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Conn syndrome (primary hyperaldosteronism) results from excessive aldosterone secretion, often due to an adrenal adenoma, leading to hypertension, hypokalemia, and metabolic alkalosis. Cushing disease involves cortisol, Addison disease involves adrenal insufficiency, and Waterhouse-Friderichsen is associated with adrenal hemorrhage.

According to Rumack’s Diagnostic Ultrasound:

“Conn syndrome is due to excessive secretion of aldosterone, often secondary to adrenal cortical adenoma.”

The Doppler ultrasound image shows an elevated peak systolic velocity (PSV) of 637 cm/s, an elevated end-diastolic velocity (EDV) of 312 cm/s, and a low resistive index (RI) of 0.51 at the arterial anastomosis of a renal transplant. These findings are characteristic of significant renal artery stenosis (RAS) at the transplant vascular anastomosis.

Key sonographic features of renal artery stenosis:

Peak systolic velocity (PSV) > 250–300 cm/s at the stenotic segment (this case: 637 cm/s)

Post-stenotic turbulence with spectral broadening

Low resistive index (RI < 0.56 suggests downstream vasodilation)

Elevated acceleration time (AT > 0.07 sec), and reduced acceleration slope

Aliasing on color Doppler due to high velocity

In this image, the marked increase in velocity with spectral aliasing and low RI is diagnostic of transplant renal artery stenosis — the most common vascular complication post-transplant, typically occurring at the site of surgical anastomosis.

Differentiation from other options:

A. Iliac arteritis: A rare condition, not typically presenting with these Doppler changes.

C. Renal vein thrombosis: Would show reversed or absent diastolic flow, not elevated systolic velocities.

D. Arteriovenous malformation (AVM): Produces a high-velocity, low-resistance waveform but is associated with color bruit, aliasing, and pulsatile venous waveforms — not evident here.

The ultrasound image shows a blind-ending, non-compressible, tubular structure in the right lower quadrant with a target or bullseye appearance in transverse section — highly suggestive of the appendix.

Sonographic features of the appendix (especially in suspected appendicitis):

Blind-ending tubular structure arising from the cecum

Non-compressible on graded compression

Diameter >6 mm is suggestive of appendicitis

May demonstrate a “target sign” in transverse view (concentric ring-like appearance)

Increased echogenicity of surrounding fat in cases of inflammation

May contain an appendicolith or show hyperemia on color Doppler if inflamed

The location (right lower quadrant) and appearance in this case are classic for the normal or potentially inflamed appendix.

Differentiation from other options:

A. Fallopian tube: Located more in the adnexal regions and usually not visible unless distended (e.g., hydrosalpinx).

B. Ureter: Usually not visualized on ultrasound unless dilated due to obstruction.

D. Jejunum: Has valvulae conniventes ("keyboard sign") and peristalsis; does not present with a blind-ending tubular appearance from the cecum.

Budd-Chiari syndrome is caused by hepatic venous outflow obstruction, resulting in hepatomegaly, ascites, right upper quadrant pain, and liver dysfunction. It may be due to thrombosis or compression of the hepatic veins or IVC.

According to Rumack’s Diagnostic Ultrasound:

“Budd-Chiari syndrome results from hepatic venous outflow obstruction and presents with hepatomegaly, ascites, and right upper quadrant pain.”

The ultrasound image demonstrates a longitudinal view of the right kidney. Within the renal pyramids, there are multiple echogenic foci, some showing posterior acoustic shadowing—findings characteristic of medullary nephrocalcinosis. This sonographic appearance is strongly associated with medullary sponge kidney (MSK).

Medullary sponge kidney is a congenital disorder of the renal tubules that results in ectatic (dilated) collecting ducts in the renal medulla. The dilated ducts frequently become calcified, leading to the "paintbrush" or "bouquet of flowers" appearance seen in the renal pyramids on ultrasound. These calcifications are most often bilateral and symmetrical, further aiding the diagnosis.

Comparison of answer choices:

A. Fungal balls (mycetomas) typically appear as mobile, non-shadowing echogenic masses within the collecting system, often in immunocompromised patients.

B. Renal cell carcinoma usually presents as a solid mass with irregular borders and variable echogenicity—this image does not show a mass.

C. Acute pyelonephritis may show renal enlargement, decreased echogenicity, or loss of corticomedullary differentiation—but not calcification of the pyramids.

D. Medullary sponge kidney is correct due to the punctate echogenic foci within the medullary pyramids, consistent with nephrocalcinosis.

Color Doppler imaging can detect ureteral jets, which represent urine entering the bladder from the ureters. The presence of bilateral ureteral jets confirms ureteral patency. Gray scale may show hydronephrosis but does not directly assess flow.

According to Rumack’s Diagnostic Ultrasound:

“Color Doppler demonstrates ureteral jets within the bladder, confirming ureteral patency.”

The ultrasound images show a heterogeneous, solid-appearing mass within the right kidney. The patient has a history of hypertension and hematuria—classic clinical features that raise suspicion for renal cell carcinoma (RCC), especially in an adult.

Renal cell carcinoma is the most common primary malignant tumor of the kidney in adults. Common presenting symptoms include:

Hematuria (most frequent symptom)

Flank pain

Palpable abdominal mass

Hypertension (due to increased renin secretion)

Sometimes paraneoplastic syndromes (e.g., polycythemia due to erythropoietin production)

Ultrasound Features of RCC:

Solid renal mass, often with heterogeneous echotexture

May contain cystic components, calcifications, or necrotic areas

May distort the renal contour

Doppler may show internal vascularity

Differentiation from other options:

B. Adenoma: Rare and typically small, benign cortical lesions. They do not typically present with hematuria or hypertension and cannot be reliably distinguished from RCC on ultrasound.

C. Nephroblastoma (Wilms tumor): Pediatric renal tumor seen almost exclusively in children under age 5.

D. Pheochromocytoma: Arises from the adrenal gland (not the kidney); associated with hypertension but not hematuria.

On ultrasound, tendons appear as cord-like hyperechoic structures with linear fibrillar echotexture when imaged in long axis. The fibrils are highly reflective, creating the typical hyperechoic appearance. Posterior shadowing is not typical unless there is calcification.

According to Rumack’s Diagnostic Ultrasound:

“Tendons have a highly organized hyperechoic linear fibrillar pattern when examined along their long axis.”

The image shows a transverse view of the left lobe of the liver with the portal triads clearly visible. The "parallel channel" or "double barrel" sign is observed—where dilated intrahepatic bile ducts run alongside the portal veins, creating a characteristic sonographic pattern of paired anechoic (black) tubular structures.

This sonographic feature is diagnostic for dilated intrahepatic bile ducts and is typically seen in obstructive jaundice or biliary obstruction from conditions such as:

Choledocholithiasis (stone in the common bile duct)

Stricture or mass compressing the bile ducts

Cholangiocarcinoma

The intrahepatic bile ducts normally are too small to visualize clearly unless dilated. Their dilation gives the liver a "too many tubes" appearance, where bile ducts become as prominent as the portal veins.

Comparison of answer choices:

A. Normal intrahepatic ducts are not usually seen this clearly or prominently on ultrasound.

B. Dilated intrahepatic — Correct. The parallel channel sign supports this diagnosis.

C. Dilated common bile duct would be visualized extrahepatically, typically anterior to the portal vein near the head of the pancreas.

D. Dilated common hepatic duct is also extrahepatic and seen in the porta hepatis, not within the liver parenchyma.

The clinical presentation—tender, swollen breast with erythema and fever—in a lactating female strongly suggests acute mastitis. The sonographic findings support this diagnosis. In the image, the breast parenchyma shows diffuse, hypoechoic, and heterogeneous echotexture with increased vascularity, which is consistent with inflammatory changes typical of mastitis.

Mastitis is a common complication during lactation, particularly in the first few weeks postpartum. It results from milk stasis and subsequent bacterial infection, commonly due to Staphylococcus aureus. Ultrasound features of mastitis include:

Ill-defined, hypoechoic, edematous areas in the breast parenchyma

Increased Doppler flow due to hyperemia

Skin thickening

Ductal dilatation may also be present

If left untreated, mastitis may progress to abscess formation, which would appear as a localized, complex fluid collection with peripheral hyperemia and internal debris. However, the image does not show a well-formed fluid collection consistent with abscess.

Option B (Ductal carcinoma): Inappropriate here due to the acute clinical scenario and patient age. Ductal carcinoma typically presents as a hypoechoic mass with irregular margins and posterior shadowing, not diffuse edema or inflammatory changes.

Option D (Galactocele): This benign milk-filled retention cyst typically appears anechoic or with fluid–fluid levels but lacks signs of inflammation and systemic symptoms such as fever.

Option A (Abscess): This could be a differential, but abscesses usually present with a well-defined anechoic or complex mass. The absence of a discrete collection and the diffuse appearance makes mastitis more likely.