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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 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.

The coronary vein (left gastric vein) is a common collateral pathway in portal hypertension. It often becomes dilated and may demonstrate hepatofugal (reversed) flow as blood diverts from the high-pressure portal system into systemic collaterals.

According to Zwiebel’s Introduction to Vascular Ultrasound:

“The left gastric (coronary) vein is a frequent site of hepatofugal flow in portal hypertension, reflecting collateral development.”

Transitional cell carcinoma (TCC) typically presents as a non-mobile, polypoidal, focal intraluminal mass projecting from the bladder wall. Mobility of the lesion helps differentiate TCC from blood clots or debris.

According to Rumack’s Diagnostic Ultrasound:

“Bladder TCC most often appears as a non-mobile, polypoid mass attached to the bladder wall.”

The ultrasound image labeled “SAG RUQ KIDNEY” demonstrates a midline sagittal view showing a renal parenchymal structure that extends across the midline anterior to the aorta and vertebral bodies, suggesting the presence of a horseshoe kidney.

A horseshoe kidney is a congenital renal anomaly in which the lower poles of both kidneys are fused across the midline by a parenchymal or fibrous isthmus. This isthmus typically lies anterior to the aorta and inferior vena cava and can be seen as a hypoechoic band of tissue crossing the midline on ultrasound.

Ultrasound findings characteristic of a horseshoe kidney:

Abnormally low position of the kidneys in the abdomen

Renal tissue (isthmus) bridging the lower poles anterior to the great vessels

Renal axes may be more horizontal than usual

Kidneys may appear closer together or “kissing” the spine anteriorly

Differentiation from other options:

A. Duplicated collecting system: Manifests as two separate collecting systems within one kidney, often with a central renal sinus split into two — not typically midline bridging.

B. Crossed renal ectopia: Involves one kidney crossing midline and fusing with the other on the opposite side, but they do not form a midline isthmus.

D. Pelvic kidney: A single kidney located in the pelvis due to failed ascent — it does not appear as midline fusion of two kidneys.

The most common symptom of cholelithiasis (gallstones) is biliary colic, characterized by intermittent right upper quadrant or epigastric pain often triggered by fatty meals. Jaundice occurs in complications such as choledocholithiasis.

According to Rumack’s Diagnostic Ultrasound:

“Gallstones may cause biliary colic — episodic upper abdominal pain often related to food intake.”

The sonographic images depict an acute thrombotic process involving the portal venous system. The absence of cavernous transformation in the setting of portal vein thrombus indicates that the process is acute. In chronic portal vein thrombosis, collateral vessels form in the porta hepatis to bypass the obstruction, a process known as cavernous transformation.

Sonographic features suggesting acute portal vein thrombosis:

Echogenic thrombus within the portal vein lumen

Absence of flow on color Doppler

Enlarged portal vein diameter early in the process

No evidence of cavernous transformation (i.e., no serpiginous collateral vessels at porta hepatis)

Cavernous transformation is a hallmark of chronic portal vein thrombosis and takes weeks to months to develop. Therefore, its absence on ultrasound supports an acute diagnosis.

Differentiation from other options:

A. Free fluid: Non-specific and may or may not be present in hepatic vascular thrombosis.

B. Ductal dilatation: Related to biliary obstruction, not portal or hepatic venous thrombosis.

C. Hepatic vein thrombosis: Seen in Budd-Chiari syndrome, which affects hepatic outflow, not portal inflow.

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.

Lateral decubitus positioning allows shifting of internal echoes within the bladder, helping differentiate mobile debris (such as blood clots or sediment) from adherent masses like tumors. This technique is helpful in evaluating questionable bladder filling defects.

According to Rumack’s Diagnostic Ultrasound:

“Changing the patient’s position, such as turning to the lateral decubitus, can help distinguish mobile debris from attached bladder wall lesions.”