Ebook Differential diagnosis in ultrasound (2nd edition): Part 1

Differential Diagnosis
in
ULTRASOUND



Differential Diagnosis
in
ULTRASOUND
Second Edition
Sumeet Bhargava
MBBS DNB (Radiodiagnosis) FCGP FIAMS FICRI MNAMS

Assistant Professor
Department of Radiology and Imaging
Subharti Medical College
Meerut, Uttar Pradesh, India

Satish K Bhargava

MBBS MD (Radiodiagnosis)
MD (Radiotherapy) DMRD FICRI FIAMS FCCP FUSI FIMSA FAMS

Professor and Head
Department of Radiology and Imaging
School of Medical Sciences and Research
Sharda Hospital
Sharda University, Greater Noida, Uttar Pradesh, India
Formerly, Professor and Head
Department of Radiology and Imaging

University College of Medical Sciences
(University of Delhi) and GTB Hospital, Delhi, India
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of the editors. Where appropriate, the readers should consult with a specialist or contact the
manufacturer of the drug or device.
Differential Diagnosis in Ultrasound

First Edition: 2005
Second Edition: 2013
ISBN 978-93-5025-999-3
Printed at


Dedicated to
My loving late wife
Kalpana
Whose inspiration and sacrifice
have made possible to
bring out this book



Contributors
Anoop Kumar Durga Das
Resident
Department of Radiology
and Imaging
University College of
Medical Sciences
(University of Delhi) and
GTB Hospital, Delhi, India

Avneesh Kumar Singh
Senior Resident
Department of Radiodiagnosis
and Imaging
All India Institute of

Medical Sciences (AIIMS)
Ansari Nagar, New Delhi, India

Anubhav Sarikwal
Senior Resident
Department of Radiology
and Imaging
University College of
Medical Sciences
(University of Delhi) and
GTB Hospital, Delhi, India

Gopesh Mehrotra
Professor
Department of Radiology
and Imaging
University College of
Medical Sciences
(University of Delhi) and
GTB Hospital, Delhi, India

Anupama Tandon
Senior Lecturer
Department of Radiology
and Imaging
University College of
Medical Sciences
(University of Delhi) and
GTB Hospital, Delhi, India

Mamta Motla
Ex Senior Resident
Department of Radiology
and Imaging
University College of
Medical Sciences (University of
Delhi) and GTB Hospital
Delhi, India

Anurag Agarwal
Additional Director
National Board of Examination
Ansari Nagar, New Delhi, India

Meenakshi Prakash
Resident
Department of Radiology
and Imaging
University College of
Medical Sciences
(University of Delhi)
and GTB Hospital
Delhi, India

Ashish Verma
Assistant Professor
Institute of Medical Sciences
Banaras Hindu University (BHU)
Varanasi, Uttar Pradesh, India

viii

Differential Diagnosis in Ultrasound

Pardeep Kumar
Senior Resident
Maulana Azad Medical College
and Associated GB Pant Hospital
New Delhi, India
Pushpender Gupta
Department of Radiology
Wake Forest University Baptist
Medical Center, Medical Center
Boulevard, Winston-Salem
North Carolina, USA
Rajul Rastogi
Ex Senior Resident
Department of Radiology
and Imaging
University College of
Medical Sciences
(University of Delhi) and GTB
Hospital, Delhi, India
Presently,
Yash Diagnostic Center
Civil Lines, Moradabad
Uttar Pradesh, India
Satish K Bhargava
Professor and Head

Department of Radiology
and Imaging
University College of
Medical Sciences
(University of Delhi)
and GTB Hospital
Delhi, India

Shuchi Bhatt
Reader
Department of Radiology
and Imaging
University College of
Medical Sciences
(University of Delhi) and
GTB Hospital
Delhi, India
Sumeet Bhargava
Assistant Professor
Department of Radiology
and Imaging
Subharti Medical College
Meerut, Uttar Pradesh, India
Swati Gupta
Resident
Department of Radiology
and Imaging
University College of
Medical Sciences
(University of Delhi) and

GTB Hospital, Delhi, India
Thingujam Usha
Resident
Department of Radiology
and Imaging
University College of
Medical Sciences
(University of Delhi) and
GTB Hospital, Delhi, India


Preface to the Second Edition
With the feedback from the practicing selenologists and
residents, more text and illustrations have been added so
as to make this book more handy for better interpretation
at bedside. I am sure the book in the present format will
be more acceptable and useful to the residents, sonologists
and practitioners in their day-to-day practice.
Sumeet Bhargava
Satish K Bhargava



Preface to the First Edition
Since the introduction of ultrasound (US), this modality
has evolved from its primitive nature to its present
glamorous status. Its popularity in radiology has always
been due to its cost-effectiveness, easy availability and
noninvasive nature. Its diagnostic role has been explored
in every organ system and its usefulness felt every time.

Its support in therapeutic techniques is unparalleled.
Radiology without ultrasound is unimaginable.
Almost always realtime US is the initial investigative
tool in the radiology department. Many a time, this
modality is enough to establish a diagnosis and always
provides a direction for further evaluation. Its uniqueness
lies in its operator-dependent nature. As the ultrasonologist
scans through the region of interest, recognition and
interpretation of the important findings are important for
establishing and imaging diagnosis. It is also imperative to
know the various conditions producing a particular
sonographic finding. Only ultrasound can be judiciously
used to answer the question posed to the radiologist. This
book is a special effort to provide a concise knowledge of
the differential diagnosis of a sonographic finding. A list of
the various clinical conditions and their short description
is the main feature of the text. The information has been
kept concise and unnecessary repetition avoided. Line
diagrams and illustrations have been added to support the
text. The aim of this book is to assist the sonologist with
logical interpretation of the scan. I hope this attempt will
prove useful to all practicing sonologists.
Sumeet Bhargava
Satish K Bhargava



Acknowledgments
I am grateful to my colleagues and friends who gave
timely support and stood solidly behind me in our joint

endeavor of bringing out this book which was required
keeping in view of wide acceptability of ultrasound in
developing countries. My special heartfelt thanks are due
to the sincere and hardworking staff of M/s Jaypee
Brothers Medical Publishers (P) Ltd, New Delhi, India,
particularly, Shri Jitendar P Vij (CEO), Mr Tarun Duneja
(Director-Publishing), Ms Samina Khan and Mr KK
Raman (Production Manager). It is indeed the result of
the hardwork of the staff of M/s Jaypee Brothers Medical
Publishers (P) Ltd and the contributors who have always
been in keen desire to work with smiling faces and with
polite voices as a result of which this book has seen the
light of day.



Contents
1. CHEST ........................................................................... 1
1.1. Chest Overview ................................................ 1
Satish K Bhargava
1.2. Pleural Effusion ................................................ 8
Sumeet Bhargava, Satish K Bhargava
1.3. Pleural Plaque ................................................. 15
Sumeet Bhargava, Satish K Bhargava
1.4. Pleural Masses ................................................ 16
Satish K Bhargava, Sumeet Bhargava
1.5. Mediastinal Lymphadenopathy .................. 18
Pushpender Gupta, Satish K Bhargava
1.6. Vascular Lesions of Mediastinum .............. 18
Sumeet Bhargava, Pardeep Kumar, Satish K Bhargava

1.7. Cystic Masses of Mediastinum .................... 19
Sumeet Bhargava, Satish K Bhargava
1.8. Diaphragm ....................................................... 21
Satish K Bhargava, Pushpender Gupta
2. NECK LESIONS ........................................................ 29
2.1. Thyroid ............................................................. 29
2.1.1. Solitary Thyroid Nodule .................... 29
Satish K Bhargava, Avneesh Kumar Singh,
Pushpender Gupta
2.1.2. Carcinomas ........................................... 41
Sumeet Bhargava, Satish K Bhargava,
Avneesh Kumar Singh


xvi Differential Diagnosis in Ultrasound
2.1.3. Thyroid Calcification .......................... 45
Sumeet Bhargava, Satish K Bhargava,
Avneesh Kumar Singh, Pushpender Gupta
2.1.4. Differential Diagnosis on the Basis of
Echogenicity of Thyroid Nodules ..... 47
Sumeet Bhargava, Satish K Bhargava,
Avneesh Kumar Singh
2.1.5. Cystic Thyroid Nodule ....................... 49
Satish K Bhargava, Sumeet Bhargava,
Pushpender Gupta
2.2. Salivary Gland ................................................ 52
Pushpender Gupta, Satish K Bhargava
2.2.1. Enlargement of Salivary Gland ......... 52
Satish K Bhargava, Pushpender Gupta,
Gopesh Mehrotra

2.3. Neck Masses .................................................... 59
Satish K Bhargava, Sumeet Bhargava
2.4. Cervical Lymphadenopathy ......................... 69
Satish K Bhargava, Rajul Rastogi
3. HEPATOBILIARY SYSTEM AND
ABDOMEN ................................................................. 74
3.1. Generalized Increase in
Liver Echogenicity .......................................... 74
Satish K Bhargava, Sumeet Bhargava
3.2. Generalized Decrease in
Echogenicity of Liver ..................................... 81
Sumeet Bhargava, Satish K Bhargava, Swati Gupta
3.3. Solitary Echogenic Liver Mass ..................... 83
Satish K Bhargava, Sumeet Bhargava
3.4. Shadowing Lesions of Liver ......................... 90
Sumeet Bhargava, Satish K Bhargava


Contents

xvii

3.5. Hepatoma, Bull’s Eye or Target
Lesion of Liver ................................................ 93
Sumeet Bhargava, Satish K Bhargava
3.6. Periportal Hyperechogenicity of Liver ....... 95
Sumeet Bhargava, Satish K Bhargava
3.7. Periportal Hypoechogenicity ....................... 97
Sumeet Bhargava, Satish K Bhargava
3.8. Focal Hypoechoic Lesions ............................. 98

Pardeep Kumar, Satish K Bhargava
3.9. Cystic Lesions of Liver ................................ 104
Pardeep Kumar, Satish K Bhargava
3.10. Mixed Cystic and Solid Lesions ................ 120
Satish K Bhargava, Pardeep Kumar
3.11. Patterns of Hepatic Metastasis ................... 127
Satish K Bhargava, Pardeep Kumar
3.12. Nonvisualization of Gallbladder
on Ultrasound ................................................ 132
Sumeet Bhargava, Satish K Bhargava
3.13. Diffuse Gallbladder Thickening ............... 136
Sumeet Bhargava, Satish K Bhargava
3.14. Focal Gallbladder Thickening ................... 141
Sumeet Bhargava, Satish K Bhargava
3.15. Echogenic Fat in Hepatoduodenal
Ligament ......................................................... 148
Sumeet Bhargava, Satish K Bhargava
3.16. Congenital Biliary Cyst ............................... 148
Sumeet Bhargava, Satish K Bhargava
3.17. Differential Diagnosis of
Pericholecystic Fluid .................................... 150
Ashish Verma, Satish K Bhargava,
Sumeet Bhargava


xviii

Differential Diagnosis in Ultrasound

3.18. Differential Diagnosis of

IHBR Dilatation ............................................ 152
Ashish Verma, Satish K Bhargava, Sumeet Bhargava
3.19. Differential Diagnosis of
EHBR Dilatation ........................................... 154
Satish K Bhargava, Ashish Verma, Sumeet Bhargava
3.20. Abdominal Wall Masses ............................. 157
Satish K Bhargava, Ashish Verma, Sumeet Bhargava
3.21. Acute Abdomen ............................................ 165
Satish K Bhargava, Ashish Verma, Sumeet Bhargava
3.22. Abdominal Lymphadenopathy ................. 179
Satish K Bhargava, Sumeet Bhargava, Ashish Verma
4. SPLEEN ..................................................................... 183
4.1. Nonvisualization of Spleen on
Ultrasound ..................................................... 183
Sumeet Bhargava, Satish K Bhargava
4.2. Cystic Lesion of Spleen ............................... 184
Sumeet Bhargava, Satish K Bhargava
4.3. Solid Splenic Lesion .................................... 191
Sumeet Bhargava, Satish K Bhargava
4.4. Hyperechoic Splenic Lesion ....................... 196
Sumeet Bhargava, Satish K Bhargava
5. PANCREAS .............................................................. 199
5.1. Differential Diagnosis of Cystic
Pancreatic Masses ......................................... 199
Sumeet Bhargava, Satish K Bhargava,
Ashish Verma, Rajul Rastogi
5.2. Differential Diagnosis of
Solid/Complex Lesion ................................. 203
Satish K Bhargava, Sumeet Bhargava, Ashish Verma

Contents

xix

6. GASTROINTESTINAL TRACT .......................... 211
6.1. Ultrasound Differential
Diagnosis of GIT .......................................... 211
Sumeet Bhargava, Gopesh Mehrotra, Rajul Rastogi
6.2. Stomach .......................................................... 214
Sumeet Bhargava, Shuchi Bhatt, Rajul Rastogi
6.3. Gastric Dilatation ......................................... 216
Sumeet Bhargava, Rajul Rastogi
6.4. Duodenum ..................................................... 221
Satish K Bhargava, Sumeet Bhargava
6.5. Small Bowel and Colon ............................... 222
Sumeet Bhargava, Satish K Bhargava, Rajul Rastogi
6.6. Differential Diagnosis of Acute
Appendicitis (Appendiceal Lesions) ........ 235
Sumeet Bhargava, Satish K Bhargava,
Anoop Kumar Durga Das
6.7. Role of Rectal Endosonography ................ 241
Satish K Bhargava, Sumeet Bhargava,
Meenakshi Prakash, Anoop Kumar Durga Das
7. RETROPERITONEUM .......................................... 243
7.1. Differential Diagnosis of
Solid Masses .................................................. 243
Ashish Verma, Satish K Bhargava, Sumeet Bhargava
7.2. Differential Diagnosis of
Pseudomasses ................................................ 250

Ashish Verma, Sumeet Bhargava, Satish K Bhargava
7.3. Differential Diagnosis of Cystic
Lesions and Fluid Collection ..................... 251
Sumeet Bhargava, Satish K Bhargava, Ashish Verma


xx

Differential Diagnosis in Ultrasound

8. RENAL ...................................................................... 253
8.1. Differential Diagnosis of Renal
Pseudotumor ................................................. 253
Satish K Bhargava, Rajul Rastogi, Ashish Verma
8.2. Differential Diagnosis of Cystic
Renal Disease ................................................ 255
Sumeet Bhargava, Satish K Bhargava, Ashish Verma
8.3. Differential Diagnosis of
Complex/Solid Renal Masses .................... 261
Satish K Bhargava, Ashish Verma, Rajul Rastogi
8.4. Differential Diagnosis of Hypoechoic
Renal Sinus .................................................... 267
Ashish Verma, Satish K Bhargava, Rajul Rastogi
8.5. Differential Diagnosis of Hyperechoic
Renal Nodules ............................................... 268
Ashish Verma, Satish K Bhargava, Shuchi Bhatt
8.6. Differential Diagnosis of Dilated
Pelvicalyceal System and Ureter ............... 270
Sumeet Bhargava, Ashish Verma,
Satish K Bhargava, Rajul Rastogi

9. URINARY BLADDER ............................................ 279
9.1. Differential Diagnosis of
Bladder Wall Thickening ............................ 279
Sumeet Bhargava, Satish K Bhargava, Ashish Verma
9.2. Differential Diagnosis of Bladder
Contour and Caliber Abnormality ............ 286
Satish K Bhargava, Sumeet Bhargava, Ashish Verma
10. ADRENAL GLAND ................................................ 290
10.1. Bilateral Large Adrenal Gland ................... 290
Satish K Bhargava, Sumeet Bhargava


Contents

xxi

10.2. Unilateral Adrenal Masses ......................... 293
Satish K Bhargava, Sumeet Bhargava
10.3. Large Solid Adrenal Masses ....................... 297
Sumeet Bhargava, Satish K Bhargava
10.4. Cystic Adrenal Masses ................................ 299
Sumeet Bhargava, Satish K Bhargava
10.5. Adrenal Pseudomasses ................................ 300
Sumeet Bhargava, Satish K Bhargava
11. PERITONEAL AND MESENTERIC
MASSES .................................................................... 301
11.1. Round Solid Masses in Mesentery ........... 301
Satish K Bhargava, Sumeet Bhargava
11.2. Ill-defined Mass ............................................ 303
Satish K Bhargava, Sumeet Bhargava

11.3. Loculated Cystic Peritoneal Masses ......... 310
Satish K Bhargava, Sumeet Bhargava
11.4. Solid Peritoneal Lesions ............................. 312
Satish K Bhargava, Sumeet Bhargava
12. SCROTUM ............................................................... 322
12.1. Differential Diagnosis of
Acute Scrotum ............................................... 322
Sumeet Bhargava, Satish K Bhargava, Ashish Verma
12.2. Differential Diagnosis of
Scrotal Calcification ..................................... 328
Satish K Bhargava, Sumeet Bhargava, Ashish Verma
12.3. Differential Diagnosis of Scrotal Gas ...... 332
Satish K Bhargava, Rajul Rastogi, Ashish Verma
12.4. Differential Diagnosis of
Scrotal Masses ............................................... 332
Sumeet Bhargava, Satish K Bhargava,
Rajul Rastogi, Ashish Verma


xxii

Differential Diagnosis in Ultrasound

13. TESTIS AND EPIDIDYMIS ................................. 341
13.1. Differential Diagnosis of Cystic
Testicular Lesions ......................................... 341
Ashish Verma, Sumeet Bhargava, Satish K Bhargava
13.2. Pediatric Testicular Masses ........................ 345
Sumeet Bhargava, Ashish Verma, Satish K Bhargava
13.3. Differential Diagnosis of

Epididymal Lesions ..................................... 350
Ashish Verma, Sumeet Bhargava, Satish K Bhargava
14. PROSTATE ............................................................... 354
14.1. Differential Diagnosis of Prostatic Cyst .. 354
Satish K Bhargava, Sumeet Bhargava, Rajul Rastogi
14.2. Müllerian Cyst .............................................. 354
Satish K Bhargava, Sumeet Bhargava, Rajul Rastogi
14.3. Ejaculatory Duct Cyst .................................. 356
Rajul Rastogi, Sumeet Bhargava, Satish K Bhargava
14.4. Seminal Vesicle Cyst ................................... 357
Satish K Bhargava, Ashish Verma,
Sumeet Bhargava, Rajul Rastogi
14.5. Hypoechoic Lesions ..................................... 358
Rajul Rastogi, Anubhav Sarikwal, Sumeet Bhargava
15. BREAST .................................................................... 364
15.1. Cystic Lesions ................................................ 365
Satish K Bhargava, Rajul Rastogi
15.2. Hyperechoic Lesions .................................... 370
Satish K Bhargava
15.3. Hypoechoic Lesions ..................................... 371
Satish K Bhargava, Mamta Motla
15.4. Malignant Lesions ........................................ 373
Satish K Bhargava, Mamta Motla


Contents

xxiii

15.5. Ductal Dilatation .......................................... 375

Anupama Tandon, Satish K Bhargava
15.6. Benign vs Malignant .................................... 376
Anupama Tandon, Satish K Bhargava
15.7. Mastitis ........................................................... 377
Satish K Bhargava, Anurag Agarwal
15.8. Benign Lesions .............................................. 379
Anurag Agarwal, Satish K Bhargava
15.9. Malignant Lesions ........................................ 383
Sumeet Bhargava, Rajul Rastogi, Satish K Bhargava
16. MUSCULOSKELETAL SYSTEM ......................... 389
16.1. Hyperechoic Foci within
the Synovium ................................................ 389
Rajul Rastogi, Satish K Bhargava
16.2. Cystic Mass in Popliteal Fossa ................... 389
Rajul Rastogi, Satish K Bhargava
16.3. Hip Joint Effusion in Adults ...................... 390
Sumeet Bhargava, Satish K Bhargava
16.4. Proliferative Synovitis ................................. 391
Rajul Rastogi, Satish K Bhargava
16.5. Tendon Tears ................................................. 391
Rajul Rastogi, Satish K Bhargava
16.6. Pediatric Hip Joint—An Overview ........... 393
Satish K Bhargava, Sumeet Bhargava
17. ORBIT ........................................................................ 418
17.1. Orbital Pathologies ...................................... 443
Satish K Bhargava, Ashish Verma, Anubhav Sarikwal
17.2. Low Reflectivity Lesions ............................. 443
Satish K Bhargava, Ashish Verma, Anubhav Sarikwal
17.3. Medium Reflectivity Lesions ..................... 444
Satish K Bhargava, Ashish Verma

xxiv

Differential Diagnosis in Ultrasound

17.4. High Reflectivity Lesions ........................... 444
Satish K Bhargava, Ashish Verma
17.5. Well-circumscribed Masses/Lesions ......... 444
Satish K Bhargava, Ashish Verma
17.6. Infiltrative Lesions ....................................... 444
Satish K Bhargava, Ashish Verma
17.7. Serpiginous Lesions ..................................... 446
Satish K Bhargava, Ashish Verma
17.8. Differential Diagnosis of Orbital
Muscle Enlargement .................................... 446
Satish K Bhargava, Ashish Verma
17.9. Differential Diagnosis of
Unilateral Proptosis ..................................... 448
Satish K Bhargava, Ashish Verma
17.10. Differential Diagnosis of
Bilateral Proptosis ........................................ 457
Satish K Bhargava, Ashish Verma
17.11. Differential Diagnosis of
Pulsatile Proptosis ........................................ 458
Satish K Bhargava, Ashish Verma
18. NEONATAL AND INFANT BRAIN .................. 459
18.1. Cystic Lesions ................................................ 459
Shuchi Bhatt, Satish K Bhargava
18.2. Solid Lesions ................................................. 461

Shuchi Bhatt, Satish K Bhargava
18.3. Prominent Choroid Plexus ......................... 462
Shuchi Bhatt, Satish K Bhargava
18.4. Destructive Lesions of Brain ...................... 463
Shuchi Bhatt, Satish K Bhargava
18.5. Ventriculomegaly ......................................... 467
Shuchi Bhatt, Satish K Bhargava