Robert O'Reilly Ultrasound Lab

23/03/2020

23/03/2020

The patient presented to the ultrasound department with sever lower abdominal pains with a palpable lump at the left lateral aspect of her c-section scar. The had complained that pain coincides with her menstrual cycle but of recent was especially tender after a vigorous gym session. The referring doctor was concerned about an ovarian cyst or an abdominal wall tear.

The ultrasound could demonstrate a normal uterus, ovaries, kidneys and bladder. Of note was an irregular, lobulated hypoechoic mass confined to the subcutaneous fat superficial to the intact re**us abdominus.

When colour doppler was applied to differentiate between and solid and cystic mass, internal vascularity could be demonstrated on colour doppler therefore suggesting a solid lesion. The sonographic features were suggestive of an abdominal wall endometrioma most likely implanted at the time of the C-Section.

A bit more information from radiopaedia on abdominal wall endometriomas / Scar endometriosis.

Scar endometriosis is a term given to endometriosis occurring in a Cesarian section scar. It can be located in the skin, subcutaneous tissue, re**us muscle/sheath, intraperitoneally, or in the uterine myometrium (within uterine scar).

Epidemiology
The reported incidence of abdominal scar endometriosis following Cesarean section is 0.03-0.6% 6.

Clinical presentation
Patients may complain of tenderness to palpation and a raised, unsightly hypertrophic scar. Most patients have cyclical pain (up to 70%) 5. The pain is usually intermittent and associated with the patient's menstrual cycle but it may be constant in nature. Some reports state that only as low as 20% of the patients exhibited cyclical symptoms. The overlying skin may be hyperpigmented due to deposition of hemosiderin. Some patients may be asymptomatic 4.

Pathology
It is thought to be caused by implantation of endometrial stem cells at the surgical site at the time of uterine surgery.
Radiographic features

For general imaging features of endometriosis: refer to the parent article.

Ultrasound
Sonographic features are not specific. A subcutaneous nodule having relatively irregular borders, a heterogeneous echotexture with internal scattered hyperechoic echoes surrounded by a hyperechoic ring of variable width, and vascularity may be present. Occasionally cystic changes may be present 6.

CT
Well-defined soft tissue nodule with heterogenous post-contrast enhancement and streaky appearance in the surrounding tissue.

MRI
The most sensitive imaging modality. Often accurately locates the lesion in relation to a previous C-section scar, with signal characteristics similar to that of background endometriosis.

https://radiopaedia.org/articles/scar-endometriosis

27/02/2020

The patient presented with intermittent nausea and vomiting and epigastric pain. The referring doctor was concerned about gall stones. The ultrasound could demonstrate the following.
There was subtle gall bladder wall thickening measuring 3.3mm in thickness (3mm is the upper limits of normal), but no gall stones or polyps. No dilated intrahepatic ducts were noted. The common bile duct at the porta hepatis was distended. While following the common bile duct down to the head of the pancreas, numerous hyperechoic foci with distinct shadowing could be demonstrated within the CBD and are suggestive of common bile ducts calculi.

Information on CBD caluli:

Clinical presentation
Stones within the bile ducts are often asymptomatic and may be found incidentally, however, more frequently they lead to symptomatic presentation with:

biliary colic
ascending cholangitis
obstructive jaundice
acute pancreatitis
Pathology
Stones within the bile duct may form either in situ or pass from the gallbladder, and when recurrent tend to be pigment stones, and are thought to be associated with bacterial infection 1.

Radiographic features
Ultrasound
Although ultrasound is usually the first investigation for biliary disease, it has average sensitivity for the detection of biliary stones within the bile duct. Sensitivity has been variably reported between 13-55% 2, with newer studies having higher values due to improved equipment.

Ultrasound should be performed both longitudinally and transversely through the duct with particular attention paid to the very distal portion of the common bile duct as it passes through the pancreatic head (best assessed transversely).

Findings include:

visualization of stone(s)
echogenic rounded focus
size ranges between 2 to >20 mm
shadowing may be more difficult to elicit than with gallstones within the gallbladder
~20% of common bile duct stones will not shadow
twinkling artefact may be useful to detect occult stones
dilated bile duct
>6 mm + 1 mm per decade above 60 years of age
>10 mm post-cholecystectomy
dilated intrahepatic biliary tree
gallstones should increase suspicion, especially if multiple and small
Recently endoscopic ultrasonography (EUS) has also been used with very high sensitivity and specificity.

https://radiopaedia.org/articles/choledocholithiasis

26/02/2020

Patient presented with left flank pain but no history of trauma.
The referring doctor had asked for lumbar spine and left hip x-rays to exclude any lumbar pathology of left hip joint pathology. On the x-ray no significant pathology could be demonstrated to account for the patients pain. Of note was a small density projecting into the left renal shadow. Concern was raised for the possibility of a kidney stone and an abdominal ultrasound was performed.
The ultrasound could be demonstrate a 7mm intrarenal calculus within the upper pole of the left kidney. No hydronephrosis (backlog or urine) could be demonstrated on the ultrasound. With an appropriate diagnoses the patient could return to the referring practitioner for treatment.

A bit of information on Kidney stones:

Urolithiasis refers to the presence of calculi anywhere along the course of the urinary tracts. For the purpose of the article, the terms urolithiasis, nephrolithiasis and renal/kidney stones are used interchangeably, although some authors have slightly varying definitions of each.

Epidemiology
Most patients tend to present between 30-60 years of age 1.

The lifetime incidence of renal stones is high, seen in as many as 5% of women and 12% of males. By far the most common stone is calcium oxalate, however, the exact distribution of stones depends on the population and associated metabolic abnormalities (e.g. struvite stones are more frequently encountered in women, as urinary tract infection as more common) 8.

Clinical presentation
Although some renal stones remain asymptomatic, most will result in pain. Small stones that arise in the kidney are more likely to pass into the ureter where they may result in renal colic. Hematuria, although common, may be absent in ~15% of patients 1. Strangury is also occasionally present. Some patients may also present with the complication of obstructive pyelonephritis, and may, therefore, have a septic clinical presentation.
https://radiopaedia.org/articles/urolithiasis

10/02/2020

Patient presented with elbow pain. The patient has had a silicone radial head prosthesis in for many years after a fracture of the radial head. The concern from the orthopedic doctor was that there may be a joint space synovitis.
The ultrasound could be demonstrate the presence of a bicipitoradial bursitis with debris within the bursa.

Bicipitoradial bursitis refers to inflammation of the bicipitoradial bursa.

The bicipitoradial bursa surrounds the biceps tendon in supination. In pronation, the radial tuberosity rotates posteriorly, which compresses the bicipitoradial bursa between the biceps tendon and the radial cortex, which consequently increases the pressure within the bursa.

Epidemiology
It typically presents in adults and may be more common in males.

Clinical presentation
Patients often present with elbow swelling, pain, tenderness, redness, and limited movement.

Radiographic features:
Ultrasound
There may be evidence of distention of the bicipitoradial bursa by fluid, which appears anechoic, or hypoechoic soft tissue. Nodular soft-tissue debris and small calcifications may be seen within the fluid. The distal biceps tendon should be evaluated for injury. Power Doppler imaging may show hyperemia and suggests active inflammation.
https://radiopaedia.org/articles/bicipitoradial-bursitis

07/02/2020

The patient presented with lower abdominal pain.
The concern from the referring doctor was that of an ovarian carcinoma. An abdominal ultrasound was performed.
The ovaries were identified and no ovarian lesions could be demonstrated.
Incidental note was the of a gall stone within a contracted gall bladder.
A focally dilated portal vein could be demonstrated with swirling of the portal venous blood on colour doppler. The portal vein measures 21mm in width (upper limits of normal is 14mm) and the area of focal dilatation measures 25mm in length. Direct luminal continuity was demonstrated with the portal venous system.

A bit more info on a portal vein aneurysm.
Aneurysms of the portal vein are extremely rare and represent only 3% of all aneurysms of the venous system.

Clinical presentation
Most patients are asymptomatic but may present with nonspecific abdominal pain as a major symptom.

Pathology
Both congenital and acquired causes have been proposed. Acquired causes may include:

-portal hypertension: could be contributory but is not essential to the development of portal venous system aneurysms; indeed, the majority of patients do not have portal hypertension or chronic liver disease
-necrotizing pancreatitis
-abdominal trauma or surgery
-liver cirrhosis
-Location
-The most common locations for aneurysms of the portal venous system are:

splenomesenteric venous confluence
main portal vein
intrahepatic portal vein branches at bifurcation sites
The rarest locations are the splenic, mesenteric, and umbilical veins.

Radiographic features
Diagnosis can be made when the portal vein exceeds 20 mm in diameter.

Ultrasound
Color Doppler ultrasound is the most helpful diagnostic tool. Further workup may not be necessary. An aneurysm appears on ultrasound as an anechoic mass showing direct luminal continuity with the portal venous system and displays spectral findings characteristic of the portal venous system on color Doppler interrogation.

CT
Dynamic helical CT demonstrates simultaneous enhancement with the portal system.

MRI
In T1-weighted images, aneurysms are hypointense owing to the flow-void phenomenon .

Complications
Complications include:

thrombosis and distal embolism
portal hypertension
rupture
compression of the duodenum
compression of the common bile duct causing jaundice, cholestasis, and cholelithiasis
https://radiopaedia.org/articles/aneurysms-of-the-portal-venous-system

31/01/2020

The patient presented with trauma to the anticubital fossa of the elbow. The x-ray of the elbow was unremarkable but surgical emphysema was evident and an ultrasound was recommended. The patient complained of poor strength when flexing the elbow. At the ultrasound the following information was obtained.
-The distal biceps tendon appeared intact at the level of the radial tuberosity and no bicipitoradial bursitis could be demonstrated.
-There was a full thickness tear of the brachialis on the lateral aspect deep to the biceps muscle with a haematoma that could be demonstrated within the muscle belly.
-Contusion of the biceps muscle belly was noted but no intramuscular tear.
With the necessary information the the referring doctor could now make an informed decision as the management of the patient.

23/01/2020

The patient presented with anterior elbow. The patient describes playing with his grandchild and catching him or her and immediately feeling pain. The ultrasound lab could demonstrate the following.
There was a full thickness, full width rupture of the distal biceps tendon with significant tendon retraction of at least 47mm. No calcification or avulsed fragments could be demonstrated. Despite the significant tendon retraction the lacertus fibrosus appeared thick, but intact. A part of the distal biceps tendon could still be seen attached to the radial tuberosity level. With the appropriate information the patient could return to the general practitioner for management.

21/01/2020

Amanzimtoti, KwaZulu-Natal

21/01/2020

Come visit us @ Robert O'Reilly Ultrasound Lab for all your imaging requirements. We also offer 4D pregnancy imaging. For bookings contact us on 031 942 6622 or email admin@ultrasoundlab.co.za

17/01/2020

17/01/2020

17/01/2020

What to do when you are board? Ultrasound shark doo doo doo doo.