1. BRIEFLY DISCUSS THE FOLLOWING:
1.DENSE PERSISTENT NEPHROGRAM
2.BRONCHIECTASIS
3.ULTRASOUND SCAN FINDINGS OF LIVER
CIRRHOSIS
RABIU M. ABBAS
RADIOLOGY DEPARTMENT , AKTH
MARCH,2023
4. INRODUCTION
• The nephrogram is the radiographic image of contrast-filled
renal parenchyma
• Normally three different phases of renal contrast enhancement
follow each other after the administration of intravenous
contrast.
• CORTICOMEDULLARY
• NEPHROGRAPHIC
• EXCRETORY
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5. • During the first phase, contrast material reaches the renal
cortical capillaries resulting in a density differentiation between
the cortex and medulla.
• Afterwards, the contrast material is filtered by the glomeruli
and enters the renal tubules resulting in a homogenous
appearance of the kidney
• During the last phase, the excretory phase, the contrast is
excreted into the calyces causing the renal collecting system to
appear
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7. WHAT IS A PESISTENT NEPHROGRAM
• A persistent nephrogram is an abnormal nephrogram defined
as the renal retention of contrast material and may occur
bilaterally or unilaterally .
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10. List of imaging modalities
• Plain abdominal radiograph (KUB)
• Renal USS (Contrast enhanced)
• Excretion Urography
• CT- urography
• MRI
• Scintigraphy
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11. KUB
• Have a limited role
• May show causal factors like
urolithiasis or evidence of soft
tissue mass along the renal
system
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12. USS
• Gray sacle USS may show
• renal stone
• hydronephrosis,
• renal parenchymal disease
• evidence of renal artery stenosis
on Dopper interrogation
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13. CE-USS
• It has been proposed as a replacement for CECT
• The contrast agent is initially visualized in the renal artery, progressing
to the sinus, the renal cortical, and after a delay of several seconds to
the renal medulla.
• The first 30–40 s (sec) post injection is appropriate for the arterial
phase and then 30–40 s for the venous phase .
• Its role is still under study
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14. IVU/ CT urography
• Imaging with iodinated contrast typically demonstrates an
immediate or mildly delayed nephrogram, but without
excretion into the collecting system.
• Delayed 12-24 hour imaging would also
demonstrate persistent nephrogram due to stasis of contrast
within the renal tubules.
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19. MRI
• MRI has the advantage of superior soft-tissue contrast,
which provides a powerful tool in the detection and
characterization of renal lesions
• fast imaging techniques are essential because of respiratory
motion of the kidneys
• In MR urography, the pyelocalyceal system and the ureters
are visualized using heavily T2-weighted images or T1-
weighted images with gadolinium contrast
• May show evidence of renal stone, renal atery stenosis as
causes of delayed nephrogram
• May also show hydronephrosis
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24. INTRODUCTION
• Bronchiectasis is defined as an irreversible abnormal
dilatation of the bronchial tree.
• It has a variety of underlying causes, with a common
aetiology of chronic inflammation.
• HRCT is the most accurate modality for diagnosis.
• Two groups make up the majority of cases: post-infectious
and cystic fibrosis.
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25. EPIDEMIOLOGY
• The prevalence, incidence and mortality of non-cystic fibrosis
bronchiectasis have all increased over recent years
• Estimated around 212,000 people are currently living with
bronchiectasis in the UK
• Bronchiectasis is more common in females than males
• 60% of diagnoses are made in the over-70 age group.
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26. CAUSES
Central Lower lobe Upper lobe bronchiectasis Middle lobe bronchiectasis
Williams campbell
syndrome (rare)
Post infective
bronchiectasis
Cystic fibrosis Non-tuberculous
mycobacterial infections
Aspergillosis Pulmonary aspiration
diseases
Tuberculosis Middle lobe syndrome in
children
Congenital Hypogammaglobulin
emia
Non-tuberculous
mycobacterial infection
Tracheobronchomegaly (also
known as mounier kuhn
syndrome)
Bronchiolitis obliterans Allergic bronchopulmonary
aspergillosis (ABPA)
Allergic bronchopulmonary
cystic fibrosis
Primary ciliary dyskinesia Chronic hypersensitivity
pneumonitis
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27. Clinical presentation
• Bronchiectasis typically presents with
• Recurrent chest infections
• Productive cough more than 8 weeks
• Production of copious amounts of sputum
• Haemoptysis
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28. Subtypes
• According to macroscopic morphology, three types have been
described, which also represent a spectrum of severity
• Cylindrical bronchiectasis
• Bronchi have a uniform calibre, do not taper and have parallel walls (tram
track sign and signet ring sign)
• Commonest form
• Varicose bronchiectasis
• Relatively uncommon
• Beaded appearances where dilated bronchi have interspersed sites of
relative narrowing
• Cystic bronchiectasis
• Severe form with cyst-like bronchi that extend to the pleural surface
• Air-fluid levels are commonly present
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30. BRONCHOARTERIAL RATIO
• Diameter of a bronchus should measure approximately 0.65-1.0
times that of the adjacent pulmonary artery branch
• Between 1 and 1.5 may be seen in normal individuals, especially
those living at high altitude
• Greater than 1.5 indicates bronchiectasis
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32. Plain radiograph
• Chest x-rays are usually abnormal but are inadequate in the
diagnosis or quantification of bronchiectasis.
• Tram-track opacities are seen in cylindrical bronchiectasis,
and air-fluid levels may be seen in cystic bronchiectasis.
• Overall there appears to be an increase in bronchovascular
markings and bronchi seen end-on may appear as ring
shadows .
• Pulmonary vasculature appears ill-defined, thought to
represent peri-bronchovascular fibrosis
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35. CT
• A number of features are helpful in diagnosing
bronchiectasis :
• bronchus visualised within 1 cm of the pleural surface
• especially true of lung adjacent to costal pleura
• most helpful sign for early cylindrical change
• lack of tapering
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36. Scoring systems
• BRICS (Bronchiectasis Radiologically Indexed CT Score)
• The score was validated with, and intended for, high-resolution CT (HRCT) of the
chest.
• bronchial dilatation
• absent = 0
• mild (lumen just > diameter of adjacent vessel) = 1
• moderate (lumen 2-3 times > diameter of adjacent vessel) = 2
• severe (lumen >3 times diameter of adjacent vessel) = 3
• number of bronchopulmonary segments with emphysema
• none = 0
• 1-5 = 1
• >5 = 2
• The score ranges from 0 to 5, with 1 indicating mild disease, 2-3 indicating moderate
disease and 4-5 indicating severe disease.
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41. TRANSTHORACIC USS
• Normal: normal examination with no abnormal findings.
• B-lines: defined as laser-like vertical reverberation artifacts that arise
from the pleural line and extends to the end of the screen without
fading, and moves in synchrony with the lung movement.
• C-profile (consolidation): defined as the presence of a subpleural
echo-poor region with tissue-like echo texture whose dimensions
remained unchanged throughout the respiratory cycle and sometimes
contains hyperechoic punctiform images which represent air
bronchogram
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48. INTRODUCTION
•Liver cirrhosis is the pathologic outcome of many
chronic liver diseases, in which repeated injury to the
liver results in fibrosis, scarring, and ultimately
functional impairment
•The classic defining histological evaluation of
cirrhosis will reveal diffuse regenerative nodules
surrounded by dense fibrosis, with parenchymal
distortion and collapse causing disruption in hepatic
vascular structures
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49. INTRODUCTION 2
• Imaging and image-guided procedures have a role in prevention,
screening, diagnosis, and management of cirrhosis .
• Currently, radiological imaging and serum markers have become
more favorable options in diagnosis, staging, and grading of chronic
liver diseases
• The gold standard for diagnosis of cirrhosis has traditionally been a
liver biopsy
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50. INTRODUCTION 3
• Most physicians rely on imaging and clues of impaired
hepatic function as the major basis for diagnosis of cirrhosis.
• One-year mortality ranging from 1%-57% depending on the
stage .
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53. Ultrasound
• Ultrasound Scan (USS) is commonly the first imaging
procedure performed during the evaluation of suspected
liver disease.
• The role of ultrasound in cirrhosis includes:
• Diagnosis of cirrhosis
• Screening for hepatocellular carcinoma (HCC)
• Diagnosis of portal hypertension.
• Identification of other complications like ascites
• Provide a guide during biopsy
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54. The normal liver
• Normal liver parenchyma has a homogenous echotexture
with marginally higher echogenicity compared to the
adjacent kidney .
• The outline is smooth and regular
• Normal hepatic vessels have smooth walls with anechoic
lumens and low resistance waveforms; normal portal veins
have thin echogenic walls and monophasic waveforms;
• And normal hepatic veins lack discernible walls and have a
triphasic waveform
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55. Imaging Features
US features
• Small liver, increased echogenicity, coarse, heterogeneous
• Nodular surface
• Blunt
• Regenerating nodules: hypoechoic
• Simple cysts and hemangiomas are rare in cirrhotic livers
• Unequal distribution of cirrhosis in different segments (sparing type)
• Evidence of portal hypertension.
• Splenomegaly
• Ascites
56. FINDINGS CONT.
• Surface nodularity has been shown to be the most common ultrasound
feature in cirrhosis.
• The alternating areas of necrosis and regenerative nodules result in
areas of parenchymal collapse and bulging.
• The ability to additionally evaluate for other signs and complications
of cirrhosis, such as dilated portal vein/portosystemic collaterals,
splenomegaly and ascites indicating portal hypertension, makes
ultrasound an even stronger method for evaluation .
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57. DOPPLER USS
• Colour Doppler can show portal vein flow, flow reversal, and
collateral flow, which help evaluate for portal hypertension.
• Enlarged, tortuous hepatic arteries (corkscrew appearance)
suggesting increased flow velocity
• There may also be stasis in the hepatic veins as in the case of
thrombosis.
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58. THEN…………
• As cirrhosis progresses:
• the normal triphasic waveform of the hepatic veins become biphasic
and even monophasic because of diminished vascular compliance
secondary to fibrosis .
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64. CONTRAST USS
• Contrast-enhanced ultrasound may have a role in the
diagnosis of cirrhosis.
• Diminished mean hepatic venous transit time is similar to
that of perfusion CT
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65. SONO- ELASTOGRAPHY
• Useful to assess the amount of fibrosis.
• Suggested values for diagnosis are:
• >7 kPa: advanced fibrosis
• 12.5-15 kPa: cirrhosis
There are three techniques available:
• Transient Elastography (Fibroscan)
• Acoustic Radiation Force Impulse Elastography (ARFI),
• Shear Wave elastography (SWE)
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66. FIBROSCAN
• For moderate fibrosis (fibrosis stages 1 and 2), the technique of choice
is Fibroscan as it produces significantly better results than ARFI
elastography
• Limitations of include:
• missed diagnoses (2-11%)
• operator-dependent
• difficult measurement in obese patients and ascitic patients and the
small volume of liver parenchyma
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69. CONCLUSION
• Cirrhosis is an increasing cause of morbidity and mortality that
requires accurate and early detection for optimal treatment and
management.
• Ultrasound is commonly the first step in radiological
examination in patients suspected of having liver disease.
• The ultrasound findings in conjunction with using color
Doppler to assess for flow velocities allows for better detection
of cirrhosis, portal hypertension, and hepatocellular carcinoma.
• However, nonspecific findings should be further evaluated by
CT, MRI, or biopsy depending on the clinical context.
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