November and December Cases of the month

​Congratulations to the winners of the November and December ultrasounds of the month, Drs Daniels and Kopischke! Check your mail boxes next week for a Kaldis gift card.
 
Dr. Daniels used her POCUS skills to identify a case of pyelonephritis with developing renal abscess, and Dr. Kopischke detected a classic case ofhydronephrosis  with intrarenal stones.
 
Pyelonephritis
Ultrasound findings in acute pyelonephritis are often normal. In severe or chronic infections you may see pelvic wall thickening (Image 1,black arrow) or hypervascularity identified using color doppler. POCUS is more useful in identifying complications including emphysematous pyelitis and renal abscess. Emphysematous pyelitis is caused by gas forming bacteria and will have areas of hyperechogenicity within the renal parenchyma with classic “dirty shadowing.” Renal abscess will appear as well circumscribed hypoechoic areas with internal septations (image 2, black circle)

​Nephrolithiasis and Hydronephrosis
The primary application of renal POCUS is to evaluate for obstructive uropathy by identifying the presence or absence of hydronephrosis. Hydronephrosis can be graded from mild to severe depending on the amount of dilation of the collecting system( Image 1). A common clinical indication for renal POCUS is diagnose and grade the degree of hydronephrosis in renal colic. Depending on your pretest probability, you can forgo unnecessary CT scans and urology consults which in turn can decrease ED LOS. One proposed algorithm is listed below (Image 2). You can occasionally identify intrarenal stones which appear as hyperechoic foci within the collecting system with posterior shadowing (Image below)

Author: Arthur Forbriger 
Editor: Allison Zanaboni ​