Dr_Hari Ram_radiology.

06/11/2025

Fetal Intraperitoneal Meconium Pseudocyst

🤰A routine fetal scan revealed an intra-abdominal cystic mass in the fetus.
The ultrasound (US) examination revealed a large, complex cystic and solid intra-abdominal mass located within the peritoneal cavity. The mass exhibited a heterogeneous appearance, suggesting a collection of material (likely meconium) contained by reactive peritoneal and omental tissue. The inner contents appeared predominantly echogenic (bright), consistent with calcified or concentrated meconium debris. The walls of the mass were well-defined, suggesting a pseudocyst formation rather than an encapsulated true cyst.
The video clearly demonstrates a large, complex, predominantly echogenic mass with irregular internal septations and bright foci of calcification, characteristic of a walled-off meconium collection (pseudocyst) or an inflammatory solid reaction (fibroadhesive form of MP).
The amniotic fluid volume was increased (polyhydramnios), often resulting from associated bowel atresia or extrinsic mechanical obstruction due to the mass effect of the pseudocyst itself. No clear evidence of a definitive cause, such as a localized atresia or volvulus, was definitively demonstrated, but the presence of the pseudocyst strongly suggests a prior intestinal perforation.
🩺
Meconium pseudocyst formation is a known outcome of intrauterine intestinal perforation. The perforation is most commonly seen in the ileum, often proximal to an obstruction. Common etiologies of this obstruction include intestinal atresia or stenosis, meconium ileus, volvulus, or internal bowel hernia; the first two and meconium ileus account for 65% of cases.
Pathogenesis of Pseudocyst Formation:
When meconium escapes the bowel, the body's inflammatory response leads to the formation of adhesions that contain the collection, creating the cystic mass visualized on US. Alternatively, the reaction may form a solid, non-cystic mass where calcium deposits seal the perforation. In such "solid" cases, distinguishing the meconium collection from an abdominal tumor may be challenging.

The presence of calcifications and a complex, highly echogenic interior strongly favors the diagnosis of a meconium pseudocyst over other cystic etiologies.

This condition has an estimated prevalence of approximately 0.29 per 10,000 live births and is associated with significant morbidity and mortality, historically ranging from 11% to 50%. A common sequel of MP is the formation of a meconium pseudocyst—a contained collection of extruded meconium walled off by adhesions from the surrounding bowel loops and omentum. This report details a case where a fetal abdominal mass was identified prenatally, consistent with a meconium pseudocyst.

Management and Prognosis:

Historically, the prognosis for meconium peritonitis and pseudocyst was poor, but it has improved with advancements in surgical techniques. Treatment typically involves surgical resection postnatally. Definitive procedures can be difficult in the early neonatal period, and patients often require multiple surgical interventions.
The current gold standard for large meconium pseudocysts involves a two-stage approach: initial cyst decortication and a temporary enterostomy, followed by elective reversal later on. Some authors also recommend immediate cyst drainage and decompression via paracentesis following birth, with a delayed definitive resection.

31/10/2025

Case Report: Budd-Chiari Syndrome in a 44-Year-Old Female

A 44-year-old female was referred from Gastroenterology PIMS Hospital for abdominal ultrasound to evaluate chronic abdominal complaints and suspected portal hypertensive changes, with no prior imaging available for comparison. There was a history of hysterectomy; other relevant systemic history, thrombophilia risk factors, and liver function tests were not provided at the time of imaging, limiting clinicoradiologic correlation at baseline.

A comprehensive grayscale and Doppler whole-abdomen ultrasound was performed, assessing hepatic parenchyma, hepatic veins, portal vein, biliary tree, spleen, kidneys, and pelvis. Attention was paid to hepatic venous patency, collateral pathways, portal vein caliber and flow, and features of portal hypertension and ascites.

Key ultrasound findings
- Liver size normal with mildly coarse echotexture; no surface nodularity documented, suggesting early parenchymal change rather than established cirrhosis.
- Marked caudate lobe enlargement, a typical compensatory hypertrophy in hepatic venous outflow obstruction due to its separate venous drainage pathways.
- Right hepatic vein thick, echogenic, and cord-like, consistent with chronic occlusion; multiple intrahepatic veno-venous collaterals were present, indicating development of alternative outflow channels.
- Left and middle hepatic veins appeared patent; main portal vein showed normal appearance; intrahepatic biliary radicles were not dilated.
- Mildly increased periportal and pericholecystic echogenicity; gallbladder mildly edematous without calculi; CBD not dilated.
- Spleen was grossly enlarged to approximately 19 cm, supporting portal hypertension; no splenic hilar varices visualized.
- Kidneys were normal bilaterally; urinary bladder normal; uterus not visualized consistent with prior hysterectomy; mild ascites present.

Impression
- Occluded right hepatic vein with intrahepatic veno-venous collaterals and caudate lobe hypertrophy, highly suggestive of Budd–Chiari syndrome (hepatic venous outflow obstruction), with preserved patency of left and middle hepatic veins and normal main portal vein appearance.
- Early parenchymal hepatic changes without overt surface nodularity, in keeping with subacute to chronic venous congestion rather than established macronodular cirrhosis at this time.
- Features of portal hypertension including gross splenomegaly and mild ascites; no varices were detected sonographically at the splenic hilum on this study.

Recommendations
- Laboratory: Complete liver panel, INR, CBC with platelets, renal function, and serum albumin; thrombophilia workup including JAK2 V617F (myeloproliferative neoplasms), factor V Leiden, prothrombin G20210A, protein C/S and antithrombin levels, antiphospholipid antibodies, and homocysteine, guided by clinical assessment.

- Management pathway: If short-segment RHV stenosis/occlusion is confirmed and accessible, consider endovascular recanalization with balloon angioplasty ± stenting; if hepatic vein recanalization is not feasible or portal hypertension is clinically significant, evaluate for TIPS to decompress portal system; initiate anticoagulation after bleeding risk assessment and etiologic evaluation in coordination with hepatology and interventional radiology teams.
- Surveillance: Periodic ultrasound with Doppler for shunt/stent patency if treated, spleen size, ascites, and development of nodularity or regenerative nodules; endoscopic screening for varices as per portal hypertension protocols.

14/08/2025

🚨 Understanding Hypertrophic Pyloric Stenosis (HPS) in Infants 🚨



HPS is a condition where the pyloric muscle (connecting the stomach and small intestine) thickens, leading to gastric outlet obstruction.

Symptoms: Typically appear between 3 to 6 weeks of age, but can start earlier or later.

Look out for:

Nonbilious projectile vomiting, often after feeding.Constant hunger, despite vomiting.
Wavelike stomach contractions after feeding.
Dehydration and weight loss.

Diagnosis:

A doctor might feel an "olive-sized" mass in the baby's upper abdomen (the thickened pylorus).

Ultrasound is the preferred imaging method, providing a direct view of the pyloric muscle and avoiding radiation exposure.
Classic sonographic signs include the antral ni**le sign, cervix sign, and target sign.

Important: HPS can cause electrolyte imbalances, specifically hypochloremic metabolic alkalosis, due to loss of stomach acid from vomiting. Early diagnosis and treatment are crucial to prevent dehydration and malnourishment.

If you notice these symptoms in your infant, contact the healthcare provider immediately for prompt evaluation and treatment.

05/08/2025

Acute ovarian torsion during pregnancy is a fairly uncommon complication with a high patient morbidity and fetal mortality if not immediately treated. Ovarian torsion should be considered a clinical diagnosis, and a high level of clinical suspicion is needed by the practitioner to ensure that this diagnosis is not missed.

Torsion of the o***y in the third trimester is rare as the compressive effect of the gravid uterus restricts the mobility of the ovarian pedicle. However this case clearly demonstrates that it can occur and needs to be considered as a differential diagnosis when patients present with an acute abdomen.

Additionally this highlights the difficulty in producing good quality radiological imaging of the pelvic organs in advanced pregnancy. Radiologists often have limited experience of pelvic imaging in the third trimester, so in all but the most experienced hand, a definitive diagnosis may not be forthcoming. This case serves to remind us of the importance of clinical acumen alongside diagnostic test as well as ensure that the correct incision is performed to ensure good surgical access. Furthermore, ultrasound scan examinations in early pregnancy should also address the cervix and the adnexa leading to early diagnosis and management of ovarian masses, thus avoiding later emergency situations and the possibility of preterm deliveries.

The patient presented at 30 weeks of gestation, with a 4-hour history of sudden, severe and constant abdominal pain in the left iliac fossa. She found changing position incredibly painful and examination displayed involuntary guarding and rigidity of the left side of her abdomen. The pain was associated with uncontrollable vomiting. There was no history of vaginal bleeding and normal fetal movements had been felt.

Ultrasound assessment demonstrated fetal heart movements, cephalic presentation, and an anterior high lying placenta. Internal os was closed and cervical length was 32 mm. Previous LSCS scar appear healthy for the gestation. On further examination left adnexal region demonstrated approx 6 x 4 cm sized left ovarian dermoid with twisted pedicle.

Fetal monitoring using cardiotocography was reassuring.

On opening the abdominal cavity through a midline laparotomy incision, a large purple but not necrotic left sided mass was noted.

The left o***y was then examined and it was torted thrice and appeared as a purple enlarged structure of 6 × 4 cm. There were some well perfused white parts noted on the o***y on close examination. A cystectomy of the left dermoid and evacuation of blood clots were performed.

01/08/2025

01/08/2025

Q: Assign chorionicity and amnionicity in this pregnancy?

Determining chorionicity (number of placentas) and amnionicity (number of amniotic sacs) in a pregnancy is crucial for proper management and to identify potential risks. This is best done with an ultrasound examination during the first trimester, ideally between 11+2 and 14+1 weeks gestation.

09/07/2025

03/05/2025

In cases of obstructive azoos***mia, dilated vas deferens and ejaculatory ducts can be observed on ultrasound. This finding suggests an obstruction in the reproductive tract preventing s***m from being released. Specifically, ultrasound may reveal dilation of the epididymal tubules, rete te**is, or the proximal vas deferens. In addition, transrectal ultrasound can better visualize dilated seminal vesicles or ejaculatory ducts, indicating an obstruction.

Other Imaging:

In some cases, further imaging like vasography (contrast injection into the vas deferens) or MRI may be used to evaluate the extent and nature of the obstruction.

Treatment:

The treatment for obstructive azoos***mia depends on the cause and location of the obstruction, and may include surgical repair of the vas deferens or ejaculatory ducts, or procedures like vasectomy reversal.

***mia

03/05/2025

An interstitial ectopic pregnancy, a type of tubal ectopic pregnancy, is diagnosed using ultrasound by identifying a gestational sac located within the intramural (uterine) part of the fallopian tube, outside the endometrial cavity, and surrounded by minimal myometrium (less than 5mm). The "interstitial line sign," an echogenic line connecting the gestational sac to the endometrial cavity, is a helpful indicator.

Key Ultrasound Findings for Interstitial Ectopic Pregnancy:

• Empty Uterine Cavity:
The endometrial cavity should be free of a gestational sac.
• Eccentric Gestational Sac:
The gestational sac is located laterally in the interstitial (intramural) part of the tube, outside the endometrial cavity.
• Thin Myometrial Mantle:
The myometrial layer surrounding the gestational sac is less than 5mm thick.
• Interstitial Line Sign:
An echogenic line extending from the endometrial cavity to the gestational sac is a characteristic finding.
• Intense Peri-trophoblastic Blood Flow:
Doppler ultrasound may reveal an increase in blood flow around the gestational sac.

3D Ultrasound can be helpful in visualizing the location of the gestational sac and assessing the thickness of the myometrial mantle, particularly in the fundal region of the uterus.

10/04/2025

Lens dislocation - The lens is seen floating en face in the vitreous chamber associated with vitreous hemorrhage and detachment.

10/04/2025

Transcervical migration of endometrial polyp prolapsing through the introitus.

Polyps can be a common cause of postmenopausal bleeding. In premenopausal women they may cause intermenstrual bleeding, metrorrhagia and infertility.