Ultrasound differentials
Terms
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Cystic lesions of liver
DDx
Grouped by how common -
COMMON – simple cysts
UNCOMMON –
-abscess
-hematoma
-cystic mets (ovar, lung, sarc)
-biloma
RARE –
-aneurysm / AVF
-adenoma
-echinococcus
-biliary cystadenoma - Calcified hepatic masses
-
* Large +/- mass
– mets (col, mucin ovar, brst, stom)
- fibrolamellar HCC
- old hematoma
- old abscess
* Small w/o mass
– granulomas
- PCP
- biliary stones - Hepatic target lesions
-
* Common – mets, HCC
* Uncommon – lymphoma, adenoma, FNH, fungal microabscesses - Diffuse hepatic inhomogeneity
-
* Common – cirrhosis, mets (breast), fatty change
* Uncommon – HCC, hep fibrosis, lymphoma - Homogeneous hyperechoic lesions in liver
-
* Common – hemangioma
* Uncommon – mets, fatty change, HCC
* Rare – adenoma, FNH - GB masses
-
common – polyps, adenomyomatosis, GB CA, tumefactive sludge
uncommon – mets (melanoma), chronic GBitis -
GB wall thickening
biliary vs non-biliary causes -
* biliary – GBitis, adenomyo, CA, HIV cholangiopathy, sclerosing cholangitis
* nonbiliary – hepatitis, pancreatitis, CHF, hypoproteinemia, cirrhosis, portal HTN, lymphatic obstr - GB fossa shadowing
-
stone-filled GB
porcelain GB
emphysematous cholecystitis - Intrahepatic biliary ductal echogenic foci
-
pneumobilia
stones
calcified HA
PV gas - Bile duct wall thickening
-
-CBD stones
-cholangioCA
-cholangitis (scler, asc, HIV, orient)
-pancreatitis -
Porta hepatis cystic lesion
DDx -
choledochal cyst
liver cyst
duodenal duplication cyst
omental or mesenteric cyst
pancreatic pseudocyst
R renal cyst
HA aneurysm - DDx simple renal cyst
-
caliceal diverticula
aneurysm/pseudoaneurysm
AVM
papillary necrosis
obstr upper pole duplication
lymphoma - Renal cystic disease
-
ADPKD
acquired cystic disease
VHL
TS
MCDK - Solid renal mass
-
RCC
AML
TCC
oncocytoma
lymphoma
mets - Intraluminal mass in collecting system
-
TCC
blood clot
fungus ball
fibroepithelial polyp
malacoplakia
stone
sloughed papilla - Complex cystic renal masses
-
hemorrhagic cyst
infected cyst
multiseptated cyst
abscess
hematoma
cystic RCC
multilocular cystic nephroma
cystic Wilm’s - Urothelial thickening
-
pyelonephritis
ureteral calculi
relieved obstruction
transplant rejection
transplant ischemia
TCC - Nephrocalcinosis DDx
-
medullary sponge kidney
RTA
HPT
Lasix therapy in kids - Renal parenchymal disease seen on ultrasound
-
GN
AIDS
amyloid
drugs
HTN
DM - Solid hypoechoic pancreatic mass
-
CA
focal pancreatitis
lymphoma
mets
islet cell tumor
thrombosed aneurysm
peripancreatic lymph node - Cystic pancreatic lesions
-
pseudocyst
micro / macrocystic tumor
IPMT
SPEN
ADPKD
VHL
CF
tortuous splenic artery
splenic artery aneurysm - Splenic cyst
-
epidermoid
trauma
parasitic - Splenic solid lesion
-
hemangioma
lymphoma
infarct
abscess
granulomatous/sarcoid
extramed hematopoeisis
mets (melanoma) - Splenomegaly
-
*COMMON
- CHF, portal HTN
- lymphoma, leukemia
- hepatitis, mono
- hemolytic anemias
*UNCOMMON
- glycogen storage dz
- malaria
- myelofibrosis - Cystic scrotal lesions
-
hydrocele
varicocele
spermatocele
epididymal cyst
intratesticular cyst
tubular ectasia of rete testis
tunica albuginea cyst - Solid testicular lesions
-
seminoma
mixed germ cell tumor
epidermoid cyst
mets
lymphoma
microlithiasis
mimics of tumor – focal orchitis, atrophy, infarct, abscess, hematoma, adrenal rests - Solid extratesticular lesions
-
adenomatoid tumor of epididymis
chronic inflammatory mass
sperm cell granuloma
scrotal pearl - Enlarged hypoechoic testis
-
orchitis
torsion
lymphoma
diffuse seminoma - Hypoechoic prostate nodule
-
CA
prostatitis
atrophy
fibrosis
infarct
BPH -
Bladder wall thickening
DDx -
Bladder outlet obstruction
tumor
infection
RTx
neurogenic -
Bladder wall calcification
DDx -
Schistosomiasis
cytoxan
RTX
interstitial cystitis
TB
TCC - Thickened hyperechoic endometrial stripe
-
*Pregnancy related
– nl early IUP
- ectopic
- incomplete Ab or RPOC
- endometritis
- molar preg
*Postmenopausal
– hyperplasia /polyps /CA
- tamoxifen
- HRT - Hypoechoic structures in hyperechoic endometrium
-
*Premenopausal
– molar pregnancy
- RPOC
- degenerated fibroid
- degenerated placenta
*Postmenopausal
– hyperplasia /polyps/ CA - Fluid in endometrial cavity
-
*Acquired (cervical sten) – cervical CA, endometrial CA, endometritis, PID, RTX
*Pregnancy related – early IUP, pseudogestational sac, blighted ovum
*Congenital – imperforate hymen, vaginal septum, vaginal atresia, rudimentary uterine horn - Uterine enlargement or distortion DDx
-
fibroids (#1)
adenomyosis
pregnancy - Uterine bleeding
-
endometrial atrophy
hyperplasia
polyps
CA
adenomyosis
submucosal fibroid - Uterine and vaginal cystic masses
-
Nabothian cyst
Gartner’s duct cyst
Bartholin cyst
hydrometrocolpos - Shadowing in endometrial cavity
-
IUD
Ca++ from fibroids or TB
gas - Congenital uterine anomalies
-
septate
bicornuate
didelphys
arcuate
unicornuate
hypoplastic
in-utero DES exposure - Cystic adnexal masses
-
Endometrioma
Hemorrhagic ovarian cyst
Dermoid
Abscess
Cystadenocarcionoma
Ectopic pregnancy - Complex pelvic masses
-
*Ovarian – ectopic, TOA, endometrioma, hemorrhagic cyst, torsion, dermoid, CA
*Tubal – pyosalpinx
*Uterine – pedunculated fibroid, extruded IUD, CA
*Other – pelvic abscess, appy, tic-itis, hematoma, pelvic kidneys, iliac aneurysm - Pelvic masses with homogeneous low-level echoes
-
TOA
endometrioma
hemorrhagic cyst - Solid ovarian masses
-
fibroma
thecoma
endometrioma
germ cell tumor
CA
mets
mimics - pedunc fibroid, LAD - Endometrial filling defect by HSG
-
submucosal fibroid
air bubble
endometrial polyp
blood clot
retained POC
IUP
synechiae - Tubal filling defects by HSG
-
polyp
CA
tubal pregnancy
air bubble - Tubal irregularity by HSG
-
SIN
tubal diverticula
endometriosis
post-op changes
TB - Diverticula seen on HSG
-
uterus – adenomyosis
isthmus – SIN, TB - Pseudokidney sign on US
-
IBD
Tumor
Intussusception
Always exclude pelvic kidney - 1st trimester bleeding DDx
-
normal IUP
abortion
ectopic
GTD
subchorionic hemorrhage - Signs of spontaneous abortion
-
TV 18mm MGSD without embryo
13 mm MGSD without YS
5 mm CRL without heart motion - Empty gestational sac
-
normal early IUP
blighted ovum
pseudosac with ectopic - Echogenic central cavity of uterus
-
decidual reaction
hemorrhage
RPOC - Complex intrauterine mass
-
missed abortion
fetal demise
molar pregnancy
degenerated fibroid
endometrial CA - Elevated MSAFP
-
incorrect dates
multiple gestation
NTD
abd wall defect
GI obstruction
renal anomalies
fetal hepatitis
placental hemorrhage - Low MSAFP DDx
-
Downs
trisomy 18
incorrect dates
fetal death
hydatidiform mole
not pregnant - Hydrops DDx
-
*Immune
*Nonimmune (most)
– cardiac tachyarrh or defect
- chromosomal
- twin-twin transf
- anemias
- infection
- idiopathic - Polyhydramnios DDx
-
*Maternal – DM, HTN
*Fetal – NTD, prox GI obstr, chest masses, twin-twin transf, nonimmune hydrops, chromosomal, infection
*Idiopathic -
Oligohydramnios DDx
(DRIPPC) -
Demise
Renal anomalies
IUGR
PROM
Post-dates
Chromosomal anomalies -
Placentomegaly
>4cm thick
DDx -
hydrops
maternal DM
maternal anemia
TORCH
intraplacental hematoma - Small placenta DDx
-
maternal HTN
toxemia
severe DM
IUGR - Abnormal placental echotexture
-
*partial mole
*hydropic placenta
*hemorrhage or abruption
*chorioangioma
*common but minor findings (venous lakes, infarcts) -
Umbilical cord abnormalities
-single artery
-enlarged cord
-other -
solitary artery - trisomy 13, 18, structural anomalies
enlarged cord – edema, hematoma, cysts, mucoid degeneration of Wharton’s jelly
other – knots, varices, straight cord, nuchal cord, vasa previa - Abnormal lower uterine segment
-
*cord prolapse (T-burg & call OB)
*incompetent cervix
*placenta previa
*cerclage
*low fibroid - 3rd trimester bleeding
-
placenta previa
abruption
cervical lesions
idiopathic -
Masses during pregnancy
-uterus
-adnexal
-other -
*uterus – fibroid, focal contraction, GTD, hemorrhage
*adnexal – CLC, dermoid, theca lutein cysts, other ov neoplasms
*other – PID, appendiceal abscess - Signs of fetal death
-
no fetal heartbeat
absent fetal movement
overlapping skull bones (Spalding’s sign)
gross distortion of anatomy (maceration)
soft tissue edema - Cystic CNS structures
-
*Supratent – CPC, hydroceph, hydranenceph, porenceph, holoprosenceph, arachnoid cyst, teratoma
*Posterior fossa – DW malf, arachnoid cyst, mega cisterna magna
*Midline cysts – cavum septum pellucidum, dorsal cyst in ACC, vein of Galen AVM - Hydrocephalus seen on prenatal US
-
obstructive - NTD (Chiari II), DW cplx, aqueductal stenosis, ACC (colpocephaly)
nonobstructive – hemorrhage, infection - Cystic head and/or neck masses on prenatal US
-
cystic hygroma
encephalocele
hemangioma
teratoma
branchial cleft cyst
thyroglossal duct cyst
nuchal cord - Cystic back masses seen on prenatal US
-
NTD
cystic teratoma - Hyperechoic brain mass seen on prenatal US
-
hemorrhage
teratoma
callosal lipoma - Incomplete skull mineralization seen on prenatal US
-
OI
hypophosphatasia
achondrogenesis -
Skull deformities seen on prenatal US
-Lemon sign
-Cloverleaf skull -
*Lemon sign – normal, myelomeningocele, encephalocele
*Cloverleaf skull – craniosyn, thanatophoric dwarf - Kyphoscoliosis seen on prenatal US
-
isolated – hemivertebra, butterfly vertebra
complex – VACTERL, limb-body wall complex, skeletal dysplasias - Cystic thoracic masses seen on prenatal US
-
CDH
CCAM (types 1,2)
cysts (bronch, duplic, pericard)
cystic hygroma - Solid echogenic thoracic masses seen on prenatal US
-
*CDH
*CCAM (type 3)
*Sequestration
*Tumors (teratoma, neurogenic tumors, cardiac rhabdomyoma) - Pleural effusion seen on prenatal US
-
*unilat usu due to lung masses – CDH, CCAM, sequestration
*bilateral – hydrops, lymphangiectasia
*uni or bilateral – infection, chromosomal, idiopathic - Absent stomach bubble on prenatal US
-
oligohydramnios
swallowing prob - CNS defect
EA
CDH
situs abnormality
trisomy 18 - Double bubble sign on prenatal US
-
assoc with polyhydramnios
duodenal atresia
annular pancreas
proximal jejunal atresia
gut duplication - Dilated bowel seen on prenatal US
-
atresia / stenosis
volvulus
meconium ileus
enteric duplication
Hirschsprung’s
proximal obstructions usu a/w polyhydramnios
distal obstructions usu a/w nl amniotic fluid -
Echogenic bowel seen on prenatal US (as bright as bone)
DDx? -
normal variant in 2nd trimester
CF (common)
Downs
IUGR
CMV
SB atresia or volvulus
swallowed blood in amn fluid - Abdominal calcification seen on prenatal US
-
meconium peritonitis (most common)
meconium ileus
atresias
volvulus
renal
liver TORCH
neuroblastoma
teratoma
fetal gallstones - Hydronephrosis seen on prenatal US
-
UPJ (#1)
UVJ
duplex collecting system
BOO (PUV, prune belly) - Common renal anomalies detected by prenatal US
-
agenesis
ectopic kidney
hydronephrosis
ARKD
MCDK - Cystic abdominal structures on prenatal US
-
hydronephrosis
fluid-filled dilated bowel
ascites
meconium pseudocyst
cysts (mesent, urachal, duplication, ovarian, choledochal) - Liver abnormalities on prenatal US
-
*calcification – TORCH
*cysts – simple, polycystic dz, choledochal cyst, Caroli’s, hamartoma
*masses – teratoma, hepatoblastoma, hemangioma, hemangioendothelioma, hamartoma - Splenomegaly seen on prenatal US
-
immune hydrops
PROM
TORCH - Ascites seen on prenatal US
-
hydrops
meconium peritonitis
urine ascites
infection
pseudoascites - Anterior wall defects
-
midline – omphalocele
lateral – gastroschisis, amniotic band syndrome
infraumbilical – bladder or cloacal exstrophy - Sacral region anomalies seen on prenatal US
-
teratoma
meningocele
duplication cyst
caudal regression syndrome - Polydactyly on prenatal US
-
familial
trisomy 18, 13
Meckel-Gruber syndrome
chondroectodermal dysplasia - Clubfoot seen on prenatal US
-
amniotic band syndrome
trisomy 18
meningocele
idiopathic - Features of trisomy 21
-
–ECD
–echogenic bowel
–nuchal tranlucency/thickening
–short humerus and femur
–pyelectasis
–cystic hygroma
–duodenal atresia
–echogenic cardiac focus
–widened iliac angle - trisomy 18 features
-
–clenched fists
–cardiac anomalies
–cystic hygroma
–omphalocele
–strawberry shaped calvarium
–choroid plexus cyst
–enlarged cisterna magna
–myelomeningocele
–rocker-bottom and clubfoot - trisomy 13 features
-
–IUGR
–Holoprosenceph, Mega cisterna magna
–cleft lip/palate, cyclopia
–hypotelorism
–nuchal thickening
–hydrops
–enlarged echogenic kidneys
–omphalocele
–polydactyly, rocker/ clubfoot
-clenched overlapping digits
–cardiac anomalies - Turner’s features
-
–coarctation
–bicuspid aortic valve
–nuchal thickening
–cystic hygroma