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URORADIOLOGY
Congenital Anomalies
Renal dysplasia:
The presence of abnormal tissue within the kidney cartilage, muscle, primitive nephrons
and cysts
Renal hypoplasia:
Renal ectopia:
Failure of the normal ascent, the kidney remains within pelvis or the lower abdomen and
deriving its blood supply either from iliac vessels or lower abdominal aorta .
- It is frequently associated e malrotation.
- May be intrathoracic kidney.
D.D.: nephroptosis = redundancy in the length of ureter.
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Malrotation:
- Commonest variety is the renal pelvis ant. to renal vess. retains its foetal relationship to
kidney and calyces lies posteriorly to and on either side of pelvis.
- It may lead to obstruction hydronephrosis or infection.
Fusion:
"Hoarse shoe kidney" commonest
- The kidneys are united in majority at their lower poles by a bridge of renal tissue or
fibrous band ,crossing in front of the aorta, spine and I. V. C.
- The kidney are low in position & close to spine with their long axis parallel to spine, we
have more hydronephrosis and incidence of Wilms.
Renal duplication:
1- Complete:
Involves the renal pelvis and the whole length of the ureter.
- Each division of pelvis is drained by its own ureter opening separately into the bladder .
- Ureter draining the upper moiety always open below and medial to ureteric orifice for the
lower moiety { may be ectopic ureter up to 6 ureters drain the kidney}.
2- Incomplete:
Confined to renal pelvis or the ureter but the ureteric divisions unite in the abdomen or
pelvis "yo yo reflux !!". Commonly associated e urinary infection and reflux.
Ureterocele:
Congenital cystic dilatation of lower end of ureter
Types:
- Simple: when orifice is within the bladder.
- Ectopic: when orifice lies outside bladder lumen (ectopic ureter).
Effect: obstruction and stone formation.
1) I.V.U
- The dilated lower end when filled e contrast media produces a circular area of increased
density within bladder which is surrounded by a radiolucent halo produced by ureterocele
wall cobra head appearance ch ch .
- when it is not filled e contrast round filling defect.
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2) CYSTO-URETHROGRAPHY:
With dense contrast media may obscure the simple ureterocele.
ECTOPIC URETER:
- A case in which the ureteric orifice lies outside the bladder lumen.
- In males, the ectopic orifice, commonly opens into the post. urethra but may open into
seminal vesicle , epididymis and rarely rectum.
- In females ,commonly situated in the vestibule but may open into vagina , cx, uterus,
fallopian tube.
- It is usually associated e duplication of whole length of ureter and orifice draining the
upper moiety .
1) I-V-U:
1- Enlarged renal shadow produced by dilated upper renal segment.
2- Lower segment of kidney is displaced downwards and lateraly Drooping
flower
appearance.
3- Ureter draining lower renal segment is deformed by dilated ectopic ureter.
4- Bladder base may be elevated by the dilated ureter.
5- Ureterocele of ectopic ureter usually larger than simple ureterocele obst. of ureters &
may prolapse into urethra urethral obstruction.
2) U.S. may show a dilated upper moiety pelvicalyceal system.
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1-muticystic kidney.
2- multipe cysts e lower u.t obstruction.
1- polycystic disease of the young (AR):
a- In new born
B) In child hood
2- In adult (AD).
3- Von Hippel-Lindau syndrome.
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C-Cortical cysts:
1- simple cyst.
2- multi locular cyst.
D- Medullary cysts :
1-medullary sponge kidney.
2- medullary cystic disease.
3- papillary necrosis.
4)pyelogenic cysts.
E- Miscellaneous Intra renal cysts:
1- Traumatic : hematoma.
2 - Inflammatory: T.B,hydatid.
3- Neoplastic: cystic degeneration of neoplasm.
F- Extra - parenchymal cysts:
1-para pelvic cyst .
2- perinephric cyst urinoma .
G-Cystic dialysis disease .
Multicystic kidney:
-Non familial,usualy uni lateral.
-It may be associated e other congenital anomalies e.g.TOF,VSD.
-Pathology:
The entire kidney is composed of numerous cysts, contain clear fluid and are embedded in
undifferentiated mesenchymal tissue ,but no identifiable renal tissue.Usually unilateral to be
differentiated from polycystic kid.
-C\P : the commonest cause of abdominal mass in infancy.
-Radiologically:
1-Plain:
- Large mass extending from loin displacing the gass shadow.
-Cyst wall calcification Ring like densities.
2- I- V-U:
- Mainly reveal non - functioning kidney.
- Draining ureter is absent or atretic.
- Compensatory hypertrophy of other kidney.
3- U / S:
-Multiple non- communicating cysts, variable in size resembling a bunch of graps with no
identifiable renal sinus.
4-C.T
-Replacement of kid. by a large mass containing numerous cysts with septa.
-Cyst wall calcification.
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D.D
1- wilms tumour
I.V.U:
-Enlarged kidneys with the characteristic striated mottled nephrogram (streaks radiating
from renal papillae to renal cortex)
- Impairment of renal function non visualization of calyces .
U.S:
- huge enlaged kidney(s).
- Increased renal parechymal echogenicity(interfaces by walls of tubules) with loss of the
cortico- medullary differentiation bright echo pattern because cysts are so small to be
resolved by U.S.
C.T:
-Bilateral enlarged kidneys with exaggerated foetal lobulation.
On enhancement mottled app. in cortex and medulla representing dilalated
tubules
(streaks in parenchyma)
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B) U S:
-As in infantile type.
-Increase echogenicity of the liver due to periportal fibrosis.
C)C.T:
-Areas of low attenuation representing tubular ectasia .
-Mutiple liver cysts communicating with bile ducts.
-May be splenomegally & ascitis =P+ +
dysplasia
AD
undiff.
Tissue inbet.atretic.
normal
Tissue inbet..ureter
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U.S:
1. Renal enlargement.
2. Multiple cysts of varying size which generally dont communicate with
pelvicalyceal system.
C.T:
1-Renal enlargement.
2- Multiple cysts of varying size, shows water density. Increased density in infection or hge.
3- calcified cyst wall.
Angiography:
shows curvilinear displacement of the arterial branches.
MRI: .
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* Nephrotomography:
Sharply defined regular defect .
C) U. S.:
well defined , thin walled anechoic pattern with distal enhancement (posterior
enhancement).
D) C-T:
-Non enhancing (if enhance tumour or abscess) .
- Sharply defined regular lesion e renal parenchyma of low attenution
(0-20 H.U) .
- May show calcification in cyst wall or infection or hge (atten. Value)
E)Angiography:
Avasculasr lesion causing displacement and elongation of the arterial branches .
F)Cyst Puncture (U S or C T guided):
* Aspriation of cyst fliud cytology and injection of water -soluble contrast
media.
N.B.:
pyelogenic(calicyeal) cysts:
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- A linear slightly irregular channles , radiating into medulla produced by dilated tubules
(communicate e pelvi calyceal system).
- Enlarged minor calyx draining affected segment forming a wide arc.
C- U/S
- well defined, highly echogenic pyramides d.t multiple cysts(not parenchymatous as
young polycyst.)which is too small to be resolved by echo.
D- C-T
-Enhanced scan shows small medullary cysts & dilated tubules.
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Renal Neoplasms:
A) parenchymal renal tumous:
1- Benign tumours:
-Angiomyoloma .
-Oncocytoma ( small solid mass, hypodense)
- Reninomas ( isodense hypovascular subcapsular)
- Multi locular cystic nephromas.
- Meso balstic nephroma.
- Mesenchymal tumours ( Fibroma, myoma , Lipoma, haemangioma)
2- Malignant tumours :Primary - Adeno carcinoma (hypernephroma)
-Nephro blastoma (wilms tumour )
- Sarcoma
- Lymphoma (V. rare )
Secondary- metastesis
B- Tumours of the renal pelvis and ureter(= urothelial tumours):
1)Epithelial origin commonly Malignant
- transitional cell carcinoma ..... papilliform
- squamous cell carcinoma ...... ulcerated plaque & stricture
2) Non epithelial origin commonly benign
- haemangioma , fibroma , myoma
3)Cholesteatoma:It is not a true tumour( it is a filling defect formed by desquamated stratified squamous epith
which result from squamous metaplasia of transitional eqith d.t chronic irritation e.g stone )
STAGING( CT):
T 1confined to capsule +mild calyceal displacement
T 2 lange T. confined to capsule+ calyceal or pelvic displacement
T3 A perinephric or peripelvic fat
B thrombus in Renal vein
C thrombus in I-V-C
T4 surroundings & may be distal metastasis
ORIGIN:
- arises from ! epith cells of renal tubules, it may develop following cortical adenoma
PATHOLOGY:
Age:
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- on section it shows yellow colour d.t cells containing lipids & cholesterol.
- shows areas of hge and necrosis .
- it infiltrates capsule late.
Microscopically: - large rounded malignant cells arranged in cords & solid masses.
- cells may be large highly vaculated or small e dark granular cytoplasm
- scanty and vascular stroma.
- many areas of hge and necrosis
Spread :
- local.
-Blood cannon ball metastases(more common)
-Lymphatic
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Stage 2
Stage3
D) C/T:
the method of choice for pre operative staging:
1-Soft tissue mass:
*on precontrast scans:
hypodense mass distort renal outline and shows areas of breaking down or calcification.
* on post -contrast scans :
- vascular tumors a transient period of marked enhancement during arterial phase
of rapid I.V bolus injection . Subsequently the tumour enhances to a degree less than renal
tissue patchy app .
-Avascular tumour no enhancement.
2-Extension of tumour through renal capsule:
nodular infilterates of soft tissue density within the lucent peri- renal fat .
3- Renal vein involvement :
-best demonstrated by rapid sequence scanes at level of the renal vein
following bolus injection
-the presence of low atten. area within lumen of an opacified vein
(=definit diagnosis)
-other signs of venous occlusive lesions:
-Diffuse renal swelling.
- Prolongation of cortical opacification time.
- Dilatation of the renal vein .
4-I-V-C affection :
with bolus injection may show dense peripheral ring e less opacified central column
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NephroblastomaWilms tumour
(adenosarcoma =embryoma)
- Peak incidence 1-5 yrs ( it can occur in young adults)
-Common presentation abd mass and hypertention(vascular invasion,renin,compression)
also pain& metastases
*It arises from embryonic mesodermal remenants from which kidney arises (totipotent cells).
*Before age of 5 yrs.
*It is ! commonest renal tumour of childhood .
*Rapidly growing tumour which destroys ! kid. tissue .
*It infilt. the capsule v. early and extends to the near by structures.
*On section ,cut surfase is homogenous, greyish.
*Shows areas of hge &necrosis
MICROSCOPE:
* It is mixed embryonal malig. tumor solid masses of malig epith cells showing glandular or
tubular formatiom +sarcomatous element.
*fusiform or rounded cells.
*smooth or striated muscle, cartilage, myxomatus tissue may be present.
spread :local
Blood
metastases
Radiologically:
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LYMPHOMA:
-It is very rare,common in non - hodgkin, primary lymphoma is very rare.
-The only one e hypoechoic low attenuation!!.
1-plain&IVP:
- Diffuse renal lymphomatous infilteration renal enlargement(comm. Bilateral) e normal
outline and elongated attenuated calyces .
{D-D: leukaemia ,multiple myelomas}
2-U.S:
-Shows lymphomatous deposits as well defined hypoechoic e distal enhancement + lymph
nodes+ renal enlargement.
3- C-T:
- lymph deposits appear as low attenuation which dont enhance.
( Direct extension of retroperitoneal lymphomatous diseaseureteric obstruction, renal
vascular occlusion)
Renal metastasis:
1) C.T indistingiushed from 1ry renal carcinoma.
2) Angio usually avascular.
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Angio-myo- lipomas:
-They are actually hamartomas, consisting of a mixture of muscles ,fat, and blood vessels
(C T density).
-Occur in 80 % of patients e tuberculosis.
-Imaging:
1- I-V-P:
space occupying lesion e a radiolucent component.
2-U-S:
highly echogenic mass.
3- C T:
large mass e fat attenuation value ( 0-(- 60) H-U ) intermixed areas of increased tissue
density (muscle& blood.vs ).
4-Angio:
highly vascular mass supplied by wide tortous vessles arising from renal arteries e ccc
aneurysmal dilatation,&early venous filling.
5-M R I:
--bright on T1,very low on fat suppresion.
Oncocytoma:
- Rare ,considered to be a low grade hypernephroma.
-Common in old age& in males.
-Imaging:
1-IVU& US: usually well defined solid mass.
2- C.T: hypodense well defined mass.
3- Angio:
- well defined mass e lucent rim.
-it contains radiating vs in( = spoke wheel pattern)
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Imaging:
1- plain : soft tissue mass displacing bowel& cacification.
2- I-V-U: intrarenal mass which may herniate into the renal pelvisfilling defect in
nephrogram &displacement or compression of calyces.
3-US:
multiple cysts e highly echogenic septa.
4-C T:
multiple cysts separated by thick septa which may show enhancement.
5- Angio:
avascular mass.
Mesoblastic Nephroma:
-Considered to be congenital wilms tumuor.
1- plain: large soft tissue mass.
2- I-V-U: large intra renal mass which displases&distores pelvicalyceal sys.
3- U S: echogenic mass e cystic degeneration.
4- Angio: neo- vasculairty within the mass.
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Urothelial Tumours:
C/P: loin pain and haematuria.
Imaging:
1-I-V-U:
a) Papillary tumours( = Transitional Cell Carcinoma or Papilloma): 90%
-Filling defect e lobulated surface.
-The ureter dilates at the site of tumour to accomodate tumour expanding lesion.
-Retrograde urography:
* Protrusion of tumour into the dilated ureteral lumen wine glass appearance.
*Trapping of contrast within interstices of papillary growth stippled appearance.....
stippling sign.
B) Sq. Cell carcinoma : 10%
- Usually manifests itself as a stricture without filling defect.
- In renal pelvis usually causes strictures obstruction and infiltration of perirenal tissue.
2- U/S:
iso echoic solid mass has an echogenic rim due to renal sinus fat.
-shows -presence of hydro nephrosis
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3-C.T:
1- mass within renal pelvis e slight enhacement mass may lead to balloning of renal pelvis
obstruction of the calyces with proximal dilatation.
-Extension to wall of renal pelvis,renal sinus fat, renal parenchyma and perirenal spaces
can be shown.
2- ureteric tumors: irregular thickening of ureteral wall e invasion of retroperitoneal fat
and obst. Uropathy.
4-Angio:
relatively avascular.
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B)Solid
1- Benign.
2- Malignant.
3- Pseudo Tumour.
4- inflammatory masses:
* Renal abscess.
* tuberculoma.
* xanthogranuloma,pyelonephritis.
Investigations:
-clinically suspected renal mass:
* plain and I V U+/- tomography.
* US:
(simple cyst or
solid or
Mixed)
*C.T or angio .
*aspiration cytology.
*C T or angio.
1-Plain:a.UT
I. Soft tissue mass, displacing gas shadow.
ii. Calcification curvilinear in simple cyst.
punctate or amorphous tumour.
calcified tuberculoma.
iii. Metastatic deposits in pelvis and spine.
iv. inflammatory abscess loss of psoas line.
scoliosis : concave to side involved.
b. Chest :
-T.B.
-Cannon ball metastasis.
2-I.V.U.
3-U/S.
4- C.T.
5- Angio.
6- Isotopes non specific area of activity :
a. Cyst.
b. Inflammatory mass.
c. Neoplasm.
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Staging of UB tumours :
MRI:
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Carcinoma of bladder :
-It is commonest carcinoma in Egyptian males.
-Pre-cancerous lesions :
1. Bilharziasis.
2. Exposure to aniline derivatives.
3. Abuse of analgesic.
4. Smoking.
- Pathology:
Non Bilharzial
Bilharzial
1. Age > 60y
20-30y
2. Site : trigone
lateral side then spread
3. Macrocop. papillary
-Nodular fungating mass
nodular
-malig ulcer
ulcerative
-diffuse infilteration
4. Microscopic : transitional cell
sq. cell. carcinoma.
-Imaging :
Diagnosis is usually established by cystoscopy. Then staging by:
A. Plain ::
-Presence of calcification in trans. cell carcinoma.
B. Cystogram :
- Papillary tum. well defined lobulated filling defect.
- Non papill. tum plaque like irregular defect with ill defined margins.
- Reflux can occur, when there is ureteric involvement.
C. U/S:
- Trans abdominal, trans urethral, trans-rectal.
-Can demonstrate tumours as small as 5mm in diam. and the extent of bladder wall
invasion.
D. C/T:
Best done with filling of small bowel.
rectum & sigmoid by enema.
They not diff between T1 & T2.
-MRI can diff. T2 & T3A.
-Due to presence of peri-vesical and pelvic fat, extra vesical extension can be easily detected
by C.T.
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Vesical diverticula :
-Causes :
1-congenital.
2-due to lower U.T obstruction BNO.
prostate.
ureth.
3-traction(sliding hernia,adhesions).
4-false
-Effect :
- Urine stasis infection & stone formation.
- Reflux if ureteric orifice lie inside diverticula.
- Obstruction of lower ureter by a large diverticula.
-Micturating cystogram :
- Should be done, as simple cytogram is an unreliable.
- The divert. may be quite small on the resting film, but become greatly distended during
micturation.
-plain: stone not changing position.
-DD :
1. Vesical duplication.
2. Hour glass bladder.
(They contract normally and empty during micturation.).
Neurogenic bladder :
-Loss of normal control of micturation due to lesion of spinal cord (chordoma is commonest
cause) and peripheral nerves.
Radiolog. app.:
A).U.M.N.L micturating cystogram:
1. A large atonic, smooth walled bladder.
2. Enlarged residue.
3. Complete absence of bladder contraction.
4. Voiding produced by abdominal compression.
5. Bladder neck and urethera are normal.
B) L.M.N.L micturating cystogram:
1. Reduced capacity of bladder.
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Congenital anomalies:
1-Ectopia vesica :
2-Duplication :
3-Urachal anomalies.
Bladder trauma :
-Causes :
-Fracture pelvis.
-Instrumentation.
-Penetrating wound
-Imaging :
a. Plain :
-Fracture pelvis.
-Obliteration of psoas outlines in extra peritoneal rupture.
-In penetrating wounds air fluid level.
b. I.V.U :unriglity of upper U.T.
may shows, extra-vasated urine.
c.cysto-gram: -may shows deformity & displacement of bladder by pelvic haematoma.
-Intra-peritoneal extra-vasation contrast. medium gravitates to most
dependent part of pelvic cavity and loops of gut produce a ch. ch. round filling defects.
- Extraperitoneal contrast media go to perivesical spaces.
Stones :
Ca phosphate
single, large, laminated
Renal calcification:
1. Renal calculi.
2. Nephro-calcinosis.
3. Dystrophic calcification.
1. Renal calculi:
- Most commonly seen in middle age.
-Etiology of stone formation :
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Urinary obstruction:
- Hydronephrosis :
-Dilatation of renal pelvis and calyces + thinning of the renal parenchyma.
NB. : hydro-calicosis:
-dilatation of one or more calyces in the absence of renal pelvis dilatation.
-Usually occurs 2ry to obst. of a calyceal. infandibulum by T.B scarring, calculi, crossed
vessels.
NB. Hydro-ureter :
- dilatation of ureter which either obstructive or non obstructive v.u reflux.
Causes :
a. Pelvi-ureteric obstruction :
1. Intra-luminal lesions :
- congenital : P.U.J obstruction
Ureteric atresia.
- Acquired stones, blood clot.
Paplillary tumour
fungal ball, cholesteatoma (rare).
2. Extra-luminal :
* Intra-mural strictures of ureter : either: - Benign : T.B , Bilharzial, post operative.
- Malignant . Sq. cell carcinoma.
*Extra-ureteric - extrinsic strictures :
-Pelvic inflammatory disease
-Retro-peritoneal fibrosis post. operative.
pancreatitis.
-Invasion by tumour e.g. cancer ovary, rectum.
- Crohns disease, aberrant renal As.
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Chronic obst.
-Renal size or
-Faint
-delayed calyceal
nephrogram
opacification(pyelogram)
-Parenchymal thickness
-pyelosinus extravasation
nephrogram
no
pesistant
-Calyceal crecents.
Late(in both):
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-It may shows, fine, white lines arranged radially in parenchyma perpendicular to renal
margin ... represent contrast med. within the engorged tubules.
ii) Modest renal enlargement in 50%:
due to enlarg. of renal tubules and interstitial oedema.
iii)Delayed calyceal opacification :
-abscence of contrast medium in collecting system 15 minutes after infection (delayed
films).
- Once opacification occurs it points to site of obstruction and opacification will persist
for hours.
iv) Little dilatation of pelvic calyces & ureter proximal to obst.
v) Pyelosinus extra vasation :(spontaneous)
- Overdistension of the collecting system may causes rupture at its weakest point calyceal
fornix extra-vasation of C.M. into the peri-calyceal and peri-pelvic spaces and enter into
the renal sinus.
-Sometimes the extra-vasated urine is encysted urinoma within renal sinus.
2. Chronic obstruction :
A. Renal size : determined by duration & degree of obst. The kidney may be small or large.
B. Absence of obstruct. nephrogram the nephrographic density is characteristically faint
due to obst. atrophy.
C. Massive hydro nephrosis.
D. Parenchymal thickness :
- Measured by distance between edge of calyces and the outer surface of nephrogram.
- Normally it ranges from 2.5 cm in mid portion to 3.5 cm at the poles.
- End-stage obst. atrophy is characterised by marked thinning of the renal parenchyma
thin band surrounding the dilated calyces, forming rim or shell nephrogram.
E. Calyceal crescents :
- Thin semi-lunar collection of C.M, denser than nephrogram, in the renal medulla, parallel
to convex margin of the ballooned calyces.
- They represent, the C.M. within collecting tubules.
B) U/S: -Detection of hydronephrosis in ch. obst.
C) C.T:
Plays a minor role in 1ry diagnosis of obst. than I.V.U & U/S.
D) angiography : not used.
E)Radio istope scans.
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2.Individual pictures:
A. Bladder neck obst.
Pathogenesis :
hypertrophy of bladder neck as part of the generalised hypertrophy of detrusor muscle
which may be :
1. Primary :
hypertrophy of musculosa.
fibrosis of subserosa
spasm fo neuro muscular incoordination
ii. Secondary due to urethral obst.
iii. congenital very rare.
Incidence & C/P :
- Adult more common, presented by C/O & O/E of prost. enlargment prost. is normal.
- Childhood less common, presentes by retention, R. failure.
Radiolog. cysto-urethrogram :
1. Trabeculation, saculation and divert. formation.
2. Narrowing of bladder neck.
3. Hypertrophied B. neck protrusion into bladder base intra-vesical impression.
4. Narrowing of distal urethral lumen due to poor flow through the obstructing bladder neck.
5. Vesico-ureteric reflux.
DD :
1. Neurogenic disorders : associated with other neurolog. signs.
2. Prominance of bl. neck :. normally, no signs of obst.
3. Spinning top urethra : a + b + c.
basal sacculation (c)
hypertrophied bladder neck (a)
Spinning top urethra.
distal urethral stenosis (b).
B. Prostatic enlargement
- The commonest cause of lower UT obst. in elderly.
- It is due to benign hyperplasia.
prost-carcinoma.
N.B.
*433.8cm
(2=calculated weight).
*average wt 20gm.
*benign hypertrophyperiurethral central zone.
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1. Benign hyperplasia:
Site: transitronal zone (bet.periph. & central zone).
Radiological app.:
1. Plain increased bladder shadow d.t. residual urine.
prost. Calculi.
2. I.V.U.:
a. Obst. changes in upper U.T.
b. Enlargement and elevation of lower ureters fish hook app.
c. Elevation of bladder base above sym.pubis
d. Thick wall e trabeculations & diverticuae.
e. Protrusion of prost. into bladder base large, smooth, rounded or lobulated
filling defect..ccc
f. Residue is present at post evacuat films.
3. Micturating cysto-gram.:
a. Prost. urethra length > 3cm.
b.Residual urine.
stretched on surface of gland slit lumen.
normal curvature.
deviation with asymmetrical enlargement.
prost. nodule protruding into lumen of the urethra filling defect.
4. Trans rectal U/S : dimensions & volume.
- Diffuse enlargement of gland with an intact capsule.
- Homogenous echo pattern, may appear heterogenous if complicated by areas of infection
or stone formation.
5. C.T + MRI:
Homogenous enlargement of gland with well defined border and preservation of fat planes.
Staging:*T1.intracapsular e normal glandular outline
*T2.intracapsular e irregular glandular outline
*T3.carcinoma beyond prostatic capsule
*T4.carsinoma fixed to adjacent organs
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- Prost biopsy.
E.)C.T + MRI: -imp. for extension but not tumour itself ,non homogenous, enlarged
prost with ill defined irregular outline.
- Invasion of fat planes and seminal vesicles.
- Nodal involvement mainly iliac groups (EXT).
C. Urethral valve obst.
- Occurs only in male.
- Age : mainly infants & childhood.
-C/P : R.F., urinary tract infection, incontenance.
-Types :
.Site : commonly post. urethra at level of verumontanum/vernumonatous? (rounded
projection on post. part of prost. ureth.).
1. Bicuspid valves of mucosal fold.
2. uni-cuspid .. (most common).
3. Incomplete diaphragm : traverse the post. urethra.
.-Radiolog. App: cysto-gram:
1. Hypertrophy of muscular wall of the U.B.
2. Trabeculation, sacculation & divert. formation.
3. Post. urethra :
- dilated, proximal to site of obst.
- dilatation usually ends abruptly with a convex lower border bulging dawnward.
4. Free valve margin linear filling defect within the dilated urethra.
5. Diaphragm : may be seen traversing post urethra just distal to vernumonatous.
6. Veisco-ureteric reflux may or may not be seen.
7. Hypertrophy of bladder neck spinning top urethra.
General S&S:
*tortous ureters ,dilated system, progresive renal failure
*trabeculated UB,diverticulae,residue,reflux,BN hypertrophy
*uretheral dilatation(General+esp. for urethra)
1-dilated.abrupt
2-valve.filling defect or diaphragm traversing
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D. Urethral stricture
Types & causes :
- Congenital false : urethral instrumentation.
true : occurs in boys, at. the junction of bulbous with memberanous urethra
&may be associated with anal atresia.
-Acquired :
1. Traumatic memb. ureth. direct injury .
fracture pelvis .
prost. ureth. instrumentation
following prostatectomy
2. Inflammatory :
- ant - ureth. gonococcal, S.
- post - ureth. gonococaal, T.B., B.
3. Neoplastic: transitional cell papilloma,
sq. cell carcinoma.
-Technique of Ex :
-Injection of umbradil U in retrograde urethrogram .
-micturating cystogram.
-Radiolog. App:.
a. Narrowed segments of urethra which may be multiple:
- If very short they may be missed.
b. Post inflammatory changes filling of
- Para-ureth glands small cavities, 1-2mm along the side of urethral lumen.
- Cowpers gland & ducts short narrow channels arising from post. part of the prost.
urethra, diverging from midline as passing backwards.
Vesico ureteric reflux :
-The competence of normal uretero-vesical junction depends on 3 factors :
1. obliquity of intra-mural course of ureter.
2. Surrounding bladder musculature.
3. Mucosal flap valve produced by the intra-vesical submucosal ureter.
-Causes :
A. primary reflux :
-generally considered to be cong. anomaly caused by a short intra-mural course of the distal
ureter through the bladder wall.
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B. Secondary Reflux :
1. Cong. anomalies : vesical divert.( if involve orfice).
duplication of ureter (lower moiety.)
ectopic ureter.
2. Cystitis : acute or chronic
3. Bladder carcinoma : infiltration of orifice rigidity reflux.
4. Neurological lesions.
5. Surgical operations on lower ureter.
6. Lower U.T obst.
Diverticulae of the bladder :
-Cong deficiency in bladder musculature.
-V.U. reflux may occur, when they involve ureteric orifice.
Duplication :
-The ureter from lower moiety opens into the bladder above & lateral to orifice of ureter
draining the upper moiety.
This ureter, therfore has a shorter and less oblique course through bladder musculature
less effective valvular mechanism reflux into ureter draining lower moiety.
Cystitis :
-Produces oedema, rigidity & fibrosis interfering with normal valvular mechanism.
- Acute cystitis transient reflux.
- Chronic cystitis permenant reflux.
Bladder Carcinoma :
-Infilteration of neoplasm around ureteric orifice rigidity and incompetence.
Lower U.T. obt.
Reflux is not due to intra-vesical pressure but occur when a para-ureteric saccule involves
ureteric-orifice .
Classification : 4 grades of severity :
-Grade I : reflux confined to lower pelvic portion of a normal sized ureter.
-Grade II : reflux extending up to kidney during voiding with no uretral dilatation.
-Grade III : reflux extending up to kidney in resting state & during voiding with no ureteral dilatation.
-Grade IV : reflux up to kidney with dilatation of upper tract.
(International reflux study in children classification.read in Sutton)
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NB :
- Primary reflux has natural tendency to improve at any time during childhood as growth
with bladder wall thickness a greater intra-mural course of ureter & more effective anti
reflux mechanism.
- 80% of grade I reflux improve within 1st few years.
-Technique micturating cystography
Isotope.
Renal Infection:
Non specific :
- Acute pyelo-nephritis.
- Renal and peri-renal abscess.
- Chronic pyelo-nephritis local reflux nephropathy
-Xan thogranulomatous pyelo. nephritis.
Specific :
renal T.B.
Renal B.
Hydatid disease
fungal infection.
Acute pyelo-nephritis :
-C/P : bacteuria, pyrexia and flank pain& V U reflux.
-Radiolog. app.:
1. Plain :
ill-definition of border of kidney.
2. I.V.U:
-Usually normal.
- There may be increase kidney size.
attenuation of calyces.
delayed excretion.
dense persistant nephrogramwith little or no pyelogram may
be due to tubular blockage by pus acute suppurative pyelonephritis.
(no papillary or calyceal abnormality e no cortical loss).
3. U/S, C.T. :
-mainly appear normal.
-Complications :
-Abscess : intra or extra renal.
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A.)Renal abscess :
-Imaging:
1. Gives, the radiology. changes of acute pyeloneph.
2. Evidence of a mass displacing collecting. system and deforming the renal outline.
3. Communication with a calyx an irregular cavity similar to T.B.
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- Renal calculus.
- Non fn kid, large.
- Multiple non-enhancing masses (lipid & pus).
Urinary tuberculosis:
-Pathology:
T.B of the lung or bone...Tub. bacilli via blood stream bacilli arrested at the
glomeruli (cortex)...Bacilli surrounded by tub. ReactionTub. foci (usually
bilateral)Healing in mild infectionEnlargement of foci which coalese together.
Arrested at this stage.
ulceration into the pelvis : ureter, U.B. vas, epidid, sem.vesicles.
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Urinary schistosomiasis :
- Pathogenesis :
- Produced by infestation by schistosoma haematobium.
-The adult worm, inhabits the submucosa of bladder where the ova are deposited. ova
calcify and excrete a toxin producing tissue necrosis and extensive fibrosis.
-Radiology app.:
1. Plain.
1. Calcification :
- The most diagnostic finding.
- Commonly involves bladder, less commonly lower ureter.
-The appearance of calcification varies according to degree of bladder distension:
*With bladder distended : forms thin linear apacity outlining the bladder margin.
*With bladder empty : forms thick linear opacity or calcified plaque.
2. Stones.
2. I.V.U:
A). Urinary bladder:
- Earliest change ... swelling of its mucosa giving cobble stone pattern.
- In advanced cases .... papillomatous granulomata may form filling defects within its lumen
... carcinoma is a common complication.
B). Ureter :
ureteral dilatation and tortuosity even in the absence of obstruction.
*In earliest stages ... dilatation is confined to the lower 1/3 with irregular margin and
granulomata may produce small round filling defect.
* In advanced cases .... the dilatation may involve the whole length of the ureter and the
pelvis.
ureteral strictures ... most frequently in the lower of the ureter hydro-nephrosis +
hydroureter
3. Micturating cystourethrogram :
-In early stages normal.
-In advanced stages 1.Decrease U.B capacity with thickened irreg. wall.
ii. Reflux due to fibrosis around the vesico ureteric junction.
iii. Bladder neck obst due to fibrosis.
Hydatid disease:
- Plain : calcification.
- IVP :
1. The cysts start in renal cortex have the same radiological picture of simple renal cyst.
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2. The cyst may rupture into a calyx .... so it fill with contrast in I.V.U & daughter cysts
within parent one may form filling defects + sometimes the collecting system communicate
with the space between ecto. and endocyst... so the contrast medium will present in cyst
wall produces an ill defined opacity around cyst.
- U/S & C.T. :
- Shows unilocular or multi-locular cysts with well defined wall and has water density (CT).
- The presence of daughter cysts is diagnostic.
Glomerulonephritis
-Ag Ab reaction (PSGN).
-It means generalised damage to glomeruli.
-The kidney frequently appears normal.
- The only abnormality that may seen ... symmetrical change in size :
*acute stage.. swolen kidney.
*chronic stage.. small kidney.
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Haematuria:
Causes :
I. Lesions in urinary tract :
1. Renal :
-Cong. polycystic disease
Med. sponge.
-Renal trauma.
-Acute, chronic pyelo nephritis, renal T.B, G.N.
-Renal calculi.
-Renal vein thrombosis.
-Renal masses hyper-nephromas.
pelvis : papilloma, angioma .
2. Ureteric : Stones ,tumour.
3. Vesical : trauma , stone, cystitis, tumours,T B,bilharziasis.
4. Prostatic : prostatitis , S.E.P, malig tumour.
5. Uretheral : Rupture, urethritis , stricture, stone , growths.
II. Disease in the adjacent organs :
-Inflammatory : appedicitis, salpingitis, pelvic abscess spread to wall of U.B.
-Carcinoma : ca rectum, ca. uterus infilteration through bladder wall haematuria.
III. Blood diseases :
-Purpura, haemophilia, leukeamia.
Radiology approach :
I. Plain :1. Abdomen & pelvis:
A.) Kidneys :
i. Site : may be displaced by mass.
ii. Size :*Unilateral, smooth, enlarged kidney :
1. Congenital : fused ectopia, multi cystic kidney.
2. Traumatic : haematoma, urinoma.
3. Inflammatory acute deg. glomerulo-nephritis.
acute pyelo-nephritis.
hydro-nephrosis, pyonephrosis.
4. Neoplastic : infilteration as leukaemia, lymphoma.
5. Vascular : renal vein thrombosis.
Acute ischaemia.
*Unilateral, small, sized kidney :
A. Scarred : T.B., ch. pyelonephritis.
Infarction.
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Value :
1. It can define the site, size and contour of kidney.
2. Detection of calyceal dilatation.
3. Cortical thickness.
4. Calcification and stones highly echog. + acoustic shadow.
5. Any mass lesion size, site, outline well defined.
ill defined.
echogenicity : cystic of solid or mixed.
6. Detection of metastasis + lymph nodes in malig. Lesions.
7. Guided biopsy.
IV. C.T. :
- Used in equivocal ultrasonic finding.
- Can asses site, size, outline, attenuation, value, calcification and enhancement pattern of
any mass.
- Detection of extra renal extension of lesion
- Vascular elements renal vein, I.V.C.
- Lymph nodes + retro-peritoneal structures.
V. Angiography :
1. For vascular lesions haemangioma of kidney.
renal artery aneurysm.
2. Vascular involvement in malg. tumour.
3. For embolectomy in life-threatening haematuria.
4. Before partial nephrectomy(= preoperative).
VI. Isotopes scanning.
VII. MRI.
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-Direct force.
-Shearing force : acceleration & decelation due to difference in mobility of membraneous
and prost. Urethra.
Types of Injury: (Based on urethrographic findings):
-Type I : Post. urethra is stretched 2ry to hoematoma in the prost. bed.
-Type II : prostate & urethra are disrupted.
extra-vasation is supra-diaphragmatic (urogenital diaphragm).
-Type III : Injuries both in membran, urethra and urogenital diaphragm.
Extra-vasation & hoematoma extend to proximal bulbous urethera.
Radiolo. appearance :
1. Fracture pelvis.
2. Urethrogram:
-Type I : stretching of the prost urethra with no extra-vasation
-Type II : extra-vasation of C.M. into pelvic extra-peritoneal and limited inferiorly by
intact urogenital diaphragm.
-Type III : extra vasation above and below the diaphragm.
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2. Kidney :
-Etiology:
- Mobile kidney.
- Hydro-nephrosis, tumour, cyst.
-C/P :
- History of trauma.
- Haematuria.
- Flank : tenderness, contusion, palpable mass.
- Shock.
-Classification of renal injuries :
1. Mild minor.
2. Mjaor severe.
3. Catastrophic.
1. Minor :
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Radiolog app.:
A. Plain :
1. Lower rib fracture.
2. Fracture of tr. proceses of lumb verteb.
3. Loss of definition of peri-nephric tissue.
4. Focal loss of psoas line.
5. Elevation of hemidiaphragm on same side.
6. Scoliosis with convexity to opposite side due to contraction of psoas muscle.
B. Urography :
1. Enlargment of the renal outline.
2. Nephrotomography with high dense C.M. is imp.:
- Complete cortical laceration.
- Extra-vasation of C.M. into renal parenchyma.
peri-nephric.
subcapsualar space.
3. Calyceal laceration may occur extravasion of the C.M.as above.
( N.B. Chronic urinary extravasion Urinoma)
C. U/S :
- Perinephric or para-nephric hypoechoic or hyper echoic collection.
- Change in size of the kidney.
-Tear in the kidney, pelvi-caly, system as hypoechoic line within the renal
parenchyma.
D. C.T :
- Deep parenchymal laceration.
- Peri-renal Hge hyperdense.
- Extra-vasion of C.M either into pararenalspaces renal parenchyma.
- Associated liver or splenic injures .
E. Angio-graphy :
A sub-capsular hoematoma, will cause stretching of the capsular
vesseles around haematema.
3. Catastrophic :
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as major .
- shuttered kidney.
- multiple fracture planes separating functioning renal fragment.
e.Angio-graphy:
- pedicle injury renal occlusion.
avulsion (DD : renal spasrn if less than 2hr. after trauma).
thrombosis.
-Complication of renal injury :
A. Immediate : occur within 6 weeks
1. Hge
2. Sepsis due to peri-nephric abscess or acute pyelo nephritis.
3. Fistula formation.
4. Significant urinary extra-vasation grades:
-Grade I
: intra parenchyma.
-Grade II
: beyond renal capsule but confined to the Gerotas fascia.
-Grade III
: free retro-peritoneal extra-vasation.
B. Delayed :
1. Hypertension due to ischaemic fragments of renal parenchyma.
2. AV. Fistula.
3. Post traumatic pseudo-anaurysm.
c.U/S:
d.C.T:
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b. U/S :
1- Renal swelling.
2- Large hypo-echoic pyramids, which indicate infarction and necrosis.
3- Hyperechoic cortex.
4- Indistinct cortico-medullary junction.
c. Angiography :
1. Poor filling of cortical vesseles leofless tree appearance.
2. Delayed arterial washout C.M.
3. Stretched intra-renal Vs.
-Radiolog. App:
a. Tc99m D.T.P.A : A good perfurson with poor uptake (D.D. rejection).
b. U/S: normal.
c..I.V.U :
Increasingly dense persist nephragram dt. leakage of tubular filterate
through damaged tubular wall.
Swollen kidney.
Elongated calyx due to renal oedema.
3. Fluid collection :
A. Lymphocele .
- Typically, it is inframedial to transplanted kidney.
- Reuslt from leakage of lymph from interrupted lymph vesseles of doner or recep.
Kidney.
-Radiolog. app.:
- 99Tcm D.T.P.A: cold area.
- U/S: fluid collection (hypo-echoic) with septation
B. Urinoma.
- Extra-vasation of urine from site of implantation (from U.B or ureter) or from donar
kidney into retro-peritoneal.
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-Radiolog. App:.
a. 99Tcm D.T.P.A:
extra-urinary hot spot .
b. U/S
:
Fluid collection, may be septated.
c. I.V.U, cystography, retrograde urography : to detect the site of leak.
4. Obstruction :
-Causes :
a. - Ureteric stenosis :
b. Fluid collection:
aedema
fibrosis
pressure.
Renal Ischemia:
-Etiology
Less common :
c. Thrombosis or embolism.
d. Compression by tumour.
e. Aneurysm, angioma.
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5. Extension of tumour.
-C/P :
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Renal failure :
(1)
(2)
Differential diagnosis:
Gas in the urinary tract :
Gas inside bladder :
1. Vesico-intestinal fistula : divert. disease, carcinoma, of colon or rectum.
2. Cystitis : due to gas forming organisms e.g.E.coli esp in D.M.
3. Following instrumentation.
4. Penetrating wound.
Gas in bladder wall :
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Cong. Hypoplasia.
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4. Renal dysplasia.
B. Bilateral .
1. Generalised arterio sclerosis Normal calyces.
2. Chronic glonerulo - nephritis.
3. Chronic papillary necrosis.
4. Arterial hypotension.
5. Causes of unilat. small kidney occuring bilaterally.
N.B.
Small kid.
large kid.
( Uni or / bilat.)
persrs obst.
Cong.
RAS
Trauma
Radiation
Inflamation
Renal infarction
Vasc
Miscell
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2. Multiple myeloma.
III. Abnormal fluid accumulation :
1. Acute tubular necrosis.
2. Acute cortrical necrosis.
IV. Neoplastic infiltration:
Leukaemia & lymphoma.
V. Inflammatory cell infiltration:
Acute interstitial nephritis.
N.B.Cong : inf polycystic medullary sponge kid
Tramua :
Inflamma : hydronephrosis , acute GN, TN & PN
Neopl : leukc, lymphoma, MM
vasc : renal V thrombosis
Miscell : Amyloid, acromegally.
VI. Miscellaneous :
1. Renal vein thrombosis.
2. Acute renal papillary necrosis.
3. Infantile polycystic disease.
4. Sickle cell anaemia.
5. Bilateral hydronephrosis.
6. Medullary sponge kidney.
7. Acro-megally.
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DD :
-Persistent fetal lobulation ( normal size kidney)
-Normally : cortex parallel to interpapilary line.
-Lobar infarction: broad depression over normal calyx.
-Reflux nephropathy: focal scar over dilated calyx.
Nephrographic patterns:
A. Immdiate faint persistent nephrogram:
1. Proliferative necrotizing disorder as before acute GN. AGN
2. Renol vein thrombosis.
3. Chronic severe ischaemia.
B. Immediate distinct persist nephrogram:
1. Acute tubular necrosis.
ATN
2. Causes of acute renal failure.
3. Acute hypotension.
C. Increasingly dense nephrogram:
1. Acute obst.
Obst., RVT
2. Acute hypotension.
3. Acute tubular necrosis.
4. Acute pyelonephritis.
5. Renal vein thrombosis.
6. Multiple myloma.
7. Acute papillary necrosis.
D. Rim nephrogram:
1. Severe hydro-nephrosis.
Hydro
2. Acute complete arterial occlusion.
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E. Striated nephrogram:
1. Acute ureteric ob.
2. Infantile polycystic disease.
3. Medullary sponge kidney.
4. Acute pyelonephritis.
Inf PCK
Dilated ureter:
(Dont Forget Stone, Reflux)
A. Obstruction :
1. Within lumen:
a. Calculus.
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b. Blood clot.
c. Sloughed papilla.
2. In wall:
a. Oedema or stricture due to colculus.
b. Tumour.
c. T.B stricture & inflammtory.
d. B.
e. Ureterocoele.
f. Mega-ureter = functional dilat. Of distal ureter.
3. Out side wall:
a. Retro-perit fibrosis, endometriosis, pregnancy.
b. Cancer cx or bladder, prostate.
c. Retro-caval ureter, on right side only.
the distal ureter lies medial aL3 to dilated
proximal portion.
abnormal dev. of IVC (not ureter).
B. Vesico - ureteric reflux.
C. No obst or refulx. : 1. post portum.
2. Following relief of obst.
3. U.T. infection.
Bladder calcification :
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Bladder fistula :
a. Congenital:
Etopia vesica.
Imperforated anus (high type).
b. Inflammatory:
Diverticular disease, crohns disease.
Appendicular abscess.
c. Neoplastic :
Carcinoma of colon, bladder, ovary.
Radiotherapy.
d. Trauma .
Infertility:
Definition : difficulty to conceive.
(N.B Sterility : impossibility of having children).
Etiology :
A. Male factors :
I. General
1. Old age.
2. Obesity.
3. Endocrine problem:
-hyper parathryroidism.
-pituitary disorder.
4. Psychological factor.
5. Addiction, alcoholism.
B. Female factors :
I. General
1. Constitutional diseases : TB,
leukaemia.
2. Nutritional deficiencies.
3. Obesity.
4. Psychological factor.
5.Intoxicationalcholism-lead
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poisoning.
6. Endocrine factor:
-myxoedema.
-hyperprolactin.
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1-Uterus:
a. Epithelial origin :
Benign :
- cyst : serous cyst adenoma.
mucinous cyst adenoma.
simple cyst.
- solid : papilloma.
Malignant:
- primary : -solid .
-cystic: Papillary serous cystadeno carcinoma.
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3. Uterus:
1. Size
2. Wall
3. Locules
4. Debris
5. Effect
6. Movement
Benign
< 10m
smooth
uni or multilocular with septa
-ve
mass effect
empty abd. appearance
mobile
Malignant
> 10cm
irregular, poorly defined
- complex with solid compon
- + ve echogenic
Ascitis, metastasis
Nodules or nodes
Fixed to pelvic wall or
omentum.
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d. Hydro & metrocolpus : accumulation of fluid or blood in uterine cavity and vagina due to
labial fusion or imperforate hymen. Commonly occurs in young female.
G. C.T.:
Is used in: -suspecious ovarian, cervical or body malignancies for staging and
lymph node invasion, ascites,
calcification.
H. Lymphography :
For visulalisation of lymph nodes in uterine carcinoma.
I. Angiography .
J. M.R.I.
MRI : hypo
Fibroid
Cancer
Endometrisois
Ovray
junctional zone
low on both if bright redeg. endom, cancer
bright on both
bright on both
bright follicles on T2.
Uterine fibromyoma
-It is a benign lesion of the uterus and are mostly oestrogen dependant.
-Pathology :
- N.E.A polyp :
1. Sub serous type.
2. Submucous type.
3. Interstitial type.
- M.E liomyoma (fibrous tissue + muscle).
-C/P : Bleeding, discharge, infertility and pain.
-Radiolog. Examination :
1. Plain abdomin : soft tissue swelling in the pelvis, patchy calcification.
2. H.S.G according to type :
i. Sub-mucous type multiple, polypoid or single smooth filling defect.
ii. Interestitial type bulky uteriaus, distortion
iii. Sub. serous type may be normal or effect of pressure may be seen.
3. Cysto gram :
- Fundal impression on bladder.
- Large fibroid deviation or obst. of ureters.
4. U/S :
- Masses in or arising from myometrium.
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-Us :
Pseudomyxoma peritonii :
-Entire peritoneal cavity filled with poorly (hypo) echoic. mucinous deposits dt rupture of mucinous
cystadenoma.
Serous cystodenoma :
-Thin wall, hypo or anechoic cyst. may show thin internal septae.
Mucinous cystadenoma :
-The same but contain thick int. septa.
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Cystadeno carcinoma :
- Complex cyst, solid componant, ascites.
Abortion:
-Interruption or termination of pregnancy before age of 28 weeks.
Types :
1. Threatened abortion : Internal os closed.
2. Inevitable abortion : Internal os opened
3. Incomplete : parts of foetus passed & parts retain in the uterus.
4. Complete.
5. Missed .
6. Cervical : stenosed ext. os, prevent expulsion of completely separated ovum.
7. Septic abortion.
8. Therapeutic ,, & criminal abortion.
9. Habitual abortion : condition in which consecutives, spontanesus abortion takes place.
Etiology :
A.
Maternal causes :
I. General
i. Acute causes : fever: measles.
truma.
poisoning.
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as infertility.
-Imaging :
I- Plain: Air gas forming infection - bowel hernia.
Calcification : a. Testicular : -Tumour.
-T.B.
-Trauma.
b. Peritesticular vas deferens curvi linear in D.M.,B., T.B
phleboliths in varicocele.
epididymis calcif. in cyst wall.
II. US( 5-7.5 MHZ).:
-Indications - Scrotal swelling.
-Scrotal pain.
-Scrotal trauma.
-Subfertility:
varicocele test. atrophy. -Ectopic testis.
Scrotal Swelling:
I. Testicular tumour : 1ry
- 95% are germ cell (origin) rest mesenchymal, sertoli or leydig cell.
- 25-35 yrs in undescended testis.
C/P: Painless swelling, 10 % bilat.
U/S: -Seminoma :( most common.)-hypoechoic + ascas of necrosis +
hydrocele.
-Teratoma :- younger age.
-mixed echo cystic + echogenic areas (bizzare echopatten)
-hydrocele.
- Embryonal cell + Chorio-Carcinoma highly malig.
-MRI.
-C.T: paraoartic + para caval LN (at level of renal hilum)
-2ry from kidney + prostate : -older age.
- leukemia + lymphoma diffuse hypoechoic.
II. Hydrocele cause : - cong.
- Acq trauma tumour.
U/S: transonic +/- int. echoes in hemato or pyocele.
III. Epididymal cyst, spermatecele.
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Scrotal pain :
1.
Epididymoocrchitis :
-Usu. testis not involved - usually dt UTI with: chlamydia, Ecoli, gono, TB, S.
U/S : epididymis : enlarged - hypoechoic + hydrocele + abcess.
Chronic cases echogenic - thick tunica albuginia.
Isotope.
2. Tumour.
3. Varicocele : more on left left adenocarc. of kid renal vein.
Doppler : asses flow.
U.S.:
4. Torsion : (U/S changes within 1hr. of onset to save the testis.)
U/S testis hypoechoic + enlarged.
+/- epid enlarged.
+/- hydrocele.
Doppler diff. from epididymoorchitis.
Isotopic cold area surrounded by activity.
Investigation of impotence
-Papaverine v.d ( smooth muscle relaxant) erection if not : d.t. arterial insufficiency .
venous leak from corpora .
*Doppler : superf. + deep penile arteries.
*Angio: common + int. iliac then aortic flush angio.
*Cavernosography: veins if any dilated veins ligation.
(N = following papaverine no veins seen).
*Pharmacocavernosometry to evaluate venous drainage (inject paprarverine & dilute contrast.
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Obstetrics
-Items:
1. Diagnosis of early preg.
2. Assessment of fetal growth.
3. Fetal positons & presentation.
4. Placenta.
5. Fetal abnormalities.
6. Amount of liquior amnii.
7. Post maturity.
8. Pelivemtery.
9. Fetal death.
10. Ectopic preg.
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iii.
Embryo with a heart beat in all pregnancies > 40 days when gestational sac >
9mm.
B. Foetal growth :
1. 5-11 weeks: by gestational sac length ( at rate of 0.7-1.75mm/day) 1st trimester.
2. Crown - rump length : from 5-14 w.
1st trimester.
3. foetal femoral length : from 11-22w
2nd trimester.
4. Bi-parital diameter : from 14-38 week. 2nd and 3rd trimester.
5. Head circumference, abd. ciramference.
-Growth retardation :
Def.: 5th centile (%) for weight.
Risk factors :
1. Maternal : hypertension, renal & cardiac diseases.
2. Placental bleeding in early pregnancy.
3. Multiple pregnancy.
4. Previous growth retarded baby.
Types :
Type I :
time onset : 2nd trimester.
form : symmetrical, the whole body being affected.
causes:( foetal): - Genetic.
- Chromosomal abnormalities.
- Malformation., I.U. infection.
- Drugs : alcohol, smoking.
Type II :
time of onset : 3rd trimester.
form: asymmetrical, the trunk being affected > head H.C/A.C
ratio (head/abd) trunk smaller < head
causes (maternal & placental): Hypertension.
- Renal vascular disease.
- Placental insufficiency.
- Idiopathic.
C. Foetal position and presentation :
- Lie : relation of long axis of foetus to that of mother longit.
- Presentation : the part of foetus lying lower vertex.
- Attitude : relation of different parts of foetus to one another flexion.
- Position : relation of back of foetus to ant. abd. wall Lt. ant. occipit.
- Any abnormality of the lie, presentation & attitude , should arouse suspicious of
abnormality of the mother & the foetus:
Maternal causes :
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- Ovarian dermoid.
- Uterine fibroid.
- Abnormalities of pelvis.
Foetal :
- Placenta previa, hydrops.
- Polyhydromnios, multiple pregnancies.
- Foetal death .
D. Placental development and abnromalities :
1. Normal placnetal development :
The placenta can be identified at about 8ws as a granular thickening of gest sac.
a. Entire surface of placenta is covered with villi implantation ot 6-7 w. (Gest.
age week).
b. Villous placenta (chorion frondosum) develop 7-11 w.
c. Atrophy of remaining villi (chorion laeve) 7-11 w.
d. Three layers of placenta identify 12w.
-Basal plate.
-Placent. substance.
-Chorionic plate.
2. Placental grading :
- The normal placenta show U/S feature which change as the pregnancy progresses:
O homogenous + no + no + no
I echogenic (scattered) + no + no
II echogenic (comma) + calcificaties + demarcated cotyledons
III all + echo poor areas (central)
Changes in 3 zones Grannum classification
Grade O
Grade I
GrII
Basal layer
No densities ie
no calcification
No densities
placent. substance
Finely
homogenous
few
scattered
echogeneic areas
Linear
Echo-densities
arrangement
of comma shape
small
echodensitis
choronic plate
Straight & well
defined
subtle undulation
Demarction
of
cotyledons (endo)
directed to basal
layer
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Grade III
septation of
cotyledons,
extending to the
basal layer
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Placental hge :
1. Retro-placental hge : concealed ante part hge. separation of placenta.
2. Marginal Hg . separation of placenta.
3. Pre-placental Hge : either subamniotic or subchorionic.
4. Intra-villous thrombosis intra-placental sons lucencies.
Placental Abruption :
Premature separation of normally sited placenta either : marginal or retro-placental.
Cause of a thickened placenta > 4 cm:
1. D.M.
2. Foetal hydrops
3. Intra-uterine infection.
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E. Foetal abnormalities:
1. Foetal death :
-C/P : absent foetal movement.
- Plain x-ray findinges:
a. Spalding sign :- over riding of the cranial bone.
-evident between 5-15 day after death.
b. Gas translucenies : seen in blood vessels of chest, Abd, & heart
- transient for 12 hrs. only.
c. Attitude of extreme flexion 5-15 day after death.
d. Devels halo sign : elevation of peri-canial fat by underlying
soft tissue oedema.
- appear within 2 days after death.
e. failure to grow on serial films.
f. Disparity between clinical & radiolog. estimation of maturity.
g. Constancy of foetal postion.
- U/S findings :
1. The vital sign of foetal movement & cardiac pulsation are
absent.
2. Other delayed signs U/S spalding sing, halo sign.
3. Abnormal gastational sac (early in 1st trimester).
2. Extra-uterine pregnancies (ectopic):
- Plain x-ray :
1. Unusual : lie, attitude (swiming), position high, low in abdom).
2. Constancy of foetal attitude, position on repeated examination.
3. In lateral view foetus may overlape maternal spine or closed
to maternal abd. wall.
4. Unusual clarity of the foetus.
5. Absence of shadow of uterus.
6. Abdominal gas of mother overlie the foetus.
- U/S :
1.U/S evidence of an intra-uterine pregnancy exlude the
diagnosis.
2. Endo-metrial thickening (decidual cast), pseudo-gest sac.
3. Adenexal mass (complex echogenic mass).
4. Fluid in Douglas pouch.
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Causes of oligohydromnios :
A. Severe :
1. Renal agenesis.
2. Premature rupt. of memb.
3. Sever growth retardation.
B. moderate :
1. Bilat renal anomalies.
2,3. as above.
5. Congenital abnromalities of foetus:
A. Hydrops foetalis:
Def. Excessive fluid accumulation in the extra-vascular component :
= s.c. oedema + ascitis, pl. & peric effusion.
Types :
1. Immune hydrops:
Rh. Incompatibility.
Blood group abnromality.
2. Non-immune : late manifest. of many sever diseases.
Plain X-ray :
- Attitude Buddha.
- Elevation of peri-cranial fat : Halo sign.
U.S.
B.Thyroid, cystic hygroma :
- Soft tissue mass of neck extension of neck face or brow
presentation
C. Renal :
- Hydro-nephrosis.
- Multcystic kid.
- Poly-cystic kid.
D. CN.S:
1. Anencephally : the cranial vault fail to develop and bone of skull base,
face are maldeveloped.
2. Micro-cephally : facio-cranial disproportion.
3. Hydrocephalus : usually associated with spina bifida.
-U/S : - distended lateral ventricle.
- head size : B.P.D & H.C.
4- Spina bifida: - Failure of fusion of post neural arch. at 3-4 weeks.
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3. The bones of skull are hard, thick & suture lines and fontanels
are narrowed or closed.
4. Appearance of an ossification center in cuboid bone at birth.
5. Presence of large ossif. c. in upper end tibia and lower end
femur (normally at birth 36-40 w).
6. Distorted pelvic cavity.
7. Malpresentation : breech, brow.
B. U/S :
1. Change in placenta grade III.
degeneration of placenta or separation.
calcifciation.
2. Marked in amount of liquor (turbid).
3. Measurement of foetus : B.P.D, H.C.:, A.C :all are above of 42 weeks.
4. Signs of predisposing factors e.g. malpresent, anencephaly.
5. Signs of distress of the foetus.
G. Pelvi-metry :
-Clinical indication:
1. Persistent breach presentation.
2. Following difficulties of the previous labour.
3. Post-maturity.
4. Failure of head engagement after 36th w.
5. Suspected pelvic deformity : old rachitic female.
-Obstetric feature of pelvis.
1. Gynagecoid pelvis : -optimum round pelvic brim.
-max. trans. diameter is anterior.
2. Android pelvis (male): - max. trans. diameter is displaced posterior.
3. Anthropoid :
- oval conjugate > trans diameter.
4. Plate pelloid : - brood or flat trans > cong.
- Abnromal pelvis :
A. Congenital :
i. Achondroplasia conjugate line.
lordosis.
ii. Nagel pelvis aplasia of one sacral ala asymm. pelvis.
iii. Robert pelvis both sacral ala fail to develop.
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B. Acquired :
1. Traumatic pelvic deformity.
2. Metabolic disease rickets, osteo malacia bone softening
weight bearing tri-radiate pelvis.
3. Spondylolisthesis.
4. Hip disease : septic or T.B., dislocation.
5. Polyomyelitis.
6. T.B or osteomylitis of the spine.
-Radiographic technique :
The measurement taken on the film are subjected to geometric enlargement which
must be reduced by an appropriate correction factor :
Distance of appropriate plane of pelvis from focal spot
___________________________________________
Focal film distance.
Technique:
Pelvimetry :
1. True conjugate line 11cm. from sacral promontory to sup. and post.
part of body of s. pubis.( Lat/erect).
2. Pubo sacral line 11.5 cm, from lower most fipart sacrum to inferior
& post of body (lat/erect).
3. Transverse D 12.5 cm from widest diameter of pelvis.(AP / supine)
4. Inter-spinous : 10cm between two spinous processes( AP / supine).
U/S:-Indications for U/S in first trimester :
1. Threatened abortion.
2. Suspected ectopic preg.
3. Uncertain L.M.P.
4. Evaluation of retained products post spontaneous abortion.
5. Assessment of success of ovulation induction.
6. Retained I.U.D.
7. Evaluation of pelvic mass in early pregnancy.
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H.S.G:
-Indications :
1. Demonstration of tubal patency.
2. Cong. anomalies, of ut. & cx.
3. Abortion (habitual abortion).
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-Contraindication :
1. Pregnancy.
2. Acute pelvic infection.
3. Week, before and after menstruation.
4. Severe, cardiac and renal disease.
5. Sensitivity to C.M.
-N.B. : Ashermans syndrome :
Adhesions or absence of uterine canal following delivery, pregnancy or curettage.
U/S :
- May shows normal shaped uterus with no cavity.
- Haemotosalpinx or haematometra.
Ovarian masses:
A. Simple cystic structures :
1. Follicular cyst.
2. Cyst adenoma.
3. Polycystic ovaries (multiple, 5-8 mm in diameter, echogenic stroma).
4. Cystic teratoma.
B. Complex (mainly cystic):
1. Cystadeno carcinoma.
2. Dermoid.
3. Abcess
4. Ectopic preg.
5. Endometriosis (chocolate cyst).
C. Complex (mainly solid):
1. Cyst adeno-carcinoma.
2. Dermoid.
3. Ectopic preg.
D. Solid :
1. Adeno -carcinoma.
2. Solid teratoma .
3. Fibroma.
4. Lymhoma.
5. Metastasis .
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Breast:
Anatomy :
1- Functional element (parenchyma ducts and alveoli).
2- supportive element: (stroma fat loose CT dense c.t).
N.B. Most of the glandular tissue are located at the upper outer quadrant that is
most of the tumor are seen at that site .
Radilogical and pararadiological methods of examintion of the breast:
A. Mammography :Technique: is based on principles of soft tissue film these are :1- Low K-V (soft film ).
2-High M-A-S (to compensate low K-V- for adequate exposure).
3-Collimating beam (to decrease the scattering radiation ).
4- Small focal spot ( to decrease geometrical blur).
5- Short object film distance (to decrease geometrical blur).
6- Non screen film to give the maximum details (decrease scattering).
7- Compression of breast to thickness & movement (decrease blur)
Views:
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INDICATION :
C. Galactography :
-Indication :
Blood stained nipple discharge .
-Technique : Blunt needle into nipple select duct inject contrast (urographin)
films see opacified ducts.
-Data :
1- Course: -Regular.
-Amputation = duct carcinoma.
2- Calibre (up to 2mm): - Smooth dilatation (pregnancy and lactation ).
- Irregular narrowing with distal dilatation
invasive ductal carcinoma .
3-Filling defects (in the duct): - Smooth : papilloma, granuloma .
- Irregular: invasive intraductal carcinoma
D. Thermography:
Non specific to demonstrate thermal and vascular abnormality in different
breast lesions infection (abcess).
malig.
E. Computed tomomogaphy :
Its main side effects (high dose of irradiation )
- Cysts: appears as well defined low density area.
- Solid mass : appeares as homogenous area of high density (soft tissue density ).
- Detection of axillary and internal mammary lymph nodes.
- Enhanced scans 60 H.U suggests malignancy .
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F. MRI:
High sensitive method with no inoizing radiation.
Limitations:
1- Economic factor.
will be solved
2- Time consuming ( take I hour).
will be solved
3- Uncomfortable for patient.
as in CT.
4- Can not detect microcalfications.
O.K.
G. Xero-mammograghy:
- High dose of radiation.
- Using selenium plates.
-+ ve and -ve zerogram.
H. Digital mammography:
- Using the already taken views scanned by laser scanner into computer
manipulated and contrast alteration.
- Using phosphrelation plates instead of the film laser scanner ,,,,
- Using digital detectors direcly into computer.
N.B.
Fiberoadenosis
Fibroadenoma
Cyst
Lipoma
Fat necrosis
Galactocele
Abscess
BENIGN LESIONS:
Density
margin &calcification
similar to breast or if
large
more dense
density
density
density
egg shell
egg shell
ill defined
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MAMMOGRAPHY:
Normal mammographic patterns:
1- Adolescent pattern: young girls -Less fatty element (less stroma).
- Dense glandular disc, clearly separated from subcutaneous fat
- Ducts, vessels and trabeculae are not identified difficult diagnosis of the mass. ---- Clear retro mammary fat.
2- Mature glandular pattern:
- Adult females, especially after repeated pregnancies
- Fat amount increased within glandular portion so more definite structures - as
ducts vessels.
3- Fatty atrophic pattern:
-Perimenopausal female ,fertile, multipara.
-Excess fat replacing the glandular portion good demonstration of the pervious
structures, also lactiferous ducts may be seen.
-Better demonstration of masses and calcification.
MAMMOGRAPHIC DATA:
A-MASS :
sign
Benign
Malignant
1 Density
increased density
2 Texture
homogenous
heterogenous
3 Margin
regular
4 Speculation
-ve
+ ve
5 Lucent halo
found
+/-
6 Size
clinically = radioloqy
clin> radiology
B- calcification:
1-Microcalcification = Malignant.
-0.08 -0.1 mm.
- Granular / elongated with irregular outline.
- Commonest in scirrhous carcinoma - usually occurs in clusters = > 5 in
tumour or outside (punch like).
2- Macrocalcification coarse = Benign.
A- regular and smooth:
-Ring /tubular along ducts duct ectasia.
surrounding a transradient center
- Pop-corn fibroadenoma.
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Benign
Malignant
skin
no skin dimpling
nipple
no retraction
retracted
fat
no obliteration
obliterated
parenchymal
pattern
compressed
destroyed
ducts
+/- dilated
dilated
vascularity
increased
L.NS
++ ve LN. enlargement
perifocal
haziness
no
yes
Fibroadenoma:
-Well defined contour all around.
-Halo translucency around (capsule).
-Homogeneous, Small, No skin or deep attachment.
-Pop-corn calcification.
Malignant lesion:
- Nipple retraction.
- Skin dimple, thick.
-Ill-defined mass.
- Micro calcification.
- Stellate fibrous bands.
- Cooper lig. Involvement.
- Hazy scalloped contour.
-Commit sign (orbit cone). Mostly scirrhous.
N.B.:-Signs of malig .without definite mass?? Paget dis.
-Worst is mass in an already dense breast (glandular or cystic)&also in ! upper
medial quadrant (not seen easily in the film).
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Disease
X ray mammography
Ultrasonography
1. Cyst.
Types:
-Simple.
-Thick content.
-Hemorrahgic.
-Infected.
-Sebaceous.
-Multiple.
Single or multiple
Well defined density
Shape: smooth border
+/- lucent rim of fat (halo)
DD (fibroadenoma
2. Abscess.
Like cyst
3. Lipoma.
Anechoic
Well defined
Rounded or oval
Post acoustic enhancement
Surrounding tissue is (normal or
compressed)
Special
Thick content fine echos
Infected irregular hazy lesion
with mild echogenicity
Hgic dense internal echoes
If acute as infected with loss of
echo free texture of subcutaneous
fat.
Chronic = +/- illdefined
heterogenous echos
Well defined hypoechoic
No post acoustic enhancment
4.Fibroadenoma
-most common
-Young adult
-Uni/bilateral
DD
Cystosarcoma phylloides
(non homogenous)
5. Mammary dysplasia
-Common
-Cystic
formation
-Epithelial
Proliferation
-Premalig.
Well defined
Mixed density
(fibrotic, cystic, glandular)
Ductal proliferation
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6. Carcinoma
-Scirrhous Medullary
MRI :
1- Abcess T1 low center + high capsule .
- T2 Strong enhance.
2- Fibroadenosis cysts : low T1 high T2 Not enhance.
diffuse + delayed enhancement in proliferative type.
3- Fibro adenoma : low signal
post contrast very strong (Myxoid 40 %, not enhance (= fibrous).
4- Papilloma enhance expect sclerosed (solitary + subareolar Benign.)
(multiple Malignant).
5- Lipoma not enhance, high on T1.
6- Cancer fast + focal enhancement .
> 83 %, 60 sec. Post contrast.
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Carcinoma in situ.
tumour < 2 cm.
tumour 2 5 cm.
tumour > 5 cm < 10 cm + skin infiltration and pectoral fixation.
tumour
> 10 cm.
no.
Axillary mobile.
Axillary fixed.
Supra clavicular.
no.
Metastases.
FIBROADENOSIS:
Age: child bearing period.
CIP: periodic mastalgia related to menstrual cycle - palpable nodularity - tenderness
of breast tissue.
RADIOLOGICAL APPEARANCE (mammography):
Mass:
-Similar density as breast tissue except if large density.
- Margin : smooth rounded ovoid or lobular.
but m.b partly irregular or ill - defined as they develop form surrounding
fibroadenoid tissue.
-+/-Cysts prominent ducts.
Calcification :
-Smooth calcification central or peripheral .
Changes in breast architecture:
- Architecture is deformed by mass.
- Halo around ! lesion d.t. compressed fat.
- Prominent ducts.
Vascularity :.
no Perifocal haziness.
Size of lesion = or > clinical size.
U/S:
Small ,well-defined with uniform internal echoes - dense echoes of int. calcification
(u/s: fat hyperechoic but in breast hypoechoic and glands are hyperechoic).
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Thyroid Swellings
CAUSES :
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3)Computed tomography:
-Can differentiate between thyroid and parathyroid tumors .
-LN.
-Extension.
4) Isotope study : (I131 or T.C 99 m )
- Nodule hot = toxic
cold = Malignant or
Benign (cyst, focal thyroiditis, degenerative) U/S
- Retrosternal goiter activity is below sternal notch .
5) M.R.I.:
- Clear demonstration of thyroid mass and retrosternal extension with coronal and
sagittal scans .
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B- Benign tumours:
1) Juvenile naso pharyngeal angioflbroma:
-The commonest benign tumor of the nasopharynx.
- In pubescent males.
C/P: -Epistaxis and nasal obstruction.
-Dark red mass in the nasal cavities and post nasal space.
C.T:
1- The mass arise at or close to the base of pterygoid lamina .
2- Bone erosion in this site (constant feature ).
3- Expanding into the nose and post nasal space .
4- Tendency to spread laterally through pterygo-maxillary fissure
A- widening of the fissure.
B- Extension into the infratemporal fossa.
5- Anterior : bowing of the posterior wall of the antrum (important sign ).
6- Involvement of orbit proptosis (late.).
7- Coronal cuts extension into sphenoid sinus and cranium .
8- Post-contrast studies (bolus):
A- Considerable contrast enhancement .
B- Help to delineate limit of lateral extension in infratemporal fossa.
CAROTID ANGIO:
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1- Functional disorders:
-Cricopharyngeal dysfunction (appears in cineradiology)
2-Traumatic lesions:
-FB ( fish or meat bones, coins, pins ) lodged in the upper oesophagus, pyriform
fossa, between the cords - perforation by F.B or instrumentation widening of
the retropharyngeal soft tissue space (haematoma).
3- Infection: Retropharyngeal abscess.
4- Laryngoceles:
-An air filled sac arising from laryngeal ventricle and saccule:
1- Congenital.
2-Acquired (expiration against resistance ) e.g. - glass blowers.
- trumpeters.
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Paranasal sinuses:
Acute sunusitis :
Thick mucosa.
Fluid level.
Osteomeatal complex.
Complication of acute sinusitis
1-Empyema, mucocele.
2- Osteomyelitis.
3- Orbital cellulitis.
4- Brain abscess.
Chronic sinusitis:
Thickened mucosa.
bone density.
Obliteration of sinus cavity.
(Mucocele expansion with no destruction + loss of translucency of the sinus)
Benign tumors:
-
Ivory osteoma.
Inverted papilloma : from middle meatus of nose antrum
(histological name)
Fibrous dysplasia: ground glass radiolucent area with island of
calcified bone.
Ossifying fibroma.
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(1)
(2)
(3)
(4)
1-