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gu [2017/07/07 18:30] (current)
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 +====== Contrast Rxn ======
 +{{reaction.jpg?​500|Don'​t freak out}}
  
 +====== Pelvis ======
 +
 +===== Anatomy =====
 +  * Extraperitoneal cavity: contiguous with retroperitoneal space
 +  * Retropubic space of Retzius: contiguous with posterior pararenal space + extraperitoneal fat
 +  * Perineum: below pelvic diaphragm
 +  * Parametrium:​ contained within broad ligament
 +  * Denonvillier’s fascia: positioned between prostate and rectum
 +
 +====== Kidneys ======
 +  * Combination of coritcal & medullary nephrocalcinosis suggests primary oxaluria
 +===== Grades of Vesicoureteral Reflux =====
 +{{:​gradesofreflux.jpg|Grades of Vesicoureteral Reflux}}
 +
 +===== Cortical Nephrocalcinosis (COAG) =====
 +  * Cortical Necrosis (Acute)
 +  * Oxalosis
 +  * Alport Syndrome
 +  * Glomerulonephritis (Chronic)
 +
 +===== Medullary Nephrocalcinosis (MARCH) =====
 +  * Medullary Sponge Kidney
 +  * Alkali Excess
 +  * RTA (Type 1, Distal), Renal Medullary/​Cortical Necrosis
 +  * Chronic Glomerulonephritis
 +  * Hyperoxaluria,​ Hypercalcemia (Hyperparathyroidism),​ Hypercalciuria
 +
 +===== Papillary Necrosis (POSTCARD) =====
 +  * Pyelonephritis
 +  * Obstruction
 +  * Sickle Cell
 +  * TB/Trauma
 +  * Cirrhosis
 +  * Analgesic Nephropathy
 +  * Renal Vein Thrombosis
 +  * Diabetes
 +
 +===== Diffusely Hyperechoic Kidneys (HIV MAN) =====
 +  * HIV
 +  * Inflammation
 +    * Glomerulonephritis
 +    * HTN, DM
 +  * Vascular
 +    * SLE / Vasculitis
 +  * Multiple Myeloma
 +  * Acute Tubular Necrosis / ARPCKD
 +  * Nephrocalcinosis
 +
 +  * ESRD
 +  * Hemolytic Uremic Syndrome
 +
 +===== Bilaterally Enlarged Kidneys (TIM VPC) =====
 +  * Tumor
 +    * Leukemia / Lymphoma
 +    * Myeloma
 +  * Inflammation (acute)
 +    * Glomerulonephritis
 +    * Interstitial Nephritis
 +    * ATN
 +  * Metabolic
 +    * Amyloid
 +    * Diabetes
 +    * Gaucher'​s
 +    * Acromegaly
 +  * Vascular
 +    * Bilateral renal vein thrombosis
 +  * Polycystic Kidney Disease
 +  * Collagen Vascular Disease
 +
 +===== Bilaterally Small Kidneys (IR RAS) =====
 +  * Inflammation (chronic)
 +    * Pyelo, Glomerulonephritis,​ Interstitial Nephritis
 +  * Reflux (chronic infection)
 +  * Bilateral renal artery stenosis
 +===== Unilaterally Small Kidney (VOX HS) =====
 +  * Vascular (RAS / RVT)
 +  * Obstruction
 +  * XRT
 +  * Hypoplasia
 +  * Subcapsular hematoma (chronic)
 +
 +===== Urethral Stricture =====
 +  * iatrogenic
 +  * post-infectious (gonococcal or non-gonococcal)
 +  * non-infectious irritation (chemical or Reiter'​s)
 +  * traumatic injury
 +  * neoplasm (long, irregular stricture ± fistula)
 +
 +
 +
 +===== Bosniak Classification =====
 +  * Category I - No atypical features
 +    * US - anechoic without internal echoes, with good thru transmission and a barely perceptible but well defined wall
 +    * CT - fluid density, no enhancement and imperceptible wall
 +  * Category II - homogeneously hyperdense cyst that is not enhancing, or thin (<1mm) septations or thin wall Ca+
 +    * must be 3 cm or less in diameter, have one quarter of its wall extending outside the kidney so the wall can be assessed, and be nonenhancing after contrast material is administered
 +  * Category IIF - minimally complicated cysts that need follow-up
 +    * not well defined by Bosniak but consists of lesions that do not neatly fall into category II
 +    * have some suspicious features that deserve follow-up up to detect any change in character.
 +  * Category III - true indeterminate cystic masses that need surgical evaluation, although many prove to be benign
 +    * thicker septations or multiloculated,​ coarser Ca+ or solid component that is not enhancing
 +    * may show uniform wall thickening, nodularity, thick or irregular peripheral calcification,​ or a multilocular nature with multiple enhancing septa
 +    * hyperdense lesions that do not fulfill category II criteria are including in this group.
 +  * Category IV - needs nephrectomy
 +    * nonuniform or enhancing thick wall, enhancing or large nodules in the wall, or clearly solid components in the cystic lesion
 +    * enhancement of at least 10 HU
 +
 +===== RCC Staging =====
 +  * Stage 1 -> confined by renal capsule (completely in kidney)
 +  * Stage 2 -> beyond capsule but confined within Gerota’s fascia
 +  * Stage 3A -> extension to renal vein or IVC
 +  * Stage 3B -> positive lymph nodes
 +  * Stage 3C -> both venous extension and adenopathy
 +  * Stage 4A -> grows through gerotas fascia into adjacent organs (other than adrenal)
 +  * Stage 4B -> distant mets
 +===== Grading of Renal Lacerations =====
 +FIXME
 +
 +====== Ureter & Bladder ======
 +
 +===== DDx Small Bladder (CITRUS) =====
 +  * cystitis cystica
 +  * interstitial cystitis
 +  * TB
 +  * rads
 +  * unused bladder
 +  * surgery and schistosomiasis
 +
 +===== DDx Pear-shaped Bladder (CILLI) =====
 +  * Collection - urinoma, hematoma, abscess
 +  * IVC obstruction
 +  * Lymphoma / adenopathy
 +  * Lipomatosis
 +  * Iliopsoas hypertrophy
 +
 +
 +===== DDx for ureteral filling defects =====
 +  * Fungus ball
 +  * Ureteritis cystica -> epithelial/ subepithelial cysts due to inflammation or irritation (metaplasia of Brunn’s nests)
 +  * Clot
 +  * Fibroepithelial polyp
 +  * Endometriosis
 +  * Stone / Sloughed papilla
 +  * Tumor / TB
 +
 +  * Leukoplakia:​ associated with Schistosomiasis;​ premalignant → squamous cell carcinoma
 +  * Malakoplakia:​ chronic gram (-) infection (E. coli #1); ↑ DM → foamy macrophages (Hansemann) with PAS (+) inclusions (Michaelis-Guttman bodies); raised yellow lesions
 +    * looks like ureteritis cystica
 +
 +===== DDx hemorrhagic cystitis =====
 +  * viral and bacterial infection
 +  * drugs - cyclophosphamide (cytoxan)
 +  * eosinophilic
 +  * cystitis cystica
 +
 +===== Pseudodiverticulosis =====
 +  * 1-3 mm outpouchings ​
 +  *  DDx -> calculi / infections / CA (#1 = TCC)
 +
 +===== Ureteral TCC =====
 +  * Risks: azo-dyes, cyclophosphamide,​ phenacetin
 +  * Radiographic:​
 +    * “Wine glass/​goblet” deformity (dilated distal ureter)
 +    * Bergman sign (coiled retrograde catheter)
 +===== Ureteral displacement =====
 +  * Distribution:​
 +
 +^    ^  **Medial** ​ ^  **Lateral** ​ ^
 +|**Above Pelvis**|Retroperitoneal fibrosis\\ Retrocaval ureter \\ (right; at L3)|Psoas hypertrophy\\ LAD\\ AAA\\ Central tumor|
 +|**Below Pelvis**|Pelvic lipomatosis\\ Iliac LAD/ aneurysm\\ Iliopsoas hypertrophy\\ Hutch diverticulum|Fibroids\\ Ovarian masses|
 +
 +  * Medial
 +    * Retroperitoneal fibrosis: drugs (methylsergide,​ ergotamine);​ XRT; prior surgery; malignancy; connective tissue disorders
 +    * Retrocaval ureter (right only)
 +    * Pelvic lipomatosis:​ ↑ black males; “tear-drop” or “pear”-shaped bladder; associated with ureteritis cystica
 +    * Other: hematoma; iliac LAD or aneurysms; adnexal mass; surgery
 +  * Lateral: ​
 +    * AAA
 +    * LAD; psoas hypertrophy
 +    * Central pelvic mass
 +    * Retroperitoneal fat (≠ pelvic lipomatosis)
 +
 +===== DDx for ureteral stricture =====
 +  * Infection: TB; Schistosomiasis;​ abscess; fistula
 +  * CA: metastases; local extension; TCC; lymphoma
 +  * XRT
 +  * Inflammation:​ calculi; instrumentation;​ stent; endometriosis
 +===== DDx for ureteral dilatation =====
 +  * Obstruction
 +  * Reflux
 +  * Primary megaureter (“beak” sign)
 +===== DDx for bladder filling defects =====
 +  * Tumor: TCC; adenocarcinoma;​ squamous cell carcinoma; metastases (pheochromocytoma) ​
 +  * Extrinsic masses: BPH; uterus (fibroids); etc.
 +  * Other: calculus; thrombus; ureterocele (pseudoureterocele due to inflam/ tumor); foreign bodies
 +===== Hutch Diverticulum =====
 +  * adjacent to UVJ; ↑ vesicoureteral reflux
 +===== Bladder Carcinoma =====
 +  * Clinical: transitional cell (90% malignant); risks = azo-dyes; phenacetin; cyclophosphamide;​ focal thickening of bladder wall; perivesical spread; LAD (> 10 mm)
 +  * Staging:
 +    * Stage A: limited to mucosa + submucosa
 +    * Stage B1: superficial muscular layer
 +    * Stage B2: deep muscular layer
 +    * Stage C: perivesical fat
 +    * Stage D: seminal vesicles, prostate, or rectum
 +===== Bladder Trauma =====
 +  * Contusion: interstitial
 +  * Extraperitoneal:​ due to pelvic fracture, dissection into retroperitoneum + scrotum + thigh
 +  * Intraperitoneal:​ usually blunt trauma with distended bladder; DX requires adequate bladder distention (> 250 ml)
 +
 +===== DDx for Bladder Ca2+ (SCART) =====
 +  * Schistosomiasis (↑ squamous cell carcinoma)
 +  * CA; cyclophosphamide (cytoxan); calculus
 +  * Alkaline encrusting cystitis
 +  * Radiation
 +  * TB
 +
 +====== Urethra ======
 +===== Urethral Anatomy =====
 +
 +==== Anatomy (male) ====
 +  * Anterior = penile + bulbous (penoscrotal junction)
 +  * Posterior = membranous (between inferior margin of verumontanum + tip/ cone of bulbous urethra) + prostatic
 +    * Cowper’s glands: contained within membranous urethra with ducts entering the bulbous urethra
 +    * Glands of Littré: located primarily along dorsal penile urethra → infections (gonococcus;​ chlamydia)
 +
 +{{urethra.png}}
 +
 +===== Urethral Injuries =====
 +  * Clinical: risks = pelvic trauma (especially multiple pelvic fractures); absence of blood at meatus does not exclude urethral injury → RUG
 +  * Subtypes:
 +  * Type I: posterior urethra stretched
 +  * Type II: posterior disruption (above urogenital diaphragm)
 +  * Type III: anterior + posterior disruption
 +  * Type IV: bladder neck injury with extension to urethra
 +  * Type IVa: periurethral extravasation with intact urethra
 +  * Type V: anterior disruption (“saddle” injury); ↑ bulbous urethra
 +===== Female Urethral Diverticulum =====
 +  * Clinical: most often acquired due to infection of Skene’s glands; ↑ posterior wall; SXS = dysuria + dribbling + dyspareunia (3 D’s); ​
 +TX = surgical resection (diverticulectomy)
 +  * Radiographic:​ focal outpouching along posterior urethra; impression along inferior bladder (= “male prostate”);​ best seen on MRI
 +  * Complications:​ infection; calculi; CA (squamous cell)
 +===== DDx for Urethral Strictures (TIICB) =====
 +  * Trauma
 +  * Inflammatory;​ infections (prostatitis;​ phlegmon; etc.)
 +  * Calculus
 +  * BXO (= balanitis xerotica obliterans):​ variant of lichen sclerosis et atrophicus (white plaques) → phimosis/ meatal stenosis; premalignant (penile squamous carcinoma)
 +===== Hypospadias =====
 +  * ↑ cryptorchidism (30%) + inguinal hernias (10%)
 +===== DDx for Urethral Tumors =====
 +==== Benign ====
 +  * Fibroepithelial polyp: solitary; pedunculated;​ attached near veru montanum; ↑ child/ young adult
 +  * Transitional cell papilloma: ↑ prostatic/ bulbomembranous urethra; ↑ bladder papillomas; older adults
 +  * Adenomatous polyp: ↑ young men; adjacent to veru montanum
 +  * Penile squamous papilloma / condyloma acuminata: verrucous lesion in penile urethra; associated with cutaneous disease
 +
 +==== Malignant ====
 +  * Squamous cell carcinoma (70%): distal 2/3 of urethra; risks = venereal disease; ↑ stricture (> 80%)
 +  * TCC (10-20%): posterior 1/3 of urethra; ↑ multifocal
 +  * Adenocarcinoma (10-20%): arise from periurethral glands (Skene; female) and glands of Cowper/ Littré (male)
 +
 +
 +
 +====== Testes ======
 +
 +===== Testicular Cancer =====
 +  * Clinical: seminomas → orchiectomy + XRT; nonseminomas (radioresistant) → orchiectomy + chemotherapy
 +  * Staging:
 +    * Stage I: limited to testes and spermatic cord
 +    * Stage II: lymph nodes below the diaphragm
 +    * Stage III: lymph nodes above the diaphragm
 +      * A: lymph nodes only
 +      * B: extranodal mets
 +  * Lymphatic spread: along gonadal veins → renal hilar nodes; external iliac nodes → para-aortic nodes
 +  * Hematogenous spread: uncommon except for choriocarcinoma
 +  * Cryptorchidism:​ located from inferior renal pole to superficial inguinal ring; ↑ risk of torsion (↑ 10x) + malignancy (↑ 50x); usually atrophic ​
 +===== Extratesticular Mass DDx =====
 +  * Inguinal hernia
 +  * Inflammatory mass such as infection, sarcoidosis
 +  * Benign neoplastic processes such as adenomatoid tumor, epidermoid inclusion cyst
 +  * Malignant processes such as soft tissue sarcomas, mesothelioma of the tunica, lymphoma, and metastatic disease. ​
 +
 +===== Peyronie'​s Disease =====
 +  * Calcification of tunica albuginea of corpora cavernosa
 +  * Idiopathic, older men (> 45 yrs old)
 +
 +====== Prostate ======
 +===== Anatomy =====
 +  * U/S → hyperechoic central gland = transitional + central zones
 +  * Transition zone (5%): periurethral → BPH
 +  * Central zone (25%): ejaculatory ducts
 +  * Peripheral zone (75%): carcinoma (> 80%); hypoechoic
 +===== BPH =====
 +  * periurethral transitional zone; enlarged, lobulated gland; cystic degeneration;​ Ca2+; elevation of bladder base; bladder wall thickening and trabeculation
 +===== Prostatic Cysts =====
 +  * Midline:
 +    * Mullerian duct: larger; extend superiorly
 +    * Utricular cyst: smaller; communicate with urethra; ↑ hypospadias
 +    * Ejaculatory duct cyst: acquired; due to obstruction
 +  * Eccentric:
 +    * Cystic prostatitis/​ carcinoma
 +    * Cystic BPH
 +  * DDX = seminal vesicle cysts → unilateral; ↑ ipsilateral renal agenesis (= Zinner syndrome) > cystic renal disease (APKD), renal ectopia, duplication,​ ectopic renal insertion
 +
 +===== Prostate Carcinoma =====
 +  * Clinical: # 2 male CA; enlarged gland with nodules; periprostatic stranding; regional nodes; direct extension to seminal vesicles, bladder; mets to axial skeleton
 +  * Radiographic:​ hypoechoic; ↓ T2 lesions in peripheral gland (DDX = prostatitis;​ fibrosis; hemorrhage)
 +==== Staging ====
 +  * Stage A: nonpalpable
 +  * Stage B: confined to prostate
 +  * Stage C: capsular involvement
 +    * 1: invasion
 +    * 2: penetration
 +    * 3: seminal vesicles
 +  * Stage D: metastases
 +    * D1: pelvic LN
 +    * D2: bone; distant LN
 +  * Treatment: Stage A/B → radical prostatectomy +/- XRT; Stage C/D → hormone therapy +/- XRT
 +
 +====== Peritoneal Cavity, Vessels, and Nodes ======
 +===== Fluid in peritoneal cavity =====
 +  * Ascites: serous; due to CHF, cirrhosis, hypoproteinemia,​ venous obstruction;​ accumulates in greater peritoneal space; density = 10-15 HU
 +  * Exudative ascites: pancreattis → accumulates within lesser sac; peritonitis;​ bowel perforation
 +  * Hemoperitoneum:​ density > 30 HU; “sentinel bleed” → accumulates at site of hemorrhage
 +  * Pseudomyxoma peritonei: due to appendiceal mucocele or mucinous cystadenocarcinoma of the ovary (> urachal/ endometrial CA); peritoneum filled with gelatinous mucin; Ca2+
 +===== Pneumoperitoneum =====
 +  * due to bowel perforation,​ pneumothorax,​ or mechanical ventilation
 +===== Peritoneal tumors =====
 +  * Peritoneal carcinomatosis:​
 +    * Etiologies: ovarian, pancreatic, gastric, and colon carcinoma
 +    * Radiographic:​ malignant ascites; tumor nodules/ Ca2+ → bowel wall nodularity; mesentery; “omental cake”; pouch of Douglas (“Blumer’s shelf); adnexa/ ovaries (Krukenberg tumor)
 +  * Peritoneal (cystic) mesothelioma:​ 20-40% in abdomen; ↑ women 30-40 years; irregular thickening of peritoneal surfaces; multilocular cysts; ascites; bowel compression without obstruction
 +  * Mesenteric lipodystrophy (= retractile mesenteritis):​ fat-density mass with tethering/ kinking/ angulation of adherent bowel loops
 +===== Abscess =====
 +  * Clinical: complications of trauma or surgery; pancreatitis;​ bowel perforation;​ commonly located within pelvis, subhepatic and subphrenic spaces
 +  * Radiographic:​ loculated fluid collection; thickened walls; gas; thickening of fascia; obliteration of fat planes; ascites; pleural effusions
 +===== DDx for cystic abdominal masses =====
 +  * Abscess
 +  * Loculated ascites
 +  * Pancreatic pseudocyst
 +  * Ovarian cyst/ tumor
 +  * Cystic teratoma: fat, water, Ca<​sup>​2+</​sup>​
 +  * Enteric duplication cysts: lined by GI mucosa
 +  * Lymphocele: complication of surgery / trauma
 +  * Cystic lymphangioma:​ mesenteric / omental
 +===== DDx for pelvic cystic masses =====
 +  * Ectopic pregnancy: adnexal/ tubal ring
 +  * TOA: tubo-ovarian abscess
 +  * Endometrioma
 +  * Ovarian neoplasms
 +  * Ovarian cysts
 +  * Extra-GU origin: abscess; urinoma; duplication/​ mesenteric cyst; etc.
 +===== Lymph nodes =====
 +  * Pathology: lymphadenopathy:​ > 10 mm in abdomen and pelvis; > 6 mm in retrocrural and porta hepatis regions
 +  * Hodgkin’s lymphoma: 40% of total; contiguous spread
 +  * Non-Hodgkin’s lymphoma: 60% of total; noncontiguous spread; ↑ GI involvement
 +===== DDx for hypodense intra-abdominal/​ retroperitoneal LAD =====
 +  * Infection: MAI > TB (↑ AIDS), histoplasmosis
 +  * Whipple’s disease: glycogen deposition
 +  * Tumors: lymphoma (post-therapy);​ nonseminomatous testicular CA; mucinous adenoCA (rare)
 +===== Trauma =====
 +  * Hemoperitoneum:​ density (30-45) HU; (60-80) HU → active bleeding (> 100 HU with contrast); “sentinel clot” → adjacent to injured organ (> 60 HU); free intraperitoneal contrast → bowel/ bladder perforation
 +  * Pneumoperitoneum:​ perforated viscous; PTX; mechanical ventilation;​ post-op
 +  * Subcapsular hematomas: crescentic → flatten parenchyma
 +  * Lacerations:​ jagged, linear low density areas
 +  * Intraparenchymal hematomas: rounded, low density areas
 +====== Retroperitoneum ======
 +===== Retroperitoneal fibrosis =====
 +  * ST-encasement of retroperitoneal vessels/ ureters without anterior displacement (DDX = lymphoma); prominent enhancement
 +  * Drugs: methylsergide;​ hydralazine
 +  * Lymphoma
 +  * Metastases: lung; breast; carcinoid
 +  * Other: AAA; trauma; surgery; instrumentation
 +  * Ormond’s disease: idiopathic
 +===== DDx for retroperitoneal masses =====
 +==== Malignant ====
 +  * MFH (#1)
 +  * Liposarcoma (#2)
 +  * Other: leiomyosarcoma;​ metastases; RCC/ adrenal extension
 +==== Benign ====
 +  * XGP
 +  * Neural tumors
 +  * Lymphangioma;​ hamangioma; lipoma
 +  * Teratoma (dermoid)
 +===== Retroperitoneal Fibrosis =====
 +  * Associated w/
 +    * aortic aneurysms
 +    * inflammatory bowel dz
 +    * urinomas
 +    * retroperitoneal hematomas
 +    * aortic and iliac graft procedures
 +    * infections
 +    * ergot alkaloids
 +    * sclerosing cholangitis
 +    * fibrosing mediastinitis
 +===== Waterhouse-Friderichsen syndrome =====
 +  * massive, usually bilateral, hemorrhage into the adrenal glands caused by fulminant meningococcemia
 +===== Low-density Retroperitoneal Nodes =====
 +  * Neoplastic
 +    * Testicular (particularly teratocarcinoma)
 +    * Epidermoid carcinoma of GU tract
 +    * Lymphoma
 +    * Leiomyosarcoma
 +  * Infectious
 +    * Whipple'​s Dz
 +    * MAI
gu.txt · Last modified: 2017/07/07 18:30 (external edit)