What does an intense acoustic shadow mean on ultrasound. Ultrasound signs of stones and formations. Ultrasound image of the gallbladder. Hyperechoic lesion with acoustic shadowing

Complete collection and description: hyperechoic structures in the kidneys without a shadow and other information for human treatment.

Hyperechoic inclusions are most often detected at the time of ultrasound of the kidneys. They look like areas of tissue with large acoustic seals. This may indicate the presence of stones of the onset of urolithiasis or be formations in the form of a tumor.

Such inclusions have a denser structure compared to the surrounding tissues, they respond well to ultrasound, thereby creating increased echogenicity. On the monitor of the ultrasound machine, they appear as white spots.

Hyperechoic inclusions Type and structure

On an ultrasound machine examining the kidneys, these neoplasms are shown as small linear, dotted or volumetric structures with a high echogenicity index. They can be seen within the renal tissue.

In the practice of medicine, it is noticed that the data hyperechoic inclusions are calcifications, point particles are isolated from them without accompanying an acoustic shadow, called microcalcifications. If there is a microcalcification in the nodular formation, then it is possible to declare the development of a malignant tumor that has begun.

Since hyperechoic formations begin to manifest themselves clearly only in malignant tumors, the following types of structures are distinguished in malignant tumors:

Half of the echogenic formation is made up of psammoma bodies.
Only 30% is calcified.
Sclerotic areas - 70%.

If a benign tumor of the kidney is detected during ultrasound, then there are no psammoma bodies at all, calcifications are also rare. Most often, sclerotic areas are noted.

Types of hyperechoic inclusions, their diagnosis

These inclusions in the kidneys can only be detected by a specialist during the diagnostic procedure. The conclusion may indicate kidney stones and the presence of sand. To date, there are several types of data inclusions:

Point inclusions, which are visible to the naked eye, since they do not have an acoustic shadow and are small.
Formations also with no acoustic shadow only big size. They are rarely localized in the kidneys, they are found by ultrasound of the kidneys. They appear in both malignant and benign tumors.
Large formations with acoustic shadow. They correspond to the sclerotic parts.

Ultrasound can most accurately detect hyperechoic inclusions in the kidneys. In addition, their presence can be suspected for a number of symptoms. These may be:

Elevated temperature.
Change in color of urine.
Frequent colic in the region of the kidneys.
Severe pain in the abdomen or below the belt or constant pain in the groin.
Vomiting and nausea.

These symptoms are universal and similar to the manifestations of many other diseases, therefore, if kidney stones are suspected need to see a doctor immediately y. To avoid the progression of the disease, a complete diagnostic examination should be carried out every six months with the delivery of blood, urine, and feces tests. In this way, the development of diseases can be prevented and some diseases can be avoided.

Prevention of stones in the stomach is frequent consumption of fluids in the form of water, infusion of wild rose, tea with herbs (mountain ash, oregano, mint and others). Thanks to it, the body will be cleansed of toxins and salts, which occurs during each urination.

Treatment of hyperechoic kidney formation

Hyperechoic inclusions, as a rule, appear in the form of:

Scar tissue.
Kidney stone disease.
Inflammatory process, for example, kidney abscess, carbuncle.
Growths in the form of cysts that contain fluid.
Hemorrhages in the kidney. Kind of a hematoma.
Tumors of the kidneys of benign (with lipoma, fibroma, adenoma, hemangioma) or malignant orientation.

If the ultrasound revealed suspicions of these diseases, then the doctor advises the patient a comprehensive examination using MRI. Sometimes, in severe cases, a kidney biopsy may be needed.

Hyperechoic inclusions can be cured, but this will not be an easy treatment. Stones are removed in several ways. The basis of the first method is frequent urination, which is caused by various diuretic herbs or drugs prescribed by a doctor. This method treats small formations up to 5 mm.

Abdominal surgery is indicated for sufficiently large stones. The alternative is removal of stones with a laser, which crushes and then removes. Stones can also be removed using ultrasound.

Tumor pathologies of malignant or benign content are removed surgically. Hyperechoic formations and cysts are removed by partial excision (resection). If the malignant disease is advanced, the tumor is removed along with the kidney, and then treatment with chemotherapy drugs is prescribed. In such a radical case, constant dieting is required.

Remember that only a qualified specialist can make an accurate diagnosis. Treatment is based on renal ultrasound and test results. Self-medication is not worth it, as this often leads to an aggravation of the situation.

During an ultrasound examination of the kidneys (ultrasound), dense solid formations in these organs can be detected - hyperechoic inclusions in the kidneys. Ultra high frequency acoustic waves are not reflected by healthy kidneys. Areas with high acoustic density indicate the presence of seals in the renal tissue, which is a good reason for additional examination of the patient.

Types of hyperechoic inclusions

For the most part, hyperechoic inclusions in the kidneys are represented by non-cellular structures in the form of fibrous-sclerotic areas, frame elements of connective tissue, or calcifications. They don't have liquid.

There are several types of acoustically determined formations in the kidneys:

Kidneys with small hyperechoic inclusions - have pronounced point inclusions of small sizes, without the formation of an acoustic shadow.
There are also volumetric hyperechoic inclusions without acoustic shadows in the kidneys - if they are large enough, they are rare in the kidneys, more often such visual changes are found in the thyroid gland.
Huge hyperechoic inclusions in the kidneys with echoes may indicate the presence of malignant neoplasms (tumors) in the organs.

What does the presence of renal hyperechoic inclusions indicate?

Volumetric or linear hyperechoic inclusions in the kidneys may indicate the presence of urolithiasis, and areas with increased acoustic density are renal calculi (stones). The absence in this case of the echo of shadows excludes urolithiasis.

Kidneys with small hyperechoic inclusions, if they are dashed, are not considered by doctors as a pathology, since these can also be vessels. In the worst case, these are foci of fibrosis.

To exclude the possibility of developing oncological diseases, doctors must prescribe additional studies:

blood test for tumor markers;
biopsy of kidney tissue;
daily analysis of urine for the presence of mineral salts;
general blood analysis.

The final diagnosis is established only by the doctor, comparing the results of ultrasound with the clinical manifestations of the disease, additional laboratory tests.

The procedure for ultrasound examination of the kidneys allows you to determine the features of the functioning of this organ, the integrity of its structure and the absence of any possible pathologies in the form of malignant or benign formations. Normal kidneys are round, symmetrical and do not reflect ultrasonic waves. If there are deviations, a change in the size and shape of the kidneys, their asymmetric location, as well as various formations that reflect ultrasound can be detected.

Hyperechoic inclusions in the kidneys are new formations or foreign bodies that do not contain liquid, have low sound conductivity and high acoustic density. Since the density of foreign structures is higher than the density of the renal tissue, ultrasonic waves are reflected from them during the study and create the phenomenon of hyperechogenicity.

What is hyperechogenicity and acoustic shadowing

The kidney casts an acoustic shadow

"Echogenicity" is the ability of solid and liquid physical bodies to reflect sound waves. All internal organs are echogenic, otherwise ultrasound would be simply impossible. "Hyper" means beyond anything, in our case - beyond the usual echogenicity of kidney tissues. A hyperecho signal means that something has appeared inside the kidney that can powerfully reflect ultrasonic waves.

The doctor on the screen determines the inclusion by a light, almost white spot, and immediately pays attention to whether the detected inclusion casts an acoustic shadow, that is, a bunch of ultrasonic waves that have not passed through it. An ultrasonic wave is slightly denser than air, so only a very dense object can prevent it from passing through itself.

Hyperechoic inclusions are not an independent disease, but a signal of the development of pathology inside the kidney.

Clinical picture: symptoms and signs

Without ultrasound, the presence of neoplasms is almost impossible to determine, however, as a rule, they are accompanied by the following symptoms:

elevated temperature against the background of pain in the lower back;
changed color of urine (it becomes brown, bright or dark red);
colic (single and paroxysmal) in the renal region;
persistent pain (acute and / or aching) in the groin;
constipation alternating with diarrhea;
nausea and vomiting.

Types of inclusions and possible diseases

What does a hyperechoic formation look like on ultrasound

If in the cavity of the kidney, and more often both, seals of a large volume (0.5-1.5 cm3) are found, casting an acoustic shadow, they indicate stones inside the kidney. A volumetric formation with a fixed shadow may indicate a sclerotic lymph node, which was formed after a purulent-inflammatory process or during a chronic inflammatory disease.

Sclerosis is a pathological replacement of healthy functional elements of an organ with connective tissue, followed by a violation of its functions and death.

If a single formation is found inside the kidney that does not cast an acoustic shadow, it can be a signal:

cystic cavity filled with fluid or empty;
sclerosis of the vessels of the kidney;
small, not yet hardened calculi (stones);
sand
inflammatory process: carbuncle or abscess;
fatty compaction in the renal tissue;
hemorrhages with the presence of hematomas;
the development of tumors, the nature of which needs to be clarified.

If hyperechoic formations are small (0.05-0.5 cm3), reflected on the screen with bright sparkles, and there is no acoustic shadow, these are echoes of psammoma bodies or calcifications, which often, but not always, indicate malignant tumors.

Psammoma (psammous) bodies are layered formations of rounded forms of protein-fat composition, encrusted with calcium salts. They are found in the joints of blood vessels, the meninges, and some types of tumors.

Calcifications are calcium salts that precipitate into soft tissues affected by chronic inflammation.

The study may reveal a combination of several varieties of hyperechoic inclusions with or without a shadow.

The composition of malignant tumors in 30% of cases includes calcifications, in 50% of cases - psammoma bodies, in 70% of cases sclerotic areas are fixed.

There is a high probability of seeing hyperechoic inclusions in the kidneys in the presence of urolithiasis, foci of infection, chronic or recurrent inflammatory diseases: glomerulonephritis, hydronephrosis, paranephritis.

Accurate diagnosis and additional procedures

Under the guidance of a doctor who analyzes the clinical picture of your disease, you should undergo further examinations to clarify the nature of the formations.

If stones, sand, hematomas in the kidneys are suspected, a general and daily urine test is prescribed, which determines the composition of mineral salts in it, as well as a blood test to determine the weak links in the body's metabolism.

If the kidney was injured, a hemorrhage occurred in it, a fatty deposit or cyst formed, the vessels became sclerosed and an operation is required, an MRI is performed to determine the exact location of the inclusions.

If oncology is suspected, a blood test for tumor markers and a biopsy of organ tissues are necessary. When the quality of the tumor is in doubt, it is desirable to conduct sonoelastography (a type of ultrasound), which detects cancer in the initial stages, determines the location and size of the tumor, even of a microscopic size. A highly qualified specialist can visually differentiate the quality of the neoplasm.

The discovery of hyperechoic bodies is not a reason for confusion or inaction, it is necessary to immediately examine, establish a diagnosis and begin treatment.

Prevention and treatment

Surgery to remove a kidney tumor

Preventive measures usually include the use of traditional methods of treatment. So, to remove sand or small stones, various diuretic herbal preparations and medicines prescribed by the attending physician are effectively used. Larger stones (more than 5 mm) are either removed or crushed with a laser or ultrasonic radiation, followed by removal by lithotripsy. Inflammatory kidney disease is treated with antibiotics.

When malignant and benign tumor pathologies are detected, surgical intervention is performed. Benign neoplasms and cysts are removed by resection or partial excision. In malignant tumors, the entire kidney is removed using chemotherapy and various radiation methods.

Accurate diagnosis and treatment program is possible only when contacting a qualified and experienced specialist: a nephrologist or urologist.

Hyperechoic inclusions in the kidneys are usually found during ultrasound. This means that ultrasound reveals separate areas in which the structure has changed towards a higher density.

On the screen, they appear as lighter spots. The reasons for this deviation may be different.

The procedure for examining the kidneys with ultrasound is often used. This is a completely harmless method that is not contraindicated even during pregnancy.

This technique helps to determine the degree of integrity of the organ, the possibility of its functioning, to detect various formations and the tumor process.

What could such a picture mean?

The concept of echogenicity includes the ability to reflect ultrasonic waves. All organs and tissues that exist in the human body have this ability to varying degrees.

A term such as hyperechogenicity implies the most powerful reflection, which is characteristic of very dense structures.

The following structures can give a similar picture:

calcifications;
fibro-sclerotic changes;
inclusions of protein-lipid nature.

Hyperechoic inclusions are divided into several main types:

Formations that have a three-dimensional appearance and an acoustic shadow. These are quite large changes that give calculi, areas of calcification, lymph nodes prone to sclerosis.
The formation is voluminous, but without the presence of an acoustic shadow. Such a picture occurs in the presence of a neoplasm of any nature, small stones, cysts, sclerosis of the kidney vessels.
Bright, small inclusions are pronounced, without acoustic shadow detection. Perhaps their appearance in a diffuse form of cancer, or the presence of psammoma bodies.

What diseases should be suspected?

If a specialist describes the presence of hyperechoic inclusions, then the attending physician may suggest the following diseases:

inflammatory kidney disease (nephritis);
abscess;
hematoma;
cicatricial changes;
benign and malignant tumors;
cyst.

The very description of such formations is not a diagnosis, but their detection should be the reason for contacting a doctor to clarify the true nature of this deviation. If necessary, the patient undergoes a standard abdominal operation.

What to do next?

After receiving the results of the ultrasound, the doctor conducts additional diagnostics. This necessarily includes general tests, as well as blood for tumor markers, a study of urine for the presence of salts in it, in some cases a biopsy is performed.

The diagnosis also includes the clinical picture of a particular disease. The patient may complain of back pain, dysuric phenomena, general weakness, attacks of renal colic, fever, often worried about frequent and painful emptying of the bladder, urinary incontinence, nausea and vomiting.

Hyperechoic formation in the kidney is treated in two main areas:

impact on the cause of this pathology;
symptomatic therapy.

When confirming urolithiasis, conservative treatment is first applied. It includes taking diuretic herbs and drugs, following a certain diet (depending on the qualitative composition of the stones), normalizing metabolic processes.

In the absence of effect and the presence of large formations, lithotripsy with ultrasound or laser is recommended.

In some cases, KSD will require surgery. The most modern technique is the removal of the stone using endoscopic techniques.

Detection of a malignant tumor process requires immediate surgery. If the cancer is at an inoperable stage, then doctors resort to palliative methods to slow its growth and spread.

For the prevention of diseases and the treatment of the kidneys and urinary system, our readers recommend Cirrofit Drops, which consist of a set of medicinal herbs that enhance each other's actions. Drops can be used to cleanse the kidneys, treat urolithiasis, cystitis and pyelonephritis.
Doctors opinion...

Pain relief is carried out by prescribing analgesics, narcotic and non-narcotic effects.

Sometimes the neoplasm is removed along with the kidney, after which radiation and chemotherapy are applied.

If hyperechoic inclusions are the result of diffuse dystrophic processes in the absence of an acute or chronic disease, then treatment is not required.

On ultrasound hyperechoic inclusions visualized as dotted, linear or volumetric structures of high echogenicity, determined within the formation tissue; some of the hyperechoic structures may be accompanied by an acoustic shadow (see Fig. 120).

The traditional interpretation of hyperechoic inclusions is " calcifications", while they are subdivided into" microcalcifications" corresponding to point hyperechoic particles without acoustic shadow, and " macrocalcifications"- hyperechoic areas with a characteristic acoustic shadow. The presence of "microcalcifications" in the node is regarded by most researchers as one of the most likely signs of its malignancy.

We observed hyperechoic inclusions much more often in malignant tumors (75%) than in benign (5%) nodes. At the same time, three types of structures were identified morphologically in malignant tumors: 1) psammoma bodies (50%), 2) calcifications(30%) and, most often, 3) areas of sclerosis(about 70%). Unlike malignant neoplasms, psammoma bodies were not morphologically determined in benign nodes; in rare cases, the presence of calcifications(5.13%). The most frequently identified areas of sclerosis(more than 60%).

The results obtained are consistent with the data of Garretti L. et al. and Leung C. S. et al. about the presence of psammoma bodies in the tissue of 25 - 50% of papillary carcinomas, as well as the works of Kuma K. et al. , Zaccheroni V. et al. and Bruneton J. in which it is noted that, in addition to malignant tumors, calcifications are morphologically detected in nodular goiter and follicular adenomas.

In accordance with the ultrasound characteristics and morphological content, hyperechoic structures of thyroid neoplasms can be divided into three types:

1) bright dots ;

2) 3D without acoustic shadow;

3) 3D with acoustic shadow.

Bright point hyperechoic inclusions are the predominant ultrasound sign of psammoma bodies, less often small calcifications (Fig. 171). In the presence of an ultrasonic feature, the morphological ratio of these elements is approximately 4:1.

Rice. 171. Papillary carcinoma (histopathological preparation): A- psammoma bodies (histopathological preparation - cit. according to T. I. Bogdanova, fragment); AT- calcification (histopathological preparation - cit. by Rubin E., fragment).

psammoma bodies(Fig. 172) are a special kind of calcifications. These structures are extremely important in the ultrasound diagnosis of papillary carcinomas. “A distinctive feature of papillary carcinoma is the presence psammoma bodies, resembling a cut of a tree trunk with characteristic rings, increasing from the center to the periphery. Psammoma bodies can be found in the stroma of the tumor and the surrounding tissue of the thyroid gland, in the lymphatic capillaries, especially in the diffuse sclerosing variant of papillary carcinoma, and also in metastases of papillary carcinoma to the lymph nodes. According to most researchers, they are formed at the site of destruction of papillae, which is why they are often referred to as "tombstones" of dead papillae. Psammoma bodies should not be confused with calcifications that are observed in any thyroid pathology, and not only in papillary carcinoma ”(cited by Bogdanova T.I.,).

Psammoma bodies and calcifications have the highest acoustic density of all structures of the thyroid gland and thyroid neoplasms. This feature makes it possible to visualize these elements already at sizes that are slightly more than half the wavelength at a frequency of 7.5 MHz (from 100 μm). The size of psammoma bodies is variable, but usually does not exceed the ultrasonic wavelength (200 µm). Sonographically significant (visualized) are individual structures with a size of 100 - 150 microns, as well as clusters smaller bodies of 30 - 50 elements ("bunch of grapes"), the total size of which can reach 500 - 600 microns.

Rice. 172. Psammoma body(pathohistological specimen) [cit. according to Yamashita S., 1996].

On ultrasound, psammoma bodies are visualized as multiple, very bright, punctate hyperechoic structures without acoustic shadowing(Fig. 173). The described ultrasonic feature corresponds only to these structures. The degree of hyperechoicity of psammoma bodies is the highest of all hyperechoic structures; they are clearly defined against the background of tissue of any echogenicity. In some cases, this feature is of decisive importance in the ultrasound diagnosis of isoechoic carcinomas.

Rice. 173. Bright point hyperechoic inclusions. Education size 39 mm, irregular shape, without clear boundaries, unevenly reduced echogenicity. In the tissue of the node, multiple bright dotted hyperechoic structures without an acoustic shadow are determined. Point hyperechoic inclusions are localized mainly in isoechogenic areas of the tumor. PTHI is a non-encapsulated papillary carcinoma of a papillary-solid structure with numerous psammoma bodies.

In quantitative terms, microcalcifications in papillary carcinomas are less common than psammoma bodies. They are visualized as single bright echoes without an acoustic shadow (Fig. 174). The same ultrasonic sign can be observed in the presence of separate groups of psammoma bodies.

Rice. 174. Bright point hyperechoic inclusions. Education size 13 mm, irregular shape, without clear boundaries, unevenly reduced echogenicity. In the tissue of the node, separate bright point hyperechoic structures without an acoustic shadow are determined. PTGI is a non-encapsulated papillary carcinoma of a typical papillary structure with single calcifications.

Bright point hyperechoic inclusions were determined only in papillary carcinomas (65%). In the presence of an ultrasound sign, morphologically, in the tissue structure of these tumors, psammoma bodies (80%) were most often detected, less often - small calcifications (20%) and areas of sclerosis (6.5%).

The greatest severity (number) of point hyperechoic inclusions is observed in the papillary-solid structure of papillary carcinomas, especially in the diffuse-sclerosing variant of the tumor. In these cases, multiple bright point echo signals are determined not only within the neoplasm tissue, but also throughout almost the entire volume of the thyroid gland, as well as in enlarged regional lymph nodes. The noted ultrasonic feature is consistent with the results of morphological studies of Bogdanova T. I. et al. , which emphasize that psammoma bodies are formed at the site of destruction of papillae in malignant papillary tissue, tumor metastases to the lymph nodes, as well as the lymphatic capillaries of the surrounding thyroid tissue, especially in the diffuse sclerosing variant of papillary carcinoma.

Thus, the visualization of multiple bright point echoes is one of the most significant independent ultrasonic features. malignant papillary tissue. It is necessary to differentiate bright dotted hyperechoic inclusions with the “comet tail” echo signal.

Volumetric hyperechoic inclusions without acoustic shadowing are determined both in benign and malignant formations, in an approximate ratio of 1: 7. They are the predominant ultrasound sign of fibrous-sclerotic areas, which are detected by pathohistological examination of these nodes in more than 80% of cases.

In patients with benign volumetric hyperechoic inclusions without acoustic shadowing are visualized mainly as single structures and are observed in all types of benign nodular pathology (Fig. 175).

Rice. 175. Volumetric hyperechoic structure without acoustic shadow. Isoechoic formation of the correct form, with a hydrophilic border, contains separate small cystic cavities. In the tissue of the node, a large hyperechoic structure without an acoustic shadow is determined. PTGI is a heterogeneous adenoma with sclerotic and cystic changes.

Often, linear hyperechoic echo signals are interpreted as "fibrous foci", visualized in the tissue of benign nodes containing multiple small cystic cavities (Fig. 176). These echo signals arise due to the usual acoustic effect of amplification of the posterior wall of the hydrophilic cavity (cystic, vessels) and are not morphologically fibrous structures.

Rice. 176. Pseudofibrosis. The isoechoic node of the correct form, with a discontinuous hydrophilic border, contains multiple small slit-like cystic cavities, along the posterior surface of which hyperechoic amplification of the echo signal is noted.

For papillary carcinomas pronounced fibro-sclerotic changes from the side of the stroma are characteristic (Fig. 177).

Rice. 177. Sclerosis(histological specimen, scheme) . Papillary thyroid carcinoma, diffuse sclerosing variant. Signs of diffuse tumor growth, severe sclerosis(histological preparation - cit. according to T. I. Bogdanova).

On ultrasound examination of these tumors, single volumetric hyperechoic areas without an acoustic shadow can be observed, but multiple structures are more often visualized (Fig. 178).

Rice. 178. Volumetric hyperechoic structures without acoustic shadow. Hypoechoic formation 24 mm in size, irregularly shaped with preservation of the contour, indistinct border, the presence of tortuous vascular structures. The node contains multiple hyperechoic areas without acoustic shadowing. PTGI is an encapsulated papillary carcinoma with severe sclerotic changes.

We observed hyperechoic inclusions without acoustic shadowing in all anaplastic, 35% papillary, 25% medullary, and 10% follicular carcinomas.

Volumetric hyperechoic inclusions with acoustic shadowing correspond to areas of sclerosis and large calcifications in a morphological ratio of approximately 3: 1. This ultrasonic sign can also be observed with large accumulations of psammoma bodies.

Volumetric hyperechoic inclusions with an acoustic shadow are determined mainly in the tissue of malignant nodes (83%) and much less often in benign ones.

At benign hyperechoic inclusions with an acoustic shadow are observed quite rarely in nodular pathology, they were noted by us only in 4% of patients, while in all cases they were determined sonographically single structures (Fig. 179).

Rice. 179. Volumetric hyperechoic structure with acoustic shadow. Isoechoic formation 46 mm in size, regular shape, with a uniform hydrophilic border, the presence of multiple different-sized cystic cavities. In the tissue of the node, a single large hyperechoic structure with an acoustic shadow is determined (c). PTGI is a heterogeneous adenoma with isolated calcifications.

In patients with malignant tumors, an ultrasound sign was observed in a third of cases, more often multiple structures (Fig. 180). The presence of volumetric hyperechoic inclusions with acoustic shadowing was noted in a quarter of patients with papillary and one third of patients with medullary carcinomas.

Rice. 180. Volumetric hyperechoic structures with acoustic shadow. Education size 25 mm, irregular shape, without clear boundaries, unevenly reduced echogenicity. Multiple hyperechoic structures with acoustic shadowing are identified. PTGI is a non-encapsulated papillary carcinoma of a follicular-solid structure with severe stromal sclerosis.

More than half of the patients had combination various hyperechoic inclusions: with benign nodes, hyperechoic structures with and without acoustic shadows were observed, which morphologically corresponded to the presence of fibrous-sclerotic areas and calcifications; in patients with malignant neoplasms, various combinations of bright dotted with volumetric ones were determined, which corresponded to the presence of psammoma bodies, foci of sclerosis and calcifications (Fig. 181).

Rice. 181. Combination of various hyperechoic inclusions. Education size 47 mm, irregular shape, without clear boundaries, unevenly reduced echogenicity. Multiple point and volumetric (with acoustic shadow) hyperechoic inclusions, as well as various tortuous vascular structures, are determined. PTGI is a non-encapsulated papillary carcinoma, predominantly of a papillary-solid structure with pronounced fibrous-sclerotic changes, an abundance of calcifications and psammoma bodies.

Thus, hyperechoic inclusions are much more often observed in the tissue of carcinomas than benign nodes. Availability multiple hyperechoic structures of any kind, especially bright dotted ones, is a significant independent ultrasound sign of malignant tumors of the thyroid gland.

When conducting an ultrasound examination, both kidneys are necessarily examined, since they are a paired organ. In this case, hyperechoic inclusions in the kidneys can be detected, which are localized both on both sides and in one organ. These inclusions can be located anywhere in the kidney. Their localization largely depends on the unfavorable factors that caused the appearance of these inclusions. If a similar pathology is detected on ultrasound, the patient must undergo a course of treatment and subsequently undergo regular preventive examinations.

Features of the disease

Hyperechoic inclusions in the kidneys are localized both on both sides and in one organ

Healthy kidneys have a uniform structure, are located symmetrically, and their shape is smooth and regular. During ultrasound, the renal tissues should not reflect ultrasonic waves. As a result of various pathological processes, the structure of the organ and its appearance may change depending on the state of the inclusions and the severity of the disease itself.

With various pathologies, both kidneys can be located asymmetrically relative to each other. They can be enlarged or reduced in size. The outlines of the organ may be uneven, and inside the ultrasound, degenerative tissue changes are visible, due to which poor conductivity of the ultrasonic wave is observed. In the case of deposition of sand or stones in the kidneys, as well as the appearance of various neoplasms, the echogenicity of the affected areas of the organ changes.

Worth knowing: echogenicity is the reflection of a sound wave from a solid or liquid substance.

In fact, every organ of the human body has a certain echogenicity. Thanks to this, ultrasound can see the outlines of organs, assess their size and structure. Hyperechogenicity refers to an excessively strong reflection of a sound wave. This indicates the presence of any inclusions in this organ.

As a rule, during ultrasound examination of the kidney, hyperechoic inclusions are visible in the form of white spots, which are an extra element in the structure of the organ. In this case, the doctor using the equipment can immediately determine the absence or presence of an acoustic shadow. According to this indicator, it is very easy to determine the density of hyperechoic inclusions.

Varieties of inclusions and their diagnostics

If hyperechoic inclusions in the kidneys were found on ultrasound, only a doctor can accurately determine what it is

If hyperechoic inclusions in the kidneys were found on ultrasound, only a doctor can accurately determine what it is. The detection of such inclusions signals the development of a pathological process in the organ, but is not an independent disease. For example, if calculi or sand are found, a kidney stone disease (urolithiasis) is diagnosed.

Each hyperechoic inclusion indicates a certain pathological process in the kidneys. For diagnosis, it is important to determine the type of echogenic inclusion. They are usually divided into two categories:

Kidney stones (sand and stones). Various neoplasms of the kidneys.

In most cases, hyperechoic formations are determined in the parenchyma of the organ and in the thickness of the pyramids of the kidneys. An ultrasound examination of the kidney can reveal the following types of kidney formations:

Small elements without acoustic shadow. On the monitor screen, they are visible as bright bright dots. Inclusions of considerable size, which may be benign neoplasms. Large elements with an acoustic shadow, which are malignant tumors of the kidneys. Confirmation of this diagnosis can be found on ultrasound calcifications, psammoma bodies in the neoplasm, as well as areas of sclerotic tissues.

During the ultrasound examination, several types of echogenic inclusions can be detected at once. Solitary formations without an acoustic shadow may indicate the presence of the following pathologies:

Kidney cyst. Sclerosis of the vessels of the kidneys. Carbuncle and abscess. Fat deposits on the renal pyramids. Renal hemorrhages (hematomas).

To confirm the disease detected on ultrasound, an additional examination of the patient is carried out. Be sure to conduct a laboratory study of urine and blood, X-ray examination using a contrast agent. Magnetic resonance imaging may also be ordered. In some cases, a kidney biopsy is required.

Symptoms

In the acute stage, the patient may feel pain localized in the lumbar region.

Since hyperechoic inclusions in the kidneys always indicate the presence of a pathological process in this organ, other symptoms of this disease are necessarily present. Their manifestations depend on the nature of the disease. So, in the acute stage, the patient may feel the following symptoms:

temperature rise to significant levels; nausea and vomiting; urine has a cloudy color and an unpleasant odor; pain localized in the lumbar region; pain may radiate to the lower abdomen and groin.

Such clinical symptoms are inherent in many diseases in the acute phase and during exacerbation of the chronic process. Depending on the disease, ultrasound can reveal the syndrome of echogenic pyramids. It is very important to assess the state of the parenchyma of the organ against the background of these pyramids.

By itself, this syndrome does not pose a threat to the life of the patient and is only a symptom of another disease that can be accurately diagnosed after an additional examination. If such a syndrome is detected, a laboratory study of urine and blood is mandatory. According to deviations in the composition of blood and urine, conclusions can be drawn about the presence of nephropathy or even renal failure.

Important: in some cases, this syndrome is not a sign of kidney disease, but only indicates the condition of the organ.

For example, in thin people, as well as in children, very often during ultrasound of the kidneys, sharply outlined prominent pyramids and parenchyma of the organ are found. During an ultrasound examination of newborns, the condition of the pyramids themselves, their structure and the fluids released through them are assessed.

Treatment and prevention

In the treatment of a chronic disease in remission, physiotherapy procedures are used.

After an ultrasound scan and a set of additional instrumental and laboratory studies have been carried out, treatment is prescribed, the main goal of which will be to eliminate the cause of the disease, as well as to combat the accompanying symptoms. Depending on the nature of the pathological process, the patient's condition and the stage of development of the disease, conservative medical or surgical treatment can be used.

Medicines for treatment are chosen by a urologist or nephrologist. Based on the results of the examination, it is assigned:

antibacterial therapy; symptomatic treatment; anti-inflammatory drugs; prescribed diet; the patient must comply with a certain drinking regimen.

In the treatment of a chronic disease in remission, physiotherapeutic procedures are used, as well as homeopathic preparations. With the permission of the attending physician, herbal treatment can be used. In case of complications, more radical methods of treatment and specific measures are used.

As a preventive measure for various diseases of the urinary system, the following rules can be called:

Timely treatment of other diseases. Regular preventive check-ups. Compliance with the optimal drinking regimen. Proper nutrition.

It is worth adding that moderate physical activity, walks in the fresh air, good nutrition, and hygiene are considered good prevention of any diseases. You also need to avoid hypothermia, and during the period of respiratory diseases take multivitamin preparations.

What is hyperechogenicity and acoustic shadowing

The kidney casts an acoustic shadow

Hyperechoic inclusions are not an independent disease, but a signal of the development of pathology inside the kidney.

Clinical picture: symptoms and signs

Without ultrasound, the presence of neoplasms is almost impossible to determine, however, as a rule, they are accompanied by the following symptoms:

elevated temperature against the background of pain in the lower back; changed color of urine (it becomes brown, bright or dark red); colic (single and paroxysmal) in the renal region; persistent pain (acute and / or aching) in the groin; constipation alternating with diarrhea; nausea and vomiting.

Types of inclusions and possible diseases

What does a hyperechoic formation look like on ultrasound

Sclerosis is a pathological replacement of healthy functional elements of an organ with connective tissue, followed by a violation of its functions and death.

If a single formation is found inside the kidney that does not cast an acoustic shadow, it can be a signal:

cystic cavity filled with fluid or empty; sclerosis of the vessels of the kidney; small, not yet hardened calculi (stones); sand inflammatory process: carbuncle or abscess; fatty compaction in the renal tissue; hemorrhages with the presence of hematomas; the development of tumors, the nature of which needs to be clarified.

Psammoma (psammous) bodies are layered formations of rounded forms of protein-fat composition, encrusted with calcium salts. They are found in the joints of blood vessels, the meninges, and some types of tumors.

Calcifications are calcium salts that precipitate into soft tissues affected by chronic inflammation.

The study may reveal a combination of several varieties of hyperechoic inclusions with or without a shadow.

The composition of malignant tumors in 30% of cases includes calcifications, in 50% of cases - psammoma bodies, in 70% of cases sclerotic areas are fixed.

Accurate diagnosis and additional procedures

Under the guidance of a doctor who analyzes the clinical picture of your disease, you should undergo further examinations to clarify the nature of the formations.

The discovery of hyperechoic bodies is not a reason for confusion or inaction, it is necessary to immediately examine, establish a diagnosis and begin treatment.

Prevention and treatment

Surgery to remove a kidney tumor

Accurate diagnosis and treatment program is possible only when contacting a qualified and experienced specialist: a nephrologist or urologist.

During ultrasound of the kidneys, tissue zones are often found, in which the structure and acoustic density are distorted. Hyperechoic inclusions in the kidneys are the name of such tissue structures. These are cell-free microstructures where protein-lipid deposits, as well as deposits of calcium and protein salts, accumulate. On the screen of the ultrasonic device, the inclusions are presented in the form of white spots. The appearance of hyperechogenic inclusions indicates the development of many pathologies, therefore it is important to understand in detail the clinical picture of hyperechogenicity, the diagnostic process and methods of treating the consequences.

Concepts - hyperechogenicity and acoustic shadow?

Echogenicity refers to the ability of bodies of liquid and solid consistency to beat off ultrasonic waves. All organs located inside a person are echogenic, which is what allows ultrasound examination. Ultrasound helps to study the activity of the kidneys, determine their integrity and confirm or exclude the presence of neoplasms of a malignant or benign nature. In a healthy person, the organ is round in shape with a symmetrical location and inability to reflect sound waves. In cases of pathologies, the size of the kidneys changes, the location becomes asymmetrical and inclusions appear that can beat off sound waves.

On ultrasound, hyperechoic inclusions look like white spots.

The word "hyper" means an increased ability of echogenic tissues to reflect ultrasonic waves. During the ultrasound, the specialist sees white spots on the screen and determines whether they have an acoustic shadow, more precisely, an accumulation of ultrasonic waves that have not passed through it. Waves have a much higher density than air, so they can only pass through a dense object. Hyperechogenicity is not a separate disease, but a symptom that indicates the appearance of various kinds of pathologies inside the kidneys.

Symptoms of hyperechogenicity

The syndrome of hyperechoic pyramids of the kidneys has a number of symptoms:

an increase in body temperature caused by pain in the lumbar region;
change in the color of urine (from light yellow to brown or burgundy, sometimes with blood impurities);
stabbing pain in the body;
pain in the groin area;
stool disorders;
bouts of nausea and vomiting.

Types of hyperechoic inclusions in the kidneys

Hyperechoic formations are classified into 3 types based on how they are seen on ultrasound of the kidneys:

A large inclusion that casts an acoustic shadow. Most often it develops due to the appearance of stones in the organ or inflammatory processes and lymph nodes.
Large formation without acoustic shadow. It is diagnosed with the development of cysts, fatty layer in the renal sinuses, atherosclerotic vascular disorders, small stones and sand, cancerous and benign tumors.
Small and bright formations in which there is no acoustic shadow. They talk about the presence of psammoma bodies or microcalcifications.

Possible diseases

Large hyperechoic inclusions indicate the development of such pathologies in the kidneys:

urolithiasis disease;
inflammation of a different nature.

When single hyperechoic inclusions are diagnosed in the organ and no acoustic shadow is observed, this indicates such conditions:

hematomas;
sclerosis of the vessels of the organ:
small stones that have not yet had time to get stronger;
scar tissue;
fatty seals in the renal sinuses;
cysts;
the presence of sand;
benign neoplasms;
malignant neoplasms.

Large hyperechoic inclusions may indicate the development of urolithiasis.

If bright sparkles are visible on the monitor of the ultrasound machine and there is no acoustic shadow, this indicates an echo signal of pmammoma bodies (compounds of protein-fat composition framed by calcium salts) and calcifications (calcium salts), which sometimes indicate the development of malignant neoplasms. In the composition of cancerous neoplasms, in 30% of cases there are calcifications, and in 50% - psammoma bodies.

Gallbladder diseases are a special section in modern medicine, to which specialists pay increased attention. On the one hand, the pathology of the gallbladder (for example, polyps) can be completely asymptomatic, but tends to be malignant. On the other hand, some diseases, such as calculi of the gallbladder and biliary tract, are accompanied by severe attacks of pain and can lead to serious complications. As a result of prolonged stone pressure on the mucous membrane of the bladder, ulcers and bedsores may occur in it, diverticulum-like protrusions, internal and external biliary fistulas, perforations with the development of subhepatic or subdiaphragmatic abscesses, bile peritonitis may form. The movement of gallstones may be accompanied by blockage of the cystic duct, dropsy of the gallbladder or its empyema. When the stone obturates the outlet section of the common bile duct, it occurs. Long-term presence of a stone in the bile ducts and the addition of an infection lead to the development of cholangitis. The prolapse of a large gallstone from the gallbladder into the intestine through the formed anastomosis can lead to intestinal obstruction. Therefore, timely diagnosis of diseases of the gallbladder and ductal system is very important.

The formation of bile in the liver is a continuous process, but its entry into the intestine normally occurs mainly in the process of digestion. This is provided by the reservoir function of the gallbladder and its rhythmic contractions with consequent relaxation of the sphincter of Lutkens and then the sphincter of Oddi, located at the confluence of the common bile duct into the intestine (Fig. 1).

Rice. one. Schematic representation of the position of the gallbladder on the visceral surface of the liver.

1 - the bottom of the gallbladder;
2 - cystic duct;
3 - own hepatic artery;
4 - ;
5 - gastrohepatic ligament;
6 - left lobe of the liver;
7 - caudate lobe of the liver;
8 - inferior vena cava;
9 - caudate process;
10 - neck of the gallbladder;
11 - right lobe of the liver;
12 - body of the gallbladder;
13 - square lobe of the liver.

On an empty stomach, the gallbladder contains 30-80 ml of bile, but it can concentrate 5-10 times more hepatic bile. With stagnation of bile in the bladder, its amount may increase. In women, the gallbladder in a state of functional rest has a slightly larger volume than in men, but it contracts faster. With age, the contractile function of the gallbladder decreases.

Ultrasonography is one of the most informative and accessible instrumental methods for diagnosing gallbladder diseases.

The acoustic properties of ultrasound make it possible to detect the smallest echogenic structures located in the gallbladder.

With the help of ultrasound, the time of diagnostic search is significantly reduced. Unlike computed tomography (CT) and magnetic resonance imaging (MRI), with ultrasound, the researcher himself is directly involved in obtaining the image, which has its pros and cons. Positive is the possibility of a more targeted and detailed study of the object under study. The negative side is that the quality of the image and its interpretation largely depend on the experience of the researcher and the correctness of the methods used by him.

Polyps in the gallbladder are found in 6% of the total population. In 80% of cases, polyps in the gallbladder are observed in women who have given birth after the age of 30 years. Since polyps do not clinically manifest themselves in any way, their diagnosis is most often accidental and occurs during an ultrasound scan in a patient for completely different reasons.

Although the causes of polyps on the walls of the gallbladder have not been established, and the symptoms are not obvious, four types of such formations are known. Most often, according to statistics, the following types are found in the gallbladder in patients today.

Inflammatory polyp of the gallbladder - is a kind of inflammatory reaction of the mucous membrane of the gallbladder itself, manifests itself in the patient in the form of various growths of the granulation internal tissue of the affected organ.

Often, doctors also diagnose gallbladder adenoma. This happens because it is a kind of benign tumor in the form of a polypoid growth of the glandular tissue of the patient's gallbladder.

Also of note is papilloma or polyposis of the gallbladder in some patients. Such a papilloma is a benign tumor of the bladder mucosa in the form of peculiar papillomas or papillary growths of various appearance and structure.

The most common type is the so-called cholesterol polyp of the gallbladder, which is an elevation of the mucous membrane of the gallbladder with cholesterol deposits on it. Cholesterosis is quite common among patients referred for surgery with a clinical diagnosis of "polyps" or "polyposis of the gallbladder", according to some reports from 42 to 95% of cases.

Ultrasonography is an effective means of detecting the polypoid form of cholesterosis. The following sonographic characteristic of cholesterol polyps is considered traditional: motionless hyperechoic structures that do not give an acoustic shadow and are attached to the wall of the gallbladder. The contours of such formations, as a rule, are even, and the sizes of such formations are different, more often they do not exceed 10 mm (Fig. 2).

Rice. 2.

a) Solitary polyp in the gallbladder (hyperechoic parietal immovable formation, with even contours, without acoustic shadow).

in) Polyp-mesh form of cholesterosis, polyps up to 5 mm in size, increased echogenicity.

G) Single polyp in the gallbladder.

However, according to some reports, the size of cholesterol polyps can be more than 20 mm. In addition, large polyps (7% of the total) may have reduced echogenicity and a scalloped contour.

Small cholesterol inclusions that form a diffuse mesh in the thickness of the submucosal layer 1-2 mm in size look like a local thickening or thickening of the gallbladder wall and in some cases (see Fig. 2) cause reverberation (sonographic symptom "comet tail").

With widespread cholesterosis, multiple hyperechoic formations are visualized, giving a picture of a "strawberry" gallbladder (Fig. 3).

Rice. 3. Ultrasound picture of polyps in the gallbladder.

a) Multiple polyps in the gallbladder, a picture of "strawberry" gallbladder.

b) In the color Doppler imaging mode, blood flow is not recorded.

The nature of the polyp stem is traditionally considered in oncological practice as a sign associated with the malignant nature of the formation. The likelihood of possible malignancy is greater if it has a wide base, and not a thin stem. However, it is necessary to take into account the possibility of a false-positive diagnosis of a wide base in large polyps due to their limited displacement in the gallbladder lumen. Trembling, reminiscent of a candle flame, is observed in polyps of small size and elongated shape, and indicates their thin stalk.

Cholelithiasis (cholelithiasis; calculous cholecystitis) is a disease caused by the presence of stones in the gallbladder and bile ducts. The incidence of gallstones increases with age, reaching 45-50% in women over 80 years of age. In men, gallstones are 3-5 times less common, in children - extremely rare. Only in 20% of cases, gallstones exist asymptomatically ("silent" calculi).

There are two main mechanisms for the formation of gallstones: hepatic exchange and vesicoinflammatory. The hepatic-metabolic mechanism consists in the formation of gallstones due to factors such as unbalanced nutrition with a predominance of coarsely dispersed animal fats (pork, lamb, beef) in the diet to the detriment of vegetable fats; neuroendocrine disorders, for example, those associated with dysfunction of the endocrine system of an age-related nature and hypofunction of the thyroid gland; lesions of the hepatic parenchyma of toxic and infectious origin; hypodynamia and stagnation of bile. As a result, the liver produces lithogenic bile, that is, capable of forming cholesterol or mixed stones. In the gallbladder-inflammatory mechanism, gallstones are formed under the influence of the inflammatory process in the gallbladder, leading to physicochemical changes in the composition of bile (dyscholia). A change in the pH of bile to the acid side, which is characteristic of any inflammation, leads to a decrease in the protective properties of colloids, in particular the protein fractions of bile, and the transition of a bilirubin micelle from a suspended state to a crystalline state. In this case, a primary crystallization center is formed, followed by a layering of other ingredients of bile, mucus, epithelium, etc.

Gallstones are dense formations, the number of which can be from one to several thousand, the size is up to several centimeters in diameter, and the weight is up to 30 g or more. In the gallbladder, stones are more often rounded, in the common bile duct - ellipsoid or oblong, in the intrahepatic ducts - branched. Depending on the composition, cholesterol, pigment-cholesterol, cholesterol-pigment-lime, pigment and calcareous stones are distinguished; when cut, they have a pigment core and a layered structure.

The clinical picture of gallstone disease is diverse. Conventionally, chronic pain, chronic recurrent, dyspeptic, angina pectoris and a number of other clinical forms are distinguished. A characteristic ultrasound sign of a calculus in the gallbladder is its acoustic shadow. Such a shadow occurs due to the high density of the stone compared to soft tissues. The presence or absence of a shadow helps distinguish a stone from a gallbladder polyp (Fig. 4).

Rice. four. Ultrasound picture of stones in the gallbladder.

a) Single gallbladder calculus (mobile hyperechoic structure, giving a clear shadow path).

b) Multiple stones of the gallbladder.

in) Multiple calculi of the gallbladder, change in location with a change in body position (mobility of calculi).

G) Disabled (completely filled with calculi) gallbladder, reduction in the size of the gallbladder (shrinkage).

Choledocholithiasis. The presence of calculi in the bile ducts can be assumed primarily on the basis of the classic Charcot triad - pain in the upper right or middle of the abdomen, chills with fever and jaundice. However, this triad occurs only in 30% of patients with choledocholithiasis. According to the literature, approximately 75% of patients with choledocholithiasis complain of pain in the right upper quadrant of the abdomen or epigastric region, and cholestatic jaundice develops in some patients, in 18-84% of cases it is present in history or present at the time of examination.

The most difficult for clinical diagnosis is asymptomatic choledocholithiasis, which occurs in 19.8% of patients.

The fate of the calculus in the common bile duct may be different. He can, together with the current of bile, "slip" through the sphincter of Oddi into the duodenum (duodenum), without causing any complications. This option is possible if the calculus is small (1-3 mm). Another option is a valve stone (more than 3 mm) in the common bile duct, which does not interfere with the outflow of bile, but does not go into the intestine. Such a calculus can be in the choledoch for days, months and even years, increasing in size. In the end, it clogs the choledoch, causing a violation of the outflow of bile from the liver and / or pancreatic juice from the pancreas. Even the smallest stone can cause such a blockage. Blockade of the common hepatic duct disrupts the outflow of bile from the liver, obstructive jaundice develops.

Well-known sonographic signs of choledocholithiasis are divided into direct and indirect. Direct ultrasound signs include the expansion of the choledochus more than 7 mm and the presence in its lumen of hyperechoic structures of various sizes, giving a shadow path. Indirect ultrasound signs include biliary hypertension, an increase in the head of the pancreas, the presence of changes in the liver parenchyma in the paravesical zone. However, the localization of the stone in the intrapancreatic part of the choledochus and in the ampulla of Vater's papilla significantly complicates its diagnosis. If the size of the stone is smaller than the diameter of the choledochus, or it partially blocks the lumen of the duct, jaundice may be relapsing. In such cases, complete obturation can occur when the stone moves along the duct and clogs the common bile duct in places of physiological narrowing. Then there is persistent biliary hypertension with a corresponding clinical picture of jaundice.

As an illustration, we present our own clinical observations.

Clinical observation 1

Patient T., 62 years old, was admitted to the clinic with complaints of pain in the right hypochondrium, yellowing of the skin.

From the anamnesis it is known that in 1991 the patient underwent cholecystectomy for cholelithiasis.

Ultrasound of the abdominal cavity organs performed upon admission revealed that the liver was slightly enlarged, the echostructure was diffusely heterogeneous, increased echogenicity, dilated intrahepatic ducts were visualized. Portal vein 12 mm. The gallbladder has been removed. The common bile duct is expanded to 15 mm, narrowed towards the terminal section. In the lumen of the common bile duct, there are multiple calculi in diameter from 8 to 15 mm. The pancreas is of normal size, the contours are even, clear, the structure is heterogeneous, increased echogenicity, the duct is 1 mm. The spleen is of normal size, structurally unchanged. Splenic vein 7 mm. Conclusion: condition after cholecytectomy. Ultrasound picture of a low hepatic block caused by choledocholithiasis (Fig. 5).

Rice. 5.

a, b) In the lumen of the common bile duct, there are multiple hyperechoic structures of various diameters, giving a clear acoustic shadow.

To clarify the diagnosis, endoscopic retrograde cholangiopancreatography was performed ( ERCP) with endoscopic papillosphincterotomy ( EPST). The mouth of the BDS cannulated with a lateral papillotome, the aspiration test is positive, cloudy bile is obtained. With the introduction of 40 ml of a contrast agent, an enlarged choledochus up to 25 mm, lobar and segmental ducts, multiple rounded moving shadows of calculi from 0.8 to 20 mm are contrasted. Lateral papillotome incision within the anatomical limits of 1.0 cm. During the revision of the common bile duct basket Dormia extracted 3 stones with a diameter of 15 to 20 mm, putty bile with flakes. The contrast loss in the duodenum is moderate. Conclusion: choledocholithoextraction (Fig. 6).

Rice. 6. Endoscopic retrograde cholangiopancreatography.

a, b) Concretions of the choledochus. The presence of multiple filling defects against the background of a contrast shadow of the common bile duct, manifested by rounded and polygonal areas of enlightenment along the shadow of the bile ducts.

Given the presence of large calculi and the inability to remove all calculi during ERCP, the patient underwent choledocholithotomy, choledocholithoextraction.

The postoperative period proceeded without complications. In a satisfactory condition, the patient was discharged under the supervision of a surgeon at the place of residence.

Clinical observation 2

Patient L., aged 74, was admitted to the clinic with a diagnosis of cholelithiasis. Chronic calculous cholecystitis. Multiple choledocholithiasis. Mechanical jaundice severe. Purulent cholangitis.

Ultrasound of the abdominal cavity revealed: the liver is slightly enlarged, the contours are even, clear, the structure is heterogeneous, increased echogenicity. Portal vein 12 mm. Expansion of intrahepatic ducts, lobar 5 mm, common hepatic duct (OPP) expanded to 20 mm, the lumen is represented by structures according to the density of small calculi, putties extending into the lumen of the right lobar duct. The gallbladder is 89x32 mm in size, the wall is 2 mm, it contains similar masses. The common bile duct is 15 mm, the lumen is also represented by calculi and putty. The pancreas is of normal size, the contours are even, the structure is diffusely heterogeneous, increased echogenicity, the duct is not dilated. Spleen of normal size, medium echogenicity, splenic vein 7 mm. Conclusion: gallbladder stones. Ultrasound picture of a low hepatic block caused by choledocholithiasis (Fig. 7).

Rice. 7. Ultrasound picture of choledocholithiasis.

a) Enlarged gallbladder (blue arrow), common bile duct calculi (red arrow).

b) Multiple hyperechoic structures in the lumen of the common bile duct, with a clear shadow path.

When conducting ERCP found: BDS is in a typical place, 1 cm in diameter, at the bottom of the diverticulum without signs of inflammation, up to 0.4 cm in diameter. The mucosa over it is hyperemic. The mouth is visualized. Bile is not supplied. The longitudinal fold is partially visible, as it is located almost completely in the diverticulum. Cannulation of the BDS with a lateral papillotome. The aspiration test is positive. Introduced 20 ml of contrast agent. The common bile, common hepatic, lobar hepatic, terminal parts of the segmental ducts are contrasted. In the lumen of the choledochus, multiple filling defects from 0.5 to 2 cm are determined, the choledochus is expanded to 2.5 cm in diameter. After revision with a Dormia basket, 4 calculi of 1 cm each and many small ones up to 0.5 cm were removed. The outflow in the duodenum was restored. A calculus up to 2 cm in diameter is located 12 cm from the papilla; it is not possible to grab the calculus with a basket and remove it. Lost drainage is installed above the level of the calculus. Conclusion: choledocholithiasis, choledocholithoextraction, purulent cholangitis (Fig. 8).

Rice. eight. Endoscopic retrograde cholangiopancreatography. Multiple calculi of the choledochus.

a) Choledoch, completely filled with calculi.

b) Choledoch with calculi (red arrow), discharge of contrast into the intestine (blue arrow).

Given the presence of large calculi and the impossibility of removing them with ERCP, the patient underwent cholecystectomy, choledocholithotomy.

Clinical observation 3

Patient K., 85 years old, was admitted to the clinic with complaints of yellowing of the skin after a painful attack, diagnosed with cholelithiasis. Chronic calculous cholecystitis. Choledocholithiasis. Mechanical jaundice of mild severity.

Ultrasound of the abdominal cavity revealed: the liver is of normal size, the structure is diffusely heterogeneous, the intrahepatic ducts are dilated, the lobar ducts are up to 8 mm. Portal vein 12 mm. The gallbladder is 100x34 mm in size, in the lumen there are mobile calculi with a diameter of up to 8 mm. The common bile duct - 17 mm, in the lumen of the calculus - up to 13 mm. The pancreas is of normal size, the contours are even, clear, the structure is heterogeneous, increased echogenicity, the duct is 1 mm. The spleen is of normal size, the splenic vein is 7 mm. Conclusion: gallbladder stones. Ultrasound picture of low hepatic block due to choledocholithiasis (Fig. 9-11).

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