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Neonatal & Pediatric Kidneys & Adrenals Flashcards

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1
Q

Kidneys are developed from embryonic parenchymal masses called ___.

A

renuculi

the former are called lobes and remnant lobes with incomplete fusion is termed fetal lobulation

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2
Q

What does a neonatal kidney look like sonographically?

A

large, hypoechoic renal pyramids
thin cortex, greater echogenicity than liver
sinus is hypoechoic and indistinct
arcuate arteries at base of pyramids and are punctate and echogenic

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3
Q

Why is the renal cortex so echogenic in a neonate?

A

due to glomerulus primarily in the cortex

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4
Q

What are the normal measurements for the bladder wall in a neonate?

A

<3mm

when empty, <5mm

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5
Q

What does a neonatal adrenal gland look like sonographically?

A

thin echogenic medulla

thicker hypoechoic rim

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6
Q

What are common causes of hydronephrosis?

A

obstruction, reflux, and abnormal muscle development

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7
Q

What is the sonographic appearance of hydronephrosis?

A

visible renal parenchyma, central cystic component, small peripheral cysts budding off large central cyst, visualization dilated ureter

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8
Q

What is the most common type of obstruction of the upper urinary tract?

A

uteropelvic junction obstruction

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9
Q

What is associated with UPJ obstruction?

A

multicystic dysplastic kidney

bilateral envolvement may occur (UPJ) along with contralateral multicystic dysplasic kidney or vesicoureteral reflux

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10
Q

What is the sonographic finding with UPJ obstruction?

A

pelvocalyceal dilation without ureteral dilation, when obstruction pronounced dilated renal pelvis extends inferiorly and medialy, if vescicoureteral reflux or primary megaureter is present ureter may be dilated

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11
Q

What may an abscess or lymphoma cause in relation to the ureter?

A

obstruction to ureter, presence of primary megaureter, atresia, ectopic ureter may be cause of obstruction, mesenteric adenitis

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12
Q

What is mesentaric adenitis?

A

infammatory, ideopathic condition

enlarged mesenteric lymph nodes (can cause compression)

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13
Q

What does sonography show with a ureteral obstruction?

A

hydronephrosis and hydroureter with narrow segment of diastal ureter behind bladder; increased peristais in ureter distal to obstruction; diminished ureteral jet

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14
Q

What may the bladder be obstructed by?

A

neurogenic bladder, pelvic mass, congenital anomaly such as posterior urethral valves

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15
Q

What is the most common cause of bladder outlet obstruction in the male neonate?

A

posterior urethral valves

typically in area near prostate

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16
Q

What are possible causes of bladder outlet obstruction?

A

posterior urethral valves, pelvic mass/tumor, vesicoureteral reflux

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17
Q

What is the sonographic appearance of posterior urethral valves?

A

thickened and trabeculated bladder wall; key hole sign

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18
Q

What is the incidence of ectopic ureterocele?

A

occurs more commonly in females and more often on the left side

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19
Q

What is the sonographic appearance of an ectropic ureterocele?

A

fluid mass within bladder

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20
Q

Prune belly syndrome constists of the triad of what?

A

hypoplasia of abdominal muscles, cryptorchidism, urinary tract anomalies

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21
Q

What are characteristics of prune belly syndrome?

A

congential absence/deficiency of abdominal musculature; large hypoechoic dilated tortuous ureters; large bladder; patent urachus (pathway that connects bladder); bilateral cryptorchidism; dilated prostatic urethra

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22
Q

What is a serious side effect of prune belly syndrome?

A

severely affects patients have urethral atresia
can cause full bladder and low amniotic fluid volume
which can result in hypoplastic lungs

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23
Q

What is the sonographic appearance of prune belly syndrome?

A

dysplastic echogenic kidneys (severe pts); non-hydronephrotic kidneys with dilated ureters and a huge bladder (less severe)
wrinkled “prune like” abdomen clinically due to absent abdominal muscles

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24
Q

What is the most common cause of abdominal mass in a newborn?

A

multicystic dysplastic kidney

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25
What is the most common cause of renal cystic disease in neonate when hydronephrosis is excluded?
multicystic dysplastic kidney
26
What is multicystic dysplastic kidney disease?
congential, usually sporadic, renal dysplasia thought to be secondary to severe, generalized interference with ureteral bud function during first trimester
27
What are the characteristics of multicystic dyplastic kindey?
collecting tubules enlarge, grossly distorting shape of kidney remaining renal parenchyma becomes nonfunctioning
28
What occurs in nearly half MCDK cases?
contralateral abnormalities (UPJ obstruction or reflux)
29
What are the sonographic findings for MCDK?
unilateral mass resembling "cluster of grapes"; multiple discrete NON-COMMUNICATING cysts; largest cysts are on periphery; no identifiable renal pelvis
30
What is the typical pathologic presentation of autosomal recessie polycystic kidney disease?
diffuse enlargement, sacculations, cystic diverticula of medullary portions of kidney
31
When is the most severe and least severe stages seen in ARPKD?
most: neonatal stage least: infantile to juvenile stage
32
What is the most common form of ARPKD?
perinatal stage | characterized by varying degrees of renal tubular dilation and hepatic fibrosis
33
What associated findings may be seen with ARPKD?
pulmonary hypoplasia with respiratory distress and potter facies
34
What is potter facies?
hypertelorism (far set eyes), micrognathia (undersized jaw), and melotia (low set ears)
35
What is the sonographic findings for ARPKD?
bilateral renal enlargement; diffuse increased echogenicity; loss of definition of renal sinus, medulla, cortex; microscopic cystlike appearance thoughout both kidneys (dilated renal tubules); thin peripheral hypoechoic cortex in less severe case: hepatosplenomegaly, portal hypertension, renal parenchyma normal to echogenic
36
What is the normal size of renal tubules?
less than 2mm in diameter
37
What is autosomal dominant polycystic kidney disease?
adult dominant form of polycystic kidney disease | usually appears during middle age and rarely reported in young infants
38
What is the prognosis for ARPKD?
poor prognosis
39
What other organs may be involved with ADPKD?
cysts can also form in liver, spleen and pancreas
40
With ADPKD, what forms in 10-15% of patients?
cerebral berry aneurysm (saccular)
41
What is the sonographic appearance of ADPKD?
lack of significant renal impairment, normal AFV (inutero), multiple well defined cysts affecting both kidneys
42
What is the prognosis for ADPKD?
better than ARPKD
43
List the clinical symptoms of acute pyelonephritis.
sudden fever, flank pain, tenderness, increased WBC count
44
With acute pyelonephritis, where does the infection start?
infection usually begins in bladder and scends ureter into renal pelvis
45
What is the sonographic appearance of acute pyelonephritis?
increased echogenicity in renal pyramids; renal pelvis and ureter may be thickened; renal size slightly enlarged; abscess may form demonstrating mixed echogenic pattern diffuse or local
46
What is chronic pyelonephritis?
results when repeated episodes of acute pyelonephritis cause kidney to become scarred and decreased in size
47
What is the sonographic appearance of chronic pyelonephritis?
irregular renal outline; echogenic renal cortex (more so than liver); pyramids difficult to differentiate from renal parnechyma
48
Who is renal vein thrombosis most likely to occur in?
most likely to occur in dehydrated or spetic infant and is more prevalent in infants of diabetic mothers can also result from chronic pyelonephritis
49
Clinically, what does renal vein thrombosis look like?
renal enlargement, hematuria, proteinuria, low platelet count
50
Sonographically, what does renal vein thrombosis look like?
occurs in small intrarenal venous branches; enlarged kidney has nonspecifc disordered herterogenous interal echogenicity; may be coexistent adrenal hemorrhage (particularly on left side); calcification within involved veins may develop; reversed doppler flow
51
What is the most common renal tumor of neonate?
congenital mesoblastic nephroma
52
What is congential mesoblastic nephroma?
rare benign tumor; indistinguishable from wilm's tumor by any method of imaging tumor may invade adjacent structures
53
What is the sonographic appearance of congenital mesoblastic nephroma?
solid lesion, may have complex texture that includes hyperechoic, hypoechoic, or mixed echogenicity mass may extend through renal capsule into retroperitoneum
54
What is the incidence of congenital mesoblastic nephroma?
seen in children less than 1 year old
55
What is the incidence of Wilm's tumor?
seen in children older than one year old | incidence peaks between 2 and 5 years
56
What is the most common intraabdominal malginant renal tumor in young children?
nephroblastoma
57
What is the sonographic appearance of nephroblastoma?
usually has areas of echogenicity and may have calcification within; liquification may represent necrosis and hemorrhage; borders sharply marginated and well defined; bulky with hypoechoic to hyperechoic rim surrounding mass; adjacent renal tissue becomes compressed; solid mass distorting renal sinus, pyramids, cortex and renal contour; may protrude into hepatic capsule; hydronephrosis may be present; extension into renal vein or IVC
58
What is the first most common abdominal tumor of childhood?
neuroblastoma
59
What is the incidence of neuroblastoma?
occurring between age of 2 months and 2 years
60
What is neuroblastoma?
malignant tumor arises in sympathetic chain ganglia and adrenal medulla; may be on antenatal sonography or at birth
61
What are the sonographic findings of neuroblastoma?
highly echogenic; intrinsic calcification may be identified; smaller tumors appear homogeneous and hypoechoic; larger tumors appear more complex; adjacent kidney displaced inferiorly and at times lateral; increased vascularity
62
What are the predisposing factors to adrenal hemorrhage?
difficult delivery (large fetus), infants of diabetic mothers, stress or hypoxia at delivery, septicemia, shock
63
What is the sonographic appearance of adrenal hemorrhage?
ovoid enlargement of gland or portion of gland; appearance can range from anechoic to hyperechoic or a mixture
64
With an abdominal exam, how long should a child be NPO for?
0-2: 4 hours 3-5: 5 hours 6+: 6 hours
65
What is the normal pediatric size of abdominal organs?
Liver: right lobe should not extend more than 1cm below costal margin in young infant CBD: <1mm in neonates; <2mm in infants up to 1 year; <4mm in older children; <7mm in adolescents and adults GB length: 1.5-3cm in infants <1yr; 3-7cm in older children Pancreas: hyperechoic compared to liver Spleen length: 6cm in infants less than 3mo.; 12cm in children greater than 12 Portal Vein: 8.5mm less than 10 years; 10mm from 10-30 years
66
List intrahepatic causes of neonatal jaundice.
hepatitis and metabolic disease
67
List extrahepatic causes of neonatal jaundice.
choledochal duct cyst, biliary atresia, spontaneous perforation of bile ducts, shock, sepsis, neonatal lupus, histiocytosis, severe hemolytic disease, heart failure
68
What are the three most common causes of jaundice in the neonatal period?
hepatitis, biliary atresia, and choledochal cyst
69
When does neonatal hepatitis affect infants?
within first 3 months of birth
70
What are the causes of neonatal hepatitis?
infection, metabolic disorders, familial recurrent cholestasis, metabolism errors, and ideopathic causes
71
How does infection reach the liver in a neonate?
placenta, vagina/infected maternal secretions, catheters, and blood transfusions
72
How does a transplacental infection occur?
during third trimester | most common agents include syphilis, toxoplasma, rubella, and cytomegalovirus (CMV)
73
During fetal delivery, direct contact with what may lead to hepatitis?
herpes, viruses, CMV, HIV, listeria
74
What diseases may blood transfusions have?
may contain hepatitis virus, epstein-barr virus, or HIV
75
What is the sonographic appearance of neonatal hepatitis?
normal or enlarged liver; echogenic liver with decreased visualization of peripheral portal venous structures (homogeneous); non enlarged biliary ducts or GB
76
What is the incidence in biliary atresia?
more common in females
77
What is the most common form of biliary atresia?
form with absence of GB
78
Clinical features of biliary atresia include:
persistent jaundice, achoic stools, dark urine, distended abdomen from hepatomegaly
79
What is the sonographic appearance of biliary atresia?
normal or enlarged liver; echogenic liver with decreased visualization of peripheral portal venous structures (homogeneous); intrahepatic ducts not dilated; triangular cord sign
80
What does the triangular cord song represent?
scar/connective tissue where the CBD should be
81
What should be determined with the presence of biliary atresia?
polysplenia - because there is high association
82
What is a choledochal cyst?
abnormal cystic dilation of the biliary tree that most frequently affects common bile duct
83
What are the five types of choledochal cysts?
fusiform dilation of CBD, one or more diverticula of CBD, dilation of intraductal portion of CBD (choledochocele), dilation of intrahepatic and extrahepatic ducts, caroli's disease with dilation of intrahepatic ducts
84
What is the most common type of choledochal cyst?
fusiform dilation of CBD
85
Clinically, what does a choledochal cyst look like?
jaundice and pain, palpable RUQ mass
86
Why is sonography used with choledochal cysts?
used to differentiate presence or absence of GB, dilation of ductal system, presence of absence of mass
87
What are the two most common liver tumors?
hemanigoendothelioma and hepatoblastoma
88
What is an infantile hemangioendothelioma?
vascular, mesenchymal mass characterized by active endothelial growth that may cause arteriovenous shunting, which causes high-output heart failure infant
89
What is the most common benign vascular liver tumor of early childhood?
infantile hepatic hemangioendothelioma
90
When is hemangioendothelioma diagnosed?
usually diagnosed in first months of life as mass grows rapidly, causing abdominal distention
91
What is the clinical presentation of hemangioendothelioma?
hepatomegaly, serum AFP may be elevated | may be accompanied by CHF and cutaeous hemangioma
92
When do hemangioendothelioma's regress?
bening tumor usually regresses spontaneously by 12 to 18 months of age
93
What is the sonographic appearance of hemangioendothelioma?
multiple hypoechoic lesion, hepatomegaly usually heterogeneous or ischoechoic; contains cystic components from vascularstroma structure; speckled areas of calcification may be seen within mass well circumscribed or poorly marginated, solitary or multicystic, high color flow; when arteriovenous shunting is severe, celiac axis, hepatic artery, veins dilated, and infraceliac aorta small
94
What is mesenchymal hamartoma?
rare, benign tumor in asymptomatic infant younger than 2 years has multiseptate cystic masses derived from periportal mesenchyma
95
When is adenoma seen in infants?
not commonly seen in infant unless liver disease present | AFP is normal
96
What is the sonographic appearance of adenoma?
ranges from hyperechoic to hypoechoic and is nonspecific
97
What are the most common malignant tumors in childhood?
hepatoblastoma and hepatocellular carcinoma
98
Metastases in the lever may arrise from where?
neuroblastoma, Wilm's tumor, leukemia, and lymphoma
99
What is the most common primary malignant disease of the liver?
hepatoblastoma
100
What is the incidence of hepatoblastoma?
occurs most frequently in children less than 5 years, with majority occuring in children less than 2 years
101
What is assoicated with hepatoblastoma?
beckwith-widemann syndrome, hemihypertrophy, familial adenomatous polyposis, precocious puberty
102
What are the sonographic findings of hepatoblastoma?
hepatomegaly with solitary mass that may show some calcification, heterogeneous mass that may be hypoechoic areas with necrosis or hemorrhage, fleshy areas around mass are often mildly hyperechoic
103
What is the second most common malignant tumor in childhood?
hepatocellular carcinoma
104
What is the sonographic appearance of hepatocellular carcinoma?
liver is multicentric solid mass, usually without calcification; variable echogenicity color doppler should be used to evaluate portal venous structures to look for thrombus or tumor invasion
105
What is the incidence of hypertrophic pyloric stenosis?
presents most commonly between 3 and 6 weeks of age | more common in boys than girls
106
What are the symptoms of hypertrophic pyloric stenosis?
bile-free emesis, projectile vomiting, weightloss, dehydration, olive sign (palpable)
107
What is the diagnostic criteria for hypertrophic pyloric stenosis?
pyloric canal greater than 16mm and pyloric wall thickness greater than 3.5mm
108
Differential diagnosis of pyloric stenosis includes:
gastrointestinal reflux, antral web, pylorospasm, hiatal hernia, and malrotation of bowel
109
Describe the progression of acute appendicitis?
progression from acute appendicitis to perforation is more rapid in infants and young children; sometimes 6-12 hours
110
What are symptoms of appendicitis?
RLQ pain, rebound tenderness, fever, elevated WBC count, vomiting
111
What is the sonographic appearance of appendicitis?
no peristaltic motion, non-compressible, transverse measurement greater than 6mm, appendicoliths sometimes visible, free fluid
112
With appendicitis, does the presence of free fluid mean a rupture?
no
113
What is the most common acute abdominal disorder in early childhood?
intussusception
114
What is intussusception?
bowel prolapse into more distal bowel and is propelled in antegrade fashion
115
What are the different classifications of intussusception?
ileoileal, ileocecal, and ileocolic
116
What is the incidence of intussusception?
noted in children 6 months to 2 years
117
What are symptoms of intussusception?
colicky abdominal pain, vomiting, bloody stool, palpable abdominal masses
118
Describe the sonographic appearance of intussusception.
target or doughnut sign, hypoechoic outer rim, with echogenic interior, pseudokidney or sandwich appearance, color flow

Abdomen (4 decks)

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