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We're building it now GE building a world that works Sonography of Calculate and calcifications of the urinary tract Part one will cover the kidney A bright spot in the kidney can be in the parenchyma Can be in the cortex medulla or in the collecting system Medulla in Afrochalcinosis is a bunch of calcifications in the renal medulla In most of the pyramids you see bunches of calcification The size of calcification may vary because it's large here as seen here And medulla in Afrochalcinosis may be due to renal tubular acidosis medullary sponge kidney or hyperparathyroidism So here you see the size of the bunches of calcification or less compared to the previous And much less here you see the renal pyramids as enlarged and the echogenic With tiny spots and when you use high frequency you see the actual tiny specks of calcifications So this is medulla in Afrochalcinosis least great And can also be in renal tubular acidosis The calcifications may not be seen but the renal pyramids are enlarged and echogenic As a precursor and later on it will develop medullary nefrochalcinosis So renal tubular acidosis is kidney's inability to excrete enough acid or retain enough bicarbonate With a normal renal function resulting in a clinical syndrome characterized by metabolic acidosis and ultrasound we see enlarged echogenic pyramids with or without medullary nefrochalcinosis It is an autosomal dominant and recessive types are there Then another condition is transient acute tubular dysfunction in the newborn So when you happen to do scan on the newborn you see the renal the tips of the renal pyramids echogenic so here these are otherwise normal neonates this condition is seen about 4 to 5 58 percent of neonates you see as maximal hyper echogenicity seen at the apex of the pyramids or papilla as seen here so that is the pyramid renal pyramid and at the apex you see this echogenesis and extend with progressively decreasing echogenicity up to approximately halfway of the pyramid so from brightly echogenic tip of the pyramid and then decreasing towards seen up to the halfway up to the pyramid the cause is not known it returns to normal echopattern in a few days then we come to autosomal recessive polycystic disease which can also show bright spots in the pyramids this is a condition where there is variable degree of tubular dilatation cyst formation with hyperechoic foci of crystal deposition in the medullary pyramids only in some cases we see the hyperechogenic 4k so they are seen as punctate hyperechoic foci 1 to 3 millimeter in size and often casting a ring down artifact and this condition of autosomal recessive polycystic kidney in some patients we see this what looks like calcifications but they are not calcifications that is the indices with ring down artifacts this condition always accompanied by periportal hepatic fibrosis so when you see the liver you see the heterogeneous echopattern of hepatic fibrosis so some other cases examples of autosomal recessive polycystic disease which shows punctate hyperechoic foci in the enlarged echogenic pyramids and with high frequency you see the tinnitus you see the enlarged pyramid here it appears echogenic but when you see high frequency you see the tinnitus and you see the hyperechoic foci with ring down artifacts you see the ring down artifacts so that is typical autosomal recessive polycystic disease another example you see the conventional probe you see enlarged echogenic and cystic areas in the pyramids with hyperechoic foci with high frequency you see the enlarged pyramid you see the tinnitus and you also see the hyperechoic foci with the ring down artifacts very classical then we come to the renal calculate renal calculate or calcifications within the collecting system they are seen as echogenic lesion in the central echogenic area because the collecting system is in the central echogenic area of varying size and with an acoustic shadow deep to the echogenic lesion and there may be dilated collecting system due to obstruction the acoustic shadow depends on the size of the calculus and the type of calculus some calculus like phosphate may not attenuate ultrasound so the shadow may be less so when the calculus is small is seen as a small spot and the shadow may not be obvious in that case you can put a color Doppler to look for the twinkle artifact which will help to say that it is a calculus and not due to an artifact or other conditions now renal calculate they present clinically the etiology is unknown may be multifactorial the pelvic elicil system if it is non-obstructive patients are asymptomatic or they can present as hematuria when it obstructs the collecting system it can produce as pain either in the flank or the typical urethric college with or without a fever and chills due to infection and most of the calculate the site of obstruction 80 percent is at the urethra vesicle junction the dilated collecting system due to calculus may be focal calectasis as seen here due to the calculus in the minor calyx producing minor calectasis or the focal calectasis may be a major calyx because of the calculus in the infundible or in the pelvis obstructing only that major calyx or it can be renal pelvic calculus obstructing all the calyxes so results in calyx dilation of all the calyxes or maybe the calculus is at the pelvic urethric junction obstructing with the dilated calyxes as well as pelvis or it may be in the ureter which produces hydro ureter nephrosis so the dilation may be varying there is a complication of obstruction due to calculus there may be infection result in pion nephrosis which we saw in the urinary tract infection the dilated calyxes and pelvis due to upper urethric calculus that is hydro nephrosis and within the dilated collecting system you see internal echoes debris indicating infection and the renal calculus patient may be asymptomatic and it may result in silent atrophy of the kidney as seen here the size itself is become very reduced parenchymal thinning and you see a large staghorn calculus filling the kidney and patient is asymptomatic all this time you see the shadow also so staghorn calculus thin parenchymal and smaller kidney now in the newborn you may see calculus in the collecting system like this and in children being treated for some reason with frusamide may form calculate a small calculate and it is transient with withdrawal of the frusamide they disappear renal calculus may be due to stasis as seen here there is congenital puj obstruction with hydro nephrosis and there is calculus formation in the calyx or in the pelvis and it will be well that is due to stasis now renal calculate the mimickers or the differential diagnosis may be gas arterial calcification or class calcified sloughed papilla urethric stent randall's block or system with milk of calcium now calculus versus gas you see in the gas you get the ring down artifact but whereas the calculus you get the acoustic shadow so that is one of the difference but sometimes it may not be obvious you see here multiple bright spots in the calyx and there looks like there is some dirty shadow so we cannot say whether it is calculus or gas so in that case you can take advantage of the shifting of the gas by changing the position of the patient now here this is a axial scan with the patient supine so the gas is in the calyx as shown here and when you change the patient position of the patient to lift lateral decubitus so the gas will move to the non-dependent part so here the non-dependent part in lateral decubitus is the renal pelvis so the gases move to the renal pelvis you have to understand the orientation of the image here that is the patient lying supine and we do an axial scan from the flank so the image will look like this so the gas is in the non-dependent calyx here so here because we are doing scan from the flank that is the kidney of the image and the gas is in the calyx because that is the non-dependent part so when you change the position from axial scan supine gas is in the non-dependent anterior calyx so that will be the appearance of the image so okay in the gas in the non-dependent anterior calyx so when you put the patient in lift lateral decubitus you see the non-dependent part is the renal pelvis of the left kidney so previously the gas was here because change the position the gas moves to the non-dependent part that is the pelvis so because we do the scan from here it will look the image will look appear and the gas will be the renal pelvis like that so that is the kidney from the calyx it has moved to the pelvis confirming that it is gas and it is not calculus so calculus is mimicked by calcified renal artery as seen here that is the bright spots in the as if we are calculating the calyx but these splitting factors are the age of the patient so calcified arteries will be seen in old age and the branching appearance will differentiate it of course you can take an x-ray and you see the typical branching pattern of the arterial calcification another clue will be you can use a different axis so here you see coronal scan in axial scan you see the extension of the calcification as an artery linear that rules out calculus you can put color Doppler and within the calcification you will see flow and another differentiating point will be adjacent main renal artery may be calcified or other arteries like supramacentric artery you may see calcification confirming that it is not calculus and it is calcified artery it may be the echogenic spot may be due to stent you see here there is the kidney and you see the echogenic spot with shadowing mimicking a calculus but you see the stent in the renal pelvis of course the history patient may tell that the stent has been placed long time back so our patient may not remember that whether it was removed or not so patient would have forgotten when it remains for a long time then concretions form on the stent that is also will be seen as calculus but here it is the stent itself which is seen mimicking a calculus now calculus versus calcified necros papilla the differentiating point is the ring like calcification because it is the sloughed papilla on the surface the calcification forms so it appears ring like and the history of diabetes uncontrolled will be there and patient will have impad renal function because it is bilateral disease another case of you see the ring calcification in the region of medulla and a very obvious case of ring calcification in the region of medulla so that differentiates it from the calculus now Randall's block is a echogenic lesion in the central echogenic area there is no acoustic shadowing because it is mild calcification and small in size and it is seen at the tip of the papilla typically it is a precursor for clinical calculus but it is seen at the tip of the papilla on mobile and you can use high frequency and you see the medullary pyramid and at the tip you see the typical Randall's block so this should not be mistaken for a calculus that is a normal pyramid and the papilla so Randall's block versus calculus you can see multiple bright spots in the kidney and when there is no dilatation of the calicis it is difficult to appreciate but when there is dilatation of the calicis that gives a contrast and you see the calcifications at the tip of the papilla very nicely seen calculus versus system with milk of calcium so here you see a coronal scan there is echogenic lesion with shadowing and when you do a transverse scan you see that there is actually in supine there is a cyst and within that you see a echogenic level indicating that it is milk of calcium you can confirm by changing the position of the patient so here it is a axial scan in left lateral decobitus so the milk of calcium shifts its level according to the position of the patient confirming that it is cyst with milk of calcium so this is a large cyst with milk of calcium well seen with the conventional probe itself to explain the occurrence we will see the schematic diagram so that is the supine position that is the right kidney and you see a cyst with milk of calcium in the posterior parenchyma and when you shift the patient to left lateral decobitus then you will see when you scan from here you see the image orientation it will be like this with the shadow will be corresponding because the beam comes like that so that is why you see the milk of calcium and the shadow with change of position you see the left lateral decobitus position right kidney is up so the the milk of calcium shifts so the dependent part and so when you scan from the flank the appearance will be like this with the shadow and so you see the shift of the milk of calcium with because the probe beam comes like that you get the shadow corresponding so that is cyst with milk of calcium now this is an example of 45 year old man pain left loin and this is the plain x-ray and you see the IVP it is not connected to the callus there is a calcification and there is a CT scan done after the IVP reported as calcified mass but when you see an ultrasound you see peripheral calcification with a cyst in the center so when you do a transverse scan you see that the the cyst and there is there is formation of a level and you see the transverse scan and with supine and when you do right lateral decobitus you see that the shift of all the milk of calcium with the change of position confirming that it is not a calcified mass it is actually cyst with milk of calcium which is brought on so well with ultrasound and which is not diagnosed with CT scan now smaller the cysts it is difficult now here it looks like a parenchymal calcification but when you do a transverse scan you see the tiny cyst with fluid echogenic level and with the shift of position of the patient you see the level shifts confirming that it is cyst with milk of calcium even further smaller cyst milk milk of calcium will look like just bright spots but the differentiating point will be the ring dumb artifacts which goes with the cyst with milk of calcium now here again there is a cyst there is an echogenic spot so whether it is cyst with milk of calcium or a cyst with adjacent calculus without differentiate you see the cyst that is the calcification in axial scan supine whereas in axial scan in prone also the picture does not change if it is milk of calcium it should come to the opposite wall here it is not shifted indicating that it is cyst with a calculus in the adjacent calyx now calculus versus parenchymal calcification now here you see echogenic spot in the well within the parenchema so it is not in the central echogenic area to say that it is calculus in the calyx so well within the parenchema so parenchymal calcification can be seen like that and here you see multiple coalescent granulomas ecopore granulomas and in the granulomas you see small punctate calcifications this is typical appearance of tuberculosis one of the appearances of tuberculosis these calcifications coalesce without treatment to form a coalescent amorphous a mass of calcification and typically there is a superficial parenchymal scar so this appearance is a sequelae of tuberculosis now archivate arteries may appear bright particularly in old age so that should not be mistaken for calculus you see the bright spots and typical location helps us to differentiate it is at the cortico medullary junction between the cortex and medulla that is the typical location of archivate arteries so that will differentiate it from calculus it may face some difficulties with renal calculate now here this is coronal scan of the kidney the kidney looks normal there is no calculus see but when you do a transverse scan you see the kidney looks normal but you see a calculus medial to the kidney this is actually an extrational pelvis which is not distended so within that extrational pelvis there is a calculus it looks as though it is an extrational calcification but it is actually a calculus in the extrational pelvis some findings may be masked by the shadowing due to calculus here you see the kidney you see a large calculus and there is shadowing so if you tilt the probe you see the renal pelvis and there is another calculus in the renal pelvis which was masked in this section by the shadow of this calculus so you have to be careful you have to that is why we have to make a sweep of the entire volume of the kidney to avoid such mistakes now here you see a kidney coronal scan you see a large calculus with focal dialyctasis and dead end shadowing so something finding in this part of the renal parenchyma will be masked by the shadow so that is what has happened there is a large calculus shadow masks a mask in the medial parenchyma which is revealed on a CT scan coronal section so this is a disadvantage with ultrasound of course a transverse scan and a sweep may bring it out better but here in this case it was missed thank you for 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