03 Case Study NephrolithiasisNephrolithiasis refers to the formation of stones (calculi) in the kidney. These stones can vary in size and may stay in the kidney or move into the urinary tract, potentially causing pain, obstruction, or infection. Clinical History: The patient is a [age]-year-old [male/female] presenting with sudden-onset, sharp, colicky flank pain that began [duration] ago. The pain radiates toward the lower abdomen or groin and is not relieved by rest or position changes.
Associated symptoms include:
Hematuria (blood in urine)
Nausea and/or vomiting
Urinary urgency or frequency
Figer
ЁЯУД Report Sample Line- Nephrolithiasis Shows a echogenic focus measuring approximately 5 mm in the renal midcalyx with posterior acoustic shadowing, suggestive of nephrolithiasis. No significant hydronephrosis noted."
Conclussion: ЁЯУЛ Nephrolithioasis Recommendation: Follow-up imaging (repeat ultrasound or CT KUB) in 1–2 weeks to assess stone progression or resolution.
Causes 1. Dehydration / Low Fluid Intake
Most common cause
Concentrated urine promotes crystal formation
2. Dietary Factors
High oxalate intake (spinach, nuts, tea, chocolate)
High sodium diet (increases calcium excretion)
Excess animal protein (raises uric acid and reduces citrate)
Low calcium intake (paradoxically increases stone risk)
3. Metabolic Disorders
Hypercalciuria (high urinary calcium)
Hyperoxaluria (high urinary oxalate)
Hyperuricosuria (high urinary uric acid)
Hypocitraturia (low citrate levels)
4. Medical Conditions
Gout
Hyperparathyroidism
Renal tubular acidosis
Inflammatory bowel disease or Crohn’s disease
Obesity and metabolic syndrome
5. Medications
Loop diuretics (e.g., furosemide)
Topiramate (antiepileptic)
Excess vitamin D or calcium supplements
Indinavir (HIV medication – forms drug-induced stones)
6. Urinary Stasis or Infection
Recurrent urinary tract infections (especially with Proteus species → struvite stones)
Obstruction or anatomical abnormalities causing urine retention
Symptoms
Severe, sudden onset flank pain (renal colic), often radiating to the groin or lower abdomen
Hematuria (blood in urine), visible or microscopic
Nausea and vomiting
Frequent urination or urgency
Dysuria (painful or burning sensation while urinating)
Cloudy or foul-smelling urine (suggestive of infection)
Fever and chills (if infection is present)
Restlessness due to severe pain
Diagnosis
Clinical history and physical examination focusing on characteristic flank pain and urinary symptoms
Urinalysis showing hematuria, crystals, or signs of infection
Blood tests including serum calcium, uric acid, and renal function
Imaging studies:
Non-contrast CT scan of the abdomen and pelvis – gold standard for stone detection
Ultrasound – useful especially in children and pregnant women; detects stones and hydronephrosis
Abdominal X-ray (KUB) – may detect radiopaque stones but less sensitive
Stone analysis (if passed or surgically removed) for composition and preventive management
Metabolic evaluation in recurrent cases to identify underlying causes
Image Panel with Explanation
This is the explanation for Image 1.
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Topic Related MCQ Bilingual Quiz
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рдпрджि рдЖрдк рд╣िंрджी рдЪुрдирддे рд╣ैं, рддो рд╕рднी рдк्рд░рд╢्рди рд╣िंрджी рдоें рд╣рд▓ рдХрд░ें।
Biliary System Ultrasound Anatomy The biliary system anatomy refers to the visualization and evaluation of the ducts and associated structures responsible for the transport and storage of bile, primarily using grayscale and Doppler sonography. 1. Biliary System Components
The biliary system includes the following components:
Gallbladder (GB): A pear-shaped organ that stores bile.
Cystic Duct: Connects the gallbladder to the common bile duct.
Common Hepatic Duct (CHD): Formed by the junction of the right and left hepatic ducts.
Common Bile Duct (CBD): Carries bile from the liver and gallbladder to the duodenum.
Intrahepatic Ducts: Bile ducts within the liver that merge to form the right and left hepatic ducts.
2. Ultrasound Visualization
Transabdominal ultrasound is the standard imaging modality:
The gallbladder is best seen in the fasting state to ensure it's distended.
The common bile duct is visualized anterior to the portal vein in the portal triad.
The normal intrahepatic ducts are typically not seen unless dilated.
3. Normal Ultrasound Appearance Gallbladder:
Anechoic, fluid-filled structure with thin walls (≤3 mm).
Should not contain internal echoes (unless there are stones/sludge).
The gallbladder (GB) is a pear‐shaped structure located in the GB fossa, a depression on the visceral surface of the liver between the right and left lobe. The GB is usually lateral to the second part of the duodenum and anterior to the right kidney (RK). (b) Note is made of the main interlobar fissure (IF) between the portal vein (PV) and the GB. Common Bile Duct (CBD):
Anechoic tubular structure, best seen in the longitudinal plane.
Located anterior to the portal vein and hepatic artery (part of the portal triad).
The common bile duct (CBD) can be seen as a thin tubular structure with echogenic walls that, in the majority of cases, runs anteriorly and parallel to the portal vein (PV) at the level of the hepatic hilum. The hepatic artery (HA) is often seen at this level in transverse section, hence it is visualised as a small rounded or ovoid structure (depending on the angle of insonation) with echogenic walls between the CBD and the PV.
CBD Normal Diameter by Age:
Age Group
Normal Diameter
Children
≤ 2 mm
Adults (under 60)
≤ 6 mm
Post-cholecystectomy
Up to 10 mm
4. Common Pathological Findings Gallstones (Cholelithiasis):
Hyperechoic foci with posterior acoustic shadowing.
Mobile with patient position changes.
Cholecystitis:
Thickened gallbladder wall (>3 mm).
Pericholecystic fluid or sonographic Murphy’s sign (tenderness on probe pressure).
Biliary Obstruction:
Dilated intrahepatic ducts ("parallel channel" or "double barrel" sign).
CBD >6 mm (without surgery history), >10 mm if post-cholecystectomy.
Choledocholithiasis:
Stone(s) within the CBD.
Seen as echogenic foci with posterior shadowing within duct.
5. Techniques for Optimal Biliary Imaging
Patient Preparation: Fasting for 6–8 hours helps distend the gallbladder.
Patient Positioning: Supine and left lateral decubitus positions improve visualization.
Probe: Curvilinear transducer (2–5 MHz) for adults; higher frequency linear probe for thin patients or children.
Scanning Tips: Use multiple angles (subcostal, intercostal) to evaluate CBD and intrahepatic ducts clearly.
6. Clinical Relevance
Gallstones: May cause biliary colic or acute cholecystitis if they obstruct the cystic duct.
CBD Stones: Can cause obstructive jaundice, pancreatitis, or cholangitis.
Cholecystitis: Prompt diagnosis on ultrasound prevents complications like gallbladder perforation.
Postoperative Biliary Dilation: Slightly enlarged CBD is normal post-cholecystectomy unless associated with symptoms.
7. Biliary System Doppler Use
Doppler is not routinely used for biliary imaging but may help:
Differentiate vascular structures from bile ducts.
Confirm avascularity of gallbladder masses or sludge (vs. polyps or tumors).
Topic related exam Bilingual Portal Vein Quiz
Portal Vein Ultrasound – MCQ Quiz
Note: If you select English, answer all questions in English.
рдпрджि рдЖрдк рд╣िंрджी рдЪुрдирддे рд╣ैं, рддो рд╕рднी рдк्рд░рд╢्рди рд╣िंрджी рдоें рд╣рд▓ рдХрд░ें।
Hepatic Veins Ultrasound Anatomy
The hepatic veins are an essential structure in ultrasound anatomy as they provide critical information about the liver's venous drainage and can help diagnose various pathologies, such as cirrhosis, portal hypertension, and hepatic venous obstruction.
Below is an explanation of the ultrasound anatomy of the hepatic veins, including their role, locations, and characteristics during ultrasound imaging:
The hepatic veins originate from the periphery of the liver, converging into the inferior vena cava (IVC). LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. 1. Location and Anatomy
The hepatic veins are responsible for draining deoxygenated blood from the liver into the inferior vena cava (IVC). There are typically three main hepatic veins:
Right Hepatic Vein (RHV)
Middle Hepatic Vein (MHV)
Left Hepatic Vein (LHV)
These veins are positioned to drain the liver’s segments as follows:
Right Hepatic Vein: Drains the right lobe of the liver.
Middle Hepatic Vein: Drains the central part of the liver, typically between the right and left lobes.
Left Hepatic Vein: Drains the left lobe of the liver.
2. Ultrasound Visualization
The hepatic veins are best visualized using transabdominal ultrasound.
The liver’s inferior surface (especially the right lobe) is where the hepatic veins can be seen entering the inferior vena cava (IVC).
The hepatic veins typically show a pulsatile flow pattern with bidirectional flow on Doppler ultrasound.
3. Normal Ultrasound Appearance Gray-Scale Imaging:
The hepatic veins appear as anechoic (black) structures on gray-scale imaging.
They are seen as parallel lines within the liver, usually running perpendicular to the portal vein.
Doppler Imaging:
Doppler ultrasound provides detailed information about blood flow through the hepatic veins.
The flow in hepatic veins is typically pulsatile and bidirectional (with systolic and diastolic flow patterns).
Hepatic Vein Diameter by Age (Ultrasound)
Age Group
Normal Hepatic Vein Diameter
Neonates (0–1 month)
1.5 – 3.5 mm
Infants (1–12 months)
2.0 – 4.5 mm
Children (1–10 years)
3.0 – 6.0 mm
Adolescents (11–18 years)
4.0 – 7.0 mm
Adults (18+ years)
Up to ~8 mm (normal upper limit)
Hepatic Vein Doppler Normal Ranges
Hepatic Vein Doppler Normal Ranges
Parameter
Normal Range
Notes
Hepatic Vein Diameter
≤ 8 mm
May increase in hepatic congestion or disease
Hepatic Vein Velocity (PSV)
15 – 30 cm/s
Monophasic hepatopetal flow
Hepatic Vein Flow Direction
Hepatopetal
Should always flow toward the liver
Hepatic Vein Pulsatility Index (PI)
0.5 – 1.0
Higher values may indicate liver congestion or right heart dysfunction
Parameter Descriptions
PSV (Peak Systolic Velocity): Highest flow speed during systole.
PI (Pulsatility Index): Measure of the variation in velocity during the cardiac cycle.
Hepatopetal = toward liver; Hepatofugal = away from liver.
Notes:
Measurements are typically taken at the level of the hepatic hilum and perpendicular to the vessel.
In conditions like portal hypertension or right heart failure, you may see altered Doppler waveforms such as reversed flow or blunted waveforms.
Hepatic veins can show dampened or monophasic flow in hepatic congestion, especially in cirrhosis or Budd-Chiari syndrome.
Common Hepatic Vein Variations
1. Hepatic Vein Trifurcation: A variation where the main hepatic vein divides into three branches instead of two.
2. Early Branching of Right Hepatic Vein: In some cases, the right hepatic vein branches early before entering the liver.
3. Hepatic Vein Congenital Absence: Rare condition where a hepatic vein may be congenitally absent or malformed.
Clinical Relevance
Portal Hypertension: Elevated pressure in the portal system can lead to dilated hepatic veins and abnormal Doppler patterns.
Hepatic Vein Thrombosis: Obstruction of the hepatic veins can lead to hepatomegaly, ascites, and hepatocellular damage.
Budd-Chiari Syndrome: Hepatic vein thrombosis can cause liver congestion, leading to severe symptoms.
TIPS Procedure: Transjugular Intrahepatic Portosystemic Shunt (TIPS) is a treatment for portal hypertension that connects the portal vein to the hepatic vein.
4. Hepatic Veins and Blood Flow Normal Flow: Hepatic veins carry blood from the liver toward the inferior vena cava. On Doppler, you should see a pulsatile waveform because the venous return is influenced by the cardiac cycle.
Systolic flow (toward the heart)
Diastolic flow (away from the heart), especially during ventricular relaxation.
Normal Waveform Characteristics:
Hepatic veins typically show a regular triphasic waveform, with both systolic and diastolic flow.
The normal velocity of blood in the hepatic veins is typically between 10 and 30 cm/s.
5. Pathological Findings in Hepatic Veins
When assessing the hepatic veins in ultrasound, certain pathological conditions can alter the normal appearance of the veins.
a) Cirrhosis:
Cirrhosis can cause liver fibrosis, leading to increased resistance in the hepatic venous outflow.
This can result in abnormal Doppler flow patterns, such as reversed flow or reduced pulsatility.
b) Portal Hypertension:
Portal hypertension leads to increased pressure in the portal venous system and can cause hepatic vein dilation and abnormal flow.
Reversed or dampened flow in the hepatic veins on Doppler may be observed due to the high pressure in the portal circulation.
c) Hepatic Vein Obstruction (Budd-Chiari Syndrome):
In hepatic vein thrombosis or Budd-Chiari syndrome, there may be complete or partial obstruction of the hepatic veins, leading to reversed blood flow and distended hepatic veins.
This condition is characterized by the absence of the typical pulsatile flow and can cause hepatomegaly, ascites, and liver congestion.
d) Hepatic Vein Thrombosis:
Hepatic vein thrombosis results in a loss of the normal pulsatile pattern in the Doppler waveform.
This can be seen with liver congestion and ascites.
6. How to Visualize Hepatic Veins on Ultrasound
To visualize the hepatic veins properly:
Patient Position: The patient should be in a supine position with the right arm extended to allow better access to the liver.
Probe Selection: Use a curved array probe for optimal imaging, typically 2-5 MHz in frequency.
Scan Plane: Start with the longitudinal view of the liver and then rotate to a transverse view to visualize the hepatic veins draining into the IVC.
Doppler Settings: Apply Doppler on the hepatic veins, focusing on the flow pattern in both systole and diastole. You should see a pulsatile wave that is normal in healthy patients.
7. Hepatic Veins Doppler Imaging in Normal vs. Abnormal Conditions Normal:
Clear, pulsatile flow pattern.
Triphasic waveform.
Abnormal (in pathologies like cirrhosis, portal hypertension, or Budd-Chiari Syndrome):
Monophasic waveform.
Absence of diastolic flow.
Dampened or reversed flow.
Reduced pulsatility or loss of triphasic waveforms.
Related MCQ Hepatic Veins Ultrasound – MCQ Quiz
Hepatic Veins Ultrasound – MCQ Quiz
Note: If you select English, answer all questions in English.
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Portal Vein SystemThe portal vein system (also called the hepatic portal system) is a network of veins that collects blood from the gastrointestinal organs and spleen and delivers it to the liver for processing.
The portal vein system is a venous network that carries nutrient-rich, deoxygenated blood from the gastrointestinal tract, pancreas, spleen, and gallbladder to the liver. It allows the liver to metabolize nutrients, detoxify substances, and filter pathogens before the blood enters systemic circulation.
Normal Portal Vein Anatomy (on Ultrasound)
Origin: Formed by the confluence of the splenic vein and superior mesenteric vein (SMV) posterior to the neck of the pancreas.
Course: Travels superiorly and to the right, behind the first part of the duodenum and head of the pancreas, into the porta hepatis.
Branches:
Main Portal Vein (MPV) divides into. (right and Left).
Right Portal Vein (RPV): Further divides into anterior and posterior branches.
Left Portal Vein (LPV): Often has a U- or J-shaped curve before branching into medial and lateral segments.
Normal Portal Vein Diameter by Age (Ultrasound) Portal Vein Diameter by Age
Age Group
Normal Portal Vein Diameter
Neonates (0–1 month)
2.5 – 4.5 mm
Infants (1–12 months)
3.0 – 5.5 mm
Children (1–10 years)
4.0 – 7.0 mm
Adolescents (11–18 years)
6.0 – 9.0 mm
Adults (18+ years)
Up to ~13 mm (normal upper limit)
With deep inspiration
May transiently reach ~16 mm
Portal Vein Doppler Normal Values
Portal Vein Doppler Normal Ranges
Parameter
Normal Range
Notes
Portal Vein Diameter
≤ 13 mm
May transiently increase with inspiration
Portal Vein Velocity (PSV)
20 – 40 cm/s
Steady, monophasic hepatopetal flow
Portal Vein Flow Direction
Hepatopetal
Should always flow toward the liver
Portal Vein Pulsatility Index (PI)
< 0.5
Higher values may indicate right heart dysfunction or portal hypertension
Portal Vein Resistive Index (RI)
N/A
RI not typically measured in PV; applies more to hepatic arteries
Parameter Descriptions
PSV (Peak Systolic Velocity): Highest flow speed during systole.
RI (Resistive Index):
PI (Pulsatility Index):
Hepatopetal = toward liver; Hepatofugal = away from liver.
Notes:
Measurements are typically taken at the porta hepatis, perpendicular to the vessel.
In portal hypertension, diameter may exceed 13–16 mm in adults.
Portal vein diameter can be affected by hydration, respiration, and body habitus.
Common Portal Vein Variations
1.Trifurcation Pattern (10–15%)
MPV divides into RPV anterior, RPV posterior, and LPV simultaneously.
No true right portal vein trunk.
Can be a pitfall in planning liver surgery or transplantation.
2. Early Branching of RPV (5–10%)
RPV divides before reaching the hepatic parenchym
Important in preoperative planning.
3. Quadrifurcation
Rare; MPV gives rise to four primary branches.
May complicate segmental anatomy interpretation.
4. Right Posterior Portal Vein Arising Directly from MPV
Instead of forming a common RPV trunk, the posterior branch comes off MPV directly.
5. Cavernous Transformation
Not a congenital variant, but a collateral venous network forming due to chronic portal vein thrombosis.
Appears as multiple tortuous vessels in the porta hepatis region.
Ultrasound Appearance & Considerations
The portal venous system can be recognised on ultrasound as a tubular structure with echogenic walls that enters the liver together with the hepatic artery (HA) at the level of the hepatic hilum (a), and reaches the more distal liver segments. (b) Posterior branch of the right portal vein (RPV); (c) left portal vein (LPV) branches. (c) The caudate lobe can be clearly visualised in this scanning plane (asterisk) between the inferior vena cava (IVC), the ligamentum venosum (LV), and LPV. CBD, common bile duct; EHPV, extrahepatic portal vein.
Clinical Relevance of Variations
Portal Hypertension: Elevated pressure in the portal system, often due to cirrhosis.
Portal Vein Thrombosis: Obstruction of blood flow due to clot.
TIPS Procedure: A shunt between the portal and hepatic vein to reduce portal pressure.
Topic related exam Bilingual Portal Vein Quiz
Portal Vein Ultrasound – MCQ Quiz
Note: If you select English, answer all questions in English.
рдпрджि рдЖрдк рд╣िंрджी рдЪुрдирддे рд╣ैं, рддो рд╕рднी рдк्рд░рд╢्рди рд╣िंрджी рдоें рд╣рд▓ рдХрд░ें।
Hepatic artery Doppler anatomy ultrasoundDoppler ultrasound of the hepatic artery is a crucial component of hepatobiliary imaging, especially in liver transplant evaluation, liver tumors, or portal hypertension. Here's a guide to the anatomy, technique, and Doppler interpretation:Anatomy of the Hepatic Artery (HA) on Ultrasound 1. Origin and Course
The common hepatic artery (CHA) arises from the celiac trunk.
It gives rise to:
Gastroduodenal artery (GDA)
Proper hepatic artery (PHA) → divides into right and left hepatic arteries.
The right hepatic artery (RHA) often runs posterior to the common bile duct and anterior to the portal vein (in the portal triad).
2. Portal Triad on Ultrasound
Portal vein: Largest and most posterior (echogenic walls)
Hepatic artery: Small and pulsatile (anterior and medial)
Common bile duct (CBD): Thin-walled and anechoic (anterior and lateral)
Doppler Ultrasound Technique Preparation
Patient fasting 6–8 hours for better visualization.
Use a curved array transducer (3–5 MHz) or high-frequency linear probe (for transplant or detailed studies).
Scanning Approach
Begin at the porta hepatis, identify the portal vein, then locate the hepatic artery.
Use color Doppler to confirm pulsatile arterial flow.
Apply spectral Doppler to evaluate flow velocity and waveform.
Parameter
Normal Value / Characteristic
Waveform
Low-resistance monophasic
Systolic Peak Velocity (PSV)
~30–100 cm/s
Diastolic Flow
Continuous, forward
Resistive Index (RI)
0.55–0.80
Clinical Applications Liver Transplant Evaluation
Assess patency of the hepatic artery.
Detect hepatic artery thrombosis, stenosis, or pseudoaneurysm.
Portal Hypertension: Evaluate for arterioportal shunting or altered flow. Liver Tumors:Tumor vascularity, arterialization of lesions (e.g., HCC). Tips for Better Imaging
Use power Doppler for slow/low-volume flow.
Adjust PRF and gain for optimal waveform clarity.
Apply angle correction (< 60°) for accurate velocity measurement.
