grade II (mild-to-moderate) – pelviectasis + dilatation of major calyces
• Grade III (moderate) – pelviectasis + dilatation of minor calyces
• Grade IV (severe) – Grade III features + noticeable cortical thinning

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 INFECTions of the kidney

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Pyelonephritis

• Infection of kidney
• Ascending infection – eg. from E.Coli infection (about 85% of the cases)
• Hematogenous route - eg. from Staphylococcus aureus (about 15% of the
cases)
• Common in women (ages 15 – 35yrs)
• 2% of pregnant women may develop acute pyelonephritis
• Poorly treated or untreated pyelonephritis may lead to abscess formation

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ACUTE Pyelonephritis – CLINICAL SYMPTOMS

• Flank pains
• Fever
• Lab findings ( Bacteriuria, pyuria, leukocytosis)

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ACUTE Pyelonephritis – USG features

• Renal enlargement
• Compression of renal sinus
• Loss of cortico-medullary differentiation
• Abnormal echogenicity [either hyperechoic (from likely haemorrhage) or
hypoechoic (from likely edema) ]
• Perirenal free fluid collection
• Poorly marginated masses (in focal pyelonephritis)
• Gas within renal pyramids and parenchyma (emphysematous
pyelonephritis)

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ACUTE Pyelonephritis – USG features

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Focal Pyelonephritis – USG features

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Renal abscess– USG features

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Emphysematous pyelonephritis

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 Benign kidney lesions

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ANGIOMYOLIPOMA

• Very common kidney lesion

• Usually found in young women
• Made up of vascular, muscular and fatty tissue

• USG appearance - small, well-defined hyperechoic lesion within

parenchyma of kidney

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Reading assignment
• Read on kidney stones (nephrolithiasis)
• Difference between nephrolithiasis and nephrocalcinosis

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 MALIGNANT KIDNEY
LESIONS

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RENAL CELL CARCINOMA

• Also known as hypernephroma or adenocarcinoma of the kidney

• Usually in the older population (60’s and 70’s)
• Higher incidence in males
• ­ Incidence in cigarette, pipe, and cigar smokers
• Genetic factors

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RENAL CELL CARCINOMA (CONT’D)

• These tumors spread to the renal vein, the IVC, and possibly the right
atrium
• May metastasize to the liver.
• Resectability is based on how much spread there is

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USG FEATURES OF RENAL CELL CA

• Can become very large

• May appear as complex cyst or heterogeneous mass
• Increased vascularity
• Can also be necrotic in the center which will produce an echofree
zone in the center of the mass.
• These tumors have irregular borders which helps differentiate them
from cysts.

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WILM’S TUMOR (NEPHROBLASTOMA)

• Highly malignant childhood tumor

• Very treatable
• Usually seen at age 2 or 3 yrs
• Pt may have a palpable mass, malaise, weight loss, N & V, gross hematuria
• Higher incidence with several syndromes (Beckwith-Wiedemann
syndrome)
• May metastasize to lungs

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US FEATURES OF WILM’S TUMOR
• Very large solid mass; may extend across midline and down into pelvis
• May fill the renal pelvis and calyces
• May invade the IVC and heart (in stage 4)

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