NR Medical Academy

06/03/2026

DUODENUM - A VERY COMMON MIMIC ON ABDOMINAL ULTRASOUND
A: An image sent by a doctor to me asking what is that ‘sub-hepatic mass’?
That’s the duodenum seen enface on ultrasound.
B: A supine image from a hospital I m reporting, showing what looks like ‘gallstones’. I have my doubts and ask them to repeat.
C: Repeat scan 2 days later in decubitus position showing gas in duodenum. GB clear – no stones.

Duodenum is a very common mimic on abdominal ultrasound.
In A, duodenum is contracted and appears like a mass
In B: duodenum is air-filled and appears like an echogenic focus.

How not to be ‘fooled’ by duodenum?
✔ Observe for peristalsis✔ Change patient position✔ Repeat scan after 10–15 min✔ Look for gut signature (layered wall)✔ Follow continuity with bowel

Remember to:
Always scan in multiple planes
Apply graded compression
Observe for at least 30–60 seconds
Change position (decubitus or erect)

If lesion:
Moves → bowel
Peristalses → bowel
Changes shape → bowel

In true pathology:
⚠ No peristaltic movement⚠ Irregular asymmetric wall thickening⚠ Adjacent lymphadenopathy⚠ Ducts may be dilated⚠ Vascularity on Doppler
KLINIK PAKAR X-RAY NR, SHAH ALAM, SELANGOR, MALAYSIA.

05/03/2026

BLADDER STONE/VUJ STONE vs PHLEBOLITHS
Differentiating bladder stone or ureteric stone from pelvic phlebolith is a common problem.
1. Bladder Stone (Vesical Calculus)
Typically located within midline pelvis and lies within the bladder shadow.
It appears round or oval, uniformly dense or may show laminated appearance (layering).
It changes position with patient movement or on repeat imaging.

2. Pelvic Phlebolith
Phleboliths are usually lateral to bladder, are often multiple.
They are also round calcification but classically have central lucency. Thus, sometimes called “donut sign”
They are not mobile.

3. VUJ stone (vesico-ureteric stone)
It would be located along ureteric course
Draw a line connecting right and left ischial spines. VUJ or distal ureteric stone would be above this line slightly lateral to the midline. Phleboliths would be below this line.
It tends to have tooth-shaped appearance as it follows the lumen of distal ureter.
Often single.

✅ Practical teaching tip
3L rule:
Line of ureter/bladder → stone
Lateral pelvis → phlebolith
Lucency → central lucency = phlebolith
KLINIK PAKAR X-RAY NR, SHAH ALAM, SELANGOR, MALAYSIA

03/03/2026

ANTERIOR OSTEOPHYTES CAUSING FB SENSATION
44M, c/o foreign body sensation in throat. Lateral soft tissue neck x-ray showing large anterior osteophytes at C5/6 and C6/7 projecting towards the posterior pharyngeal wall. Oropharyngeal and hypopharyngeal air column are maintained. No obvious radiopaque foreign body seen. No acute airway narrowing.
Subject to clinical correlation, anterior cervical osteophytes (especially at C4–C6) can cause globus sensation, dysphagia and foreign body sensation.
KLINIK MENARA, SHAH ALAM, SELANGOR, MALAYSIA

02/03/2026

UROTHELIAL TUMOUR VS TRANSITIONAL CELL CARCINOMA (TCC)
Same case as posted recently but discussing different topic.
55M, p/w painless hematuria. Ultrasound done showing a 3.8 cm irregular vascular polypoidal mass arising from the urinary bladder wall. Findings are highly suspicious for urothelial carcinoma. Why don’t I say transitional cell carcinoma (TCC)?

Urothelial tumour is the modern term while transitional cell carcinoma (TCC) is the older term. In reality, they refer to the same disease entity.
The lining of the urinary tract is called urothelium. Therefore, urothelial carcinoma is more anatomically accurate.
Urothelial tumour can be benign (urothelial papilloma, inverted papilloma) or malignant (urothelial carcinoma)
So, all TCC = urothelial carcinoma
But urothelial tumour is a broader term (includes benign + malignant)

How to differentiate on ultrasound between benign and malignant urothelial carcinoma?
Ultrasound cannot reliably differentiate with certainty but features suggesting malignancy are:
Broad-Based Mass
Internal Vascularity on Doppler
Bladder Wall Thickening
Larger Size >1cm
Causes ureteric obstruction leading to hydronephrosis
Extravesical extension
KLINIK PAKAR X-RAY NR, SHAH ALAM, SELANGOR, MALAYSIA

01/03/2026

Dear doctors & friends,
Criteria no 9 Cardiac anomalies & pathologies are now available for download. Go to my channel
https://whatsapp.com/channel/0029VbBo6OYKgsNxHXzyt71H
and scan the QR code
Rahman

Channel • 1.1K followers • Knowledge is to be shared for the benefits of mankind.
That is my life ambition and purpose of this Channel. Interesting x-ray & ultrasound cases from my clinic or reporting pool. Cases are being updated almost daily. All cases are original and come from various GP clinics on my panel. There is so much to learn.
Dr Abdul Rahman Mohamad
Radiologist, Klinik Pakar X-ray NR
Shah Alam, Selangor, MALAYSIA
Radiology4gps@gmail.com

28/02/2026

CLAVICULAR DYSPLASIA
Fomema medical check up – where are the clavicles?
The right is almost completely absent and the lateral third on the left is also absent. This is clavicular dysplasia.
The most classic condition associated with clavicular abnormalities is cleidocranial dysplasia (CCD).
Clavicular Dysplasia can be hypoplastic, partially absent or completely absent. It can be unilateral or bilateral.
In CCD, there will be skull and dental abnormalities. These patients would have short stature & narrow thorax. They may have wide p***c symphysis & short distal phalanges.
Are they fit to work?
Clavicular dysplasia is associated with altered shoulder biomechanics and reduced load-bearing capacity. Shoulders are hypermobile. They can perform many activities but heavy load carrying may be compromise, overhead lifting especially can be difficult and there is a higher risk of soft tissue strain.
👉I had made this case unsuitable!
POLIKLINIK CAHAYA, MALAYSIA.

27/02/2026

UROTHELIAL CARCINOMA
55M, p/w painless hematuria. Ultrasound done showing a 3.8 cm irregular vascular polypoidal mass arising from the urinary bladder wall. Findings are highly suspicious for urothelial carcinoma. Urological referral for cystoscopic evaluation and biopsy is recommended.

Why this is not a stone? The mass appears attached rather than mobile. No obvious posterior acoustic shadowing.
Why neoplasm is likely?
Classic presentation of painless hematuria
Polypoidal intravesical mass
Internal vascularity
Non-mobile lesion
Why cant this be blood clot?
Clot would be mobile and avascular
🧠 Clinical Tips: 55-year-old with hematuria, assume malignancy until proven otherwise.
KLINIK PAKAR X-RAY NR, SHAH ALAM, SELANGOR, MALAYSIA

25/02/2026

25/02/2026

SEASHELLS STUCK IN THE OESOPHAGUS
54F, alleged swallowed pieces of seashell and stuck to the throat, today sustained pain.
Lateral view neck showing 3 pieces of seashells
2mm in the pharyx
8mm in pyriform sinus
17mm in proximal oseophagus
Normal pre-vertebral soft tissue thickness and no air lucency indicating no pre-vertebral abscess formation.
As seashells are sharp foreign bodies, this should be considered a medical emergency. Urgent endoscopic removal within hours, not days.
Seashells can cause oesophageal perforation, bleeding, life-threatening mediastinitis and airway compromise.
KLINIK DAMAI (KUALA SELANGOR), SELANGOR, MALAYSIA.

24/02/2026

BLADDER STONE WITH DIVERTICULUM
49M, p/w gross hematuria and recurrent UTI. Ultrasound showing a 2.3cm bladder stone (yellow arrow) with 1.3cm diverticulum at the right side of bladder laterally (red arrow). KUB x-ray of the same patient showing a large bladder stone (orange arrow).

Primary bladder stones are rare and migratory renal stones are even rarer. Most renal stones come down and passed out easily. Rarely renal stones become bladder stones.

What are major complications of bladder stone?
Chronic bladder dysfunction
Urinary tract infection

If you see thickened wall (with bladder stone), what does that means?
Thickened bladder wall can be seen in neurogenic bladder and that is the cause of bladder stone.
Or thickened bladder is due to chronic cystitis secondary to bladder outlet obstruction due to bladder stone.
Or simply, thickened bladder wall because you are not scanning in full bladder.

If you see bladder diverticulum (with bladder stone), what does that means?
Bladder diverticulum causes urinary stasis and that causes bladder stone.
Or bladder diverticulum occurs secondary to bladder outlet obstruction due to bladder stone.

Important note:
Always scan in full bladder, measure bladder volume and scan again after micturition and measure post-void volume.
KLINIK PAKAR X-RAY NR, SHAH ALAM, SELANGOR, MALAYSIA

23/02/2026

SMITH’S FRACTURE
86M, alleged fall 2 days ago. X-ray left wrist showing fracture at the distal end of radius with intra-articular involvement. The fragment is displaced anteriorly. This is consistent with Smith’s fracture. The bones are generally osteopenic indicating osteoporosis.

Smith’s fracture is fracture of the distal radius with anterior displacement of the distal fragment. Because of the direction of displacement, it is also called reverse Colles fracture.

How are Smith’s different from Colles?
Wrist position during fall: flexed in Smith and extended in Colles.
Fracture displacement: anterior in Smith and posterior in Colles
Deformity: garden spade in Smith and dinner fork in Colles
Articular involvement: can be either in Smith, usually extra-articular in Colles
KLINIK ANTAH, CHERAS, SELANGOR, MALAYSIA

21/02/2026

BREAST CYST
42F, initially presented in 2022 with a left breast lump. Ultrasound showed an 8mm well-defined simple cyst with benign sonographic features. No suspicious solid component or vascularity. Features are consistent with a benign simple breast cyst (BI-RADS 2). No surgery was done. She came again in 2026 and a similar cyst is seen at the same region. The size and shape are about the same.

What is simple breast cyst?
Simple cyst = anechoic, thin wall, posterior enhancement, no solid component, no vascularity.

What To Do for a simple breast cyst
👉 No treatment is required
👉 No aspiration is needed
👉 Routine screening follow-up only

What is the natural history of simple breast ccyst?
Can fluctuate with hormones
Can spontaneously disappear
Can remain the same
Are not premalignant

When Further Work-Up Is Needed
Solid component inside cyst
Thick septations
Internal vascularity
Rapid enlargement
Bloody aspirate
Associated suspicious mammographic finding
KLINIK PAKAR X-RAY NR, SHAH ALAM, SELANGOR, MALAYSIA