Genitourinary System

Subject: Radiology Topic: Um..? Lecturer: The usual Shifting /Date: 2nd shifting, August 9 2008 Trans group: Chicken Naguits :D Trauma classification • Grade 1 o subscapular hematoma non-expanding o contusions and small infarcts o no parenchymal laceration • Grade II o less than 1 cm laceration o non-expanding perirenal hematoma • Grade III o greater than 1 cm laceration o not extending to collecting system • Grade IV o laceration with urinary extravasation o main renal artery or vein injury with contained bleed • Grade V o main renal artery thrombosis o shattered kidney o renal hilar injury with devascularization of kidney o avulsion at UPJ CT is highly useful for: 1. Diagnosing and staging renal injuries 2. Determining the depth of cortical lacerations 3. The quantity of devascularized renal tissue 4. The status of the renal collecting system 5. The extent of peri-renal hemorrhage Clas s I II III IV

Criteria Contusions, small corticomedullary Lacerations that do not communicate with the collecting system Laceration that communicates with the collection system Shattered kidney, injury to the vascular pedicle UPJ avulsion, laceration of the renal pelvis

Bladder • Occurs in association with blunt pelvic trauma, pelvic fractures or penetrating injuries • Gross hematuria almost always accompanies bladder rupture

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Up to 95% of patients with bladder rupture present with gross hematuria The susceptibility of bladder to injury is dependent on degree of distention, a distended urinary bladder is much more prone to injury than a nearly empty one Urine extravasation, whether intraperitoneal or extraperitoneal, is dependent on the location of the bladder. Intraperitoneal rupture often results from a direct blow to a distended bladder Delayed scans may help display extravasated urine

Adrenal Adenoma • Incidence in the population is 2-8% • Diagnosis is often made as an incidental finding on CT examination • In patient with no known primary, an adrenal mass is almost always a benign adenoma • In a patient with a known neoplasm, especially lung cancer, an adrenal mass is problematic and diagnosing a metastasis versus and adenoma is critical for prognosis • CT findings o Size greater than 4 cm tend to be metastases or adrenal carcinoma - heterogeneous appearance and irregular shape are malignant characteristics o Homogeneous and smooth are benign characteristics - intracellular lipid in adenoma results in low attenuation on CT o Little intracytoplasmic fat in metastases results in high attenuation on non-enhanced CT o Non-enhanced CT (NECT) - threshold 10 HU - sensitivity 79%, specificity 96% o Contrast-enhanced CT (CECT) -because majority of CT examinations in oncology use IV contrast, the % washout is useful after 10 minutes. - adenomas have greater than 50% washout after 10 minutes -washout can also be used on adrenal masses that measure >10 HU on NECT - alternative is to do MR or PET

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU RACHE ESTHER JOEL GLENN TONI

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MR findings: • Chemical Shift - most sensitive method for differentiating adenomas from metastases - sensitivity 81-100%, specificity 94-100% - the difference in resonance rate of protons in fat and water is exploited in chemical shift -- intracellular lipid and water in same voxel result in summation of signal on “in-phase” and canceling out of signal on “out of phase” • Spleen or muscle is used as an internal standard to visually quantify signal drop-off - liver is not a reliable standard because of steatosis Adrenocortical carcinoma • Rare malignancy with a poor prognosis • Reported incidence: 2 cases per million persons • Tumors frequently are large, measuring 4-10 cm in cross-sectional diameter • Arise from the adrenal cortex • Bilateral in up to 10% of patients • Approximately 50-80% are functional tumors, with most causing Cushing syndrome • Sign and symptoms o A large palpable mass, abdominal pain, or Cushing syndrome o Cushing syndrome is the most common clinical presentation in adults with adrenal cortical carcinoma, although o Patients can present with virilization, feminization, precocious puberty, or Conn syndrome o In children, the most common clinical presentation is virilization , followed by Cushing syndrome • Endocrine syndromes associated with adrenocortical carcinoma o Cushing syndrome o Virilization and precocious puberty o Feminization o Primary hyperaldosteronism MRI findings: • A large mass - lower signal intensity than the liver on T1weighted images and - higher signal intensity than the liver on T2weighted images - often, the tumor demonstrates heterogeneously hyperintensity on T1- and T2weighted images, due to the central necrosis and hemorrhage

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Coronal and sagittal images may be helpful in determining adrenal origin of the mass, thus differentiating it from renal cell carcinoma or hepatocellular carcinoma, especially if CT is equivocal

CT • • • • •

findings Large mass (>4 cm) Central necrosis or hemorrhage Heterogeneous enhancement Invasion into adjacent structures Venous extravasation into the renal vein or inferior vena cave

Adrenal metastases • Unilateral adrenal mass or enlargement • Small masses (<1 cm) o Adenoma o Ganglioneuroma o Hyperplasia o Metastasis o Pheochromocytoma • Large masses (>4 cm) o Carcinoma of adrenal cortex o Cyst or pseudocyst o Hematoma o Infection o Inflammation (eg, tuberculosis, histoplasmosis) o Metastasis (eg, lung or breast related) o Myelolipoma o Neuroblastoma o Ganglioneuroblastoma or ganglioneuroma o Pheochromocytoma (eg, multiple endocrine neoplasia) Bilateral adrenal enlargement Common causes: hemorrhage (eg in infants, trauma, bleeding disorder), histoplasmosis, hyperplasia, metastasis (eg, lung or breast related), neuroblastoma, and tuberculosis Uncommon causes: Addison disease, adenomas, amyloidosis, carcinomas (eg, multiple, primary), infection (ie, others), lymphoma, pheochromocytoma (multiple endocrine neoplasia), and Wolman disease (eg, familial xanthomatosis) CT Findings • Appear as focal masses or distortion of the contour of the adrenal gland • Smaller than 3 cm may be homogenous • Large lesions may have central necrosis or hemorrhage. These lesions are heterogenous

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and may have thick enhancing rims. They may also invade contiguous organs such as the kidneys. Attenuation values of less than 10 HU on unenhanced

MRI Findings • Are usually hypointense on T1-weighted images and • Relatively hyperintense on T2-weighted images • The exception is metastatic melanoma, which may be bright on T1-weighted images • Occasionally, lesions may remain hyperintense on long-echo time T2-weighted images, mimicking pheochromocytomas

CASE: 43 year-old women with hypertension • A middle aged woman presented to her primary care physician with hypertension and episode sweating. She was referred to a urologist who obtained a 24 hour urinary vanillymandelic acid (VMA) which was elevated

CASE: 35 year-old women with HPN • A large, right-sided, inhomogenous, adrenal mass with a central area of low attenuation that represents hemorrhage or necrosis

Left: T1-weighted, a mixed isointense-tohypointense right adrenal mass Right: T2-weighted, the right adrenal tumor has high signal intensity Pheochromocytomas CT Findings • Large tumors (often > 3 cm) • They are usually round or oval masses with an attenuation similar to that of the liver • Larger lesions frequently demonstrate necrosis, hemorrhage, and fluid-fluid levels • As a result, they often appear inhomogenous • Calcification is rare, but it is reported MRIs • Usually hypointense or isointense relative to the liver on T1-weighted spin-echo (SE) images, and • They are highly intense on T2-weighted SE images • The reason for this difference is unknown, but likely results from the high water content in cellular homogenous tumors or the high water content in necrotic regions • Tumors that have bled show the features typical of hemorrhage, depending on the age of the hemorrhage

Normal Uterine Size: By ultrasound, the normal postmenarchal nulliparous uterus is 5-8 cm in length, 1.5-3 cm thick, 2.5-5 cm wide. Myometrium: The normal myometrium is hypoechoic, homogenous, and reasonably well demarcated from the endometrial echos Endometrial Structure: The endometrium consists of a constant basal layer (basalis), and a cycling functional layer (functionalis). The functional layer includes a thin compactum layer and a thick spongiosum layer.

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Name Of Phase Menstrual Phase Follicular phase (aka proliferative phase) Ovulation (not a phase, but an event dividing phases Luteal phase (aka secretory phase) Ischemic phase (some sources group this with secretory phase) Phase Menstrual phase Proliferativ e Phase Secretory phase

sac is often considered abnormal, but occasional normal pregnancies do not show yolk sac up to 20mm.

Days 1-4 4-14

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15-26 27-28

Days 1-4

Thickness Thin

4-14

Trilaminar

15-28

Thick

Early pregnancy • Gestational Sac first appears in the substance of the deciduas (intradecidual) at 4.5 weeks, and should be seen virtually in all normal 5 week intrauterine pregnancies. •

The yolk sac is a definite evidence of a true gestational sac, first seen at 5 weeks. It is a landmark to the early embryo, which develops along its outer margin. Yolk sac should be seen when the sac is 8-10mm. MSD by vaginal probe, or 20mm. MSD by abdominal probe.

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By vaginal probe high resolution scanning, the embryo is first seen between 5.7 – 6.1 weeks with heartbeat appearing at 6.2 weeks. Small normal embryos may not have a heartbeat. Embryo should be seen by high resolution scan at 18mm MSD, or 25mm MSD by abdominal scan.

Anembryonic Gestation (Blighted Ovum) •

By lower resolution abdominal scanning, a sac > 20mm MSD with no yolk sac is abnormal. Vaginal scanning to improve certainty should be done.

By high resolution vaginal scanning, a sac > 13mm MSD (mean sac diameter) with no yolk

Abnormal gestational sac size (3cm) neither a yolk sac not an embryo is identified.

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Obstetrical Ultrasound Measurements • Associated findings in threatened abortion •

Gestational Sac o

The first element to be measured is the gestational sac of pregnancy. It is measured in three dimensions, and the average—the MSD is used for estimating the gestational age.

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It is useful between 5-8 menstrual weeks with accuracy of +/- 0.5 week (95% CI).

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As a rough rule of thumb, the MSD + 30 = Menstrual Age in days.

Subchorionic bleeding Often visible as endometrial fluid surrounding the external (deciduas capsularis) aspect of the gestational sac. As long as the placental (decidua vera) interface of the gestational sac and deciduas remain intact, the pregnancy often continues.

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From the standpoint of hemorrhage volume estimated using--

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length (cm) x height (cm) x depth (cm) x 0.52 = volume ml less than 75-200mL is often associated with continued development.

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Embryonic Crown Length o

The length of the embryo in the longest axis (excluding the yolk sac) constitutes the crown rump length.

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This is among the best documented parameters to date the embryo, with accuracy of +/- 3-5days.

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As a rule of thumb, the CRL +6.5 = Menstrual age in weeks

Slow heartbeat Embryonic heart rate <85 bpm is a negative prognostic sign, but is less reliable in small embryos

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Small Sac

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When the mean sac diameter (MSD) exceeds crown rump length (CRL) by less than 5mm, loss rate is 80%. However this “small sac” sign occurs in only 2% of the time.

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Biparietal diameter (BPD) o

The transverse width of the head at it’s widest, usually recognized by a symmetric measure from the leading edge to leading edge of the bones, because this leading interface is most distinct.

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The BPD best used after 12 weeks. Accuracy is +/- 1.1 week 14-20 weeks, +/- 1.6 weeks 20-26 weeks, +/- 2.4 week 26-30 weeks, and +/- 3.4 weeks after 30 weeks.

Incomplete Spontaneous Abortion (embryo dead) •

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In many cases, embryo has already died. Persistent chorionic function maintains a positive HCG assay Expulsion of the sac is often delayed several days, though it may be seen to slowly migrate from the initial fundal location toward the uterine cervix.

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Head Circumference o

A measurement which considers both transverse (BPD) and front to back (APD) will be more accurate. This combined measurement is called the head circumference. A true circumference is not actually measured through. The BPD and

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APD (anterior/posterior diameter) are measured and the circumference of the result in oval calculated If the machine does not calculate Head Circumference, you can do it easily with the formula:

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(APD + BPD)/2 Circumference •

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3.14

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Head

Femur Length The femur length is a repeatable measurement with accuracy similar to the BPD. It is affected by skeleton dysplasia, but since these are rare, it is reliable measurement which confirms measurements of the head. It is best measured after 14 weeks.

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Abdominal Circumference o

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The abdominal circumference is another circumference estimate made by averaging the anterior-posture and transverse diameters times 3.14. it is made at the widest point in the abdomen, through the liver at the level of the left portal vein or stomach. Fetal Breathing Movements: Complex Reflex, Sensitive but not Specific, False + in sleep. Fetal Trunk and Extremities Movements: Moderate Complexity less Sensitive, more specific All pregnancies 26 weeks or more must show motion during routine ultrasound, if not, further evaluation id done, First Acoustic Stimulation, an if negative, Formal Biophysical Profile. Fetal tone: Simple maintenance of flexion “Fetal Position” posture. Relatively insensitive, but ominously specific often for more advanced distress. Amniotic fluid volume: not neural reflex, but a physiologic reflection of uteri ne production and uterine retention.

Ang mga sumusunod ay mga hango lamang sa mga sinabi ni doc na naitala po namin  Delayed Film – used to determine if there is a nephrogram Case of Hydronephrosis: You have a bladder which has a smooth margin outline, then the left kidney is now visualized, this is the post void the distal third of the ureter this is one hour delay. So what is the purpose of having a delayed film? We could appreciate if there is a nephrogram in the left kidney. So until the three hour delay there is no evidence of nephrogram. The patient was ultrasound, the left kidney is very small it was 8.7 with cortical thickness of 0.8, so this is a medical renal disease. So this is the rt kidney showing you the hydronephrosis. In that case the left kidney is not malfunctioning. Case of Enlarged Kidney: Another patient showing you calcification in the left pelvic region there are no calcifications in the region of the renal shadow as well as in the areas of the ureters. So this is a one minute film showing you a right kidney with a normal pelvocalyceal system, the left kidney show you a urethrogram and the left kidney is enlarged. There’s hydronephrosis in the dilated ureter to the area of the uretero pelvic junction so there is a stone. Normal Ultasound Findings: Normal Size: 9-12 Presence of corticomedullary differentiation - the medulla is usu. whiter or hyperechogenicicity compared to the cortex. Normal thickness of the urinary bladder: 0.3cm or 3mm for a well distended bladder; for a post ovoid bladder it’s 0.5cm of 5mm So how will you know if it’s a fully distended/underfield bladder? The bladder should have 200cc, if it’s less than 250cc it’s underfield in adults. Case of Nephrolithiasis In the kidney there is shadowing echogenicity, there is nephrolithiasis. Case of Acute Renal Failure Multiple shadowy echogenicity in the kidney - This is a staghorn calculi; acute renal failure because the kidney is around 7.7. So once the kidney is

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small and there is no cortical differentiation mean chronic medical renal disease. Then you have to correlate it with the serum creatinine. Serum creatinine is elevated, so most likely the px is either acute renal failure or in a chronic stage. Case of Acute Renal Failure This is the left kidney, it’s small because it’s shows 8.9 but still there is cortical differentiation. Case of Mild Pelvocalceal/Hydronephrosis Ureter Fluid filled on urine field. So the patient has lithotripsy there is no evidence of stones in the kidney but the kidney shows hydronehprosis so possibly the remaining stones were put in the distal or proximal ureter producing hydronephrosis  obstruction. So this is an example of a hydronephrosis ureter. Somehow you have a thinned out cortex and you have dilated proximal ureter. Limitation of Ultrasound: If you have a very gassy abdomen you could not visualize the distal ureters. Case of Perirenal Hematoma One of the complication of a lithotripsy is a hematoma. The patient has a perirenal hematoma. Usually the px will have utz everyday to monitor if it’s increasing or decreasing. Increasing  surgeon will evacuate hematoma. Case of Angiomyolipoma Angiomyolipoma so this is fat. In this case the px has a double collecting system, forming the entire echogenicity meaning the single collecting system in this case we now have as 2, which is a normal variant. Case of Cystitis You have a very thick walled, patient has cystitis. Case of Kidney Abscess Abnormal kidney has an abscess in the fascia. If px has prev. hx of trauma, could be hematoma. If px has prev. hx of lithotripsy also could be hematoma. Grading of Trauma Grade 1 • Hematuria with normal imaging studies • Contusions • Nonexpanding subcapsular hematomas Grade 2 • Nonexpanding perinephric hematomas confined to the retroperitoneum

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Superficial cortical lacerations less than 1 cm in depth without collecting system injury Grade 3 • Renal lacerations greater than 1 cm in depth that do not involve the collecting system Grade 4 • Renal lacerations extending through the kidney into the collecting system • Injuries involving the main renal artery or vein with contained hemorrhage • Segmental infarctions without associated lacerations • Expanding subcapsular hematomas compressing the kidney Grade 5 • Shattered or devascularized kidney • Ureteropelvic avulsions • Complete laceration or thrombus of the main renal artery or vein CT Scan useful for genitourinary dx or staging injuries, depth of the cortical laceration, extent of perirenal hemorrhage, devascularize tissue, collecting system. CT Sonoram is a plain CT Scan which is able to visualize if there are pancake calcifications in the GUT. So in px with a very high serum creatinine and they want to know if there is stone because of microscopic hematuria, CT sonogram can be done. Case of Phechromocytoma On UTZ adrenals are not visualized unless they are enlarged. If it’s >1cm, it’s enlarged. The normal structure is either a “Y’ or a “V”. if patient has lung CA, CT scan usually includes adrenals to check for metastasis. Also used for unexplained elevated BP, so px has pheochromocytoma. Most common lesion in the adrenals is the adenoma.

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