Bilateral Renal Cysts in Young Patient

Case 8
 6 yo patient with recently received a BMT and
has a rash of face and trunk.

GVHD
 SX: diarrhea, cramping, fever, n/v
“ribbon bowel”-SB fold effacement with
tubular appearance, loss of haustra, spasm,
edema, ulceration, granular mucosa in colon
”SB cast”-prolonged coating of abnormal
bowel for hours to days
Fatal in up to 15% due to opportunistic infix.
TX: steroids, cyclosporine
DDX: super infection with enterovirus

Differential Diagnosis for RIBBON LIKEBOWEL:
 Graft versus host disease
 Celiac disease
 Infection
 Radiation
 Allergy
 Ischemia
 Amyloid
 Lymphoma
 Crohn disease
 Mastocystosis

 DDX Terminal lleal Disease
 IBD- Crohn (stenosis), UC (gaping valve, backwash
ileitis)
 Tumor-Carcinoma, Lymphoma, Carcinoid
 Infection- TB, Yersinia, Salmonella, CMV
 Inflammatory-extension from cecum/appendix
 DDx Coned Cecum
 IBD
 Tumor- carcinoma, met
 Infection- TB, CMV, Actinomyces, Blasto, Typhoid,
Yersinia, Amebiasis
 Inflammation-appendicitis, typhlitis, diverticulitis

 High resolution CT (HRCT) of a patient with
systemic graft versus host disease (GVHD)
HRCT shows mild bronchial dilatation,
bronchial wall thickening, peripheral vascular
pruning and areas of patchy lung attenuation
with air trapping. Appearances suggest
obliterative bronchiolitis in GVHD.

54-year-old woman with calcinosis cutis and
sclerodermatous graft versus host disease. Radiographs of
the right lower leg (A), left lower leg (B), and left hip

 Calcinosis cutis is a condition characterized by
calcium deposits in the dermis or hypodermis [1].
There are four types of calcinosis cutis based on
etiology: dystrophic, metastatic, idiopathic, and
iatrogenic. Dystrophic calcinosis cutis is the most
common form and occurs in abnormal tissue with
normal serum calcium and phosphate levels. The
exact mechanism of calcification is unknown.
Dystrophic calcinosis is associated with connective
tissue disease such as systemic lupus erythematosis,
dermatomyositis, and systemic sclerosis as well as
devitalized tissue from trauma or infection.

Case 9
 H/O: A 40 years patient presented with PUO
and abdominal pain.

Ultrasound of thickened bowel. Relatively hypoechoic thick
walls (arrowed) with echogenic lumen. Appearances are non-
specific - in this case, Crohn's disease of the ileum.

Small bowel non-Hodgkin's lymphoma. (a) Enteroclysis examination demonstrates
a segment of ileum in the right iliac fossa with wall thickening, destruction of the
normal fold pattern and aneurysmal ulceration (arrowed) and mass effect; (b) CT
demonstrates marked wall thickening and aneurismal luminal dilatation,
containing contrast.

Non Hodgkin’s Lymphoma
 Risk: immunosuppression/ immunodeficiency, age> 50
 GI tract: Nodes> Spleen> Liver> SB, LB, stomach, pancreas,
ascites
 Other: chest, GU, bone, CNS, breast, skin, H/N
 Bowel: polypoid or infiltrating causing focal, multifocal or diffuse
irregular wall thickening and luminal narrowing
 Most commonly involves ileums of SB
 DDX thickened irregular SB folds “G Williams”
 Giardia, Whipple’s, Ischemia, Lymphangiectasia, Lymphoma,
Amyloid/ Agammaglobulinemia, Mastocytosis/ Malabsorption,
Soft tissue neoplasm (carcinoid, lipoma)

Case 10
 H/O: Young patient presented with diarrhea.

Figure 11A. Celiac disease (sprue) with reversal of jejunal-ileal fold
pattern on CT. (A) Axial contrast-enhanced image shows loops of
proximal jejunum (arrowheads) with effaced, atrophic folds. (B) Loops of
ileum show fold thickening and increased number of folds (arrows).

Small Bowel Dilatation Sprue
 Features:
 Jejunal dilitation and wall/ fold thickening leads to
ilealization jejunum (<3 folds/ inch). Compensatory
increase number of folds in ileum.
 losses of villi leads to Moulage sign (featureless
folds). Malabsorption/ excess fluid leads to
flocculation of barium.
 Complications: intussusceptions, lymphadenopathy,
ascites, hepatic steatosis from malabsorption,
malignancy (lymphoma> adenocarcinoma, SCC)

 DDX Small Bowel Dilitation
 Malfunction Denervation – gastric surgery,
Chagas
Scarring – scleroderma
Infiltration – amyloid, lymphoma, edema
(ischemia, infection)
Mechanical – gastroparesis, meds, ileus
Obstruction- mass, adhesions,
intussusceptions
Malabsorption – sprue, lactose intolerance,
ZE

 Duke DDX Dilated SB Loops With Normal Folds
Obstruction
Intrinsic – stricture-> tumor, crohn, XRT, ischemia, infection
 intussusceptions-> tumor, Meckel’s, duplication, adhesions,
lymphoid hyperplasia in children
 malrotation with paraduodenal hernia/ volvulus
 Extrinsic – adhesions (60%), hernia, closed loop obstruction,
masses
Ilues
Sprue
Scleroderma – commonset cause of intestinal pseudo
obstruction
On to the Folds
Evaluation of SBFT

 You need to ask yourself the following
questions when evaluating a SBFT.
 1-Describe the folds (this is the biggest clue)
Are the folds thickened?
If so, is it focal or diffuse?
Are they regular or irregular?
Regular – hemorrhage and edema
Irregular – inflammatory or neoplastic
 Are the folds too close together? “Hidebound”
Are the folds dilated?
Are the folds absent or displaced?

Case 11
 H/O: Adult female with abdominal pain,
hepatomegaly, diarrhea, and multiple
episodes of pseudoobstruction

Scleroderma of the bowel - note reflux into slightly dilated
distal esophagus and dilatation of small bowel with "stack-of-
coins" appearance. On the right, a stack-of-coins.

Scleroderma
 Systemic disorder with Skeletal, renal,
pulmonary and gastrointestinal
manifestations
 SB: Hidebound(stacked coins) – normal
thickness/tightly packed within dilated
segment Pseudodivertuculi messenteric
border from scarring. Pneumatosis coli
intestinalis

Hidebound or stacked coin pattern with
pseudodiverticula of antimessenteric border
 Duke Notes SB Diverticuli
 Diverticulosis – messenteric border, acquired
outpouchings ie colon with same string of
associations
 Meckel’s diverticulum – remnant of
omphalomessentric duct, arises in distal ileum,
antimessentric, rule of 2’s(w/l 2 ft IC valve, length 2
in., present age<2), 1/3 contain gastric mucosa, 2/3
symptomatic contain gastric mucosa
 Pseudodiverticuli/sacculations – cinching on
antimessenteric border from chronic inflammatory
disease with fibrosis(Crohns) and muscle
atrophy(Scleroderma)

Meckel’s Diverticulum
Meckel’s diverticulum on SBFT(arrow) during
contraction (left) and filling phase (right)

 Meckel’s diverticulum attached to the
umbilicus by the obliterated
omphalomesentric duct

 Rectal contrasted CT demonstrating inverted
Meckel’s diverticulum with intussusception.
Notice the central fat and soft tissue filling
defect

 Small bowel barium examination,
demonstrates numerous bariumfilled
messenteric
border diverticuli. Notice the absence of
hidebound pattern seen in Scleroderma and
strictures/fistula seen in Crohn’s.

Case 12
 20 yo man with tender scrotum (left side).

. On the coronal dynamic contrast-enhanced subtraction 3D fast field-echo MR images
shows early and strong increase in homogeneous contrast enhancement relative to the right
testis, while the right testis shows gradual and progressive increase in contrast enhancement.
Note that the left epididymis (arrowheads) shows early and intense enhancement.

 Clinically proved acute mumps epididymo-
orchitis in a 41-year-old man. The MR
imaging examination was performed 5 days
after the onset of left scrotal pain and
swelling. (a) Coronal fat-saturated T2-
weighted fast spin-echo MR image
(1,800/100) of the left testis (arrow) shows
lower signal intensity relative to that of the
right testis. On the coronal dynamic contrast-
enhanced subtraction 3D fast field-echo MR
images (10.2/4.1; flip angle, 35°) obtained (b)
30 and (c) 360 seconds after injection of

Epididymoorchitis
 Epididymoorchitis
 Results from retrograde spread of organisms
from bladder or prostate via the vas deferens.
 Common pathogens:
 Gonococcus
 Pyogenic (E. coli, Pseudomonas)
 Mumps
 TB

 Radiographic features:
 Epididymis and spermatic cord enlargement
 Decreased echogenicity of epididymis cord
 Focal orchitis: peripheral hypoechoic region; all
hypoechoic testicular lesions need to be followed by
US until resolution; 10% of patients with testicular
tumors present with orchitis.
 Reactive hydrocele or pyocele
 Thickening of the skin
 Calcification in chronic inflammation
 Color Doppler: hypervascularity in affected
epididymis and/ or testis.

Case 13
 H/O: Bilateral Flank Pain

Antenatal USG at 18 weeks showing bilateral enlarged
echogenic kidney with oligohydramnios!! suggestive of
autosomal recessive polycystic kidneys!!!

Urogram (X-ray) of the abdomen in a 32 year old patient, showing
polycystic kidney disease affecting both kidneys (at upper left and right,
bilateral). Polycystic kidney disease is one of the most common causes of
chronic kidney failure in adults.

Bilateral Renal Enlargement
 Causes:
 Cystic Disease (APCKD)
 Tumor/ Malignancy
 Leukemia
 Lymphoma
 Multiple Myeloma

 Inflammation (acute)
 Glomerulonephritis
 Interstitial nephritis
 Collagen vascular disease
 ATN
 Metabolic
 Amyloid
 Diabetes mellitus
 Storage diseases, acromegaly
 Vascular
 Bilateral renal vein thrombosis

 Other info:
 Unilateral Renal Enlargement
 Ureteral Obstruction
 Duplication anomalies and hypertrophy
 Parenchymal infiltration
 Cellular infiltrates
 Pyelonephritis
 Xanthogranulomatious pyelonephritis
 Contusion
 Infiltrating neoplasm
 Edema
 Acute renal vein occlusion
 Acute arterial occlusion and arteritis

 Small Scarred Kidney
 Unilateral
 Reflux Nephropathy
 Previous Renal Surgery
 -Bilateral--Renal Infracts
 Analgesic Nephropathy
 Bilateral Reflux Nephropathy

 Small Smooth Kidney
 Normal Calyces
 Renal artery stenosis
 Chronic renal vein thrombosis
 Renal hypoplasia
 Subcapsular hematoma
 Radiation therapy
 Abnormal Calyces
 Postobstructive atrophy

Case 14
 H/O: Young patient with hypertension

US of 65 years old male presented to emergency room with bilateral flank pain,
nausea and vomiting for the past 1 week. He had an ultrasound in a peripheral
hospital, which identified hydronephrosis on the right side, and percutaneous
nephrostomy tube was placed. His left kidney showed hydronephrosis with renal
stone (upper picture). This scan shows small-scarred right kidney (middle picture),
pigtail catheter could be identified (arrow) and a proximal ureteric stone could
also be seen (lower picture).

Hypoplastic Right Kidney
 Incomplete development resulting in a
smaller (<50%) kidney with fewer calyces and
papillae (usually < 5) but normal function
 Not to be confused with dysplasia, which
results from collecting system obstruction and
creates a bizarre appearance of the kidney.
Hypoplastic kidneys are smooth with short
infundibulae and sometimes have clubbed
calyces

 Segmental hypoplasia (Ask-Upmark kidney):
usually upper pole with deep transverse
groove. Associated with severe hypertension.
Etiology is controversial (congenital vs.
sequelae of pyelonephritis)

Prostate Cancer
 Represents 18% of all cancers in the US
 Second most common cause of cancer death in men
in the US (According to the Primer, 3rd )
 Incidence increases with age
 BPH does not predispose to cancer
 Origin: Most occur in outer gland (posterior and
peripheral) 70% Inner gland tumors are 30%
 Prostate Specific Antigen: elevated in cancer. Normal
is 2-4 Units

Prostate Cancer, Staging (Jewett
System)
 Stage A: non palpable tumor at biopsy
(radical prostatectomy), A1=well
differentiated, A2=poorly differentiated
 Stage B: palpable tumor, confined to prostate
(radical prostatectomy)
 Stage C: extension through prostatic capsule
but no mets (radiation tx)
 Stage D: metastases (hormonal therapy, rad
tx, chemotherapy)

 Other tx: Brachytherapy (Radiation Seed
Placement)
 Used for localized prostate cancer. Can be
performed as an alternative to External Beam
Radiation Therapy or prostatectomy
 Multiple types of implants can be used
including: Ir-192, Cs-137, I-125, Pd-103
 Contraindications: TURP, public arch
interference, Obstructive symptoms, Morbid
Obesity

Case 16
 H/O: Frequent Micturation

Pelvic Lipomatosis
 Abnormal amount of fatty tissue in the pelvis
compressing normal structures. Unrelated to
obesity or race
 Features:
 Elongation and narrowing of urinary bladder
(pear shape)
 Elongation and narrowing of rectosigmoid
 Large amount of fat in the pelvis

 Teardrop or Pear-Shaped Bladder
 Results from circumferential extrinsic
compression
 Physiological: Normal Variant, IIIiopsoas
hypertrophy
 Fluid: Hematoma (usually from pelvic
fracture), abscess
 Masses: Pelvic lymphoma, Pelvic lipomatosis,
Retroperitoneal fibrosis

Case 17
 30 year old male presents for IVP. Develops
SOB, urticaria, drop in blood pressure

Shock Kidney
 Findings: One minute film demonstrates normal kidneys. Ten
minute film demonstrates persistently dense nephrograms with
regression and disappearance of the pyelogram phase
 Almost always seen in association with a severe adverse
reaction to the administration of contrast. Hypotension leads to
(and hypotension from any cause can cause this appearance)
 When arterial perfusion pressure to the kidneys drops below the
minimum level required for glomerular filtration, tubular stasis
occurs. Any contrast that has been excreted into the kidney
stagnates
 Once Shock Kidney develops, Nephrographic desity will persist
and become progressively denser. The most dramatic finding is
regression or disappearance of the pyelogram phase. These
findings indicate a potentially life threatening hypotension as a
result of contrast reaction

Case 18
 2 years old was an unrestrained passenger in
a motor vehicle accident

Hypoperfusion complex
 Hypoperfusion complex (aka, Shock Complex)
 Typically demonstrates intense enhancement of
bowel wall, kidneys, aorta, and enhancement of
bowel wall, kidneys, aorta, and infeeerior vena cava
 Bowel loops are dilated and fluid filled and the aorta
and IVC demonstrate a diminished caliber
 Hypoperfusion complex suggests tenuous
hemodynamic stability and associated with high
mortality rate (85%)

 Scleroderma
 • Affects esophagus, small bowel and colon,
sparing the stomach
 • Atrophy of the muscular layers and
replacement with fibrous tissue
 • Associated with malabsorption
 X-ray
 • Whole small bowel is usually dilated with
close approximation of the valvulae (hide-
bound appearance) (stack-of-coins)

 • Dilatation of esophagus
 Upon standing, esophagus empties (DDX
from Achalsia which does not empty on
standing)
 • Does not have increased secretions in
small bowel as does sprue
 • May be associated with pneumatosis
intestinales

 Sprue
 • 3 diseases: Celiac Disease of Children, Nontropical sprue and
Tropical Sprue
 • Celiac disease and Nontropical sprue improve on gluten-free diet
 • Tropical sprue improves with antibiotics and folic acid
 X-ray
 • The hallmark features are: dilatation and dilution, especially
in jeunum
 • Segmentation of the barium column occurs because it moves
more slowly through areas of excessive fluid and separates from the
rest of the column-not commonly seen with newer barium mixtures
 • Fragmentation is an exaggerated example of the irregular
stippling of residual barium in the proximal bowel (which is normal)
 • Intussusception is not uncommon but is usually not obstructive; sprue
has increased risk of ca and lymphoma
 • Moulage sign is caused by dilated loop with effaced folds looking like
tube into which wax has been poured

 Whipple’s Disease
 • Glycoprotein in the lamina propia of the small
bowel is Sudan-negative, PAS-positive
 • Clinically: arthralgia, abdominal pain, diarrhea and
weight loss
 • Treated with long term antibiotics-penicillin
 • Very rare
 X-ray
 • The hallmarks of the disease are nodules and
a markedly thickened bowel wall (picket-fence)
 • Small bowel may or may not be dilated
 • Affects jejunum mostly

 Lymphoma
 • Most commonly involves terminal ileum
 • Bowel wall becomes markedly thickened
and submucosa infiltrated (picket-fence)
 • “Thumb-printing“ may be seen
 • Loops are widely separated and there may
be mass effect
 • Another form may have a large ulceration
which is confined and produces so called
“aneurysmal dilatation” of the bowel

Bilateral Renal Cysts in Young Patient

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