 Now, the third topic is abdominal mass and role of ultrasound. As I said before, for many topics, there is no protocol put forth. So, my aim is to put forth a protocol for this abdominal mass. So, mass can be due to an antenatal scan. So, an antenatal scan, they could have picked up a mass in the abdomen, so it may come for a scan. Or clinician may have felt a mass or abdominal distention or a previous scan report would have said a mass or when you are doing scan for some clinical symptom, you pick up a mass. Now, this is a case of an antenatal scan reported as abnormal mass and now you see a mass in the right adrenal area and color Doppler there is flow and that was removed turned out to be a neuroblastoma and more common one is a no variances antenatal scan and now postnatally you see that it is complicated and there is lot of debris inside. So, that is no variances which is complicated. Now, role of ultrasound in a mass is confirmation of the mass and to know the organ of origin or if not possible a plane of origin and characterization of the mass whether it is benign or malignant and if it is malignant extension of the mass and then complications due to the mass. Now, to know the organ of or plane of origin these are the various signs described will go one by one. Now, first one is the pattern recognition. So, pattern recognition is once you are seeing any number of scans and moment you do the scan by the pattern you are able to tell the diagnosis. So, one example is the hydranophenosis. You see cystic mass in the area of the kidney you see dilated calluses and the dilated pelvis. So, you know that it is hydranophenosis as opposed to a multi cystic kidney where you see multiple cysts of varying size non-communicating and you do not see any parenchyma. So, that is multi cystic kidney when you see a mass with calcifications you first out for a teratoma and if you see the pseudo kidney appearance like here you know that it is a bowel mass and if you see a cyst and you see the gut signature in the wall then you know that it is a duplication cyst and in the woman in the adnexa if you see the cogenic mass characteristic of a cystic teratoma. So, these are some examples of pattern recognition the moment you see that you know the diagnosis. Now here you see four images and here you see a cyst which is multi-cepted and it is you see the with the transducer it is compressible so it is flaxate and you see its effect on adjacent organs. So it does not produce any effect on the adjacent organs it goes around and with acute angles that means it does not respect tissue planes and here you see the colon and all around the colon you see a cyst. So, this is typical appearance of retropaltonic lymph angioma. So, this is again pattern recognition and now this is a 55 year old man there is a painful mass in the right iliac force this is the appearance you get. So, this is the convex probe so many times you may not get features on the convex scan but if you shift to the high frequencies scan you get the pattern recognition what do you see here you see multiple layers so this is called the cut on in appearance. So, cut on in appearance in the right iliac force it is a pattern recognition agnostic of musinus stadenoma of appendix because of temporal deposit of musin. Next sign is called the intra-organ sign that is the mass you see but you see that it is well within the confines of an organ. So, there is no doubt about the origin of the mass because it is within the organ this is some examples assist within the liver, multi-cepted assist within the liver and hypoallergenic mass in the liver angiomyelipoma in the kidney a calculus in the urinary bladder and a mass within the urinary bladder. So, this is intra-organ sign next is phantom organ sign where you see a large mass arises from a small organ and as a result the organ is not seen. So, here you see right kidney in the right adrenal area you see a mass and you do not see the adrenal separately. So, that is we diagnose adrenal mass now coming to the beak side. So, how is it produced? Now, this is the organ you imagine that it is ovary that is a mass arising from the ovary it keeps on enlarging. So, when it is becomes much enlarged than the organ the rest of the organ gets compressed and forms a beak over the mass. So, this is called the beak sign. So, if it is present we know that the mass is arising from the organ. So, that is the example the ovary and you see a large ecopoam mass and you see the compressed ovary with the beak sign on either side. So, this is the beak sign confirming that the mass is arising from the organ. Some other examples of beak sign in the kidney are multiple masses in the kidney and you see the beak sign in all of them. So, that is the beak sign showing that the mass is arising from the kidney. Now, claw sign. So, claw sign is multiple beak signs. So, here you see the kidney and the mass and I will convert the picture to see better similar to the claw. So, that is the kidney and that is the mass and you see the claw sign the beak on both sides. So, that is the claw sign confirming that the mass is arising from the kidney. Now, this is the reverse beak sign. Now, you see the organ and the mass, but in between you see the groove that is the reverse beak. So, when you see this that is see that suggests that the mass is not arising from the organ. They are close together, but not arising from the organ. So, this is the ganglion neuroma of the retroperitonium anterior to the kidney and you see the reverse beak sign. Now, here to stress the reverse beak sign, I will show in this example, the two month old female infant, previous ultrasound focal mass of the left clove of liver, mangyondotheliuma. Marscap reported as a tichal cystic lesion, segment 4, kori mesangkaimang hamatoma. So, referred for repeat ultrasound, you see the liver and you see the mass. So, this is looks like a necrotic mass and you see the reverse beak sign. So, that means it is not arising from the liver. Again another section you see the reverse beak, there is a mass and the liver which is compressed. So, that is reverse beak sign, so it is extra hepatic. So, what is it? Again you see is high frequency, you see the surface of the liver, there is a crater. This is the mass, this is the necrotic substance and so that is an abscess and you see the crater. So, what has happened is a ruptured liver abscess with an extra hepatic collection. You see the wide gap in the diagnosis by using signs and using the high frequency scan particularly in children. So, it is not at all a tumor, it is just ruptured liver abscess. Now, the another sign is embedded organ sign, here what happens is the an organ is embedded within the mass. So, here there is a bowel loop which is embedded in a large mass, a ecopower mass. So, this is a eccentric lymph node mass of lymphoma, embedding the loop of bowel. Here there is a mass around the kidney and embedding the kidney, this is the case of perinephoric hematoma. Now, this is central abdomen, you see a large septated cystic mass, but in the center you see gas filled bowel. And in the perpendicular to this section, you see the multi-septated cystic mass and you see a loop of bowel going through that. So, you know now you know the diagnosis, it is an eccentric lymphoma. You can see the real time, you see the whole mass moves indicating that it is intraabdominal and multi-septated and you see the peristalsis in the bowel loop, in the center. So, this is embedded organ sign, this is eccentric lymphoma. Next sign is floating iota sign, what is it? It is displacement of the abdominal iota away from the vertebral column. So, that is the iota, it is displaced from the vertebral column. This happens only when there is a later paternal lymph node mass lifting up the iota. So, it is a sign of retropytonic lymph node mass. Then you diagnose mass based on the location and shape. So, here you see a cystic mass in the region of the gallbladder in the real gallbladder force and you do not see the gallbladder separately and it is piriform taking the shape of gallbladder. So, it is dilated gallbladder. Now, this is a mass in the renal force, it has got the shape of the kidney and so it is an enlarged kidney. Then we come to the sign of continuity. Now, here you see the transverse scan of the pancreas, portal vein, you see a cyst anterior to the portal vein, cyst which is continuous with the common hepatic duct confirming that it is a colloidal cyst. So, continuity confirms the diagnosis. Now, here you see a large cyst in the right flank and you see the kidney and you see a mild dilated renal pelvis and there is a communication of the renal pelvis with its large cyst. So, this is what is the appearance. You see the kidney, you see the dilated chelicis pelvis which is communicating with the huge dilated, grossly dilated upper ureter. This is happens in a ureteric valve with cystic dilation of the upper ureter. Differential diagnosis will be a retropytonial cyst. Now, to stress on the continuity sign, I will show you two examples identical two children presenting Spain abdomen, pre both the cases previous scan reports said pseudo cyst. Case 1 and case 2, you see the cyst. Now, in case 1, you use the high frequency scan, you see the liver gallbladder, you see the cyst and you see the gut signature, so that means it is a duplication cyst. But from where you see the transverse colon here. So, the transverse colon and the wall of the transverse colon and wall of the cyst are continuous. So, continuity, sign of continuity says that it is a duplication cyst of the transverse colon. Whereas, in the case 2, in the high frequency scan, you see the cyst, again gut signature, duplication cyst, but this is the stomach and you see the wall of the stomach and wall of the cyst are continuity. So, it is a gastric duplication cyst. You can see how this has helped us to differentiate. Then tissue planes, so parietal masses will be seen in the abdominal wall as seen here a lipoma and since this of course is clearly within the abdominal wall and when you have a doubt, a real time will show that the mass does not move with respiration whereas intraabdominal structures will move. Parietal structures will fail to move confirming that it is a parietal mass whereas here there is a mass which is intraabdominal as evidenced by the respiratory movement. You see the nice movement shows that it is intraabdominal, then you can further characterize and then another sign is sign of exclusion. So, suppose see here, this is a child with a coronal scan of the left flank, you see a mass here, so this mass in the region of the left adrenal, so what are all possible? It is it can be mass in the left adrenal area and this is a transverse scan of the left flank and this is a transverse scan of the again the transverse scan of the left flank at a little higher level. So, it can be arising from the spleen, but you see the spleen normal, so it is not arising from the spleen. It is it can arise from the kidney, but again you see the left kidney, so you see the mass is not arising from the left kidney. It can arise from the adrenal, but you see again the adrenal is normal and it can arise from the tail of pancreas, again in this section you see the tail of pancreas which is normal and stomach again looks normal in both the sections. So, all the possible organs are excluded that narrows down to the mass arising from the retropyrtonin. So, this is by exclusion. Then effect of the mass, so here you see a mass in the mid-dabdomen and you see a dilated loop proximal to that and you see the loop entering the mass. So, by this you know that it is a mobile mass with obstruction with a dilated loop proximal. Here similarly hydronephrosis and you see the dilated ureter and the mass, so this is a ureteric tumor producing obstruction and hydronephrosis. The effect on adjacent organs, so this is a young girl with a mass in the supra-pubic region and the sagittal scan shows the bladder normal and post it to the bladder, you see a large cyst and the high frequencies can a little above shows that the cyst and the uterus anterior to it and you see the service within the cyst confirming that it is a hematoculpus. Another case you see the hydrometroculpus, so this effect confirms that it is hematoculpus. Now here you see in the mid-dabdomen, you have a multiceptated cyst which is a left kidney showing hydronephrosis and the cyst is compressing the ureter and producing hydronephrosis, so that confirms that it is a retropotone lymphoma compressing the ureter. Now next sign is feeding vessel sign or the fruit on the branch sign. Now here patient presenting with melena, you see mass above the urinary bladder and high frequency shows again the mass, so whether it is a mass or a fecal mass, you put on the color, you see a large vessel supplying the mass. So single vessel supplying the mass and branching. So this is the feeding vessel sign confirming that it is a polyp in the colonic polyp and this is also called the fruit on the branch, so that is the fruit on the branch. So that vessel is the stalk of the fruit, so that helps us to diagnose the polyp. Then origin of the mass started out by color Doppler, you will see some examples. Now this is the kidney and you see a mass and you see the reverse beak, so suggesting that the mass is not arising from the kidney, again here reverse beak. But when you put on the color, you see the feeding vessel is from the renal artery, so it is arising from the kidney, but it is almost like a adunculated exophytic mass from the kidney. Another mass in the left iliac fossa anterior to the sauvus muscle that is again longitudinal scan, but on color you see it is supplied by a branch from the external iliac artery. So that confirms it cannot be from the intraabdominal structure, so that narrows down to a retropyrtonal mass. Now here in the transverse scanner you see a large irregular mass and in color shows that the celiac artery is within the mass, diagnosis of celiac lymph node mass. Then another example, a mass in the region of the pancreas, the supramacentric vein is anterior. So if it is a pancreatic mass, then it should be, the supramacentric vein should be compressed, but in transverse scan you see by the vessels, this is IVC posted to the mass supramacentric vein anterior to the mass. So in between the IVC and supramacentric vein is the uncenate process of the pancreas. So the mass is arising from the uncenate process of the pancreas. There is a large mass in the mid-abdominal, colored opera shows supramacentric artery causing through it, making a diagnosis of mercentric lymph node mass, similarly an echogenic mass in the mercenary as evidenced by supramacentric artery into mercentric fibromidosis. Now there is a large mass in the right iliac flow cell and if you put color, you see the externally of vessels are pushed anteriorly by the mass making a diagnosis of a retropyrtonal mass, most likely lymph nodes. Now here again kidney with a mass, the reverse big sign, but on colored opera the flow is from the kidneys, so it is a renal mass. Now here it is a newborn with a large mass in the region of the pancreas. So how to know the origin of the mass? First is the deodorant. You see confirmed by the fluid that it is deodorant, second the iota and the IVC. So the mass is anterior to the iota and IVC and you see the supramacentric vein. So the mass is surrounded by deodorant IVC, iota and supramacentric vein. So it has to be in the head of pancreas and it is heterogeneous and in the newborn so it is a pancreatical blastome. Another case of mass and high frequency source that it is related to a small bowel loop and it is continuous with the small bowel loop involved and colored opera shows flow from the bowel loop making it as a gist from the bowel. Now some maneuvers you can use to diagnose. Now this is the left loop of where you see a mass. So it can be from the left loop, it can be from the stomach, it can be from the spleen and so if you see the stomach there is a beak of the stomach so it could be from the stomach so you give oral fluid. You see the fluid moving going all around the mass instead of the mass making a diagnosis of with the beak that it is a gliomaoma of the stomach. Similar mass but here you see the stomach being posterior so it can be from the left clove of liver but you see the beak here. So when you give fluid you see that fluid flows all around the mass except this area so making it is a polypied mass from the anterior wall of the body of the stomach and it is a gist. And this is a mass in the left hyperchondrium stomach was seen separately but you see gas inside the mass so when you give oral fluid the fluid goes into the mass confirming that it is an exomorphotic mass of gist from the stomach. Now here post uretroscopy there is a large cystic mass with hydranophrosis and you see that there may be communication so you press release with the color Doppler you see flow away and flow towards across the breach so in the ureter so this is a trauma to the ureter with a urenoma. You have to seek a mass in these situations now here in a patient with hematuria you see a clot so close look at the kidney shows that there is a mass and bleeding PR you see a mass here and you see gas all around so whether it is a fecal mass or polyp you put on the color you see flow inside making it a polyp. Bleeding PR you see a mass here with gut signature whether it is mass or duplication or meccals and for normal loop it is a peristaltic so you repeat the scan after one hour it remains the same making that it is abnormal and it is a meccals diverticulum. How Mach bilius vomiting you have to look for the mass of hypertrophic pylorextinosis in bilius vomiting you have to look for the volvulus as seen here the whirlpool sign of midget malrotation and volvulus and in red current jelly with cry you must suspect intercess option so you see intercess now clinically you suspect a mass but you do not see a mass and ultrasound now here this is the kidney and you do not see a mass in the right flank but now this is normal you see the distance posted to the kidney this is normal here it is increased so maybe you are missing and you see gas there so this gas is preventing visualization of the mass so little scan with the tilt of the patient you see that there is a large abscess with gas which is prevented because of the gas shadowy and coronals can make out the abscess so this is a posterior perinephric gas with abscess there is a child with constipation and a mass in the suprapibic reason but in ultrasound you see this can be gas in the dilated rectum but in transverse scan there I mean there was resistance felt for the transducer and transverse scan shows a huge dilated rectum with resistance so that is a fecalith this is a 40 year old woman fullness and mass felt clinically but you fail to see a mass this is a very important situation but there is resistance for the transducer so when you observe you see a rotatory movement indicating that there is a mass and mimicking bubbles so this is a cystic teratoma and imagine if you have not reported this and the surgeon operates now mimicker for a mass so here you see the urinary bladder posted to that you see a cystic mass but this is due to reverberation artifact because of gas in the rectum how to avoid you repeat the scan after some time or go to the laterally and do the section and you can another pointer is you can see the distance it will be equidistant and the pelvis will end there but you see the mass extending beyond the contentment of the pelvis you must suspect a reverberation artifact now then we come to characterization that is a cyst solid ecogenic heterogeneous and high frequency is very useful as seen here you see the kidney which was reported as solid and cystic mass in retroperitonium but here you see the big sign showing that it is intra-renal and the reverse big sign that it is also extra-renal it looks like abscess so what has happened is there is an intra-renal abscess which is ruptured and produced a perinephric abscess you see how much detail you get and this is a mass in the left globe of liver with high frequency you see that it is typically hemangioma with enhancement renal mass bilateral high frequency shows that it is classically heart somal recessive polycystic kidney it is a patient with acute pain right iliac closer there is a large mass we see that there is a tender mass of momentum fat ilium and appendix showing that it is an inflammatory mass of appendix now here there is a mass in the adrenal area and you see the broken diaphragm sign because of the difference in speed of ultrasound and that tells us that the mass contains fat so the diagnosis becomes myelolipoma here there is a so necrotic mass with color flow you so know that it is necrotic tumor now this is an ecopo mass and with enhancement so you think of cyst but when put on color there is flow inside making it a tumor and there is a cyst in the tail of pancreas which put on color if there is flow that indicates aneurysm of the splinic artery now here there is a mass in the liver in a newborn there is dilated hepatic vein and the portal vein indicating that it is a hemangiopendothelium of the liver now some maneuvers can characterize the mass here you see a mass in a patient with hematuria whether it is a mass or a clot to change the position of the patient shifts so it is clot now here a woman with lower abdominal mass there is this solid mass anteriorly with shift of position it also shifts indicated only mass which can float on fluid is fat so this is fat that brings us to a diagnosis of cystic tartaroma you see the shift in real time now characteristics may be useful if you know the age history and echo pattern now this is a child with urinary bladder you see a mass inside and with the change in position it shifts so you diagnose calculus but the history is ureteric re-implantation done three months back so within three months you cannot get such a big calculus so that brings us to a diagnosis of foreign body depth over in the urinary bladder this is assist in the pancreas with the history of acute pancreatitis so it is pseudosis and once you are diagnosed malignant mass you have to look for extension now this is renal carcinoma the breach of the perinephric fat line perinephric infiltration and when there is no perinephric infiltration the mass moves well with respiration whereas here you see that the liver moves but the kidney is fixed indicating that there is perinephric infiltration renal carcinoma there is infiltration and thrombosis of the renal wing no flow on color Doppler and extends into the IVC also so by this you know the extension here again a renal cell carcinoma extending into the renal pelvis along the ureter up to the bladder and again renal cell carcinoma with a distant hepatic metastasis now a case of hepatocellular carcinoma infiltrating the portal vein with thrombosis and a metastatic lymph node in the portaepatitis and lymphoma with involving the bowel as well as lymph nodes and we come to the complications of mass now this is the renal cell carcinoma with haemorrhage you see the perinephric hematoma and this is the hepatocellular carcinoma on the surface which is bled with a local hematoma and this is the angioma lipoma which is bled with a retroperitone hematoma now this is a movement with the distention of abdomen and pain you see asitis and in the lower abdomen you see this collapsed ovarian cyst so this is ovarian cyst which is ruptured and this is a renever abscess which is ruptured with asitis and hemoperitoneum this is a hemoperitoneum with a clot and you see a spleenic artery aneurysm which is leaked and complicated now this is a case of pain abdomen and vomiting there is a mercentric cyst as evidenced by a bowel loop but patient has presented with acute pain so that this is not explained by this diagnosis but you see this area so a close look shows that there is nemoperitoneum and asitis so what has happened is look a little more medial to that you see the whirlpool sign indicating that the mercentric cyst has resulted in volvulus producing the perforation of bowel now this is a child with ovarian cyst and with hairs indicating cystic teratoma but the patient has presented with acute pain and vomiting so you have to look for any complication and you see this area with high frequency that shows the snail shell sign of whirlpool sign and in real time you see the whirlpool sign indicating that it is ovarian cyst torsion ultrasound is also useful in follow-up after surgery for melignancy is a case of carcinoma of left kidney and follow-up shows local recurrence and it can be lymph node metastasis or it can be recurrence at the urethral cycle junction or there may be recurrent hematoma in the IVC so to stress the role of ultrasound in a mass I will show this example as the concluding case the four-year-old boy with pain in the left flank for 15 days his earlier ultrasound has been reported as iodide exist which will unusual for four-year-old and CT scan was reported as large peririnal complex cystic mass with a few mildly enlarged parietic lymph nodes so missing camel melignancy has to be ruled out this is the coronal scan transverse scan you see a large cystic mass in and the kidney is compressed here so whether it is renal or extra renal this is the real time showing that the mass moves with the kidney so maybe arising from the kidney or infiltrating high frequency transverse scan of upper pole shows the big sign showing that the mass is arising from the kidney sagittal scan shows the reverse big sign so it may be misleading sometimes and there are solid areas showing that it is a tumor and an high frequency I mean color shows flow within the septa showing that it is not a hydrat it says and it shows low resistance flow making it more melignancy and high frequency show medial to the mass shows enlarged metastatic lymph node so the final diagnosis will stir up with lymph node metastasis so this is how the various modification of your technique and various signs will help to arrive at a final diagnosis in an abdominal mass thank you very much for your patient listening