EUS Hepatobiliary & GU System


6530 Severity 9/10

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49 ? ?


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Compartments of the retroperitoneum

Anatomic relationship of the kidneys

Overview of kidney anatomy


T12 - L4 / / //

Overview of kidney anatomy

: 9-13 cm; : 4-6 cm; : 2.5-3.5 cm Gerotas fascia: Sinus
kidney, capsule, perinephric fat Hilum: vessels, nerves, lymphatics, ureter Pelvis: major and minor calyces Cortex: site of urine formation, contains nephrons Medulla: contains pyramids that pass urine to minor calyces. Columns of Bertin separate pyramids

Parenchyma surrounds the sinus

Longitudinal ultrasound view of the normal right kidney

Transverse ultrasound view of the normal right kidney

Normal left kidney

Normal filled urinary bladder

Male Pelvis

Prostate Enlargement

Longitudinal images of normal right kidney

Transverse image of normal right kidney


(Ureters) Pelvis: Sinus: (echogenic) Medullary pyramids: hypoechoic Cortex:
mid-gray, less echogenic than liver or spleen.

Capsule: smooth and echogenic

: 3.0 ~ 3.5 MHz

: 5.0 MHz

(Supine) Posterior oblique, lateral decubitus, prone

LIVER

STOMACH

I K
IVC AORTA

Clinical indications for EUS

Acute flank pain/suspected renal colic Acute urinary retension Bladder size estimation Acute renal failure Complicated UTI (APN & renal abscess) Trauma

Acute flank pain/ suspected renal colic

EUS: obstruction AAA

Acute flank pain/suspected renal colic

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(renal colic) s/s: : IVP v.s. US v.s Helical CT hydronephrosis (2K1B) stone > 50y/o, AAA

EUS:

Overview of degrees of hydronephrosis

Mild Hydronephrosis

Moderate Hydronephrosis

Severe Hydronephrosis

Hydronephrosis with acute calyceal rupture

Dilated ureter below bladder (transverse view)

Algorithm for renal colic

Renal stone
EUS:
Hyperdense lesion with acoustic shadow

Renal stone

Renal stone

Renal stone

Renal stone

Renal pelvis stone & Hydronephrosis

Ureteropelvic junction stone

Ureterovescicular junction stone

Renal cyst
1. 2. 3. 4. EUS smooth, round, or oval no internal echo well-defined margin posterior enhancement

Renal cyst

Renal cyst

Renal cyst

Polycystic kidney

Polycystic kidney

Renal abscess simple renal cyst ?

Bladder
?
Acute urine retension

U/Cfailure ?
Bladder size evaluation

 (ml) = * * * 0.75 (error: 15-35%)

Bladder index volume (AP * Transverse) 2.4cm2 = 2ml

(, obstructive uropathyUB)

Fungating bladder mass

Acute renal failure

: post-renal obstruction

Acute renal failure

Pre-renal
Kidney & IVC evaluation

Intrinsic
Difficult

Post-renal
Search obstruction

Complicated UTI (APN & renal abscess)

EUS 1. Risk factors 2. Treatment failure 3. Severe sepsis/septic shock

Risk factors for complicated APN

Elderly Male History of preexisting renal diseases Current use of catheters Previous renal calculi Diabetes mellitus

Chen KC, et al. AJEM (in press), doi:10.1016/j.ajem.2010.01.047

50F, Septic shock

50F, Peri-renal abscess

50F, Peri-renal abscess

Emphysematous Pyelonephritis

Trauma
EUS Highly operator dependent gross hematuria, or CECT

Renal trauma

Subcapsular renal hematoma (Trauma)

57M, Post-ESWL

Catheters

Pitfalls
1. Bedside US is limited in scope 2. Hydronephrosis may be mimicked 3. Presence of hydronephrosis may be masked by dehydration 4. The absence of hydronephrosis does not rule out a ureteral stone 5. Patients with an acute AAA often present with flank pain 6. A bladder mass may be a hematoma


302 Murphys sign

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Ultrasonic Murphys sign Cost-effective procedure

Triangle of Calot


: 6-8

:
Poor oral intake Abdominal pathology Biliary tract obstruction


:
stone or sludge

Left or right lateral decubitus, Left posterior oblique Partially upright


:
& ;

: acoustic window :
Anterior subcostal Coronal Right posterior oblique

: the portal triad

Longitudinal views of the gallbladder

Transverse views of the gallbladder

Intercostal views of the gallbladder

Portal vein and normal common bile duct

PV & CBD Micky Mouse sign

Hepatic venous system

ACEP
Primary: Extended:
CBD: : pneumobilia Portal vein :

Clinical indications
Gallstones and biliary colic Acute cholecystitis Jaundice and biliary duct dilatation Abdominal sepsis Ascites Hepatic abnormalities

paracentesis



Sonographic Murphys sign Impacted stone GB wall thickening Pericholecystic fluid Increased transverse GB diameter

CBD dilatation

Biliary colic algorithm

80

Acoustic shadow

Gallstones

Polyp

Polyps & Tiny stones


Fever Chills RUQ pain Leukocytosis Jaundice Positive Murphys sign

Acalculous cholecystititis 1- 5 %



acalculous cholecystitis.

> 4-5 cm
GB wall thickness ( < 3mm) > 4-5 mm (anterior wall)

Averages 5 mm in acute cholecystitis Averages 9 mm in chronic cholecystitis

:
Decreased echogeneity of the entire wall Sonographic Murphys sign Pericholecystic fluid Diffuse, homogeneous echogeneity with GB lumen (pus in lumen or GB empyema)

Sonographic Murphys Sign

:
Gallbladder wall thickening Increased transverse diameter of GB Pericholecystic fluid

Acute Cholecystitis

Chronic cholecystitis


Present in many non-inflammatory conditions
Post-prandial most common Congestive heart failure Starvation/hypoproteinemic states Ascites HIV

WES sign (wall echo shadow)

CBD Scanning Tips

45 portal vein CBDportal vein() CBDportal vein

Parallel channel sign

Choledocholithiasis

Antler signs

Mirizzi syndrome

Cirrhosis of the liver

Decreased liver size Increased parenchymal echogenicity Increased surface irregularity Distorted intrahepatic anatomy

Bacterial peritonitis

Hepatomegaly

Splenomegaly

Biliary sludge

Contracted gallbladder

Liver cyst

Liver abscess

Hemangioma

Metastatic tumors

GB stone ()
Longitudinal view Intercostal oblique view

Packed gallbladder (acoustic shadow)

Cholecystitis ? Ascites

Pitfalls
Misidentifying the gallbladder Inadequate visualization of the gallbladder and biliary system Confusion with shadowing Misdiagnosing cholelithiasis and cholecystitis Misdiagnosing dilated intrahepatic ducts Misdiagnosing ascites Cystic Duct stone Common bile duct stones Misdiagnosis of Biliary Colic


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