د خالد ألمظ Basics in Abdominal Sonar PDF

Khaled Mohammed Almaz
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Basic Notes of using Basic Sonography for
GIT specialty
& Liver specialty
& Urology specialty
For Non-Radiological Physicians
Khaled Mohammed Gomaa Almaz
Green Belt Lean Six Sigma , 6 sigma school , Cairo , Egypt 2019
1st part M.D. Public Health , Aswan , 2017
MPH , Asyut , Egypt 2011
M.Sc Internal Medicine , Asyut , Egypt 2015
Are the same
= Sonography
= Sonar
= U/S (ultra-sound)
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GIT & Urology ‫المطلوب في برايفت السونار لطبيب امراض الباطنة‬
1) Normal & Abnormal

2) L ¢ (Liver)
3) Nephropathy (Kidneys)
4) Ascites
5) Organ Enlargement
• Liver (LT & RT lobes)
• Kidney (LT & RT sides)
• Spleen
6) Portal vein diameter
• ↑→ dilatation → portal HTV
7) Detection of (Cyst , Focal lesion)
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‫ماجستير امراض الباطنة‬
‫مهارات محدودة في السونار‬
N or abnormal
L ¢ (liver)
Nephropathy (kidney)
Ascites
Enlarged organ (liver(Rt, Lt lobes) , Kidney (Rt, Lt sides) , Spleen)
Portal vein diameter (portal HIV)
Detection of (cyst , focal lesion)
-------------------------------------------------
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Report (example)
Abd. U/S
Name :
Date:
Liver : mild enlarged , hypo echo pattern , no focal lesion , no dilated

biliary radicals , normal caliber of PV & CBD.
GB: average size , shows normal wall thickness , no stones or mass
Spleen : average size , homogenous (iso) echo pattern , no focal lesion
Right kidney: average size , shows normal parenchymal thickness and

echogenicity , with good cortico-medullary differentiation , no back
pressure
Left kidney : Normal
Pancreas : Normal
Retro peritoneal area : Normal
Para-aortic LN & Mesenteric LN : no
Ascites : no ascites - or degree of ascites (mention)
Conclusion
Thx
Dr/
Density = genecity
Iso
Hypo
Hyper
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Abdominal U/S
Liver report (by abd. u/s)
1) Site
2) Size
3) Border (capsule)
4) Echo pattern
5) Blood vessels
6) Biliary system “intra-hepatic dilatation” ,
porta-hepatis (diameter P.V. ‫ فقط‬, wall of porta-hepatis)
7) Focal lesion: 1cm (solid , cystic) , D.D.: LC (by history) - HCC

a. Site
b. Size
c. Shape
d. Surface
e. = colour dopplar if Malignant lesion
f. Surrounding structure
g. Associated lesion (LN , ascites , skin lesion)
8) Peri-portal fibrosis → “P.P thickening” as Bilharziasis
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Findings
Benign hyper:
Mostly hemangioma
Adenoma
Focal fatty change
(as: focal hepatic steatosis)
Malignant hyper:
Hepatic metastasis
Colorectal cancer
Breast cancer
Renal cell cancer
Thyroid cancer
HCC (hepatoma)
Cholangio carcinoma
-------------------------------------------------
1) Focal lesion
• Hyper echo
• Hypo echo → metastasis
• Simple hepatic cyst
• Hepatic hemangioma
• Hepatic ademoma
• Hepatic metastasis
• Hepatic abscess
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2) Diffuse
• Acute hepatitis
• L¢
• Hyper-diffuse steatosis
3) Hepatic vasculature
• Normal hepatic vessel
• Portal HTN
• Portal vein thrombosis
4) Hepatic trauma
5) Biliary
• Choledocholithiasis
• Dilated intrahepatic bile ducts
• Bile duct wall thickening
• Cholangiocarcinoma
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Hepatic Patient ‫حاالت الكبد‬
Abdominal Sonar :
1. When pt is not diagnosed
2. If pt is HE "hepatic encephalopathy" not do sonar
3. If pt come with H/M : sonar will be done in emergency

room before endoscopy
4. In case of pancreatitis: may show IPF "intra peritoneal

fluid" and ask also for MS CT
5. Showing edema
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Differential Diagnosis of Hepatosplenomegaly
• Acromegaly … enlarged spleen, enlarged liver

• Autoimmune Hepatitis … enlarged liver
• Autoimmune Lymphoproliferative Syndrome - enlarged spleen, enlarged liver
• Autoimmune Thrombocytopenia … enlarged spleen
• Brucellosis … enlarged spleen, enlarged liver
• Chagas disease … Hepatosplenomegaly
• Chronic Granulomatous Disease … enlarged spleen, enlarged liver
• Chronic Hepatitis C … Enlarged spleen, Enlarged liver
• Cirrhosis of the liver … Enlarged spleen, Enlarged liver
• Classic galactosemia … enlarged liver
• Common Variable Immunodeficiency … enlarged spleen
• Congenital syphilis … swollen liver, swollen spleen
• Congenital Toxoplasmosis … enlarged spleen, enlarged liver
• Cystic Fibrosis … enlarged spleen, enlarged liver
• Gaucher Disease … spleen enlargement, liver enlargement, liver enlargement,
liver enlargement
• Hepatoma … enlarged spleen
• Hyper-IgM Syndrome … enlarged spleen, enlarged liver
• Infantile Refsum Disease … hepatomegaly (enlargement of the liver)
• Leishmaniasis … enlarged spleen, enlarged liver
• Leukemia … Swollen liver, Swollen spleen
• Liver abscess … enlarged liver
• Liver cancer … enlarged liver
• Lupus … enlarged spleen
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• Lymphoma … enlarged spleen, enlarged liver

• Malaria … Splenomegaly, Hepatomegaly
• Mononucleosis … enlarged spleen, enlarged liver
• Mucopolysaccharidosis VII … spleen enlargement, liver enlargement
• Neonatal ALD … hepatomegaly (enlarged liver)
• Niemann-Pick disease … spleen enlargement, liver enlargement
• Non-Hodgkin’s Lymphoma … enlarged spleen, enlarged liver
• Polycythemia … enlarged spleen, enlarged liver
• Portal hypertension … enlarged spleen
• Relapsing fever … enlarged spleen, enlarged liver
• Reye’s Syndrome … enlarged liver
• Right heart failure … enlarged liver
• Schistosomiasis … enlarged liver, hepatosplenomegaly
• Sickle Cell Anemia … enlarged spleen, enlarged liver
• Systemic Juvenile Rheumatoid Arthritis … enlarged spleen
• Thalassemia- mild spleen enlargement, spleen enlargement, liver enlargement
• Thrombocytopenia … enlarged spleen
• Toxocariasis … Enlarged spleen, Enlarged liver
• Typhoid fever … splenomegaly, enlarged liver
• Vitamin A overdose … enlarged spleen, enlarged liver
• Weil’s syndrome … hepatomegaly
• Wilson’s Disease … swollen liver, swollen spleen
• Zellweger Syndrome … enlarged liver
• DD Hepato-SplenoMegaly
•
• Hepatosplenomegaly (commonly abbreviated HSM) is the

simultaneous enlargement of both the liver (hepatomegaly) and the
spleen (splenomegaly). Hepatosplenomegaly can occur as the result
of acute viral hepatitis, infectious mononucleosis, and
histoplasmosis or it can be the sign of a serious and life-threatening
lysosomal storage disease. Systemic venous hypertension can also
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increase the risk for developing hepatosplenomegaly, which may

be seen in those patients with right-sided heart failure.
•
• Common causes
•
• Infection:
• Acute viral hepatitis[1 ]2[]
• Infectious mononucleosis[1 ]2[]
• Cytomegalovirus[1 ]2[]
• Rubella]1[
• Brucella infection]3[
• Hyper active malaria syndrome]1[
• Leishmaniasis]1[
• Fasciolosis
• Typhoid fever]4[
• Schistosomiasis or filariasis importants
• Septicemic plague
• Hematologic diseases:
• Myeloproliferative disease[1 ]2[]
• Leukaemia[1 ]2[]
• Lymphoma[1]2[]
• Pernicious anaemia]2[
• Sickle cell anaemia]2[
• Thalassaemia]2[
• Myelofibrosis]1[
• Metabolic disease:
| P a g e 13
• Niemann-Pick disease[citation needed]

• Gaucher's disease[citation needed]
• Hurler's syndrome[citation needed]
• Chronic liver disease and portal hypertension:
• Chronic active hepatitis]2[
• Amyloidosis]2[
• Acromegaly]2[
• Systemic lupus erythematosus]2[
• Sarcoidosis
• Human African trypanosomiasis[citation needed]
• drug abuse[citation needed]
• Obesity[citation needed]
•
• Rare disorders
•
• Lipoproteinlipase deficiency
• Multiple sulfatase deficiency
• Osteopetrosis
| P a g e 14
HEPATOMEGALY
CAUSES
HEPATITIS/INFECTION
ACUTE
• Alcohol
• Viruses
• Bacteria
• Protozoans
• Parasites
CHRONIC
• Chronic active hepatitis

CONGESTION
• Congestive cardiac failure

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• Constrictive pericarditis
• Budd–Chiari syndrome
INFILTRATION
• Fatty liver
• Amyloid
BILIARY TRACT DISEASE
• Extrahepatic obstruction, e.g. carcinoma of the pancreas, bile duct stricture
• Sclerosing cholangitis
• Primary biliary cirrhosis

MALIGNANCY
• Metastases
• Hepatoma
• Myeloproliferative disorders
• Myelofibrosis
• Leukaemia
METABOLIC
• Glycogen storage diseases
• Haemochromatosis
• Wilson’s disease (hepatolenticular degeneration)S
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• Cryptogenic cirrhosis
• Riedel’s lobe
Liver ++
Symptoms
By Mayo Clinic Staff
| P a g e 17
In itself, an enlarged liver typically has no symptoms.
Signs and symptoms of conditions that commonly cause liver enlargement include:
• Pain in the upper right belly

• Fatigue
• Muscle aches (myalgia)
• Nausea
• Poor appetite and weight loss
• Yellowing of the skin and the whites of the eyes (jaundice)
Causes
Among the most common causes of liver enlargement are:
• Alcoholic liver disease, which includes alcoholic fatty liver disease, alcoholic
hepatitis and cirrhosis
• Nonalcoholic fatty liver disease, a lifestyle-related metabolic disease
• Viral hepatitis (hepatitis A, B, C, D or E )
• Liver cancer, or cancer that has spread to the liver from a different organ
Many less-common liver diseases may also cause liver enlargement, as do some
diseases that primarily affect other organs but involve the liver indirectly. A partial
list includes:
Cancers
• Some types of leukemia

• Some types of lymphoma
• Multiple myeloma
Genetic diseases
| P a g e 18
• Hemochromatosis
• Wilson's disease
• Glycogen storage diseases
• Gaucher's disease
Heart and blood vessel problems
• Blockage of the veins that drain the liver (Budd-Chiari syndrome)

• Congestive heart failure
• Narrowing (stenosis) of the heart’s tricuspid or mitral valves
Infections
• Liver abscess, caused by parasites (amebiasis) or bacteria

• Other parasitic infections (schistosomiasis, fascioliasis)
• Relapsing fever, which humans catch from body lice or ticks
Damage from toxins
• Drug-induced liver injury from such medications as acetaminophen (Tylenol,

others) and amoxicillin-clavulanate (Augmentin, Amoclans)
• Toxic hepatitis from exposure to poisons, such as the industrial chemicals
carbon tetrachloride and chloroform
Complex liver and systemic diseases
• Amyloidosis
• Autoimmune hepatitis
• Primary sclerosing cholangitis
Causes
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The liver is involved in many of the body's functions. It is affected by many

conditions that can cause hepatomegaly, including:
• Alcohol use
• Cancer metastases (spread of cancer to the liver)
• Congestive heart failure
• Glycogen storage disease
• Hepatitis A
• Hepatitis B
• Hepatitis C
• Hepatocellular carcinoma
• Hereditary fructose intolerance
• Infectious mononucleosis
• Leukemia
• Niemann-Pick disease
• Reye syndrome
• Sarcoidosis
• Sclerosing cholangitis
• Steatosis (fat in the liver from metabolic problems such as diabetes,
obesity, and high triglycerides, also called nonalcoholic
steatohepatitis, or NASH)
Among the causes of hepatomegaly are the following:
Infective
Leptospirosis
Glandular fever (Infectious mononucleosis)]2[
Hepatitis (A,B or C)]1[
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Liver abscess (pyogenic abscess)]2[
Malaria]2[
Amoeba infections]3[
Hydatid cyst]4[
Leptospirosis]5[
Actinomycosis]6[
Neoplastic
Metastatic tumours]1[
Hepatocellular carcinoma]1[
Myeloma]2[
Leukemia]1[
Lymphoma]2[
Biliary
Primary biliary cirrhosis]2[.
Primary sclerosing cholangitis]2[.
| P a g e 21
Metabolic
Haemochromatosis]2[
Cholesteryl ester storage disease]7[
Porphyria]2[
Wilson's disease]2[
Niemann Pick disease]1[
Non-alcoholic fatty liver disease]2[.
Glycogen Storage Disease]1[
Drugs (and alcohol)
Alcohol abuse]1[
Drug-induced hepatitis]2[
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Congenital
Hemolytic anemia]2[
Polycystic Liver Disease]2[
Sickle cell disease]2[
Hereditary fructose intolerance]1[
Others
Hunter syndrome (Spleen affected)]8[
Zellweger's syndrome]9[
Carnitine palmitoyltransferase I deficiency]10[
Granulomatous: Sarcoidosis[
| P a g e 23
Treatment
Treatment of hepatomegaly will vary depending on the cause of the liver enlargement
and hence accurate diagnosis is the primary concern. In the case of auto-immune liver
disease, prednisone and azathioprine may be used for treatment.[17]
In the case of lymphoma the treatment options include single-agent (or multi-agent)
chemotherapy and regional radiotherapy, also surgery may be an option in specific
situations.Meningococcal group C conjugate vaccine are also used in some cases.[18]
In primary biliary cirrhosis ursodeoxycholic acid helps the bloodstream remove bile
which may increase survival in some affected individuals.[19]
Abd. u/s
GB report (by abd. u/s)
1) Volume (capacity) → ‫ مش الزم‬not imp ‫ في‬internal medicine
2) Size
3) Wall thickening
4) Stone
5) Posterior shadow
6) Pericholecystic collection if black with edematous wall thickening
so it is Cholecystitis
7) Mass (if present or not)
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Findings
1- Diffuse thickening of GB wall ( i.e.in all the wall)
Cholecystitis
Secondary thickening : LC
Hepatitis
Congestive Rt sided HF
Low Albumin
• Other acute inflammatory process ( in Right upper Quadrant)
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Acute pancreatitis
Duodenal ulcer
GB tr : carcinoma (infiltrative)
GB tr : metastasis
GB tr : lymphoma
2- GB stones
3- GB polyp
Spleen report: abd. u/s

1) Orientation (sagittal . axis → Main view)
2) Measurements
• Size (length , width)
• Degree of spleen size
• If 2/3 kidney → ∴ enlarged
• Mild: not cross costal margin
• Moderate: not cross umbilicus
• Severe/huge: cross umbilicus
3) Helium (sinus) of spleen → hyper echo
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4) Spenule (separated small spleen)

• Site
• Size
• Echo
• Multiplicity
5) Infiltration → Amyloidosis
6) Abscess
• Wall
• Hypo echo
• Patient history: fever
• Septum (septation)
• Border (wall)
7) DD focal lesion
• Cyst (an echo / jet black) [surface , shadow , echogenicity]
• Hypo-echo – Malignancy [lymphoma , metastasis]
• Inflammation (Abscess)
• Hyper echo → benign tr mostly Hemangioma
Calcification
• Bright echogenic
o Diffuse
TB
SLE
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Amyloidosis
o Focal lesion
Phlebitis
Hemangioma
Splenomegaly
INFECTIVE
BACTERIAL
• Typhoid
• Typhus
• TB
• Syphilis
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• Leptospirosis
• Septicaemia
• Abscess
VIRAL : • Glandular fever
PROTOZOAL
• Malaria
• (common in Africa)
PARASITIC : • Hydatid cyst
Inflammatory
• Rheumatoid arthritis
• Sarcoidosis
• Lupus
• Amyloid
NEOPLASTIC
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• Metastases
• Primary tumours
• Leukaemia
• Lymphoma
• Polycythaemia vera
• Myelofibrosis
HAEMOLYTIC DISEASE
• Hereditary spherocytosis
• Acquired haemolytic anaemia
• Thrombocytopenic purpura
STORAGE DISEASES
• Gaucher’s disease
DEFICIENCY DISEASES
• Severe iron-deficiency anaemia
• Pernicious anaemia
SPLENIC VEIN HYPERTENSION
• Cirrhosis
• Splenic vein thrombosis
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• Portal vein thrombosis
Spleen ++
Symptoms and causes
By Mayo Clinic Staff
Print
Symptoms
An enlarged spleen may cause:
• No symptoms in some cases

• Pain or fullness in the left upper abdomen that may spread to the left shoulder
• Feeling full without eating or after eating only a small amount from the
enlarged spleen pressing on your stomach
• Anemia
• Fatigue
• Frequent infections
• Easy bleeding
When to see a doctor
See your doctor promptly if you have pain in your left upper abdomen, especially if
it's severe or the pain gets worse when you take a deep breath.
Causes
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A number of infections and diseases may cause an enlarged spleen. The enlargement
of the spleen may be temporary, depending on treatment. Contributing factors include:
• Viral infections, such as mononucleosis

• Bacterial infections, such as syphilis or an infection of your heart's inner lining
(endocarditis)
• Parasitic infections, such as malaria
• Cirrhosis and other diseases affecting the liver
• Various types of hemolytic anemia — a condition characterized by early
destruction of red blood cells
• Blood cancers, such as leukemia and myeloproliferative neoplasms, and
lymphomas, such as Hodgkin's disease
• Metabolic disorders, such as Gaucher's disease and Niemann-Pick disease
• Pressure on the veins in the spleen or liver or a blood clot in these veins
Enlarged Spleen Causes
The causes of splenomegaly vary widely and range from malignancy (cancers),
infections, congestion (increased blood flow), infiltration of the spleen from other
diseases, inflammatory conditions, and blood cell diseases.
Some of the most common causes of an enlarged spleen include the following:
• liver disease (cirrhosis due to chronic hepatitis B, chronic hepatitis

C, fatty liver, long standing alcohol abuse);
• blood cancers (lymphoma, leukemia, myelofibrosis);
• infections (mononucleosis, bacterial endocarditis, malaria, AIDS,
mycobacterium, leishmania);
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• abnormal blood flow and congestion (splenic vein thrombosis,

portal vein obstruction, congestive heart failure);
• Gaucher disease (a lipid storage disease);
• blood cell disorders (sickle cell anemia, thalassemia,
spherocytosis);
• Inflammatory disease (lupus, rheumatoid arthritis);
• idiopathic thrombocytopenic purpura (ITP); and
• polycythemia vera. Continue Reading
Causes
The most common causes of splenomegaly in developed countries are infectious

mononucleosis, splenic infiltration with cancer cells from a hematological malignancy
and portal hypertension (most commonly secondary to liver disease, and Sarcoidosis).
Splenomegaly may also come from bacterial infections, such as syphilis or an
infection of the heart's inner lining (endocarditis)]4[.
The possible causes of moderate splenomegaly (spleen <1000 g) are many, and
include:
Splenomegaly grouped on the basis of the pathogenic mechanism Increased function

Abnormal blood flow Infiltration
Removal of defective RBCs
Spherocytosis
Thalassemia
Hemoglobinopathies
Nutritional anemias
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Early sickle cell anemia
Immune hyperplasia
Response to infection (viral, bacterial, fungal, parasitic)
Mononucleosis, AIDS,[5] viral hepatitis
Subacute bacterial endocarditis, bacterial septicemia
Splenic abscess, typhoid fever
Brucellosis, leptospirosis, tuberculosis
Histoplasmosis
Malaria, leishmaniasis, trypanosomiasis
Ehrlichiosis ]6[
Disordered immunoregulation
rheumatoid arthritis, including cases of Felty's syndrome
systemic lupus erythematosus
serum sickness
familial hemophagocytic lymphohistiocytosis
autoimmune hemolytic anemia
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autoimmune lymphoproliferative syndrome, an autosomal dominant disorder
sarcoidosis
drug reactions
Extramedullary hematopoiesis
myelofibrosis
marrow infiltration by tumors, leukemias
marrow damage by radiation, toxins
Organ Failure
cirrhosis
Vascular
hepatic vein obstruction
portal vein obstruction
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Budd–Chiari syndrome
splenic vein obstruction
Infections
hepatic schistosomiasis
hepatic echinococcosis
Metabolic diseases
Gaucher disease
Niemann–Pick disease
Alpha-mannosidosis
Hurler syndrome and other mucopolysaccharidoses ]7[
Amyloidosis
Tangier disease
| P a g e 36
Benign and malignant “infiltrations”
leukemias (acute, chronic, lymphoid, and myeloid)
lymphomas (Hodgkins and non-Hodgkins)
myeloproliferative disease
metastatic tumors (commonly melanoma)
histiocytosis X
hemangioma, lymphangioma
splenic cysts
hamartomas
eosinophilic granuloma
littoral cell angioma[8][9]10[]
The causes of massive splenomegaly (spleen >1000 g) are fewer, and include:
visceral leishmaniasis (kala-azar)
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chronic myelogenous leukemia
myelofibrosis
malaria
splenic marginal zone lymphoma
Treatment
If the splenomegaly underlies hypersplenism, a splenectomy is indicated and will

correct the hypersplenism. However, the underlying cause of the hypersplenism will
most likely remain; consequently, a thorough diagnostic workup is still indicated, as,
leukemia, lymphoma and other serious disorders can cause hypersplenism and
splenomegaly. After splenectomy, however, patients have an increased risk for
infectious diseases.
Patients undergoing splenectomy should be vaccinated against Haemophilus

influenzae, Streptococcus pneumoniae, and Meningococcus. They should also receive
annual influenza vaccinations. Long-term prophylactic antibiotics may be given in
certain cases.
In cases of infectious mononucleosis splenomegaly is a common symptom and health

care providers may consider using abdominal ultrasonography to get insight into a
person's condition.[11] However, because spleen size varies greatly, ultrasonography
is not a valid technique for assessing spleen enlargement and should not be used in
typical circumstances or to make routine decisions about fitness for playing
sports.[11]
| P a g e 38
Report abdominal u/s
Pancreas report by abd. u/s
1) Size (head of pancreas)

2) Echo pattern
3) Pancreas mass presence
4) Calcification
5) Peri-pancreatic collection
• 5 criteria of inflammation
Heat – loss of function – redness – swelling - pain
• Rt pleural effusion “lung” → by C X R
AP diameter head : 34 mm
Body: 29mm
Tail: 32mm
Length: 12-20 cm
Pancreatic duct: ≤ 3mm

Hyper echo Echogenic = bright
Young patient Fatty tissue
| P a g e 39
Finding:
- Pancreatitis
- Necrosis
- Abscess
- Carcinoma
- Metastasis
- lymphoma
- trauma
| P a g e 40
Report abd. Sonar
Left Renal ( Left kidney ) : separated report ‫تقرير لوحده‬
Right renal ( Right kidney ) : separated report ‫تقرير لوحده‬
1- site
2- size : increase mass ( if mass + infiltration = lymphoma)
3- shape
4- parenchymal echogenicity
5- back pressure presence (grade if present)
Pressure : distended sinus : so back pressure in ureter then in kidney
Nephropathy :
If Lt grade I and Rt grade II , look at all other parameters

- Differentiation : grade I : normal or good
Grade II : chronic
Grade III : more chronic

- Cortico medually differentiation : good acute and poor chronic
- Cortex diameter : > 1cm normal , cortex lost < 1cm , 1 ml , 3 ml
: non fun kidney
- Surface : regular : congenital – may also usually with acute
causes
Irregular : chronic pyelonephritis : no interfere from urology –

ESRD
- Back pressure : if yes >> see cortex >>urgent urology
| P a g e 41
If cortex lost & thin : referral to urology for medico legal

- If associated with obstruction and high chemistry : dialysis and
assess
- If acute cr > 10 : one dialysis until be cr = 6
And follow up with Na / K / urea / cr after 2 days in morning

- Sonar + history of acute = acute or acute on top of chronic
- Acute : normal Ca – no time to make loss Ca
- Chronic : loss Ca – high P/K/MG / uric acid – Na not specific
- Multi slice CT abdomen : one dialysis if suspect acute cause
And follow up after 2 weeks with electrolyte and sonar
6- Stone : site , size , shadow
7- cyst (any organ)
Number : multi-cystic
Poly-cystic
Note : this classification of number in any organs not only in kidneys
Echogenicity
Shape : oval – rounded
Type : are 4
8- mass : site
Size
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Shape
9- dromedary humps
Only in Lt kidney : mimic renal mass
So humps called : Pseudo tumor
Findings
Hydronephrosis
Renal stone
Focal lesion : renal cyst
Polycystic kidney
Renal cell carcinoma
Diffuse : pyelonephritis
Renal abscess
Renal trauma
Report on kidney (another example)

Capsule
Cortex
Medulla (pyramids)
Sinus (calyx & pelvis) : normally not seen
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‫‪Khaled Mohammed Almaz‬‬
‫‪Calcification :‬‬ ‫‪Cortex : Calcinosis‬‬
‫‪Sinus : Stone‬‬
‫حاالت امراض الكليتين‬
‫مريض ‪ ESRD‬ماذا عند الخروج (‪)End Stage Renal Disease‬‬
‫ماروكة – ميعاد سكرين – سونار (قبل القرار)– قرار – تحسن االعراض‬
‫ال قرار لمريض له تامين صحي‬
‫‪> if there is obstruction‬‬ ‫سونار في وحدة غسيل الكلي او قسم المسالك (تنفع)‪:‬‬
‫‪| P a g e 44‬‬
KIDNEY SWELLINGS
Kidney swellings are not uncommon. They may present silently or may
be associated with haematuria, urinary tract infections and pyrexia.
CAUSES
CONGENITAL
• Polycystic kidney
ACQUIRED
INFECTIVE
• Perinephric abscess
• TB • (common where TB is endemic)
OBSTRUCTIVE
• Hydronephrosis
• Pyonephrosis
DEGENERATIVE
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• Solitary cyst
NEOPLASTIC
• Hypernephroma
• Nephroblastoma
HISTORY
Congenital
Family history with adult polycystic kidney disease.
Hypertension may be a presenting symptom.
Hydronephrosis in infants may be a cause of failure to thrive.
Acquired
There may be a history of TB. Present with haematuria, dysuria or

pyuria.
With perinephric abscess there may be a history of diabetes.

Nephroblastoma presents with an abdominal mass, pain,
haematuria, pyrexia and weight loss within the first 3 years of life.
Enlargement RIGHT KIDNEY
| P a g e 46
• Carcinoma
• Polycystic kidney
• Hydronephrosis
• Pyonephrosis
• TB
• Solitary cyst
• Wilms’ tumour (nephroblastoma)
++ size of kidneys & renal failure

5 DD
1- ADPCK ( Poly Cystic Kidney )

2- Hydronephrosis
3- Amyloidosis
4- DM
5- HIV nephropathy
| P a g e 47
Kidneys ++
Hydronephrosis
From Wikipedia, the free encyclopedia
Hydronephrosis—literally "water inside the kidney"—refers to distension

and dilation of the renal pelvis and calyces, usually caused by obstruction
of the free flow of urine from the kidney. Untreated, it leads to
progressive atrophy of the kidney.[1] One or both kidneys may be
| P a g e 48
affected.[2] In cases of hydroureteronephrosis, there is distention of both

the ureter and the renal pelvis and calices
Causes of Kidney enlargement:
The following medical conditions are some of the possible causes of Kidney
enlargement. There are likely to be other possible causes, so ask your doctor about
your symptoms.
• Diabetes mellitus
• Lymphoma
• Bilateral hydronephrosis
• Amyloidosis
• Polycystic kidney disease
• HIV associated nephropathy
• Perinephric haematoma
• Wilms tumour
Causes of Kidney enlargement listed in Disease

Database:
Other medical conditions listed in the Disease Database as possible causes of Kidney
enlargement as a symptom include:
• Amyloidosis
• Dioctophyma renale
• Hydronephrosis
• Polycystic kidney disease, adult (autosomal dominant)
• Renal adenocarcinoma
• Renal metastases
• Wiedemann-Beckwith syndrome
| P a g e 49
List of 15 causes of Kidney enlargement
This section shows a full list of all the diseases and conditions listed as a possible
cause of Kidney enlargement in our database from various sources.
• Amyloidosis
• Bilateral hydronephrosis
• Diabetes mellitus
• Dioctophyma renale
• HIV associated nephropathy
• Hydronephrosis
• Lymphoma
• Perinephric haematoma
• Polycystic kidney disease
• Polycystic kidney disease, adult (autosomal dominant)
• Renal adenocarcinoma
• Renal metastases
• Wiedemann-Beckwith syndrome
• Wilms tumour
Overview
Enlarged kidneys are uncommon and are usually related to a few specific disorders
that are caused by birth defects, structural abnormalities, infection, pregnancy,
blockage and injury. An enlarged kidney can only be felt occasionally during an
examination, usually when the patient is an infant, a child or a thin adult, according to
the Merck Manual Online Medical Library. Other symptoms of kidney disease are
usually identified first.
| P a g e 50
Hydronephrosis
Hydronephrosis is kidney enlargement due to a blockage in the outflow of urine that

distends the kidney. According to Merck Manual Online Medical Library,
hydronephrosis can be caused by a kidney stone, blood clot, prostate enlargement,
fecal impaction, injury, infection, radiation, or a tumor. An enlarging uterus creating
pressure can cause hydronephrosis of pregnancy. The main symptom of
hydronephrosis is excruciating, intermittent flank pain. Chronic hydronephrosis may
have no symptoms. Treatment includes relieving the cause of the blockage.
Polycystic Kidney Disease
According to MayoClinic.com, polycystic kidney disease, or PKD, is a disorder

characterized by clusters of fluid-filled cysts within the kidney. Cysts also develop in
other parts of the body, although the kidneys are most severely affected.
Complications of PKD include high blood pressure and kidney failure due to
progressive loss of function. Treatment of PKD involves managing the complications
and symptoms such as hypertension, pain, urinary tract infections, kidney failure, liver
cysts and aneurysms.
Pyelonephritis
Pyelonephritis is an infection of the kidneys resulting from a bladder infection that

spreads to the kidneys or from an infection in the blood. Signs and symptoms may
include enlarged kidneys, tenderness on one or both sides of the lower back, chills,
fever, painful and frequent urination, foul-smelling urine, cloudy urine and spasms
that can cause intense pain. Antibiotics are used to treat the infection. Diabetics,
pregnant women and those with a suppressed immune system are at higher risk of
pyelonephritis.
| P a g e 51
Causes
Hydronephrosis is the result of any of several abnormal

pathophysiological occurrences. Structural abnormalities of the junctions
between the kidney, ureter, and bladder that lead to hydronephrosis can
occur during fetal development. Some of these congenital defects have
been identified as inherited conditions, however the benefits of linking
genetic testing to early diagnosis have not been determined.[7] Other
structural abnormalities could be caused by injury, surgery, or radiation
therapy.
Compression of one or both ureters can also be caused by other

developmental defects not completely occurring during the fetal stage
such as an abnormally placed vein, artery, or tumor. Bnhbilateral
compression of the ureters can occur during pregnancy due to
enlargement of the uterus. Changes in hormone levels during this time
may also affect the muscle contractions of the bladder, further
complicating this condition.
Sources of obstruction that can arise from other various causes include
kidney stones, blood clots, or retroperitoneal fibrosis.[8]
The obstruction may be either partial or complete and can occur

anywhere from the urethral meatus to the calyces of the renal pelvis.
Hydronephrosis can also result from the reverse flow of urine from the
bladder back into the kidneys. This reflux can be caused by some of the
factors listed above as well as compression of the bladder outlet into the
urethra by prostatic enlargement or impaction of feces in the colon, as
well as abnormal contractions of bladder muscles resulting from
neurological dysfunction or other muscular disorders.[6]
| P a g e 52
Treatment
Left sided hydronephrosis in a person with a single kidney. Stent is also

present.
Treatment of hydronephrosis focuses upon the removal of the obstruction and

drainage of the urine that has accumulated behind the obstruction. Therefore, the
specific treatment depends upon where the obstruction lies, and whether it is acute or
chronic.
Acute obstruction of the upper urinary tract is usually treated by the insertion of a
nephrostomy tube. Chronic upper urinary tract obstruction is treated by the insertion
of a ureteric stent or a pyeloplasty.
Lower urinary tract obstruction (such as that caused by bladder outflow obstruction
secondary to prostatic hypertrophy) is usually treated by insertion of a urinary catheter
or a suprapubic catheter. Surgery is not required in all prenatally detected cases.[15]
| P a g e 53
Nephropathy
Nephropathy is a broad medical term used to denote disease or damage of the kidney,
which can eventually result in kidney failure. The primary and most obvious functions
of the kidney are to excrete any waste products and to regulate the water and acid-
base balance of the body – therefore loss of kidney function is a potentially fatal
condition.
Nephropathy is considered a progressive illness; in other words, as kidneys become

less and less effective over time (with the progression of the disease), the condition of
the patient gets worse if left untreated. This is the reason why it is pivotal to receive
adequate diagnosis and treatment as early as possible.
Diabetic nephropathy
Diabetic nephropathy is considered a major microvascular complication of diabetes

mellitus that affects approximately one-third of all diabetic patients. It usually
accompanies albuminuria with glomerular hyperfiltration and renal hypertrophy in the
early stage, often showing a deteriorating course that can lead to end-stage renal
failure.
Histopathologically, diabetic nephropathy is characterized by glomerulosclerosis with

thickening of the glomerular basement membrane, abnormalities of podocytes
(terminally differentiated cells located in the Bowman’s capsule of the kidney) and
extracellular matrix accumulation in the glomerular mesangial area.
Proper management of hyperglycemia, hypertension and serum lipid levels is pivotal

in the prevention of the onset and progression of nephropathy in diabetic patients.
Nevertheless, no available treatment has been able to halt the progression to end-stage
renal failure, thus new therapeutic modalities to manage diabetic nephropathy are
desperately needed.
| P a g e 54
IgA nephropathy
Since its initial description in 1968, IgA nephropathy remains the most common form of
primary glomerulonephritis that can lead to chronic kidney disease. This condition is very
commonly observed in Southern Europe, Australia and Asia, whereas in Northern climates of
the Western World the incidence is approximately 5-10% of all biopsies for
glomerulonephritis.
The diagnostic hallmark of the disease is the deposition of IgA antibodies in the glomeruli,
alone or together with IgM or IgG antibodies. Activation of innate immune response and
complement, as well as the formation of immune complexes, play a significant role in clinical
presentation and severity of the IgA nephropathy.
As there is no pathognomonic clinical presentation (although young males with macroscopic

hematuria following an upper respiratory tract infection are highly suspicious for the disease),
the diagnosis requires renal biopsy. Presently available treatment options are directed towards
inflammatory and immune events that can result in renal scarring.
Other types of nephropathy
Analgesic nephropathy is a chronic renal disease caused by excessive and prolonged

consumption of analgesic mixtures that contain phenacetin or two other analgesics,
such as salicylic acid-paracetamol, salicylic acid-pyrazolones, paracetamol-
pyrazolones or two pyrazolones combined with potentially addictive substances such
as codeine or caffeine.
Renal papillary necrosis (i.e. damage to the inner medulla caused by capillary
sclerosis) represents the characteristic feature of analgesic nephropathy, and most
often arises as a result of a long term use of phenacetin. Renal complications that can
ensue are acute or chronic pyelonephritis, calcification of necrotic papillae,
urolithiasis and uroepithelial tumors.
Acute uric acid nephropathy stems from the intratubular deposition of uric acid
crystals when a high serum uric acid concentration is present. This condition usually
occurs during induction chemotherapy for malignancies with high cell turnover.
| P a g e 55
Recommended treatment options for this condition are alkalization of the urine and a
drug known as rasburicase (a recombinant urate oxidase).
Contrast nephropathy ( IVP radiology = Intravenous Pyelography Contrast )
Reflux nephropathy
Contrast nephropathy : DM Pt – MM Pt
B nephropathy ( Schistosomal nephropathy )
Malarial nephropathy
Ischemic nephropathy
Diagnostic Considerations
Diabetic nephropathy must be differentiated from cholesterol embolization, amyloidosis, and other
glomerulopathies affecting patients with diabetes.
Differential Diagnoses
• Light-Chain Deposition Disease

• Multiple Myeloma
• Nephrosclerosis
• Nephrotic Syndrome
• Renal Artery Stenosis
• Renal Vein Thrombosis Imaging
• Renovascular Hypertension
• Tubulointerstitial Nephritis
| P a g e 56
Drug Induced Nephropathy
1- Acute renal failure
Pre-renal
Renal
Postrenal
2- CRF " chronic renal failure "

3- Nephrotic $
4- Acute G.N.
5- Tubular defects
6- Acute interstitial nephritis
7- Chronic interstitial nephritis
Analgesic nephropathy ( occur after cumulative ingestion of 2-3 kg drug )
As 1- aspirin
2- paracetamol
3- NSAID
| P a g e 57
Special nephropathy
1. Contrast nephropathy ( IVP radiology = Intravenous Pyelography

Contrast )
2. Reflux nephropathy
3. Contrast nephropathy : DM Pt – MM ( Multiple Myeloma Pt =
Hematological Oncology )…
4. B nephropathy ( Schistosomal nephropathy )
5. Malarial nephropathy
6. Ischemic nephropathy
7. Gout nephropathy
8. HIV nephropathy
Also
1- Pyelonephritis
2- Urological stones
3- Iatrogenic due to ttt by drugs :
NSAID
Vancomycin
Aminoglycosides : Garamycin / Amikacin
4- GN
5- Hereditary : Alport`s $
Buerger`s $
| P a g e 58
‫أهم أعراض المغص الكلوى ؟؟‬

‫و تفسير بعض المصطلحات الخاصه بحصوات الكلى فى األشعه ؟؟‬
‫===============================‬
‫‪---Renal colic‬المغص الكلوى ؟؟‬
‫ألم شديد أسفل الظهر أو فى الجنب & قد يكون األلم فى جانب واحد أو فى الجانبين من الخلف‬
‫**ألم فى البطن‪,‬فى‪groin‬‬
‫*ألم أثناء التبول‬
‫‪Nausea & Vomiting‬‬
‫*كميه ال‪**Urine‬أقل من الطبيعى أو احتباس‬
‫*‪Fever‬‬
‫==============================‬
‫**أنواع الحصوات حسب مكانها فى الجسم؟؟‬
‫*لو الحصوه فى الكلى ؟؟‬

‫*فى الحالب؟؟‬
‫*فى المثانه؟؟‬
‫‪##Nephrolithiasis ---->> calculi in the kidneys‬فى الكلى‬
‫‪##Ureterolithiasis---->> calculi in Ureter‬فى الحالب‬
‫‪##Cystolithiasis----->> calculi in bladder‬فى المثانه‬
‫‪| P a g e 59‬‬
Report on cyst abd. U/s
A cyst is a sac-like pocket of membranous tissue that contains fluid, air, or other
substances. Cysts can grow almost anywhere in your body or under your skin.
There are many different types of cysts. Most cysts are benign, or noncancerous.
Whether a cyst needs treatment depends on a number of factors, including:
• the type of cyst

• the location of the cyst
• if the cyst is causing pain or discomfort
• whether the cyst is infected
Site
Shape round
Ovoid
Lobulated
Number (isolated , multiple)
Well marginated
Clear defined back wall
Posterior acoustic enhancement (if large enough)
Few septa
*** If no wall thickening
Small amount of layering debris
No internal vascularity on colour dopplar
| P a g e 60
Simple cyst:
• abnormal
• fluid-filled sac
• not cause harm to kidney (organ)
• not genetic as polycystic kidney (organ)
• not enlarge kidney (organ) : not reduce organ function
• not replace N structures
| P a g e 61
Report on cyst
Simple cyst
• thin wall
• regular thin wall (same thickness)
• Jet black
• No calcification (hyper echo)
• No soft tissue components
• No septation (septum)
• Posterior Acoustic enhancement
→ if not present → so it is not simple cyst
| P a g e 62
Report on
Hydatid cyst
1) Large cyst
2) Turbidity
If turbid fluid layer
+ clear fluid layer
Called fluid level
While intestinal obstruction
Air & fluid
Air – fluid level
3) +ve daughter cysts

4) Lilli sign → movable septum in fluid
| P a g e 63
Types of cysts
There are hundreds of different types of cysts. They can grow almost anywhere in
your body. Some cysts occur as part of another condition, such as PCOS or PKD.
Some of the more common types of cysts include the following:
Epidermoid cyst
These are small, benign bumps filled with keratin protein. If you have trauma around
a hair follicle within the skin, an epidermoid cyst may occur. If part of the top layer of
your skin, called the epidermis, grows deeper instead of moving outward toward the
surface to eventually be shed off, an epidermoid cyst will have a chance to form.
In rare cases, epidermoid cysts can be caused by an inherited condition called

Gardner’s syndrome.
Sebaceous cyst
Sebaceous cysts often form within sebaceous glands. These glands are part of the skin
and hair follicles. Ruptured or blocked sebaceous glands can lead to sebaceous cysts.
Sebaceous glands make oil for your skin and hair. Sebaceous cysts fill with sebum
and are less common than epidermoid cysts.
Ganglion cyst
These benign cysts usually form near the joint areas of your wrist or hand. However,
they can also develop in your feet or ankle areas. The reason they form isn’t known.
Ganglion cysts tend to occur along a tendon sheath near a joint. They’re more
common in women than in men.
| P a g e 64
Ovarian cyst
Ovarian cysts often form when the follicle that normally releases an egg doesn’t open.
This causes fluid to build up and form a cyst.
Another common type of ovarian cyst occurs after the follicle releases the egg and
improperly recloses and collects fluid. Ovarian cysts occur most often in women of
menstrual age. They’re usually found during pelvic exams.
Ovarian cysts are associated with an increased risk of cancer when they occur after
menopause.
Breast cyst
Benign cysts can develop in your breasts when fluid collects near your breast glands.
They commonly occur in women in their 30s and 40s. They can cause pain or
tenderness in the affected area.
Chalazia
Chalazia are benign cysts that occur on your eyelids when the oil gland duct is
blocked. These cysts can cause tenderness, blurred vision, and painful swelling. If
they get too big, they can cause vision problems.
Pilonidal cyst
These cysts form near the top, middle part of the buttocks. They’re usually filled with
skin debris, body oils, hair, and other matter.
Pilonidal cysts occur more often in men than in women. They can develop when loose
hairs become embedded in your skin. According to the Mayo Clinic, chronic
infections in these cysts might increase your risk of a type of skin cancer called
squamous cell carcinoma. Know the signs for different types of skin cancer to treat it
early.
| P a g e 65
Baker’s cyst
A Baker’s cyst, also known as a popliteal cyst, is a fluid-filled cyst that forms at the
back of the knee. These cysts are usually due to problems with the knee, like knee
injury or arthritis. Mobility can be limited and painful with a Baker’s cyst.
Physical therapy, fluid draining, and medication can all be used to help treat a Baker’s
cyst.
Cystic acne
Cystic acne results from a combination of bacteria, oil, and dead skin clogging the
pores. It’s the most severe type of acne in young adults, but usually improves with
age. Cystic acne can look like large, pus-filled boils on the skin. It can also be painful
to the touch.
If you believe you may have cystic acne, your dermatologist can prescribe
medications to help treat it.
Ingrown hair cyst
An ingrown hair cyst forms when a hair grows into the skin and a cyst forms beneath
it. These cysts are more common in people who shave or wax to remove hair.
Most of the time, professional medical care isn’t needed to treat ingrown hair cysts.
However, see a healthcare professional if you suspect it’s infected.
Pilar cyst
Pilar cysts are flesh-colored, benign lumps that form on the surface of the skin. Since
they’re benign, they’re typically not cancerous. However, they can grow to a size that
can be uncomfortable.
Removal is typically not necessary, but they can be removed for cosmetic preference.
| P a g e 66
Mucous cyst
A mucous cyst is a fluid-filled lump that forms on the lip or around the mouth when
the salivary glands become plugged with mucous. The most common causes of
mucous cysts include:
• lip or cheek biting

• lip piercings
• rupture of the salivary gland
• poor dental hygiene
Often, mucous cysts will go away on their own. However, if you have recurring or
frequent mucous cysts, medical treatment may be required.
Branchial cleft cyst
Branchial cleft cysts are a type of birth defect that forms a lump on an infant’s neck or
below the collarbone. This cyst can look like a large skin tag.
Healthcare providers usually recommend surgical removal to prevent future infection.
When to seek help
Schedule an appointment with your healthcare provider if your cyst becomes very
painful or red. This could be a sign of a rupture or an infection.
A healthcare provider should check your cyst even if it isn’t causing any pain or other
problems. Abnormal growths can be a sign of cancer. Your healthcare provider may
want to remove a tissue sample for testing.
| P a g e 67
Urinary Bladder ( abd sonar ) report

1- Volume / capacity = 3 diameters
------------------ = … c.c. ( normally 1000 c.c.)
2 Over distended > 2000 c.c.
Capacity : superior about 16 cm
2- Residual volume >10 c.c.
D.D. enlarged prostate : cancer – BPH (history of 5 W )
5 W : woman ( watch ) – wear – wine – weather cold – water cold
3- Wall thickness:
Diffuse
Focal : D.D. Bilharziasis ova (calcification)
Neoplasm (tumor) from pt. history
4- Mass : sub acute
Hematuria
Focal lesion
** infiltration of UB wall : ask for CT
5- Cystitis
Pain – turbid urine
** infiltration of UB wall : ask for CT
6- Jet sign of urine (fluid)

| P a g e 68
7- Ureterocele (vaginated wall inside UB) ‫للداخل‬
D.D. : UB stone
Back pressure of ureter then kidneys
8- Stone
9- Lower obstructive uropathy : prostate – valve – urethra
10- Diverticulum ( pouch ) ‫للخارج‬
11- Shape : is there abnormal shape ?? : for female patient
| P a g e 69
Finding
Bladder wall thickening
- Carcinoma
- Neurogenic bladder
- Bladder outlet obstruction
- Cystitis (follow : Chemotherapy , radiotherapy))
- Bladder diverticulum
o (out pouch from bladder wall)
- Bladder stones (calculi)
o Mobile
o Echo genic
o Black shadow
o Associated with bladder wall thickening
▪ Due to inflammation
- Bilharziasis schistosomiasis
o Nodular bladder wall thickening
o Contracted bladder
o Fibrosis of thick wall of UB
o Calcification
| P a g e 70
Report on Retro-peritoneal structure
1) LN “lymph node”
o Hypo echo
o Multiplicity
o Soft tissue
Size: if (enlarged so increase detection of) Search &

check
o lymphoma
o kidneys
o Spleen
o Para-aortic LN
o Related to retroperitoneal structures
o Liver
o IVC
o Aorta
o Helium of spleen
2) Supra renal glands
3) Stomach:
o If mass presence (gas at fundus)
o Pyloric stenosis
o Gastritis (by patient history 5 inflammation)
o Gastric ulcer by pt history 5 criteria of inflammation
Exclusion by abd. u/s.
o Gastric ulcer
| P a g e 71
4) Fluid collection retroperitoneal recess
7 sites
DD fluid collection as ascites
o Trauma → hematoma
o Blood clots
o Rupture Aorta (due to Aortic Aneurysm)
D → Aspiration
→ patient history C/P
• Sites of hematoma
o Pancreas
o Kidneys
o Aorta
o Posterior wall of UB
| P a g e 72
1) Stomach
Diagnosis : approach in Air Embolism
u/s distension of stomach
“an echoic / Jet black”
Embolus are
Multiple hyper echoic dots
as in portal vein
D → Air Embolism
Question:
Hyper echoic → White
Why not calcification?
Answer:
No calcification in blood vessels
| P a g e 73
2) C/P
1- Vomiting
And not respond to ttt
2- Abdominal distension
3- BP is Fluctuating
70/50 or 80/60
4- O2 saturation
< 90%
Normal: >92%
Nearly up to 97%
But 100% is not normal range
| P a g e 74
Sites of
Fluid collection
Trauma (collection)
Ascites
Blood clots
Rupture aorta after aortic aneurysm
1- Hepato renal ‫بين الكبد و الكلية اليمين‬
2- Subhepatic (Rt lobe)
3- Linorenal ‫بين الطحال و الكلية اليسار‬
4- Peri splenic ‫حول الطحال‬
5- Rt para-colic ‫عند مكان الزائدة‬appendix
6- Lt para-colic ‫عند مكان االمعاء‬
7- Pelvic region
| P a g e 75
Ascites ( by abd. u/s) with LL edema ( by clinical examination)
HF
LC
Nephrotic $
Respiratory Failure
Ascites with no LL edema
T.B. Peritonitis
Ovarian tumor ( M "metastasis" in peritoneum )
Mesothelioma
Unilateral shifting dullness (unilateral ascites)
Psoas abscess
Distended colon
TB peritonitis
| P a g e 76
DD of Ascites
DD of Low Albumin protein
-Gastric carcinoma.
-Atrophic gastritis.
-Intestinal lymphangiectasia.
-Whipple's disease.
-Inflammatory bowel disease.
-Celiac and tropical sprue.
-TB enteritis.
-Cancer colon.
-Congestive heart failure.
-Constrictive pericarditis.
- Esophageal carcinoma.
Liver Cirrhosis
Nephrotic Syndrome
Mal-Nutrition
PLE ( Protein Losing Entropathy )
| P a g e 77
DD leg swelling
Rare causes of Ascites
| P a g e 78
Report : retro peritoneal structures
5) Aorta
Diagnosis: abdominal aortic aneurysm (→ AAA)
Complication: rapture aorta
u/s enlargement of aorta
> 1.5 of normal size
1. abdominal aorta → 5cm
2. Pulsation of aorta
3. Rapture → free fluid in abdomen
Patient history C/P
• Shock
• Internal bleeding
• Smoker
• Atherosclerosis
• Risky in the elderly
• Abd. pain & referred to the back
• Bruit → auscultation examination
| P a g e 79
Finding of GIT sonar (gastro – intestinal sonar)
Intestine:
1) Appendicitis
2) Intestinal obstruction (Air fluid level)
3) Inguinal hernia
4) Hyper echo bowel
• Genetic as Turner $
Intestinal obstruction:
1) Air fluid level

2) Gastric distension (echo free = Jet black)
‫ → اسم خطأ ال يوجد هذا المصطلح‬gas distension
| P a g e 80
Blood Vessels
1) Portal vein
= clear wall
= > 13mm → Liver Cirrhosis
DD portal HTN : OV (hematemesis) , Piles (Melena)
= DD of L¢
Abnormal echo → hypo echo : Portal vein thrombosis
- If Hyper echoic dots → air → ∴ air embolism

-------------------------------------------------------------
2) Hepatic vein:
N → 5.5 – 6.5
→ 100% →↑ ++ of IVC
Congestive hepatopathy
> 9mm → in liver congestion
> 13mm → in pericardial effusion
DD
1) congested hepatopathy
2) Veno-Occlusive disease
3) Congested Rt sided heart Failure
| P a g e 81
3) IVC
= Not clear wall
= > 20 mm or (2.5cm)
DD
1. Congested Liver
2. Budd Chiari
If deep inspiration in patient lungs
→ Normal → IVC collapse > 50% of diameter
→ Abnormal if < 50% of diameter
≡ volume overload
TR & PR
Rt sided HF
If < 1.5cm DD : Hemorrhage
Trauma
TTT: blood Transfusion
---------------------------------------
4) Aorta: Check report of retroperitoneal structures
----------------------------------------------
5) Splenic vein
| P a g e 82
Notes → blood vessels in Liver

Portal vein
Clear wall of portal vein
> 13mm → portal HTN
Normally → iso echo
Portal vein thrombosis
Hypo echo
Ask for Dopplar
• Dopplar → is for blood vessels

• While IVC → No clear wall
• Dilated Hepatic vein
→ Congested liver
Dilated Hepatic vein
→ mean dilated I.V.C.
| P a g e 83
Report of male Genital organs
Prostate
1) Size: DD of enlargement
2) Volume / capacity (3 diameters)
→ = 25mg
→ weight
Not fluid as UB
Peripheral 95% → cancer
Zone
Central 5% → adenoma
Ask for = Biopsy
= trans – rectal u/s
3) Homogenecity or heterogenicity
4) Calcification → chronic prostatitis
5) Fluid → clear or not clear
| P a g e 84
Findings
Prostate : carcinoma – prostatitis
** cyst :
1- BPH (benign prostatic hyperplasia) precancerous

History of 5 W
Water cold – weather cold – woman watch – wine-
wear (tight cloths)
2- Stone in seminal vesicles
Testis & scrotum :
Lymphoma
Metastasis
Abscess
Cyst
| P a g e 85
Report of female Genital organs
In Internal Med. is not imp.
Uterus site
Shape
Wall thickening
Echogenicity
Fluid (same sites as Mass)
Mass of : uterus ( endometrium , myometrium "muscle")
Fallopian tube
UB
Ovary : site
Size
Shape
Cervix : length
Wall thickening
UB : shape " changes in shape of UB "
Blood vessels: presence or not of blood flow
| P a g e 86
Findings
Pelvic pain
Uterus : endometrium thickening
Carcinoma
Polyp
Fluid
Endometritis
Myometrium fibroid
Ovary : cyst
Carcinoma
Polycystic ovary
Cervix : stenosis
Polyp
Cancer
Fibroid
| P a g e 87
Clinical notes in liver and GB
Shared associated diseases:-
Pyloric stenosis : stomach
Biliary system: GB & Liver
Duodenum: ampulla of Vater
** only 3 organomegaly (enlargement) : liver – spleen – kidney
| P a g e 88
1-head of pancreas : < or = Normally 3 cm
2-long axis of GB : 12 cm
3-short axis of GB : 3-5 cm
Wall thickening of GB : < 3cm
PV diameter : dilated of > 13 , N < or = 13
But IVC : no wall in sonar ,
dilated > 20 mm in congestive liver , Budd Chiari
porta hepatis < 8 mm is N
4-CBD = 8 mm
Diameter of Rt lobe in mid clavicular line (MCL) : > 16cm
Echo pattern
** finger test for orientation of probe & U/S screen
Scanning in Abd. Sonar
‫الضغط يكون برفق بدون قوة‬
‫يشمل الضغط كل الكريستال و مقدمة البروب و هي االداة التي يمكسها الطبيب‬
‫كل المساحة علي سطح بطن المريض‬
| P a g e 89
‫معلومات‬
‫عموما بخصوص الموجات الفوق الصوتية‬
‫عند الفحص علي جسم االنسان‬
‫ال تمر الموجات في كل الحاالت‬
‫في العظام ‪ :‬ترتد الموجات و ال تكمل او تستمر ابعد من ذلك‬
‫عند الهواء ‪ :‬تتشتت و تتبعثر و ال تتكرر بعد ذلك‬
‫في االنسجة الدهنية ‪ :‬ترتد ولكن بشكل غير واضح‬
‫عند الماء ‪ :‬تخترق‬
‫** بدون تصنيف و لكن وصف الورم ‪ :‬كبد – بنكرياس – كليتين – الم اررة‬
‫االستخدام ‪indications‬‬
‫‪ )1‬اورام جهاز هضمي ‪ :‬تصنيف الورم ‪ :‬مريء – معدة – المستقيم‬
‫‪ )2‬اورام و اجسام تضغط من الخارج علي الجهاز الهضمي‬
‫‪ )3‬الحصوات ‪ stones‬في القنوات الصفراوية ‪biliary system‬‬
‫‪ )4‬تصوير كيس مليء بالسائل ‪ cyst‬في كبد – بنكرياس – ثدي – كليتين‬
‫‪ )5‬تحديد وجود و تضخم الغدد الليمفاوية وذلك سيكون البدء في الشك في‬
‫سرطان الغدد الليمفاوية‬
‫‪| P a g e 90‬‬
‫االماكن في الجسم‬
‫كبد‬
‫طحال‬
‫ررة ‪GB‬‬
‫كيس الم ا‬
‫ررة ‪Biliary System‬‬

‫قنوات الم ا‬
‫الكليتين‬
‫البنكرياس‬
‫اعضاء الحوض ‪pelvis‬‬
‫المثانة البولية‬
‫الرحم في النساء‬
‫المبيض في النساء‬
‫البروستاتا‬
‫‪| P a g e 91‬‬
‫التحليل في اعضاء الجسم بالسونار‬
‫الحجم‬
‫الشكل‬
‫انسجة العضو‬
‫وجود ‪cyst‬‬
‫نمو انسجة غير طبيعية‬
‫تراكم سوائل حول العضو‬
‫ازدياد سمك جدار العضو‬
‫وجود حصوات‬
‫عوائق تدفق الدم‬
‫‪| P a g e 92‬‬
‫** تحليل النتائج الغير طبيعية و التفسير‬
‫‪ -1‬زيادة حجم العضو ‪ :‬التهاب موضعي ‪ :‬حاد – مزمن‬
‫‪ ##‬مثل ‪ :‬قنوات صفراوية – كبد – طحال‬
‫‪ -2‬شكل غير طبيعي للعضو ‪ :‬ورم‬
‫‪ ##‬مثل ‪ :‬الكبد‬
‫‪ -3‬انسجة غير طبيعية ‪ :‬التهاب – كيس – عدوي (معدي) – ورم – سوائل‬
‫وهذه السوائل حول العضو او داخل العضو ‪ :‬صديد – التهاب – نزيف‬
‫‪ -4‬حصوات ‪ :‬في الم اررة – الكليتين‬
‫تعمل ‪black shadow‬‬
‫الن الموجات الصوتية ال تخترق الحصوات‬
‫‪| P a g e 93‬‬
Organomegaly : liver – spleen – kidney

Stones in organ : GB – Kidney
Blood vessels :
Aorta : aneurysm
Hepatic vein : hepatic congestion
Portal vein : portal HTN
IVC: hepatic congestion then Rt sided HF
‫ اكواب ماء‬6-4 ‫ يشرب‬: ‫** قبل سونار الكليتين و المثانة بساعه‬
‫ ساعة‬12 ‫عدم االكل قبل السونار لمدة‬
| P a g e 94
L 1 lumber disc structures :-
9th rib
Pylorus of stomach
Fundus GB
Celiac trunk
Superior mesenteric artery
Renal vessels
Helium of both kidneys
| P a g e 95
Q&A
Difference between :
Surface : by U/S sonar
Border : by clinical examination
Focal lesion
1- Cyst
Absorption regarding blood flow
White shadow due to cyst
By Dopplar : increase vascularity or blood flow
2- A- metastasis as lymphoma
>>> shadow appearance : white & black
B- hematoma
By Dopplar : 1- no blood flow
2- infarction as spleen
3- abscess
C- para aortic LN : around stomach – ask for CT
| P a g e 96
Cancer
Malignant >> metastasis (M & M )
Benign (bright echo) no metastasis in liver >> hemangioma
in kidney : lipoma
Colouration
Focal fat tissue : bright >> fatty liver
Focal fat sparing : ‫عكس‬fatty >> hypoechoic
Focal lesion (mass effect) : hyper – iso – hypo
Echo pattern : homogenous – heterogenous
Echogenicity = echo density
1- Isoechoic
2- Hyperechoic
3- Hypoechoic
4- Echo free – jet black – anechoic
5- Bright
| P a g e 97
Colouration in details
Echo density is in comparison to echogenicity of the liver
Anechoic ‫اسود‬
Isoechoic as normal liver ‫رمادي‬
Hypoechoic ‫ غامق عن الرمادي‬most significant and diagnostic
Bright ‫فاتح عن الرمادي‬
Hyperechoic ‫ابيض‬
Examples :-
Hyper = white
Gas
Bone
Fat
Omentum in abdomen
Fibrous tissue ( liver and kidney )
Aorta and PV
| P a g e 98
Black = anechoic
Fluid
Shadow behind gas
Shadow behind bone
Bright = echogenic
Fatty liver
Hypoechoic = dark grey : tissue
Amoebic liver abscess
Lymphoma
Malignant Tr
Standard Grey = isoechoic
LN
Intestine
Liver
| P a g e 99
Hemangioma in the liver (hyperechoic)
** no further investigation - if no calcification
- if no risky associated disease
** if abnormal healthy conditions :
Focal lesion ( 1ry & 2nd ry)
1ry : focal lesion – HCC – cholangioma
2nd ry : metastasis
( M tr ) : can be 1ry or 2nd ry
** ask CT if +ve of the following
(after detection hemangioma in the liver)
HCV
Ascites
LC
Primary cancer : HCC
Cholangiocarcinoma
Focal lesion
| P a g e 100
When to ask CT after abd. Sonar
1- LC with ascites
2- Hemangioma with associated risky disease
HCV
Ascites
LC
Primary cancer
3- Focal fatty sparing (fat out)
All liver is fatty except focal lesion
4- Diffuse hepatic pathology
a- Dark than normal
b- Not reach criteria of LC
c- No clear irregular multiple focal lesions
Ask for DD if hyper ( more to white colour ) : hemangioma
Multiple nodules
N.B. : if polyp in GB
Dopplar : PV : dilated > 13 mm
abnormal fluid (isoechoic or hypoechoic ) >> PVT
pancreatic tr ( hypo echoic mass ) : tr in head
tr in body
cystitis or mass in UB
| P a g e 101
Detection of GIT organ Inflammation

Criteria of inflammation : Hotness
Pain
Loss of tissue / organ / function
Redness
Swelling
Gastritis : medical history : epigastric pain
Vomiting
Asymptomatic
Abd. Sonar by exclusion
** as abd sonar not diagnose gastritis , so ask for CT
Cystitis : edematous thick wall ( edema is a sign of inflammation )
> 5 mm if emptied UB
> 3 mm if distended UB
Irregular surface of UB
| P a g e 102
Prostatitis : bacterial infection + inflammation
Better D by Transducer U/S with dopplar
Risky for prostate cancer
Prostate gland : enlarged ( u/s volume )
Tender ( clinical examination )
Burning sensation
difficulty urination
flu like symptoms
bloody urine
frequency
nocturia
| P a g e 103
Appendicitis : axial section
Edematous thick wall > 10 mm
Non compressible by probe
Blind ended loop
Peri regional fluid collection
Echo = bright prei-cecal fat
LN in ileocecal valve
Medical examination c/p : fever
Rebound tenderness
Abdominal pain
Don`t give medication that mask c/p
Vomiting
| P a g e 104
Cholecystitis
Most common cause : GB stone : Ca stone – cholesterol stone
Other cause : Obstruction of bile duct from : tumor – scar of the duct
Trauma
Surgery
Infection
Cyst
Parasite
Stricture
Inflammation
Risky for GB stone : +ve family history
Past history of typhoid
Female specially before menopause
Forty > or = 40 yrs old
Fertile = pregnant
Fatty BMI > 30 kg/m2 obesity
DM
Fair Caucasian
Rapid loss of weight
| P a g e 105
Acute cholecystitis :
GB stone >>> block of bile flow >>> bile stasis >>> enlarged GB
** main complication of GB stones
** GB start sterile >> then bacterial secondary infection
Chronic cholecystitis :
Repeated acute cholecystitis and always due to GB stones
Causes: GB stones
Obstruction of cystic bile duct
*** melatonin >>> inhibit cholesterol secretion
So melatonin >>> increase conversion of cholesterol into >>> bile
** GB stone types :-
1- Cholesterol stone …… > 50 % cholesterol

Bile contains , increasing cholesterol more than bile salts
Usually one stone : 2 * 3 cm
U/S : movable – posterior acoustic appearance
2- Bilirubin / pigment stone …. < 20 % cholesterol

Black or brown stone
Numerous
Bilirubin pigment + Ca salts
3- Mixed stone : as cholesterol GB stone
| P a g e 106
Common U/S findings in GB attack:

As appendicitis : +ve sonographic Murphy`s sign
+ve rolling stone sign ‫ميالن المريض للجنب‬
If difficult to D "diagnose" due to posterior shadow artifact
Note : fasting patient >> echogenic "bright" – mobile

< 2cm diameter of stone … mistake may be a sludge
Difference
Stone = calculi
Sludge = biliary sand , increase mucous + crystals in bile
| P a g e 107
C/P
Acute cholecystitis :-
Radiate to Rt shoulder
Pain > 6 hrs
Vomiting
Fever
U/S : edematous thick GB wall > 3 mm (fluid of edema : black)
Peri cholecystic fluid >>> black
+ ve sonographic Murphy`s sign
i.e. : abd. Tender from probe compression
chronic cholecystitis :-
risk factors 9 F or 6 F
asymptomatic
recurrent history
biliary colic
U/S : bright echo
Cholesterol stone : movable
Ca stone : not movable
Posterior shadow of stone
White thick wall
Chronic fibrosis
| P a g e 108
Pancreatitis
Acute case : right pleural effusion (mostly right lung) ask for CXR
Severe epigastric pain
High lipase & amylase enzymes … increase 3 times
Fever
Chronic case: pancreatic atrophy …. Length < 12cm

Calcification
Pancreatic duct dilatation
| P a g e 109
How to Read an Ultrasound Picture

Two Methods :Deciphering the Images Reading a Pregnancy Ultrasound Community
Q&A
An ultrasound may be performed for a variety of reasons, but looking at a baby in the
womb is the most common reason. If you have recently had an ultrasound and you
want to know how to interpret the images on your ultrasound, then you may benefit
from learning about some of the basics of ultrasound imaging. You may also want to
know how to pick out specific features of your pregnancy ultrasound, such as the
baby’s head, arms, or sex. Just keep in mind that ultrasounds can be difficult to
interpret, so it is best to do so with the help of your doctor.
Method 1
Deciphering the Images
1.
| P a g e 110
Disregard the text and numbers at the top of your scan. Most hospitals and
ultrasound centers use this space to include details like your name, hospital
reference number, or ultrasound machine settings. Since this information does
not have anything to do with what you see on the ultrasound image, you can
ignore this information.[1]
2.
Start from the top of the image. The top of the screen or printed image is
where the ultrasound probe was placed. In other words, the image you see
shows what the organ or tissues look like from the side rather than from the
top.[2]
o For example, if you are having an ultrasound of your uterus, then what
you see at the top of the screen or printed ultrasound would be the
outline of the tissues above your uterus. As you look further down the
screen, you will see deeper tissues, such as the lining of your uterus,
the inside of your uterus, and the back of your uterus.
| P a g e 111
3.
Consider the differences in colors. Most ultrasound images are in black and
white, but you can see differences in the shades of black and white in your
ultrasound scan. The color differences come from the differences in the
densities of the materials that the sound passes through.
o Solid tissues, like bone, will appear white because the outer surface
reflects more sound.
o Tissues that are filled with liquid, like the uterus, will appear dark.
o Ultrasound imaging does not work well for gas, so organs that are
filled with air, like the lungs, are generally not examined with
ultrasound.
| P a g e 112
4.
Watch for common visual effects. Since ultrasound uses sound to create
images of the inner structures of your body, the images are not crystal clear.
There are many different visual effects that can happen as a result of the
ultrasound’s settings, angle, or of the density of the tissues being examined.
Some of the most common visual effects to watch for include:[3]
o Enhancement. This is when part of the structure being examined

appears brighter than it should due to an excess of fluids in the area,
such as in a cyst.
o Attenuation. Also known as shadowing, this effect causes the area
being scanned to appear darker than it should.
o Anisotropy. This effect has to do with the angle of the probe. For
example, holding the probe at a right angle to some tendons would
cause the area to appear brighter than normal, so it is necessary to
adjust the angle of the probe to avoid this effect.
| P a g e 113
Method 2
Reading a Pregnancy Ultrasound
1.
Identify your womb. You can identify the outline of your uterus by finding
the white or light grey line around the edges of the ultrasound image. Just
inside of this area, there should be a black area. This is the amniotic fluid.[4][5]
o Keep in mind that the edge of the womb may not go around the entire
image. The technician may have positioned the probe in a way that
centered the image on your baby. Even if you only see white or grey
lines along one or two sides of the image, this is probably the outline of
your womb.
| P a g e 114
2.
Spot the baby. Your baby will also look grey or whitish and will be located
within the amniotic fluid (the dark area inside of the womb). Look at the area
within your amniotic fluid to try to make out the outline and features of your
baby.
o The details that you see in the image will depend on the stage of your
pregnancy. For example, at 12 weeks, you may only be able to identify
the head of your baby, while at 20 weeks, you may be able to see the
spine, eyes, feet, and heart.[6]
| P a g e 115
3.
Determine your baby’s sex. At around 18 to 20 weeks, you will have an

ultrasound to check your baby’s development, identify any problems, and
possibly even identify the sex of your baby. It’s important to remember that it
is not always possible to determine the sex of your baby at this stage and you
won’t know for sure until your baby is born.[7]
o To determine the sex of your baby, the ultrasound technician or

obstetrician will look for the presence or absence of a penis on the
ultrasound. Keep in mind that this method of determining the sex of
your baby is not 100% accurate. A visual effect may create or obscure
the image of a penis on an ultrasound.
| P a g e 116
4.
Consider a 3D or 4D ultrasound. If you are interested in seeing more details

of your baby than a traditional ultrasound can provide, then you may want to
ask your doctor about a 3D ultrasound. A 3D ultrasound can show your baby’s
facial features and it may even be able to detect certain defects, such as neural
tube defects.[8]A 4D ultrasound uses the same imaging as a 3D scan, but a 4D
scan makes a short video recording of your baby in the womb.[9]
o If you want to have a 3D or 4D ultrasound, the best time to do so is

between 26 to 30 weeks.
o Keep in mind that these scans can be quite expensive and may not be
covered by your insurance unless there is a medical reason to have one
done, such as to investigate an abnormality.
| P a g e 117
Q & A in U/S
Liver
Enlargement of Lt lobe without RT lobe ++ in some cases
‫ مش شرط ان معناها فيه‬Rt lobe ++
DD of Lt lobe ++ : Focal
1-HCC
2-Hemangioma
3-Hydatid cyst
4-abscess
DD of bright : Fatty liver
‫مقارنة كل اعضاء الجسم يكون بناء علي الوان الكبد فقط‬
Echoic degree
| P a g e 118
Hemangioma
Tr in blood vessels : vein
Artery
Not lymphatic vessels
SVC & IVC : vein 80 % drain

Lymphatic duct : 20 % drain
Ask for CT if associated disease : HCV – Ascites – LC
Tumour = Tumor
Primary cancer: HCC = Hepatoma = Malignant tr
Cholangiocarcinoma
Focal lesions
Secondary cancer = secondaries : metastasis

Focal lesions
| P a g e 119
** caudate lobe = is not area 4b in the liver segment
‫ ليس له حجم معين‬size
Caudate lobe ++ : mainly >> Budd Chiari

LC
3 places in sonar
Between IVC & porta hepatis
Midline : sagittal
Subcostal : 9th rib oblique
Subcostal : 9th rib sagittal
IVC
Intra-hepatic part of IVC : Lt & Rt hepatic veins
Dilated IVC : congested liver – Budd Chiari $
Dilated hepatic vein/s : congested liver – congestive HF

Size : N = 5.6 – 6.2 mm
Passive congestion = 8.8 mm
Pericardial effusion = 13 mm
‫ المريض ياخذ نفسه عند فحص وريد الكبد‬hepatic vein/s
Normally : occur collapsed vein
If not collapsed Hepatic vein = congested Hepatic vein = congested

IVC = CHF
i.e. : congestive HF
| P a g e 120
Nutmeg liver = congestive hepatopathy
DD of shrunken liver = LC ( alcohol – viral hepatitis )
Portal vein : come from : splenic vein – SMV " superior mesenteric V "
Contents of porta hepatis : 3 contents
1- PV >> Portal HTN ‫ال يوجد اخذ نفس للمريض‬
2- Hepatic vein = not collapsed ‫المريض ياخذ نفسه‬
3- Biliary channels = 2 white lines ‫ خط ابيض‬2
Very imp are the following :
Measure diameter of : PV = Portal HTN
Porta hepatis wall thickening = Bilharziasis
CBD dilated = bile
| P a g e 121
LC : D by Lab – C/P & medical history – U/S
Criteria : distortion of hepatic architecture (heterogenous & coarse)
Nodular regeneration
Fibrosis
May be there is ++ of caudate lobe
U/S : liver : enlarged or shrunken
Bright >> fatty liver (variable)
Ascites (jet black)
Coarse = heterogenous
Nodular & irregular surface
++ PV > 13 mm
Periportal fibrosis = thickening >>> B "Bilharziasis"
‫ال يوجد رقم محدد للقياس‬
But the wrong name is peri-portal hepatitis ‫ال يوجد هذا االسم‬
| P a g e 122
Colouration in liver
Hyper echo : B – LC – Fatty liver
An echo : hemangioma
hydatid cyst
simple cyst in breast – pancreas – kidney – liver
hepatic cyst : it is not focal fat sparing
must white shadow = i.e. posterior acoustic enhancement
but never black shadow : of stone ( no stones in liver )
diffuse hepatic pathology
hypoechoic
not clear multiple focal lesion
stage before LC
ask for CT for : hemangioma – multiple nodules
septum = septation
1- of cyst : it is complicated cyst .. not simple cyst

2- of liver parts : not called septum
but called : band between e.g. Rt & Lt lobes
| P a g e 123
Area 4b in liver has : focal fatty sparing

hepatic infiltration
Blood vessels in Liver

Hepatic vein branches : left – middle – right
PV branches : left – right
Pleural effusion
Right side in the lung = Pancreatitis
‫ال يوجد كتم نفس بعد لما ياخذ المريض نفسه في حاالت فحص الكبد‬
‫بالسونار‬
‫لذا ال يوجد عوائق لفحص السونار اذا كان المريض‬
‫ عاما‬60‫ عجوز فوق سن ال‬-1
‫ في حاالت الفشل الكبدي‬-2
‫لكن ينام علي الجانب اليسار لكي تكون الرئة اليمين عالية‬
| P a g e 124
Porta hepatis
Mission is : diameter of PV
DD : O.V. " esophageal varices "
Piles " rectal vein " referral to general surgery
Grades of piles >> for surgical ttt if indicated
Vessels and porta hepatis in liver
CBD > 8 mm so it is dilated > so ask CT
Porta hepatis : thickening diameter > 8 mm= D of Bilharziasis
‫** خطأ ال يوجد قياس او مدي محدد والقياس غير مطلوب مع اطباء امراض‬
‫الباطنة‬
‫ مم وذلك عند تشخيص البلهارسيا‬8 ‫بخصوص‬
Biliary duct 2 white lines = no wall
Portal vein : +ve wall presence
IVC & its branches ( Rt/Lt hepatic vein ) = no wall
Except in certain sites : the wall of veins appear
hepatic artery ‫** غير مطلوب كامراض باطنة اني ابحث و اعلق علي‬
| P a g e 125
Notes in Hepatology
Size
Mainly Rt lobe > 15 cm
< 9 – 10 cm so shrunken liver as LC
Lt lobe > 10 cm
Disease mainly ++ increase of Rt lobe
LC : liver size may enlarged or shrunken
Texture = echo pattern
Examples : normal
Focal lesion
Diffuse parenchymal changes :- Hyperechoic
1- B "Bilharziasis" : periportal thickening

2- Fatty liver
3- LC : coarse
Hypoechoic surface
Irregular outline
Ascites : jet black around liver
| P a g e 126
Anechoic = jet black
1- Simple hepatic cyst

Anterior part of liver
Around cyst : hyperechoic XXX not hyperechoic
But fatty , bright echoic
DD : search of simple cyst in : breast – pancreas – kidney
Blood infiltration into cyst
2- Hydatid cyst
3- Tumour = tumor
Hemangioma : one or more in number
Tr > cells in blood vessels "artery/vein"
But not in lymphatic vessels
Hyperechoic
Hepatoma = blood collection
So hypoechoic
Metastasis = multiple focal lesions
Can be : hypo – hyper echoic
DD of multiple focal lesions : lymphoma
Hepatoma
Most affecting area in liver
Area 4B : sparing – infiltration
Vessels : DD in IVC – DD in Rt & Lt hepatic veins
| P a g e 127
Q & A sonar
GB
GB capacity ‫في امراض الباطنة غير مطلوب‬
‫المريض ينام علي الجانب اليسار‬
‫ عالي الن الجانب اليمين فوق‬GB ‫لذا يكون‬
GB stones ‫ لو حصوات متكونة من كولستيرول‬: ‫مثل حاالت‬
GB mud
Site : subcostal 9th intercostal rib , not 12th intercostal rib
In MCL
Neck of GB: measurement
Mainly Long Axis : > 12 cm
While short axis : not important
Mucocele
Primary mucocele: bile fluid = echo free = jet black = anechoic
Secondary mucocele : stasis & obstruction of bile
Causes : obstruction of GB neck , causes : stone
Mass
L.N.
| P a g e 128
GB wall thickening > 3 mm : cholecystitis
Difference :
Cyst : white shadow
Stone: black shadow
Echogenecity : Ca stone : hyperechoic
Cholesterol stone (fluid): anechoic
While if Jet black superior to GB : it is Rt lobe >>> Ascites
Polyp mass > not movable > ask for CT
Ca stone > not movable
Mud in GB >> Movable
Cholesterol stone & Adhesions >> Movable >> ask for Dopplar
‫المريض ينام علي الجانب اليسار‬
‫لذا يكون الم اررة فوق الن الجانب اليمين هو اعلي‬
** why dopplar if +ve adhesions:
contents & GB wall ‫ررة و سمك الجدار‬

‫معناها ان فيه مساحة بين مكونات الم ا‬
Contents : stone – mud – mass
Def of Mud : inspissated biles ‫ملزق‬
| P a g e 129
Dilated GB : by long axis
By wall thickening
But short axis : not necessary
GB : hyperechoic if : Ca stone – Bone (Bone contain Ca)
** cholesterol stone in GB
No relation with : atherosclerosis
Hyperlipidemia " hypercholesterolemia "
But not hypertriglyceridemia TG
Bile duct dilatation
- Intra hepatic bile ducts > 2 mm

- Extra hepatic bile duct > 8 mm
Normally < or = 8 mm
Site of extra hepatic bile ducts : common hepatic ducts
Common bile ducts
If pt 60 yrs old > 6 mm ( add +1 for every 10 yrs old )
If post-cholecystectomy > 10 mm
| P a g e 130
Dilatation
Intrahepatic
Cholangiocarcinoma
Cholangitis
Choledocholithiasis
Extrahepatic
Pregnancy
Choledochal cyst " congenital dilatation of biliary duct "
Must be excluded : Tr – GB stone – inflammation
Choledocholithiasis
| P a g e 131
Intrahepatic & Extrahepatic
Pancreatic mass (adenocarcinoma) is a M tr
Site : 2/3 head & uncinate
1/3 body & tail
Sonar : Hypoechoic
Double duct sign : common bile duct – pancreatic duct
Pancreatitis
Choledocholithiasis : GB stones in bile ducts
In common hepatic duct
In common bile duct
Stone > 2 – 20 mm
Suspect if stone : small & multiple
Cholangitis : inflammation
1- Ascending : infectious
Charcot triad
Fever
Rt upper abd pain
Jaundice
2- Sclerosing : idiopathic
Stricture of biliary ducts
Cirrhosis of biliary ducts
| P a g e 132
Notes of GB
Patient fasting 6 -8 hrs
Except - small amount of diet
- juices & water
Size : N > 8 cm ( CBD ) "common bile duct"

Long axis GB : 6 -12 cm
Short axis GB : 3 -5 cm
Wall thickness : N < 3 mm
** anatomy of biliary system
Findings :
If long axis of GB > 12 cm : dilated CBD ( obstruction in GB neck )
If GB wall > 3 mm = inflammation of wall = cholecystitis
Cholecystitis : acute = edema (fluid) of wall = jet black
Chronic fibrosis = hyperechoic
** If chronic cholecystitis
& peri cholecystic edema collection " jet black around GB"
So this is a case of acute on top of chronic cholecystitis
Note GB contents : stone – mud – mass
Mud = no fluid
Mass = polyp = not movable = ask for CT
| P a g e 133
GB stone : Ca stone ( hyper echoic )
Cholesterol : not hyperechoic – it is lipid – no shadow
Movable : polyp mass – Ca stone
Polyp mass = ask for CT
Not movable : mud " inspissated biles – cholesterol stone
Cholesterol stone & if adhesion = suspect : mass – mud - stone
So ask for dopplar (why ?)
As adhesion = there is a space between GB wall & suspected contents

which are : cholesterol – mud – mass
Mud ‫ مثل الطين‬between isoechoic & hypoechoic
Acute or chronic
Peri fluid wall : outside GB
Infectious turbid fluid of bile .. DD : obstruction – inflammation
Mucocele
Primary mucocele : if long axis > 12 cm
Fluid = bile = jet black or echo free
Secondary mucocele : obstruction of bile channels
So = obstruction of GB neck
Causes: stone – mass – LN "lymph node"

| P a g e 134
Q & A sonar
Pancreas
Pancreatic mass: causes = extra & intra hepatic dilatation
Adenocarcinoma is a M tr = malignant cancer
2/3 cases in Head & uncinate process of pancreas
1/3 cases in body & tail of pancreas
U/S findings in Adenocarcinoma of pancreas
Hypoechoic
Double duct sign = dilatation of both 1- common bile duct
2- pancreatic duct
| P a g e 135
Acute pancreatitis types : necrotizing – edematous
Cause : as GB stones
D of vascular complication : thrombosis
Area of necrosis = hypoechoic
c/p : severe gastric pain
increase amylase & lipase 3 times above N level
chronic pancreatitis : intra & extra biliary dilatation
pancreatic atrophy < 12 cm long axis
calcification
pancreatic duct dilatation
if mass related to pancreas : this mass is inside pancreas ( not outside )
U/S of pancreas : M tr – pancreatitis (inflammation)
| P a g e 136
Notes in pancreas
Shape : comment on 4 parts : head – body – tail – uncinate process
Inferior to pancreas : SMV " superior mesenteric vein "
Inside pancreas : splenic vein = jet black = echo free = an echoic
Disease D by U/S :-
1- Pancreatitis inflammation
Dilated in CBD
Obstruction of ampulla of Vater
Ended with pancreatitis
Right pleural effusion ( ask CXR )
Epigastric pain
Fever
Pancreatic enzymes : high 3 times than N level
2- Simple cyst : check for other sites : liver -breast – kidney

3- Polycystic disease : liver – kidney – pancreas
4- Pancreatic pseudocyst
Increase lipase & amylase enzymes
Both enzymes decrease after 12 -24 hrs
So abd U/S is important in this case
Degeneration then fibrosis of pancreas
| P a g e 137
Chronic pancreatitis > complication : calcification

Increase lipase & amylase enzymes
Abscess in pancreas : ttt : Aspiration
Pig tail
Mass in pancreas : if hypoechoic >> 99 % pancreatic tr
Pancreatic tr >> most common tr in the head of pancreas
Not common tr in the body of pancreas
So ask for CT
| P a g e 138
Q & A sonar
Spleen
Findings : diffuse – focal lesion
Size of spleen : mild – moderate – huge
In Egypt : Bilharziasis = huge = special size
Benign tr in spleen : hematoma
Hemangioma
Lipoma
Plasmacytosis
Cancer : benign = benign cancer mass
Malignant tr
| P a g e 139
DD of Hematoma
Hematoma = blood collection outside blood vessels
Through muscular tissue
Trauma ‫ كدمة‬if collection > 10 mm
Internal hemorrhage (hge) = collection through skull & abdomen
Ecchymosis = hematoma of skin > 10 mm
Blood seepage = collection due to IM injection of heparin
** hemangioma = benign tr
Abnormal growth of blood vessels : in the skin
In internal organs
| P a g e 140
Q & A Sonar
Kidney
Rt kidney : anterior & posterior view
Lt kidney : mainly post. View
Causes of obstacles about difficulty U/S in Lt kidney : transverse colon
Spleen
If one sided compensated kidney
= DD in the other kidney : Agenesis
Hypoplasia " small sized kidney on other side "
Pyelonephritis
Surgically removed
N sized kidney + echo pattern ( Nephropathy ) grade 3
** grade 3 nephropathy that sinus = cortex ( no differentiation )
DD : Nephrotic $
DM
ARF " acute renal failure "
Pathogenesis of echo grade 3 : imbalance in perfusion of kidney
Cyst in kidney : has same type (anechoic) : oval – rounded
Cyst in other organs :
For Internist : kidney – liver – breast - pancreas
Not for internist : skin – ovary
| P a g e 141
Q & A Sonar
Retroperitoneal structures
Pulsation of aorta : appear in sonar
‫ يكفي في التقرير اني اكتب يوجد‬pulsation of aorta
Continuation of aorta ( direct branches) : celiac artery
Mesenteric artery
Renal artery
Sub-branches = indirect branches
Branches of Aorta
1. inferior phrenic a.
2. celiac a.
1. left gastric a.
2. splenic a.
1. short gastric arteries (6)
2. splenic arteries (6)
3. left gastroepiploic a.
4. pancreatic arteries
3. common hepatic a.
1. right gastric a.
2. gastroduodenal a.
1. right gastroepiploic a.
2. superior pancreaticoduodenal a.
3. right hepatic a.
1. cystic a.
4. left hepatic a.
| P a g e 142
3. superior mesenteric a.
1. inferior pancreaticoduodenal a.
2. jejunal and ileal arteries
3. middle colic a.
4. right colic a.
5. ileocolic a
1. anterior cecal a.
2. posterior cecal a. – appendicular a.
3. ileal a.
4. colic a.
4. middle suprarenal a.
5. renal a.
6. testicular or ovarian a.
7. four lumbar arteries
8. inferior mesenteric a.
1. left colic a.
2. sigmoid arteries (2 or 3)
3. superior rectal a.
9. median sacral a.
10. common iliac a.
1. external iliac a.
2. internal iliac a.
| P a g e 143
Artery
Vertebra Type Paired? A/P Description
Branch
Originates above the celiac trunk, below the
diaphragm. Passes upward and medially to
inferior the suprarenal gland, and crosses crus of
T12 Parietal yes post.
phrenic diaphragm of corresponding side. Supplies
diaphragm and gives superior suprarenal
arteries.
celiac T12 Visceral no ant. Large anterior branch
superior Large anterior branch, arises just below
L1 Visceral no ant.
mesenteric celiac trunk.
middle Crosses crus of diaphragm laterally on each
L1 Visceral yes post.
suprarenal side; supplies the suprarenal gland.
Arises just below the superior mesenteric
artery. Right renal artery passes deep to the
In inferior vena cava to right kidney; here it
renal between Visceral yes post. divides into branches. Left renal artery
L1 and L2 passes deep to the left renal vein. Divides in
hilum of kidney. Both arteries give inferior
suprarenal arteries and ureteral branches.
Ovarian artery in females; testicular artery in
gonadal L2 Visceral yes ant.
males
Four on each side that supply the abdominal
wall and spinal cord. The fifth pair is the
lumbar branches of the iliolumbar arteries.
They pass deep to the crura on side of
vertebral bodies and pass deep to the psoas
lumbar L1-L4 Parietal yes post.
major and quadratus lumborum to enter the
space between the internal oblique and
transversus abdominis muscles. Each artery
gives off a small dorsal branch, which gives
a spinal branch to the vertebral canal and
| P a g e 144
then continues to supply the muscles of the

back.
inferior
L3 Visceral no ant. Large anterior branch
mesenteric
Artery arising from the middle of the aorta at
median its lowest part. Represents the continuation
L4 Parietal no post.
sacral of the primitive dorsal aorta; quite large in
animals with tails but smaller in humans.
Branches (bifurcations) to supply blood to
common
L4 Terminal yes post. the lower limbs and the pelvis, ending the
iliac
abdominal aorta.
Lymphoma : renal
Spleen
Para aortic LN
Stomach report
Mass presence
Gas at fundus of stomach
But not comment on : ulcer
Gastritis (inflammation) : 5 criteria
Exclusion by sonar
Pyloric stenosis
| P a g e 145
Skills for Abd U/S

1- anatomy : related to organs
related to lesions
2- good scanning by sonar U/S

3- pathway of biliary system
4- focus on c/o of the patient ( pt )
professional in taking patient history
for example as 5 criteria of inflammation
5- experience by repeated training & continuous use of sonar
| P a g e 146
Orientation in U/S
Mid line
MCL " mid clavicular line "
Mid axillary line
Axillary
Sagittal ( coronal if in mid axillary line )
Angel of probe
Depth (zoom)
Contrast ( resolution of echo pattern )
Gentle compression
| P a g e 147
Measurements in abdominal U/S

Tracing
Ratio
Caliber system or measurement system
Volume or capacity ( when reporting on enlarged organ )
Must 3 diameters : GB – UB – prostate
While increase size by diameter : liver – kidney – spleen
** detection of organ enlargement : -
Volume / capacity = 3 diameters = need dual screen
1 or 2 diameters ( buttons ) : power
Freeze
Gean
Caliber
Set
Track ball
Set
Result & print
| P a g e 148
A list of normal radiological reference values is as follows:

1. adrenal gland: <1 cm thick, 4-6 cm length
2. aorta: <3 cm diameter
3. appendix: on CT <6 mm calibre
4. atlantodental distance
o adults: <3 mm
o children: <5 mm
5. azygous vein: on erect chest x-ray < 10 mm diameter
6. bladder wall: <3 mm (well distended state)
7. boehler's angle: 20-40o
8. capitolunate angle: <30o
9. carinal angle: <60-70o
10.colon:
o lumen: <5 cm
o wall: <3 mm
11.common bile duct
o <7 mm and add 1 mm for each decade over age of 60 years
o up to 10 mm post cholecystectomy
12.diaphragm (right dome is usually higher than left)
o difference between right and left: <3 cm
13.endometrial thickness
o pre-menopausal: 3-15 mm
o post-menopausal: <6 mm
14.esophagus wall: <3 mm (with distended lumen)
15.gallbladder wall: <3 mm (well distended)
16.heart (cardiothoracic ratio): <55%
17.inferior vena cava: <28 mm
18.internal carotid artery:
| P a g e 149
o PSV: <125 cm/s

o EDV: <40 cm/s
19.kidneys : 8-10 cm x 4-6 cm
20.liver span: <15 cm
21.lymph nodes
o mediastinal: <10mm in short axis
o retro-crural: <6mm in diameter
22.ovarian follicle: <2.5-3 cm
23.ovaries: volume
o pre-menopausal: <18 cc
o post-menopausal: <8 cc
24.paraspinal lines:
o left: <10 mm wide
o right: <3 mm wide
25.paratracheal stripe: <5 mm
26.pancreatic duct
1. head: 3.5 mm
2. body: 2.5 mm
3. tail: 1.5 mm
27.portal vein: <13 mm diameter
28.prevertebral soft tissue thickness (lateral c-spine x-ray):
o 7 mm at C2
o 2 cm at C7
o easiest way to remember is "7 at 2 and 2 at 7"
29.prostate volume: <25 - 30 cc
30.pulmonary artery
o descending branch of right pulmonary artery: <16 mm
(males), <15 mm (females)
| P a g e 150
o main pulmonary artery: <29 mm

31.rectum: wall thickness <5 mm
32.scapholunate angle: 30-60o
33.small bowel
o lumen: <3 cm
o wall: <3 mm
34.spleen: <12 cm
35.splenic vein: <10 mm diameter
36.testis
o vein: <2 mm diameter
o size: <5 x 3 x 3 cms (volume: 12.5-19 cc)
37.thyroid: <2 cm anteroposterior dimension
38.trachea
o chest x-ray: <25 mm (males) , <21 mm (females)
39.ureter: 30-34 cm long, 2-8 mm diameter
40.uterus
o prebuscent: length up to 3 cm, diameter around 1 cm
o nulliparous: length up to 8 cm, diameter around 8 cm
o multiparous: length up to 9.5 cm, diameter around 5.5c m
o postmenopausal: length up to 6 cm, diameter around 2 cm
41.uterine cervix: diameter less than 3 cm
| P a g e 151
Orientation of probe : Finger test
‫غير مهم قيام طبيب امراض الباطنة بعمل معادالت حسابية علي لوحة المفاتيح في‬
‫جهاز السونار‬
one or two diameters ‫لكن يكفي فقط في حالة قياس‬
& in case of capacity (volume) >> 3 diameters
Enlargement of organs ( or Tissues )
Increase in size
1- by diameter
liver ( Rt & Lt lobes )
kidney ( Rt & Lt )
spleen
2- capacity (volume) 3 diameters
GB
UB
Prostate
| P a g e 152
Mixed measurement data of abd U/S
** Between caliber & measurement
Measurements are for beginners level ‫للمبتدئين‬
Volume >> sagittal & axial
>> must 3 diameters
Sonar screen
Anterior – Posterior : the same in : saggital & coronal – axial
Anterior view : skin
Tissue
Lt lobe of liver
Pancreas
Aorta
Shadow spine
Sagittal = coronal (Mid Axillary) – long axis
Transverse = Axial = short axis
| P a g e 153
Q & A sonar
Measurements
CBD is dilated if > 8 mm … so ask for CT
But the following is wrong that porta-hepatis = 8 mm
Only measure the wall
If wall thickening > fibrosis > Bilharziasis
| P a g e 154
Principles & Rules in Abdominal Sonar

1- you see what you know
2- sonar is after knowing medical patient history
3- methods / strategy of U/S scanning
a- scan all abdomen
until find a lesion
then report on this lesion
b- regular strategy ( organ then organ )
4- obstacles for U/S investigations:
✓ obesity (fatty)
✓ heavy meals & fast food ( food inside the stomach )
✓ excess intestinal gases
so patient drinks water then D by U/S after nearly 1 hr ( 60 min )
✓ spontaneous bacterial peritonitis in hepatic patient as in the

c/p there is abdominal rigidity and tenderness.
5- patient must feel rest before U/S
6- sonar is the main investigation when needed
then if suspicion abnormal ask for : dopplar – CT – MRI
7- gentle compression of crystal probe on patient abdominal surface
body to reflect all targeted tissue body organs
8- U/S duration for patient : 10 – 20 min
9- Patient relatives are allowed ‫ المرافقين‬during D by U/S
10- Physician seating down while using U/S

11- Orientation of U/S screen by Finger test
Finger must appear on the Lt side of U/S screen when put a finger on
the U/S probe
| P a g e 155
12- Generally is to begin at main anatomy of the organ then move

downward
13- Probe must >> perpendicular 90 angle
Whatever in sagittal & coronal axis
In axial axis
14- Asking to D the disease by U/S means the physician are sure 100
% to find abnormalities
- So if physician sure that there would be no signs in U/S >> no need
to use U/S device.
15- Convert in measurement / calculation the units
mm into cm e.g. 23 mm = 2.3 cm
16- Jel is a must
To avoid air spaces on the probe
If no jel >> black area in many sites due to air
Jel >> dismiss the waves of crystals in the probe to explore and show
the perfect dimension of target organ
17- Measurements are depend on direction (axis) of U/S probe what
ever : organ / blood vessels
If blood vessels are oblique in U/S >> so measure diameter to be
perpendicular on the direction of blood vessels
18- Level of physician while using U/S at the same level of the patient
on the bed
So physician set on chair = patient lying on bed
19- Keep physician eyes on U/S screen & not look frequently on the
site of organs and not look at the probe also
20- Jel >> must enough amount
Little amount of jel >> will lead to error in D " diagnosis "
21- Move the probe slowly
22- Gentle compression means = not stressful painful for the patients.
| P a g e 156
RUSH Examination
• Rapid Ultrasound for Shock and Hypotension – the RUSH Exam.
The RUSH Exam: Rapid Ultrasound for Shock and Hypotension.
• The RUSH exam provides a framework for approaching the non-

traumatic patient in the emergency department presenting with
undifferentiated hypotension.
‫ انخفاض ضغط و صدمات ايا كان‬: ‫➢ استخدام سونار في حاالت‬
.‫نوعها‬
➢ 6 Types of Shock
Cardiogenic Shock ‫➢ في حالة هبوط عضلة القلب‬
Haemorrhagic (Hgic) Shock ‫حاد‬ ‫➢ في حالة نزيف‬
Neurogenic Shock ‫عصبية‬ ‫➢ في حالة صدمة‬
Anaphylactic Shock ‫مفرطة‬ ‫➢ في حالة صدمة حساسية‬
Septicemic Shock = Septicemia ‫➢ في حالة صدمة ناتجة عن تسمم بكتيري بالدم‬
➢ Obstructive Shock :
*Example:
Pulmonary Embolism - Cardiac Tamponade -Pneumothorax
| P a g e 157
Fast examination
❑ It is now the standard of care to perform focused assessment
using sonography for trauma (FAST).
‫يعني سونار حاالت كسور و اصابات‬.
❑ For cases of : RTA = ROAD TRAFFIC ACCIDENT
❑ Different from normal sonar procedures like not investigating

any details not related to cases of Trauma.
❑ For example : a case of Rupture Spleen … FAST U/S

examination : physician must not investigate routine
procedures like check a sign of gall bladder stones.
❑ Report of FAST sonar : only mentioned the U/S signs

regarding patient got Trauma accidents.
‫و تقرير سونار في هذه حاالت بيتجاهل كتابة تفاصيل غير هامة في‬
‫مثل فحص هذه حاالت‬
: ‫ في هذه حاالت‬targets ‫هدف سونار‬
ORGAN TEAR - FREE FLUID
| P a g e 158

د خالد ألمظ Basics in Abdominal Sonar PDF

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د خالد ألمظ Basics in Abdominal Sonar PDF

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Khaled Mohammed Almaz

Basic Notes of using Basic Sonography for

& Liver specialty

& Urology specialty

For Non-Radiological Physicians

Khaled Mohammed Gomaa Almaz

1st part M.D. Public Health , Aswan , 2017

MPH , Asyut , Egypt 2011

M.Sc Internal Medicine , Asyut , Egypt 2015

Are the same

GIT & Urology ‫المطلوب في برايفت السونار لطبيب امراض الباطنة‬

1) Normal & Abnormal

‫ماجستير امراض الباطنة‬

‫مهارات محدودة في السونار‬

Enlarged organ (liver(Rt, Lt lobes) , Kidney (Rt, Lt sides) , Spleen)

Portal vein diameter (portal HIV)

Detection of (cyst , focal lesion)

Liver : mild enlarged , hypo echo pattern , no focal lesion , no dilated

GB: average size , shows normal wall thickness , no stones or mass

Spleen : average size , homogenous (iso) echo pattern , no focal lesion

Right kidney: average size , shows normal parenchymal thickness and

Left kidney : Normal

Retro peritoneal area : Normal

Para-aortic LN & Mesenteric LN : no

Ascites : no ascites - or degree of ascites (mention)

Liver report (by abd. u/s)

porta-hepatis (diameter P.V. ‫ فقط‬, wall of porta-hepatis)

7) Focal lesion: 1cm (solid , cystic) , D.D.: LC (by history) - HCC

Focal fatty change

(as: focal hepatic steatosis)

Renal cell cancer

Hepatic Patient ‫حاالت الكبد‬

1. When pt is not diagnosed

2. If pt is HE "hepatic encephalopathy" not do sonar

3. If pt come with H/M : sonar will be done in emergency

4. In case of pancreatitis: may show IPF "intra peritoneal

Differential Diagnosis of Hepatosplenomegaly

• Acromegaly … enlarged spleen, enlarged liver

• Lymphoma … enlarged spleen, enlarged liver

• Hepatosplenomegaly (commonly abbreviated HSM) is the

increase the risk for developing hepatosplenomegaly, which may

• Niemann-Pick disease[citation needed]

• Chronic active hepatitis

• Congestive cardiac failure

• Extrahepatic obstruction, e.g. carcinoma of the pancreas, bile duct stricture

• Primary biliary cirrhosis

• Glycogen storage diseases

• Wilson’s disease (hepatolenticular degeneration)S

By Mayo Clinic Staff

In itself, an enlarged liver typically has no symptoms.

• Pain in the upper right belly

Among the most common causes of liver enlargement are:

• Some types of leukemia

Heart and blood vessel problems

• Blockage of the veins that drain the liver (Budd-Chiari syndrome)

• Liver abscess, caused by parasites (amebiasis) or bacteria

Damage from toxins

• Drug-induced liver injury from such medications as acetaminophen (Tylenol,

Complex liver and systemic diseases

The liver is involved in many of the body's functions. It is affected by many

Among the causes of hepatomegaly are the following:

Glandular fever (Infectious mononucleosis)]2[

Hepatitis (A,B or C)]1[