1) USG is not always accurate in detecting small renal calculi less than 5mm or mid/lower ureteric calculi, while CT is the gold standard for detecting all calculi. However, CT should be used cautiously due to radiation risks. 2) USG is sensitive for detecting fatty liver but cannot detect inflammation or early fibrosis. Liver biopsy is currently needed to assess nonalcoholic steatohepatitis, though new techniques like fibroscan and MR elastography may provide noninvasive alternatives. 3) Lymph nodes need to be at least 10mm on USG to be considered significant or diagnostic of mesenteric adenitis in children.

1. WHAT WE CAN SEE AND WHAT WE
CAN NOT ON USG
DR.KRISHNA KIRAN MD.DNB.FRCR RADIOLOGIST
DRSHAJI`S MRI CALICUT

3. This talk also includes
fallacies/warts of USG apart from
good points

4. Case 1
 45 year old male comes with dull pain in both
flanks.

5. Routine urine examination– no RBCs, few
crystals.
USG report

6. He shows you another report done 3 months
back.

7. What to do ..?

8. Journal of ultrasound in Medicine
2004.
USG NOT ACCURATE IN
DETECTING STONES LESS
THAN 5 MM

9. Classical appearance of a
calculus on USG

10. Arcuate artery
calcification
Milk of calcium cyst
Angiomyolipoma
Some
Ultrasound
mimics of
calculi

11. USG IN RENAL CALCULI
FOR
 Good in detecting large
renal and upper ureteric
calculi.
 Good in detecting
hydronephrosis.
 No radiation.
AGAINST
 Not good in mid and lower
ureteric calculi and small
renal calculi.
 Chemical analysis not
possible.
 Operator variation.

12.  Gold standard in detecting
renal , ureteric and bladder
calculi is CT.
 It can detect almost all
calculi.
 Gives HU values for
chemical analysis
 Risks are radiation and cost.
Hence should be used with
caution.

13. Key points
 USG is the preferred modality in initial
evaluation of renal/ureteric colic.
 Tiny calculi , middle and lower ureteric calculi
are not accurately detected.
 CT is the gold standard , should be used with
caution to avoid excess radiation.

14. CASE 2
 55 year old complains of Bloating sensation
in abdomen.
 He comes with an USG report.

16. Criteria for fatty liver on
USG
 Liver echogenicity exceeds that
of right kidney and spleen.
And
 There is beam attenuation.

17. What is grading of fatty liver
on USG
Grade 1 Grade 2 Grade 3

18. Does grade 3fatty liver
means progression to
cirrhosis..?
NO. Not necessarily
 it is a rough estimate for
fat in liver , that`s all

19. Once fatty liver is found ,
look for for causes. If no
cause is found labelled as
NAFLD nonalcoholic fatty
liver disease.This affects 10-
20% of population. Those
with normal liver enzymes
can be managed with
reduction in weight and
lifestyle modification.
Those with
persistent
elevated liver
enzymes are called
NASH
Nonalcoholic
steatohepatitis.

20. Can not be detected on USG
at present
Biopsy is
recommended to
assess
inflammation and
fibrosis.

21. Two new techniques promise to fill this gap

22. Something about fibroscan
 A new technique to assess
fibrosis of liver.
 Employs modified
ultrasound probe which
assesses velocity of a shear
wave created by a
vibratory source.
 Values of above 12.5kPa
are indicative of cirrhosis.

23. MR elastography promises to detect
fibrosis and inflammation noninvasively.

24. Key points
 USG is sensitive in detecting fatty liver.
 It can not detect liver inflammation and early
fibrosis.
 Liver biopsy is currently gold standard for
nonalcoholic steatohepatitis.
 New noninvasive techniques are promising.

25. Case 3
 A 10 year old child has recurrent abdominal
pain.

26. USG report shows

27.  ? SIGNIFICANT
 ? MESENTERIC ADENITIS

28. EALN– enlarged
abdominal lymph node Journal of ultrasound in
medicine 2007

29.  It is normal to find small nodes in children.
 Lymph nodes should show , minimum or
short axis diameter at least 10 mm to be
significant or to be called mesenteric adenitis.

30. Case 4
25 year old male with recurrent
RIF pain

31. appendicitis

32. How accurate is Ultrasound
or is it necessary..?
 Sensitivity of USG is about 70% in detecting
appendicitis.
 Main use is to rule out alternative diagnosis.

33. Is there a modality 100% accurate
in acute appendicitis
 Abdominal CT is 100% sensitive in acute
appendicitis.

34. Summary--

35. But if not done and interpreted
properly..