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Genitourinary > Fair Game > Flashcards

Fair Game Flashcards

1
Q

Case 56

What do you do with CT contrast and Metformin to avoid contrast-induced nephropathy?

A

Hold Metformin for 48 hours
Check blood for signs of CIN
Restart if all is well

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2
Q

Case 56

What do you when there is CT contrast extravasation in the arm?

A 
Elevate the arm
Cold compress
Call Surgeon
 - Lg vol high-osmolar contrast w necrosis
 - Neuromuscular dysfunction
 - Compartment Syndrome
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3
Q

Case 56

When does the severity of the soft tissue injury peak after contrast extravasation in an extremity?

A

48 hours

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4
Q

Case 56

How do you treat hives (urticaria) if Benadryl isn’t working?

A

Consider

  • Cimetidine
  • Epinephrine
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5
Q

Case 56

How do you treat a contrast reaction of hypotension with bradycardia?

A

Atropine

- Vasovagal reaction!

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6
Q

Case 56

How do you treat a contrast reaction of hypotension with tachycardia?

A

Trendelenburg position
IV fluids
Epinephrine

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7
Q

Case 56

How do you treat a contrast reaction of dyspnea?

A

Oxygen

Beta-agonist inhalants

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8
Q

Case 57

Name three causes of Medullary Nephrocalcinosis

A

Hyperparathyroidism
Renal Tubular Acidosis
Medullary sponge kidney
- typically unilateral

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9
Q

Case 57

Is renal function impaired with Medullary Nephrocalcinosis?

A 
No (particularly if it is reversed)
Unless
 - Severe, long-standing hypercalcemia
and/or
 - Renal tubular acidosis
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10
Q

Case 57

What is the most common complication of Medullary Nephrocalcinosis?

A

Urolithiasis

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11
Q

Case 58

What GU tract anomalies are associated with ureteral duplication?

A

UPJ Obstruction
Hydronephrosis
Ureterocele
Ureterovesical reflux

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12
Q

Case 58

What is the Weigert-Meyer rule?

A

Upper pole ureter
- Inserts inferior and medial to the lower pole ureter

Upper pole moiety
- Obstructs

Lower pole moiety

  • Refluxes
  • Causes lower pole atrophy
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13
Q

Case 59

What is the conventional treatment for emphysematous pyelonephritis?

A

Radical nephrectomy

Drainage / Abx is Insufficient

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14
Q

Case 59
What type of patients are predisposed to emphysematous pyelonephritis?

What is the most common organism?

A

Diabetics

E. coli

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15
Q

Case 60

What mechanism causes a horseshoe kidney?

A

Arrest of cranial migration of the kidney by the IMA

Abnormal contact of the developing metanephric tissues

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16
Q

Case 60

What are common complications associated with horseshoe kidneys?

A

Nephrolithiasis
UPJ obstruction
Duplication anomalies
Recurrent infection
Higher susceptibility to renal injury from trauma
TCC (slight increase in incidence from urinary stasis)

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17
Q

Case 61

Dx of a solid, enhancing renal mass?

A

RCC
Oncocytoma
Lipid-poor angiomyolipoma
Metastasis

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18
Q

Case 61
What percentage of angiomyolipomas have no identifiable fat on CT or MRI?

What complication is AML associated with?

A

5%

Spontaneous Hemorrhage

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19
Q

Case 62

What percentage of angiomyolipomas are associated with tuberous sclerosis?

A

20%

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20
Q

Case 62
What size of an AML increases risk of bleeding?

What causes the tumor to bleed?

How do you deal with a nonhemorrhagic AML?

A

> 4cm

Small aneurysms develop in arteries supplying AML’s

Prophylactic excision, ablation, or embolization

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21
Q

Case 63

A patient with multiple AML’s likely has?

A

Tuberous sclerosis

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21
Q

Case 63

Three skin lesion associated with Tuberous Sclerosis?

A

Adenoma sebaceum (Adenofibroma)
Nevus depigmentosus
Cafe au lait spots

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22
Q

Case 63

What percentage of tuberous sclerosis patients have AML?

A

80%

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23
Q

Case 63
What are the 6 primary features of tuberous sclerosis?

(This to me is more of a neuroradiology question!)

A 
Cortical tubers
Giant cell astrocytoma
Calcified subependymal nodules
Retinal astrocytoma
Facial angiofibromas
Ungual fibromas
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24
Q

Case 64

What other renal masses besides angiomyolipoma can contain fat?

A 
Angiomyolipoma
Rarely
 - Lipoma
 - Liposarcoma
 - Wilms' tumor (dedifferentiated)
 - RCC that engulfs adjacent renal hilar fat
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25
Q

Case 65

Define a Bosniak I renal cyst and how do you manage it?

A

Simple cyst

  • No follow-up
  • Round
  • Imperceptible wall
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26
Q

Case 65

Define a Bosniak II renal cyst and how do you manage it?

A

Minimally complex

- No follow-up

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27
Q

Case 65

Define a Bosniak IIF renal cyst and how do you manage it?

A 
Minimally complex: 6 month follow-up
>3cm
>3 septa that are thicker or nodular
Thick calcification
Hyperdense but nonenhancing
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28
Q

Case 65

Define a Bosniak III renal cyst and how do you manage it?

A

Indeterminate

  • 25-45% malignant
  • Partial nephrectomy/RFA
  • Multiple thick septations
  • Coarse calcifications
  • Hyperdense and enhancing
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29
Q

Case 65

Define a Bosniak IV renal cyst and how do you manage it?

A

Malignant

  • Partial or total nephrectomy
  • Solid and enhancing mass
  • Cystic or necrotic components
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30
Q

Case 66

What renal tumor do patients with horseshoe kidneys more commonly have?

A

TCC
- Related to renal stasis

No increase in RCC incidence

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31
Q

Case 66

Why should you always perform an angiogram in patients who have horseshoe kidney and RCC?

A

Surgical planning
Almost always have
- Aberrant arterial supply
- Anomalous Venous drainage

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32
Q

Case 66

What pathology occurs with increased incidence in the setting of horseshoe kidney?

A

Infections
Stones
UPJ Strictures
TCC

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34
Q

Case 67

What are causes of spontaneous perinephric hemorrhage

A 
Neoplasm (60%)
Complicated renal cyst
Vasculitis
Infarction
Infection
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35
Q

Case 68

DDx on U/S of a solid, heterogenous, hyperechoic mass (4 lesions)?

A

Renal cell carcinoma
Oncyocytoma
AML
Metastasis

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36
Q

Case 68

What differentiates Stage III from Stage IV RCC?

A

Stage III

  • Regional lymph nodes
  • Venous extension

Stage IV

  • Direct invasion of adjacent organs (besides adrenal)
  • Distant metastasis
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37
Q

Case 69

What are four causes of renal vein thrombosis?

A

RCC
Hyper coagulable state
Dehydration
Glomerulonephritis

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38
Q

Case 69

What has a better prognosis in Stage III RCC, venous extension or regional lymph node involvement?

A

Venous extension

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39
Q

Case 69
Why is it important to determine if renal venous tumor thrombosis with IVC thrombus extends above the level of the hepatic veins?

A

If it extends above the hepatic veins

  • Abdominal incision isn’t enough for resection
  • Requires thoracoabdominal incision w/ cardiopulmonary bypass
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40
Q

Case 70

What three diseases are associated with renal cysts and solid renal masses?

A

Tuberous sclerosis
von Hippel-Lindau Disease
Long-term dialysis

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41
Q

Case 70

What are common manifestations of vHL Disease

A 
Retinal angiomas
Renal cysts
RCC (clear cell variety)
Pancreatic cysts and cystic tumors
Cerebellar hemangioblastomas
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42
Q

Case 70

A patient with multiple renal cysts. What helps differentiate the cause between ADPKD v. vHL Disease

A

If they have pancreatic cysts, it’s most likely vHL.

Patients with ADPKD don’t get pancreatic cysts

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43
Q

Case 71

What tumors grow in the kidney in an infiltrative pattern?

A

Urothelial tumors (TCC or SCC)
Metastasis
Lymphoma
Infiltrative RCC

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44
Q

Case 71

What are common causes of bilateral or multiple renal solid masses?

A

Metastasis
Oncocytoma

Lymphoma
AML
Multifocal RCC

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45
Q

Case 72

What two renal lesions are common in patients with tuberous sclerosis?

A

AML

Renal cysts

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46
Q

Case 73

A solid renal mass with a central stellate scar (spoke-wheel on angiography) is diagnostic of an oncocytoma. T or F?

A

False

  • Highly suggestive
  • Not diagnostic
  • May be RCC

This is a surgical lesion! Biopsy won’t help. Take it out!

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47
Q

Case 74

DDx of bilateral infiltrative renal lesions (tumors and nontumors)?

A

Metastasis
Lymphoma
Infarcts
Pyelonephritis

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48
Q

Case 75

What are four ways that lymphoma involving the kidneys presents?

A

Perirenal space spread from retroperitoneum
Multifocal infiltrative renal masses
Diffuse renal infiltration
Solid renal mass (mimics RCC)

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49
Q

Case 75

How can ureteral position help differentiate lymphoma from retroperitoneal fibrosis

A

Lymphoma
- Lateral ureteral displacement

RPF
- Medial ureteral displacement

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49
Q

Case 75

What type of lymphoma involves the kidneys?

A

Non-Hodgkins Lymphoma

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50
Q

Case 76

What helps differentiate a right perinephric abscess caused by a perforated duodenal ulcer from pyelonephritis?

A

Normal cortical enhancement is unusual in pyelonephritis

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51
Q

Case 77

When you see a rim of enhancement around a renal cortical infiltrative abnormality, what is the likely diagnosis?

A

Renal infarct

The rim is caused by flow from the renal capsular artery

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52
Q

Case 78

What causes a “faceless kidney,” which is defined as a sold mass proliferating the renal sinus and obliterating its fat?

A

Transitional cell carcinoma

Squamous cell carcinoma less commonly

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53
Q

Case 79

What is the mechanism of developing xanthogranulomatous pyelonephritis (XGP)?

A

Recurrent upper urinary tract infections
- E. coli or Proteus
Calculus formation
- Obstruction
Renal inflammation with lipid-laden histiocytes
Destruction and replacement of renal parenchyma

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54
Q

Case 79

What patients are most susceptible to XGP?

A

Middle-aged women

Diabetics

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55
Q

Case 80

What mechanism causes a urinoma?

A

Laceration of the ureter at the UPJ

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56
Q

Case 80

How is a urinoma treated non-surgically to allow the ureteral laceration to heal?

A

Percutaneous nephrostomy

Ureteral stent

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57
Q

Case 80

What is a Page kidney?

A

Renovascular hypertension

  • Subcapsular fluid (or hematoma)
  • > Compresses renal parenchyma
  • > Underperfusion and ischemia
  • > Triggers renal renin-angiotensin-aldosterone system
  • -> HTN
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58
Q

Case 80

What is a Goldblatt kidney?

A

Renovascular hypertension

- Caused by renal artery stenosis or occlusion

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59
Q

Case 81

What are two ways that a subcapsular hematoma can be distinguished from a hematoma in the peritoneal space?

A

Subcapsular hematoma deforms the renal shape

- No fat plane between the hematoma and the kidney

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60
Q

Case 81

Name 3 causes of a subcapsular hematoma

A

Trauma (blunt or biopsy)
Vasculitis
Vascular malformation

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61
Q

Case 82

What are known complications of renal biopsy?

A

Hemorrhage Abscess
Hematuria Sepsis
AV fistula Page Kidney

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62
Q

Case 82

What are 5 entities that are bright on T1 weighted MRI

A

Fat Methemoglobin
Melanin Gadolinium
Protein

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63
Q

Case 82

What are two risk factors for post-biopsy bleeding?

A

Coagulopathy

Severe hypertension

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64
Q

Case 83

Besides RCC, Dehydration, and Hypercoagulability, what are other less common causes of renal vein thrombosis?

A

Sickle cell disease
Vasculitis
Amyloidosis
Lupus

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65
Q

Case 83

What percentage of patients with renal vein thrombosis develop PE?

A

33%

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66
Q

Case 84

What % of patients on long-term dialysis develop RCC?

A

7%

RCC in these patients is typically less aggressive

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67
Q

Case 84

What is also common in long-term dialysis patients?

A

Multiple renal cysts

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68
Q

Case 85
T/F
Bilateral orthotopic uretereoceles are not associated with other urinary tract anomalies.

A

True

- Ectopic ureteroceles are however

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69
Q

Case 85

Ureteroceles >2 cm have a higher risk of what complications?

A

Urinary stasis
Obstruction
Stone formation
Infection

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70
Q

Case 85
What is the maximum thickness of the radiolucent halo around an orthotropic ureterocele?

Failed resorption of what structure is the proposed cause of this abnormality?

A

2 mm

Chwalla’s membrane

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71
Q

Case 86

What is a ureterocele-like abnormality with an irregular wall surrounding its bulbous portion or a thick halo (>2mm)

A

Pseudoureterocele

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72
Q

Case 86

What causes a Pseudoureterocele?

A

Ureteral stones
Edema from a recently passed ureteral stone
Manipulation of the UVJ
Bladder tumor blocking the ureteral orifice

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73
Q

Case 87

What is an amputed calyx on an IVP or CT urogram?

A

Abrupt cutoff of the infundibulum with minimal opacification of the calyces

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74
Q

Case 87

DDx of an amputed calyx on an IVP or CT urogram

A

TCC

TB

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75
Q

Case 88
What percentage of patients with calyceal TCC have synchronous tumors of the calyces?

Bladder?

A

25%

40%

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76
Q

Case 89

What is the single most important risk factor for TCC?

A

Smoking

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77
Q

Case 89

How does TCC typically present?

A

Hematuria (72%)
Dull pain (22%)
Renal colic due to obstruction
- Rare

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78
Q

Case 90

What is a Goblet sign?

A

Ureteral dilation below a radiolucent filling defect

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79
Q

Case 90

A “Goblet sign” is pathognomonic for what diagnosis?

A

Papillary TCC

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80
Q

Case 90

What causes the ureter to dilate with a TCC giving the appearance of a goblet?

A

Long-standing, slowly growing polypoid mass that is continuously being pushed down by peristalsis

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81
Q

Case 91

DDX of multiple ureteral filling defects on IVP

A

Uric acid stones Blood clots
Air bubbles Infectious debris (fungal)
Multifocal TCC (1/3 of patients) Sloughed papillae

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82
Q

Case 91

What percentage of TCC is Papillary?

A

67%

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83
Q

Case 92

Explain forniceal rupture related to a ureteral stone.

A

Spontaneous rupture of a calyceal fornix
Relief or “pop-off” valve reducing pressure
Contrast or urine extravasates into the perirenal space

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84
Q

Case 92
How does a fornix rupture present?

Is it an emergency?

A

Sudden relief of obstructive symptoms

It is a totally benign entity of no clinical significance

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85
Q

Case 93
T/F
Renal stones are the most common cause of transplant kidney hydronephrosis?

A

False

Stones only account for 2% of post-transplant hydro

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86
Q

Case 93

What are causes of transplant kidney hydronephrosis?

A

Anastomotic stricture
Blood clot
Ureteral edema
Pertransplant fluid collection (lymphoceles)

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87
Q

Case 93
How do you treat transplant kidney hydronephrosis?

Is the hydronephrosis symptomatic?

A

Percutaneous nephrostomy
Placement of a nephrovesical stent

No - painless in transplant kidney

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88
Q

Case 94

What is the likely cause of hematuria in a patient with hematuria and large filling defect in the kidney on IVP?

A

TCC
RCC
Vascular malformation

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89
Q

Case 94

What enzyme in urine leads to rapid change of pyelocalyceal blood clots?

A

Urokinase

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90
Q

Case 95

How do you best diagnose a traumatic ureteral injury?

A

CT Abdomen/Pelvis with IV only

Early and delayed images

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91
Q

Case 95

What are typical CT findings of ureteral injury?

A

Normal renal enhancement
Medial perirenal contrast extrav
Nonopacification ipsilateral distal ureter

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92
Q

Case 95

What is the best treatment for ureteral injury?

A 
Percutaneous nephrostomy
Nephroureteral stent placement
Percutaneous urinoma drainage
NOT surgery
 - They don't do as well
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93
Q

Case 96

DDX for distal ureteral stricture

A 
Extrinsic compression
 ->Tumor
Periureteral inflammation
 -> Appendicitis, IBD, Endometriosis
Iatrogenic stricture
Infection
 ->TB or Schistosomiasis
Radiation
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94
Q

Case 96

How do you treat distal ureteral stricture?

A

Stent placement
Balloon dilation
Surgical resection

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95
Q

Case 97

What is a retrocaval ureter?

A

Abnormal course of the ureter posterior to the IVC

- Caused from anomalous development of IVC

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96
Q

Case 97

What defines medial displacement of the ureter?

A

The ureter courses medial to the L3 or L4 pedicle

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97
Q

Case 97

DDX for medial displacement of the ureter

A

Retroperitoneal fibrosis
Retroperitoneal mass
Prior surgery
Retrocaval ureter

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98
Q

Case 98

Where do most bladder tumors occur?

A

Posterolateral wall near the trigone

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99
Q

Case 98

What are the most common bladder tumors

A

TCC: 90%
SCC: 5%
Adenocarcinoma: 2%

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100
Q

Case 98

What predispose a patient to bladder squamous cell CA?

A

Schistosomiasis
Neurogenic bladder
Chronic Foley catheterization

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101
Q

Case 98

What is the most important prognostic factor for bladder cancer

A

Depth of bladder wall invasion (T2 or T3)

Treated with bladder cystectomy, not transurethral resection

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102
Q

Case 99

What causes bladder diverticula to develop?

A

Chronic bladder outlet obstruction

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103
Q

Case 99

What are common complications of bladder diverticula?

A

Chronic ureteral obstruction
Stones
Infection
Tumor

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104
Q

Case 100

What is an Indiana Pouch?

A

A urinary diversion

  • Conduit of cecum and distal terminal ileum
  • Prevents reflux and provides urinary continence
  • No need for osmtomy bag with good capacity (0.5-1 L)
  • Allows self-catheterization every 3-6 hours
105
Q

Case 100

What is the best CT technique for evaluating a urinary diversion?

A

Oral only or IV only

- Allows separation of GI and GU tracts

106
Q

Case 101

What is a Koch Pouch?

A

Continent cutaneous urinary diversion

Uses Terminal ileum

107
Q

Case 101:

What early complications occur with Koch Pouch?

A

Anastamotic leak
Dehydration
Sepsis

108
Q

Case 101:

What major late complications occur with Koch Pouch?

A

Struvite pouch stones
Afferent nipple stenosis
Reflux

109
Q

Case 102

What is The Parfait Sign on MRI?

A

3 layers seen in the bladder on postcontrast MRI
Top layer: Urine (long T1)
Middle layer: Mixture or urine and Gd (short T2)
Bottom layer: Gadolinium

110
Q

Case 103
What is the most common cause of vesicovaginal (VV) fistula in the US?

World wide?

A

XRT

Obstetric trauma

111
Q

Case 103

What CT technique should be used to detect VV fistula?

A

IV contrast only

Delayed images with 3-5mm thin sections

112
Q

Case 104

What are causes of a “pear-shaped” bladder?

A

Hematoma Urinoma
Lipomatosis IVC Obstruction
Lymphadenopathy Lymphocysts

113
Q

Case 105

Who typically gets pelvic lipomatosis…Sex and race?

A

African American Men

  • Men 94%
  • African American 2/3

Many are obese

114
Q

Case 105

What is the diagnosis if you see a pear-shaped bladder with multiple lobulated filling defects?

A

Pelvic Lipomatosis with Cystitis Glandularis

115
Q

Case 106

What are the major causes of hemorrhagic cystitis?

A

Chemical urotoxins (Cyclophosphamide)
Radiation
Immune-mediated injury (related to viruses)

116
Q

Case 106

What cancers is radiation cystitis most commonly related to

A

Prostate

Cervical

117
Q

Case 107

Does cyclophosphamide treatment increases risk for cancer?

A

Yes

118
Q

Case 107

How do you treat cyclophosphamide cystitis?

A

Forced diuresis
Bladder irrigation
Mesna

119
Q

Case 108

What is the classic symptom with bladder herniation through the inguinal canal?

A

Two-stage voiding

120
Q

Case 108

An indirect inguinal hernia lies lateral to what artery?

A

Deep inferior epigastric artery

121
Q

Case 108

What are complications of a bladder hernia?

A 
Hydronephrosis
Strangulation
Stone formation
VU Reflux
Inadvertent perforation in surgery
122
Q

Case 109

DDX for mural bladder calcification

A

Schistosomiasis - ascends to the bladder from the prostate
TB cystitis - descends to the bladder from the kidney
Radiation cystitis
Intravesical chemotherapy
Neoplasm - SCC from chronic Schistosomiasis

123
Q

Case 109

What is an imaging sign of malignant transformation in the bladder in a patient with mural calcification

A

Disruption of the calcification

124
Q

Case 110

What is an artificial urinary sphincter used for

A

Stress incontinence
Post-prostatectomy sphincter weakness
Kids with incontinence related to spinal dysraphism

125
Q

Case 111
Who typically have Congenital urethral diverticula? M or F?

Who typically have Acquired urethral diverticula? M or F?

A

Boys - 98%

Women

126
Q

Case 111

What symptoms are seen with urethral diverticula?

A

Dyspareunia
Postvoid dribbling
UTI’s

127
Q

Case 111

Urethral diverticula in women involve what segment?

A

The middle 1/3 dorsolaterally

More common in African-American women

128
Q

Case 112

How do urethral diverticula occur in females?

A

Skene’s glands posteriorly in the inferior urethra obstruct leading to more proximal diverticula (in the middle 1/3)

129
Q

Case 112

What is the most common tumor that develops in a urethral diverticulum?

A

Adenocarcinoma

130
Q

Case 113
What are the 4 parts of the male urethra?

What separates the anterior and posterior portions of the male urethra?

A 
Anterior
 - Penile
 - Bulbous
Posterior
 - Membranous
 - Prostatic

Urogenital diaphragm divides anterior from posterior

131
Q

Case 113

How is a urethral injury typically treated

A

Suprapubic catheter for 3-6 months

132
Q

Case 113
Describe the most common urethral injury?

What is it’s most common cause?

A

Type III

  • Disrupted membranous and bulbous urethra
  • Disrupted urogenital diaphragm and extravasation

MVC with pelvic fractures

133
Q

Case 114

What are three causes of a urethral diverticulum?

A

Infection
Trauma
Prolonged catheterization

134
Q

Case 115

DDX of an irregular urethra with stricture and filling defects

A

Carcinoma
- Predominantly SCC

Benign Conditions

  • Papillary urethritis
  • Nephrogenic adenoma
  • Condylomata acuminata
  • Amyloidosis
  • Sarcoidosis
  • Balanitis xerotica obliterans
135
Q

Case 115

What has a better prognosis, anterior v. posterior urethra carcinoma?

A

Anterior

135
Q

Case 115

Most commonly cited risk factor for SCC of the urethra?

A

Chronic urethral stricture of any cause

136
Q

Case 116
Define septate uterus

How is it treated?

A

Divided by fibrous septum

  • Convex, flat, or minimally indented
  • Intercornual distance less than 4 cm

Treatment
- Hysteroscopic metroplasty

137
Q

Case 116
Define bicornuate uterus.

How is it treated?

A

Divided by myometrial tissue

  • Deeply concave fundus
  • Horns are divergent
  • Intercornual distance > 4cm

Treatment
- Abdominal metroplasty

138
Q

Case 117

What is typically associated with Polycystic Ovary Disease?

A

Infertility
Hirsutism
Obesity
Oligomenorrhea

139
Q

Case 117

How is POD diagnosed with LH/FSH?

A

LH/FSH ratio >2

140
Q

Case 117
What are classic U/S findings in POD?

Are these imaging finding pathogmonic?

A

Enlarged hyperechoic ovaries
Multiple small peripheral follicles
- String of pearls

No

141
Q

Case 118

What are imaging findings of Ovarian Hyperstimulation?

A

Ovaries

  • Enlarged
  • Multiple large follicles

Associated Findings

  • Ascites
  • Pleural effusions
  • Pericardial effusion
142
Q

Case 118

Who’s at risk for Ovarian Hyperstimulation Syndrome?

A 
Thin 
Young
High Gonadotropins
High Estradiol levels
PCOD patients
143
Q

Case 118

What are complications of Ovarian Hyperstimulation?

A 
Ovarian torsion
Rupture 
 - Hemorrhagic Cyst
DVT
PE
144
Q

Case 119
What is suspected when you see a snowstorm appearance in the uterus?

What type of ovarian cysts are seen with this entity?

A

Complete hydatidiform mole

Theca Lutein Cysts

  • Multilocular cysts
  • Expand the ovary
  • 2o to overstimulation (hCG)
145
Q

Case 119

How do patients with molar pregnancy present?

A

Rapid uterine enlargement
Hyperemesis
Vaginal bleeding
Markedly elevated hCG levels

146
Q

Case 120

DDx for postpartum patients with fever and lower abdominal pain?

A 
Ovarian Vein Thrombosis
Appendicitis
Pyelonephritis
Endometritis
TOA
Acute Cholecystitis
147
Q

Case 120

What are the two most common causes of ovarian vein thrombosis?

A

Endometritis

Oncologic surgery

148
Q

Case 120

What is the most likely side of ovarian vein thrombosis?

A

Right

149
Q

Case 121

Describe a Cesarean section scar on MRI

A

Focal disruption in the junctional zone along the ventral uterine corpus

Junctional zone is inner third of myometrium

150
Q

Case 122

What causes an ovarian mass with multiple thick septations, solid peripheral nodules, and ascites?

A

Ovarian Carcinoma

151
Q

Case 122

CA-125 is elevated in what 5 entities?

A 
Ovarian neoplasm
 - Elevated in 80% of pts
Uterine leiomyoma
Endometriosis
PID
Early pregnancy
152
Q

Case 122

What are imaging features of ovarian cancer?

A 
Increased ovarian size (>7.5cm)
Solid component of the mass
Mural nodules
Internal papillary projections
Thickened septations
153
Q

Case 122

What are the four types of ovarian neoplasms

A

Epithelial
Germ cell
Sex cord-stromal
Metastasis

154
Q

Case 123

Where do ovarian cancer peritoneal implants typically go?

A

Pouch of Douglas
Ileocecal region
Right paracolic gutter

155
Q

Case 123

What is Pseudomyxoma peritonei?

A

Large amounts of gelatinous material
-> Peritoneal cavity

Transformation of peritoneal mesothelium

  • to a mucin-secreting epithelium
  • after perforation of a mucinous
  • cystadenoma or cystadenocarcinoma
156
Q

Case 124

What is Krukenberg Metastasis?

A

Mets to the ovary from GI adenoCA

  • Stomach
  • Colon
157
Q

Case 124

How do you differentiate Krukenberg Metastasis to the ovary from primary ovarian neoplasm

A

Krukenberg Mets:

  • Solid
  • Bilateral
  • Present late

Primary Mets

  • Cystic >10 cm
  • Unilateral
  • Present early
158
Q

Case 125

What is the DDX of a homogenous hypoechoic mass in the adnexa?

A

Ovarian fibroma

Pedunculate uterine leiomyoma

159
Q

Case 125

What is Meig’s Syndrome?

A

Ovarian fibroma
Ascites
Hydrothorax

160
Q

Case 125

What are the MRI characteristics of Ovarian Fibroma?

A 
Well-circumscribed mass
Low T1
Low T2 unless
 - edema
 - degeneration
161
Q

Case 125
T/F
Most Ovarian Fibromas are surgically removed.

Ovarian Fibromas secrete steroids.

A

True
- Rare malignant potential

False

162
Q

Case 126

What is the most common cause of ovarian torsion?

A

Benign cystic teratoma

Kids may get torsion without an underlying mass

163
Q

Case 126

What are the classic imaging findings of ovarian torsion?

A 
Enlarged ovary
Complex, cystic or solid mass
Dilated fallopian tube with a thick wall
 - see Case 129 image
Intraperitoneal fluid
Absent flow in the ovary
Twisted vascular pedicle
164
Q

Case 126
T/F
Doppler flow in the ovary excludes torsion.

A

False
Ovaries have dual blood supply
Doppler is therefore of limited use in torsion

165
Q

Case 127

What should you consider in a patient with a mass presenting with severe, cyclical pelvic pain?

A

Endometriosis

166
Q

Case 128
In US evaluation of an ovarian mass, what are the most important features for distinguishing between a benign and malignant ovarian mass?

A

Solid Elements

  • Presence
  • Echogenicity
167
Q

Case 128

What is the Pulsatility index on sonography?

A

(Peak systolic velocity - End diastolic velocity) /

Mean velocity

168
Q

Case 128

What is the Resistive index on sonography?

A

(Peak systolic velocity - End diastolic velocity) /

Peak systolic velocity

169
Q

Case 128

What features suggest that an ovarian mass as malignant?

A

Solid component
Flow in a septation or the solid component
Free fluid in a postmenopausal woman
Thick septation (>3mm)

170
Q

Case 129

What is the most likely cause of rapid or massive ovarian enlargement or edema?

A

Ovarian torsion

- Partial or intermittent

171
Q

Case 129

What is the vascular supply of the ovaries?

A

Ovarian artery
- Branch of the aorta
Uterine artery
- Branch of the anterior trunk of the internal iliac artery

172
Q

Case 130

What is ovarian pexy and what is its indication?

A

Ovaries are attached to superior pelvic sidewall

Removes the ovaries from radiation field in cervical CA

173
Q

Case 131

U/S showing enlarged uterus with snowstorm or cluster of grapes with hypoechoic or anechoic areas is likely?

A

Gestational Trophoblastic Disease

  • Molar pregnancy
  • Partial Mole
  • Choriocarcinoma
174
Q

Case 131

DDX of an enlarged uterus with snowstorm or cluster of grapes with hypoechoic or anechoic areas

A

Gestational Trophoblastic Disease
Degenerated uterine leiomyoma
Endometrial proliferative disease
Degeneration of the placenta

175
Q

Case 132

What are four causes of a thickened endometrium in postmenopausal women?

A 
Endometrial hyperplasia
Polyps
Carcinoma
Drugs
 - Tamoxifen
 - Estrogen replacement
176
Q

Case 132

What is the most common type of endometrial cancer?

A

Adenocarcinoma (70%)

177
Q

Case 132

What stage is endometrial cancer that invades the cervix

A

Stage IIB

178
Q

Case 133

What is the best way to assess endometrial cancer?

A

Transvaginal Ultrasound

179
Q

Case 133

What are risk factors for endometrial cancer?

A 
Obesity
Diabetes
Nulliparity
Unopposed Estrogen
Tamoxifen therapy
History of Breast or colon CA
180
Q

Case 134

What is an adnexal mass that is T1 bright, T2 dark with no fat suppression on MRI?

A

Endometrioma

- Chocolate cyst

181
Q

Case 134

What extrapelvic organs can have endometriosis?

A

Lungs
- Catamenial ptx
CNS

182
Q

Case 134
T/F
Endometriomas increase likelihood for torsion

A

False

- adhesions

183
Q

Case 134
T/F
MRI is the best modality to diagnose endometriosis

A

False

  • Laparoscopy
  • > best for diagnosis and staging
184
Q

Case 135

What is the continuum of PID?

A 
Cervicitis
Endometritis
Salpingitis
Pelvic peritonitis
Tuboovarian abscess
 - 1% of all PID patients get TOA's
185
Q

Case 136
Uterine didelphys is a result of what?

What do you see?

A

Complete failure of fusion of the mullerian ducts

Two hemiuteri, with separate cervices and vagina

186
Q

Case 136

What can cause dilation of one of the uterine horns?

A
  • Transverse vaginal septum

- Cervical stenosis

187
Q

Case 136

Uterine didelphys and Septate uterus are associated with what renal anomaly?

A

Unilateral renal agenesis

188
Q

Case 137

What is the most important feature to distinguish bicornuate from a septate uterus?

A

External uterine fundal contour
Septate: Flat or convex
Bicornuate: Concave

189
Q

Case 138

How often does ovarian vein thrombosis occur in surgical oncology patients?

A

80%

190
Q

Case 138

What does ovarian vein thrombosis look like on MRI?

A

T1 dark

T2 bright

191
Q

Case 139

Define adenomyosis

A

Aberrant ectopic endometrium within the myometrium

192
Q

Case 139

What are the imaging characteristics of Adenomyosis?

A

Junctional zone > 12mm
Ectopic endometrial glands
- T2 hyperintense foci

193
Q

Case 140
During what phase of the menstrual cycle is the endometrium thickest?

What should it measure?

A

Secretory phase

8-12mm

194
Q

Case 140
T/F
The longer a person takes Tamoxifen and the higher the dose, the greater the risk for endometrial hyperplasia or cancer.

In women treated with Tamoxifen, endometrial hyperplasia is the most common endometrial abnormality resulting in abnormal endometrial thickening.

A

True
- Especially > 5 years

False
- Endometrial polyps

195
Q

Case 141

What pelvic tumors can invade the bladder?

A

Cervical
Prostate
Urethra
Rectum

196
Q

Case 142
T/F
Patients with endometrial leiomyoma are more likely to get endometrial carcinoma.

A

True

197
Q

Case 142
T/F
Benign Leiomyomas can metastasize to the lungs.

A

True

198
Q

Case 143

DDX of a pregnant patient with pelvic pain

A 
Subchorionic hematoma
Degenerating fibroid
Adenomyosis
Focal myometrial contractions
Solid adnexal mass
199
Q

Case 143

What complications are associated with fibroids in pregnancy?

A 
Pain
Bleeding
Spontaneous abortion
Placental abruption
Fetal malposition
Mechanical obstruction of the uterus
200
Q

Case 144

What symptoms do patients with pelvic congestion syndrome present with?

A 
Pelvic fullness
Pain
 - better in AM
 - worst at the end of the day
Dyspareunia
201
Q

Case 144

How is pelvic congestion syndrome treated?

A 
Hormones
Laparoscopic ligation
Embolization
 - Ovarian vein
 - Internal iliac veins
202
Q

Case 144

Does embolization of pelvic congestion reduce fertility?

A

No

- No effect on menstruation or fertility

203
Q

Case 145

DDX of an adrenal mass

A 
Adenoma
 - most common
 - even in cancer pts
Metastasis
Hyperfunctioning Adrenal neoplasm
 - Pheochromocytoma
 - Cushing's syndrome
 - Aldosteronoma
204
Q

Case 146

What causes an adrenal adenoma to drop off in signal on chemical shift MRI?

A

Phase cancellation

- caused by the presence of both fat and water protons within the same voxel.

205
Q

Case 147
For adrenal adenoma on dynamic CT
What absolute washout is diagnostic?

How is it calculated?

A

Absolute washout of 60%

(HU at dynamic CT - HU at 15 minute delayed) /
(HU at dynamic CT - HU at noncontrast CT) x 100

206
Q

Case 147
For adrenal adenoma on dynamic CT
What relative washout is diagnostic?

How is it calculated?

A

Relative washout of 40%
(HU at dynamic CT - HU at 15 minute delayed) /
HU at dynamic CT x 100

207
Q

Case 148
T/F
The spleen should be used as the control in evaluating an adrenal adenoma on in and out of phase imaging.

A

True

Don’t use the liver!

208
Q

Case 148

What % of adenomas do not demonstrate signal drop-off on out-of-phase imaging or have HU less than 10?

A

20%

- Lipid-poor

209
Q

Case 149

What are three etiologies of adrenal hemorrhage in neonates v. adults?

A

Neonates:

  • Birth trauma
  • Anoxia
  • Dehydration

Adults:

  • Anticoagulation
  • Trauma
  • Surgery
210
Q

Case 149

What is the DDX for an adrenal mass in a neonate

A

Adrenal hemorrhage

Neuroblastoma

211
Q

Case 150

What are the three types of adrenal cysts?

A

True cysts

  • Endothelial (lymphangioma)
  • Epithelial

Pseudocysts
- Develops from prior adrenal hematoma

Infectious cysts
- Echinococcal

212
Q

Case 151

What is Waterhouse-Friderichsen Syndrome?

A

Adrenal hemorrhage associated with fulminant meningococcemia resulting in acute adrenocortical insufficiency

213
Q

Case 152

What is the most common type of true Adrenal cyst

A

Endothelial cyst

- Lymphangioma > Hemangioma

214
Q

Case 152

Is calcification a common feature of adrenal cysts?

A

Yes

- up to 54%

215
Q

Case 152

What is the most common cause of adrenal pseudocyst?

A

Adrenal hemorrhage

216
Q

Case 153
What are the two histologic contents of an adrenal myelolipoma?

Malignant potential?

A

Hematopoietic tissue
Mature adipose tissue

No malignant potential

217
Q

Case 153

What two ways do myelolipomas present

A

Incidental
Pain
- 2o to hemorrhage

218
Q

Case 154

How can you differentiate that an adrenal mass represents an adenoma v. pheochromocytoma v. metastasis

A 
Adenoma
 - CT or MRI
Pheochromocytoma
 - I-131 MIBG scan
 - Urine VMA level
Metastasis
 - PET/CT
219
Q

Case 116
Define septate uterus.

How is it treated?

A

Divided by Fibrous septum

  • Convex, flat or minimally indented fundus
  • Intercornual distance
219
Q

Case 151

Which adrenal is more prone to traumatic hemorrhage?

A

Right

- Due to compression by the adjacent liver

220
Q

Case 155

Where do pheochromocytomas typically recur postop?

A

Surgical bed
Ipsilateral retroperitoneum
- local metastasis

221
Q

Case 155

What 3 clinical tests are used for Pheochromocytoma?

A

Serum plasma catecholamine levels
24-hour urine vanillylmandelic acid (VMA)
Metanephrine levels

222
Q

Case 156

DDX of adrenal calcifications

A 
Granulomatous disease
 - TB
 - Histoplasmosis
Prior hemorrhage
Treated metastasis
223
Q

Case 156
What is the adrenal morphology in Addison’s disease?

Symptoms?

A

Small adrenals
Calcifications

Asthenia
Hypotension
Anorexia
Weight loss
Pain, N/V/D
Hyperpigmentation
224
Q

Case 156

What are the causes of Addison’s disease?

A 
Autoimmune
Adrenal destruction
 - Hemorrhage
 - Infection
Metastasis
 - Very rare
225
Q

Case 157

What syndrome is associated with Insulin-dependent diabetes, autoimmune thyroiditis, and Addison’s disease?

A

Schmidt’s syndrome

- Polyglandular Synd Type II

226
Q

Case 157

DDx for adrenal enlargement.

A 
Granulomatous adrenalitis
Adrenal hemorrhage
Mets
Lymphoma
Sarcoidosis
Amyloidosis
227
Q

Case 158

Where does renal artery stenosis typically occur?

A

Ostium

Proximal 2cm

228
Q

Case 159

What are the two most commonly affected arteries in Fibromuscular dysplasia (FMD)?

A

Renal arteries
- 70%

Carotid arteries
- 30%

229
Q

Case 159

What is the best treatment for FMD?

A

Balloon angioplasty
- 90% effective
No need for stents

230
Q

Case 160

Why should renal arterial aneurysms be treated no matter their size?

A

Increased risk

  • Rupture
  • Renal embolization
231
Q

Case 161

What do renal transplant surgeons need to know by imaging prior to taking a donor kidney?

A

Number of renal arteries (they prefer one)
Size and location of renal arteries
Number, size and location of renal veins
Size and location of the kidneys
Presence of congenital or acquired renal disease

232
Q

Case 161

What is the preferred donor kidney for transplant?

A

Left

- Longer renal vein for anastamosis

233
Q

Case 162

What is the incidence of an AV fistula post biopsy and what is the typical course?

A

Incidence
- 9%

Spontaneously Thrombose
- 70-95%

234
Q

Case 163

What are 3 indications for renal artery embolization

A

Prior to nephrectomy to treat RCC
Prior to renal tumor ablation in nonsurgical patients
Posttraumatic bleeding

235
Q

Case 164

What % of patients with HTN have renal artery stenosis?

A

1%

236
Q

Case 164

What is the restenosis rate after treating RAS?

A

Up to 25%

237
Q

Case 165

What is the success rate of uterine fibroid embolization?

A

Up to 90%

238
Q

Case 165

What complications are associated with UFE’s

A

Minor: 5%

  • Pain
  • Nausea
  • Groin hematoma
  • Amenorrhea

Major 0.5%

  • Infection
  • DVT
  • PE
239
Q

Case 166

What are the indications for a percutaneous nephrostomy?

A 
Relief of obstructive symptoms
Access for nephrolithotomy
Urothelial biopsy or ablation
 - Urothelial tumor
Whitaker test
240
Q

Case 170

Retroperitoneal Liposarcoma can be differentiated by lipoma by?

A

Soft tissue components

  • but not 100%
  • Liposarcs can be purely lipomatous
241
Q

Case 170
T/F
Poorly differentiated liposarcomas may not contain any detectable fat

A

True

242
Q

Case 171

What is Zinner Syndrome?

A

Coexistence of Ipsilateral
- Seminal Vesicle cyst
AND
- Renal dysgenesis or agenesis

243
Q

Case 171

DDX of lateral paraprostatic cysts

A

Seminal vesicle cyst
Bladder diverticula
- make sure to trace it to source

244
Q

Case 171

What renal anomalies are associated with unilateral seminal vesicle cyst?

A 
Renal Agenesis
Renal Ectopia
APCKD
Duplicated system
Ectopic Ureteral Insertion
245
Q

Case 172

What organism is associated with prostatic abscesses?

A

E. coli

  • Prostatitis
  • Hematogenous spread
246
Q

Case 173

DDX for focal area of T2 hypointense signal in the peripheral zone of the prostate gland.

A

Adenocarcinoma
Hyperplasia
Prostatitis
Hemorrhage after biopsy

247
Q

Case 173
T/F
Contrast is useful in assessing the prostate in MRI that uses an endorectal surface coil.

Some peripheral zone cancers have high signal intensity on T2W images.

A

False
- In most cases it adds no benefit

True

  • Mucinous
  • Signet-ring AdenoCA
248
Q

Case 174

What cancers cause osteoblastic bone metastasis?

A 
Prostate
Breast
Bladder
Lymphoma
Lung
Carcinoid
249
Q

Case 175

What is the filling defect in the urethra posterior to the membranous urethra?

A

Verumontanum

251
Q

Case 175

How does Chron’s disease typically affect the GU tract?

A

Direct extension of granulomatous enterocolitis

252
Q

Case 176

DDX of scrotal U/S showing branching tubular anechoic structures with garlic walls in the mediastinum testis.

A

Tubular Ectasia of the Rete Testis

  • No differential
  • Associated with epididymal cysts
  • No f/u imaging necessary
253
Q

Case 177

DDX of testicular calcified testicular mass

A 
Nonseminomatous germ cell tumor
Epidermoid cyst
Resolved infection
Hematoma
Infarction
254
Q

Case 178

What organisms typically cause Fournier’s Gangrene?

A

Polymicrobial necrotizing fasciitis

  • Gram-negative rods
  • Streptococcal
  • Staphylococcal
  • Anaerobic strep
255
Q

Case 178

Where does Fournier’s Gangrene start in women?

A

Vulva

Bartholin’s gland

256
Q

Case 179

Testicular U/S shows a linear hypoechoic band extending across the testicular parenchyma. What is the Dx?

A

Testicular fracture
- The tunica albuginea is maintained

Testicular rupture

  • The tunica is disrupted
  • Testicular contents are extruded
257
Q

Case 180

What arterial doppler findings are seen with erectile dysfunction after Papaverine injection?

A

Peak diastolic velocity > 3cm/sec

258
Q

Case 180

What are two main causes of vasculogenic erectile dysfunction?

A

Arterial inflow disease

Venous incompetence

Genitourinary (2 decks)

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