– 10 year old FS Jack Russel
– intermittent hematuria
– U/A SG 1.015 RBC’ and WBC’s, no ketones, bilrubin or glucose
– culture pending
– ultrasound of UB shows thickened wall in apex region
– object with a bright interface and minimal distal shawdowing that is mobile near trigone region- no urolith/mineral seen on x-ray (blood clot or radio lucent stone?)
– hyerechoic region with reverberation artifact seen in the thickened apical region of the bladder wall (gas? – did not see this on x-ray)
Could this be a emphysematous cystitis? If so, it is a little different from what I have seen in the past.
Hyperechoic lesion with some shadowing
Movement of object distally after agitation – has a “halo” of material around it that is freely floating in urine when viewed on clip
Hyperechoic lesion in ventral apex of bladder wall
[videoembed id=6912]
Comments
Jacquie I added an EC image.
Jacquie I added an EC image. The images are uploading large for some reason and my IT folks are working on it. But u can see for lack of better terminology EC gives a “spray” of echoes and move with the probe whereas you case has well deifined echoes that also penetrate thew wall suggesting attached mucous, blood clot and potential ulcerative penetration into the wall. I am concerned for tcc here. I would perform partial cystectomy and histopath the wall and culture it as well as the stone removal.
Best regards
Jacquie I added an EC image.
Jacquie I added an EC image. The images are uploading large for some reason and my IT folks are working on it. But u can see for lack of better terminology EC gives a “spray” of echoes and move with the probe whereas you case has well deifined echoes that also penetrate thew wall suggesting attached mucous, blood clot and potential ulcerative penetration into the wall. I am concerned for tcc here. I would perform partial cystectomy and histopath the wall and culture it as well as the stone removal.
Best regards
Hi Eric
I did not think it
Hi Eric
I did not think it looked like a typical EC as you have shown as I have seen this before but I was concerned about the possobility of gas in the region from the little reverberation artifacts coming from it. In one of my notes from a Dr. Nykamp course she says that EC usually follows the wall of the bladder and in this case the lesion is fairly focal.
As for the “stone”. It is not showing up on rads (repeated twice). Could this be something other than a stone. The urine culture is positive for Proteus Mirabilis which usually points toward a struvite stone but this should show on x-ray. Could this be a well organized blood clot? Radio lucent stone?
Are you concerned about TCC because of the thickened wall and possible ulceration? Doesn’t TCC generally start in the trigone?
Thanks
Jacquie
Hi Eric
I did not think it
Hi Eric
I did not think it looked like a typical EC as you have shown as I have seen this before but I was concerned about the possobility of gas in the region from the little reverberation artifacts coming from it. In one of my notes from a Dr. Nykamp course she says that EC usually follows the wall of the bladder and in this case the lesion is fairly focal.
As for the “stone”. It is not showing up on rads (repeated twice). Could this be something other than a stone. The urine culture is positive for Proteus Mirabilis which usually points toward a struvite stone but this should show on x-ray. Could this be a well organized blood clot? Radio lucent stone?
Are you concerned about TCC because of the thickened wall and possible ulceration? Doesn’t TCC generally start in the trigone?
Thanks
Jacquie
Tcc can start anywhere. I
Tcc can start anywhere. I think its a terrible falsehood out there that its a trigonal disease as it leads to too many chronic cystitis looking TCCs to get misdiagnosed (scope is best here or traumatic catheterization US guided or just cut it out). Having done the UGELAB procedure (http://www.sonopath.com/resources_articles.asp)_and watching the character of hundreds of these under ugelab treatment and thousands more on US dx our studies show about 1/3 at least that are potentially resectable which means they aren’t trigonal. TCC can live with stones, with uti and with inflammation so we just dont know til we have histopath on a slide.
The sand/stone in your image is partially shadowing so must be dense enough to do that. It is likely a sand ball of mucous and debris or just radiolucent. That could be gas penetration in the wall surely but not a global EC like the one i put up there at the top.
Bottom line the pathology is best cut out, sand/stones cleared out, as it will take a long time for the body to remodel those changes and there is risk of tcc and it is resectable. So I would cut it out and Tx against proteus or any other bug you grow form the wall for about 6 weeks or at least 2 weeks post culture as you never know if its in the kidneys or not.
As you can see we got the image scenario resolved as we switched server hosting and something happened there but all good now.
Great post as always.
Eric
Tcc can start anywhere. I
Tcc can start anywhere. I think its a terrible falsehood out there that its a trigonal disease as it leads to too many chronic cystitis looking TCCs to get misdiagnosed (scope is best here or traumatic catheterization US guided or just cut it out). Having done the UGELAB procedure (http://www.sonopath.com/resources_articles.asp)_and watching the character of hundreds of these under ugelab treatment and thousands more on US dx our studies show about 1/3 at least that are potentially resectable which means they aren’t trigonal. TCC can live with stones, with uti and with inflammation so we just dont know til we have histopath on a slide.
The sand/stone in your image is partially shadowing so must be dense enough to do that. It is likely a sand ball of mucous and debris or just radiolucent. That could be gas penetration in the wall surely but not a global EC like the one i put up there at the top.
Bottom line the pathology is best cut out, sand/stones cleared out, as it will take a long time for the body to remodel those changes and there is risk of tcc and it is resectable. So I would cut it out and Tx against proteus or any other bug you grow form the wall for about 6 weeks or at least 2 weeks post culture as you never know if its in the kidneys or not.
As you can see we got the image scenario resolved as we switched server hosting and something happened there but all good now.
Great post as always.
Eric