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Channel: Профессор В.Изранов

УЗИ почек

Анатомия почек

Эхосемиотика структурных изменений почек

Изранов

Врач УЗД

00:00:10

Yeah, Kamtasia has already been launched, and the recording

00:00:14

too,

00:00:22

yes, what's that tsa Well,

00:00:30

what is the number thirty-first From

00:00:33

thirty-first Well, that is, the lecture will be

00:00:35

thirty-first, think about how these very

00:00:38

processes of practical

00:00:41

classes are mastered But this is the same thing

00:00:44

there, it’s not so important It’s technically

00:00:46

very much there It’s important to look at a large

00:00:48

number of people because it’s a huge

00:00:51

problem that the variability

00:00:54

between different people is very strong. Yes, and in order for

00:00:57

the eye to get used to it, you need to look at

00:01:00

it; you can’t think of anything differently, that is, it’s

00:01:04

the question of watching a large number of

00:01:07

people at the lecture, I’m organizing Volunteers

00:01:12

Yes how to think during a practical lesson

00:01:15

and then we will discuss how to

00:01:18

ensure this But if uh everyone

00:01:21

looks at

00:01:23

uh while you are studying now During these 2

00:01:26

weeks 15-20 people you will then be

00:01:28

afraid scientifically

00:01:31

90% of obstetricians and gynecologists Who watch the ultrasound are

00:01:35

afraid just really afraid look at the

00:01:37

mammary gland because many things are

00:01:39

difficult to interpret, yes, it’s just a

00:01:42

question of looking at this basic

00:01:45

uh main

00:01:48

part, we’re starting everything.

00:02:05

So today we are

00:02:08

looking at ultrasound anatomy and the

00:02:11

general

00:02:15

rules for

00:02:17

reporting analysis related to

00:02:21

ultrasound examination of the

00:02:27

kidneys, let’s get a new patient,

00:02:30

let him have such an

00:02:32

interesting surname from the TH letters they did not indicate an

00:02:35

abstract age here it is not

00:02:37

fundamentally important that the person in this

00:02:39

case is an adult 34 years old I

00:02:41

indicated the kidneys do not have any clearly defined

00:02:44

gender characteristics Therefore,

00:02:48

in this case we do not select gender and

00:02:52

enter the tab that is associated with the

00:02:55

kidneys Look

00:02:58

We describe each kidney separately

00:03:01

if

00:03:03

there is absolute identity and the

00:03:06

norm is a tool that

00:03:12

allows you to make the filling process faster based

00:03:15

on the principle of symmetry, but

00:03:18

now it is important for us to evaluate each organ

00:03:23

step by step read acoustic access

00:03:30

by default here is not

00:03:32

filled in, this is the

00:03:35

principle of having filled fields

00:03:39

that already have some meaning and

00:03:42

unfilled ones are oriented towards the

00:03:45

norm; filled fields most often

00:03:50

characterize a situation associated with a

00:03:52

normal

00:03:55

structure in the vast majority of

00:03:57

cases with Akum Doum,

00:04:00

but not always Yes, I remember I had a couple of

00:04:04

cases when a patient came to me, clearly

00:04:11

over 150

00:04:13

kg, I couldn’t give him a kidney

00:04:17

to visualize

00:04:18

that in such cases it

00:04:23

is difficult to write acoustic access, the study is not

00:04:27

informative, and

00:04:30

then I tried to review it on a

00:04:32

fairly high-quality

00:04:34

device of

00:04:37

this almost premium class and was still

00:04:41

unable to deduce it. Yesterday I had a

00:04:44

patient of 160 kg and I wanted to look at

00:04:49

the pancreas, the entire

00:04:51

pancreatitis clinic, I was unable deduce yes, that is,

00:04:54

this happens and this acoustic

00:04:56

access We need the following form precisely for these purposes, a

00:04:59

very important point,

00:05:03

you see now the default is an empty

00:05:07

field

00:05:09

and now let’s agree that we are considering the

00:05:12

normal form, not changed,

00:05:15

the form changes for two reasons:

00:05:18

acquired congenital Yes, as

00:05:22

for congenital reasons related to

00:05:25

kidney anomalies, we will separately consider

00:05:28

this in

00:05:30

another lecture because here a large

00:05:34

number of all

00:05:35

kinds of situations occur that need to be

00:05:39

described in different ways and we will also return to this

00:05:42

When we consider

00:05:44

obstetrics Yes, because all congenital

00:05:47

anomalies are

00:05:49

visible quite early and then

00:05:51

practically manifest themselves throughout

00:05:53

life, as for acquired Toms, there is

00:06:00

some situation with a deviation of the shape from the

00:06:04

typical one, we should not

00:06:07

describe here the following field

00:06:10

dimensions and here on it Let's dwell

00:06:13

in more detail in the previous video You

00:06:16

just now received a kind of

00:06:21

examination algorithm, first they put the patient on his back

00:06:24

This fundamentally, fill your stomach in any

00:06:28

case You

00:06:32

can distort or miss half of the information put

00:06:35

on your back first put the sensor on the

00:06:37

bladder put it on the bladder

00:06:40

assess the degree of filling of the

00:06:43

bladder assess you see 100%

00:06:47

you can rule out that you do not

00:06:50

see the ureters or not, yes, that

00:06:54

is, this can be done conclusion,

00:06:56

respectively, about that part of the ureter

00:06:58

that is most difficult to

00:07:02

access, that is, for the

00:07:05

pelvic and abdominal sections, and

00:07:10

only after that When you looked at the

00:07:12

degree of filling, you excluded the expansion of the

00:07:15

ureters only at the front. After

00:07:18

that, on the back, we switched to

00:07:22

placing the

00:07:23

sensor along the

00:07:26

intercostal or the anterior axillary

00:07:29

line and then we visualize the kidney

00:07:32

together

00:07:34

with the liver Yes, as soon as we found it there,

00:07:39

we looked briefly after that

00:07:42

we turn the patient on the left side and

00:07:45

then we do a more detailed examination of the

00:07:49

kidney and immediately begin the measurement Yes,

00:07:53

finally, ideally all measurements

00:07:55

it’s better to do it on the stomach But if the

00:07:57

patient’s build allows it, 90% of

00:08:00

this can be done on the left side and,

00:08:03

accordingly, on the right side for the

00:08:05

opposite kidney, and now we begin all

00:08:08

these measurements under these conditions. Now

00:08:11

let’s ourselves Draw those

00:08:17

elements that we must evaluate.

00:08:20

So you and I We are talking

00:08:22

about the shape of the kidney,

00:08:26

and in a standard situation it is

00:08:34

bean-shaped and

00:08:43

may not be visible during an ultrasound examination, but the point is

00:08:46

that if this image is

00:08:49

now

00:08:54

drawn as if

00:08:57

the patient was lying

00:09:01

on the left side during the examination, then

00:09:04

here is the upper

00:09:05

pole and the head and here is the lower pole

00:09:14

legs and this small

00:09:17

concavity along the inner edge, it may

00:09:21

not always be noticeable, but in many

00:09:24

cases we can distinguish it, and in the patient

00:09:26

we are looking

00:09:30

at, now we are interested in the first

00:09:35

size, this size is defined as the

00:09:39

length and I display it

00:09:44

like this

00:09:46

to comment on this connection of the poles

00:09:50

means when you do a scan

00:09:55

you can accurately see the upper pole;

00:09:59

this can be

00:10:02

done simultaneously, then you should

00:10:05

simply display the upper one separately,

00:10:07

the lower one, and then change the magnification so

00:10:10

that both poles

00:10:11

fit; this size

00:10:15

can be measured in the length when both

00:10:17

poles are at their maximum are visible and in the previous

00:10:21

video I said that if you have

00:10:24

doubts, be sure to

00:10:28

measure this size several times as

00:10:44

A and here separately mark for yourself that

00:10:49

size A

00:11:03

I want to increase the font size

00:11:07

But

00:11:12

I see it ranges from 90 to 120 mm

00:11:19

And this is the length of the

00:11:22

kidney That is this is the vertical size,

00:11:36

we are talking about adults 9010

00:11:48

mm, we have already mentioned the fundamental

00:11:52

importance of these values,

00:11:55

because the

00:12:01

first thing you should do is suspect

00:12:03

some kind of anomaly or, again,

00:12:05

carefully analyze the shape due to

00:12:09

which the size will exceed the norm,

00:12:14

and once again remember about the

00:12:16

constitutional features about

00:12:17

tall people, where it may

00:12:21

differ slightly if the size is less than 9, the

00:12:30

first is that this is congenital

00:12:33

hypoplasia, and the second is that this is an

00:12:35

acquired

00:12:41

situation like a secondary wrinkled

00:12:43

kidney, and both will have additional additional

00:12:46

signs that we

00:12:48

will have to find and analyze.

00:12:50

So, if it is less than

00:12:53

90 before just two points we keep in

00:12:56

mind,

00:12:59

wrinkled hypoplasia, we are interested in the history and all the

00:13:02

accompanying other symptoms that we

00:13:05

will further

00:13:07

evaluate. After that, we must measure

00:13:12

other sizes, so here, for

00:13:14

example, let’s remember that patient, it was

00:13:16

111 mm, so I entered them and immediately got into the

00:13:21

next size w

00:13:24

width formally the width could be

00:13:27

measured like this just

00:13:43

to get

00:13:45

your bearings. You

00:13:47

can take measurements in the same position.

00:13:50

But it is more

00:13:53

correct to go straight to the transverse one.

00:14:00

How to do this, we

00:14:02

said in the previous video that you need to

00:14:04

rotate the sensor

00:14:06

90° That is if you

00:14:11

had it, say, a braid,

00:14:15

coinciding with the axis of the kidney, then you

00:14:18

simply turn it 90° and

00:14:21

then we get more or less These are the

00:14:23

outlines

00:14:35

Well, perhaps I didn’t turn out very

00:14:39

symmetrically, I’m now

00:14:44

correcting this letter, I’ll delete it,

00:15:23

here I am I drew this section that we

00:15:26

obtained during a

00:15:29

transverse scan of the kidney when we

00:15:31

rotated the sensor 90° relative to the

00:15:34

original one and, according to the rule, it is in this

00:15:38

section that we need to obtain the two remaining

00:15:43

dimensions.

00:15:45

I draw

00:15:47

this line

00:15:52

B and line C perpendicular to it.

00:16:00

Let’s

00:16:08

figure out line B as it

00:16:11

name what it

00:16:14

is This is the width Absolutely right, that

00:16:17

is, the widest area. And if

00:16:20

in relation to the patient’s torso,

00:16:22

this is the transverse size, and

00:16:26

for the kidney and for the torso, this is the

00:16:27

transverse size

00:16:30

and

00:16:32

finally the size C perpendicular to it, but

00:16:37

somehow it’s completely ugly to draw

00:16:41

with a mouse, wrong just a size

00:16:46

with this size by location will

00:16:50

be the thickness. So, this is the thickness of

00:16:54

the kidney. So we have the length, width and

00:16:58

thickness

00:17:02

here in the previous inscription, I didn’t

00:17:05

notice here, it’s written plus the length,

00:17:08

I wanted to write that this is a hyphen

00:17:13

or a

00:17:15

dash, now size B we agreed

00:17:20

that size B is the

00:17:26

width and it is equal to

00:17:30

45 60

00:17:41

mm and then, accordingly, the next

00:17:46

size c

00:17:50

is

00:18:00

52

00:18:05

mm thick and now

00:18:08

I

00:18:12

write down

00:18:19

the width and thickness in the protocol, they are indicated by these letters

00:18:26

dsht in theory, we would

00:18:29

use these

00:18:32

designations in our drawing then here will be 38

00:18:36

for example

00:18:39

yes The most important thing is that between these three

00:18:43

sizes there are

00:18:47

strictly defined

00:18:49

relationships, this system

00:18:52

of relationships let us write E separately,

00:18:59

so the

00:19:01

length

00:19:04

refers to the

00:19:08

width refers to the

00:19:16

thickness and I will repeat these letters that we

00:19:19

originally designated as

00:19:23

a to

00:19:25

B and to C

00:19:29

and in numerical terms, this

00:19:32

means the following

00:19:35

2 k

00:19:38

about and k

00:19:41

Novo, these are extremely important proportions that

00:19:45

we must

00:19:47

visually monitor all the time when the

00:19:49

sensor is installed. Even if we don’t measure

00:19:52

for us the principles of assessing these mev

00:19:58

from the form.

00:20:00

Look, I’m

00:20:06

now

00:20:23

measuring the thickness is clearly greater

00:20:32

in position Longitudinal scanning is

00:20:34

almost impossible to evaluate, it can

00:20:37

only be assessed when we rotate the sensor 90

00:20:40

degrees and most often this is associated with

00:20:43

diffuse pathology of the kidney parenchyma Yes,

00:20:46

with some chronic

00:20:49

diseases

00:20:52

that lead to changes in the

00:20:54

parenchyma itself and thickening of the

00:20:59

kidney, in this case, as I just

00:21:01

drew then this ratio has changed

00:21:04

but more or less to D K O K O that is, the

00:21:08

most important thing is that the second part of

00:21:11

our ratio is 1 to

00:21:14

08 width to thickness 1 to 08, in

00:21:19

pathological situations it changes to one

00:21:21

to one. This must be assessed, all this

00:21:25

is in terms of size

00:21:31

characteristics and

00:21:34

now it is quite clear that we will not always

00:21:37

have to

00:21:39

look at

00:21:42

adults, the question always arises of what to

00:21:45

do with children, there is such a

00:21:49

Rosenbaum formula, now we will

00:21:53

write it down, which is very convenient in terms of

00:21:57

determining the length of the kidneys

00:22:01

in children.

00:22:12

kidneys equals that is,

00:22:16

size

00:22:18

a

00:22:19

4

00:22:23

98

00:22:26

millimeters plus

00:22:33

0

00:22:36

155 multiplied

00:22:39

by

00:22:40

age in parentheses

00:22:45

month This is the formula for

00:22:51

children, there is a very

00:22:56

convenient little

00:22:58

manual by Kapustin

00:23:01

Pimanova, which among the literature

00:23:04

that I sent you is this

00:23:06

small brochure Where the

00:23:14

different ones are collected in such a general form examples And now I’m

00:23:19

showing you a small scan from there.

00:23:23

Yes, although this book itself is five

00:23:26

times smaller than a pocket format, you

00:23:28

can’t put it in a shirt or trouser pocket.

00:23:31

Yes,

00:23:32

and I want to

00:23:37

immediately target you with two things so that you are

00:23:40

very critical of units

00:23:45

of measurement It is most convenient to

00:23:49

write down all dimensions in

00:23:52

millimeters, for example in this book right

00:23:55

now. Those dimensions that I just

00:23:58

dictated to you in centimeters are indicated in

00:24:00

millimeters, and the formula that we

00:24:03

just wrote down is a millimeter formula,

00:24:05

yes, that is, this length will be in millimeters,

00:24:09

that is, for yourself. Take it for rule

00:24:12

never indicate in centimeters

00:24:15

Because if you work in obstetrics

00:24:17

there very often

00:24:18

very small values And they

00:24:21

often need to be indicated with two decimal places

00:24:25

and from this point of view

00:24:30

it will be very inconvenient

00:24:32

So as for the length of the kidneys in children This is the

00:24:36

formula convenient and guess

00:24:40

what is the length of a kidney in a newborn, judging

00:24:44

by this

00:24:46

formula, the number that stands here, yes,

00:24:50

that is, 498 about

00:24:52

5, the length of the kidney in a newborn

00:24:59

relates to

00:25:00

the age

00:25:02

older in children after a year, there

00:25:06

is a separate formula. This is the same

00:25:09

author

00:25:11

Rosenbaum proposed in the eighty-

00:25:13

fourth

00:25:17

year I write children after

00:25:23

a year, the initial value is 67

00:25:32

9 plus 679, it turns out that this is the length in

00:25:38

centimeters of the kidney,

00:25:40

which can be oriented for a year;

00:25:44

yes, in a year old child, the kidney can reach a

00:25:48

value of almost 68 mm, and the average is

00:26:02

022, also multiplied by age. But now

00:26:05

in

00:26:16

years. This is the formula for children. after

00:26:22

a year, in principle, there is a formula for

00:26:25

adults, we’ll write down about this,

00:26:29

if we come across a non-standard

00:26:30

patient, then the

00:26:34

length of the kidney is more than 120 mm

00:26:38

Or, for example, a very short

00:26:40

patient Yes, there is a woman

00:26:43

142 centimeters and the kidney is not 90 mm in length

00:26:50

but

00:26:52

85, excluding the

00:26:57

second wrinkled one kidney or not, in

00:27:00

such cases it is necessary to focus on the size,

00:27:03

so here we offer such an

00:27:10

opportunity to calculate for

00:27:18

adults the length of the

00:27:21

kidney is equal to

00:27:25

35 plus 0

00:27:30

42 multiplied by the

00:27:35

height in

00:27:40

centimeters 35 by

00:27:43

042 this will be the height in

00:27:47

centimeters multiplied by this formula for

00:27:56

adults everything that concerns the

00:28:01

kidney itself Let's go further down to our point,

00:28:05

this is a list of symptoms that we

00:28:08

must evaluate, it should always be in our

00:28:11

heads when we

00:28:13

look at a patient, the following is what we evaluate

00:28:18

and describe the contours of the kidney by default, in the

00:28:21

norm they should be dark and smooth to give the

00:28:28

kidneys, but I impose some structures that make

00:28:32

access difficult and in this case we

00:28:34

must evaluate it, yes, what prevents us from

00:28:37

fully seeing the kidney capsule? Yes, if

00:28:40

the capsule itself is broken in this case.

00:28:43

Of course, we are looking for what violates its

00:28:47

structure. Yes, and after we

00:28:51

evaluate the contours of the kidney, it is

00:28:55

further important for us.

00:29:05

here Let's draw a

00:29:08

new

00:29:25

picture and also

00:29:32

designate the longitudinal section of the

00:29:48

kidney, I

00:29:50

corrected small flaws

00:30:01

and then now we are interested

00:30:07

in the internal structure of the parenchyma consists

00:30:11

of pyramids,

00:30:31

in which the apex faces the base

00:30:34

along the outer contour of the

00:30:38

kidney, what did I say? The base faces the

00:30:41

outer contour of the kidney Yes, the apex to the

00:30:44

sinus area, they have this triangular shape.

00:30:52

And when we talk about the

00:30:54

thickness of the parenchyma, we mean

00:30:58

the distance.

00:31:00

This is from

00:31:04

the capsule to the

00:31:07

top of the

00:31:14

pyramids, I will designate the letter P,

00:31:28

let it be p, which

00:31:33

means the value is always different in the

00:31:38

middle of the outer contour and along

00:31:42

the poles and the minimum

00:31:47

normal values should be 14

00:31:51

mm; the thickness of the

00:31:54

parenchyma should be at least 14 mm. If it is less in an

00:31:58

adult, then we also always

00:32:01

suspect some atrophic

00:32:04

changes in the parenchyma of the kidney; this means that when

00:32:07

we talk about the thickness of the parenchyma, you

00:32:10

see, I measured both the thickness of the

00:32:13

cortex and the thickness of the brain.

00:32:18

Now the

00:32:19

thickness of the cortical

00:32:23

substance is indicated, and next to it is the

00:32:28

length of the pyramid. Which means this is the same

00:32:31

as

00:32:34

saying brain. Yes, I’ll take

00:32:38

a pen now and

00:32:42

sign here, I’m writing the letter

00:32:47

M, that is, in essence, this is the length of

00:32:49

the pyramid or the thickness of the Brain

00:32:53

substance. And here I’m writing to the

00:32:58

cortical

00:32:59

substance. And all this together will be equal to the

00:33:04

thickness of the parenchyma as a whole and then

00:33:07

the thickness of the parenchyma I specifically

00:33:09

indicate here, for example, up to 20 mm, what does this

00:33:13

mean up to 20, I don’t write 1420 yes, but it is clear

00:33:18

that if 20 then this is the maximum and it

00:33:21

will most often be located exactly

00:33:23

as we have now drawn along the outer

00:33:25

contour

00:33:29

in the middle segments Yes,

00:33:38

this is the thickness of the

00:33:40

parenchyma, an important point

00:33:45

that has a double meaning. In

00:33:47

situations such as

00:33:49

hydronephrosis,

00:33:51

when the pyelocaliceal

00:33:54

system expands and compresses the parenchyma, the more

00:33:58

it continues, the more the parenchyma

00:33:59

suffers and it becomes thinner, how can this be

00:34:02

assessed by the thickness of the parenchyma? Yes, if it is

00:34:04

already less than 14, we indicate signs of

00:34:07

thinning

00:34:09

of the parenchyma and this can be in situations of

00:34:14

diffuse damage to the kidney Yes, when it

00:34:17

On the contrary, due to the diffuse process, it

00:34:20

can become

00:34:22

thicker and enlarged and then the shape

00:34:25

changes what we drew

00:34:27

thickness

00:34:29

and width becomes about to width to thickness

00:34:31

is not 108 But about what about it will be yes often connected

00:34:36

with

00:34:40

this

00:34:44

Which is usually 6-8 mm yes usually

00:34:49

68

00:34:53

mm means

00:34:58

but the brain if you subtract water from 16 yes

00:35:01

it turns out also water yes But as a rule

00:35:04

the brain is larger

00:35:07

because the parenchymas are longer and

00:35:10

here the variability

00:35:12

is higher, in fact,

00:35:16

this assessment separately is

00:35:20

less acceptable for

00:35:22

everyday research.

00:35:24

And the total thickness

00:35:28

is the leading factor by which

00:35:30

we can evaluate.

00:35:33

Yes, now the Next point, the echostructure of the

00:35:36

parenchyma is already written here has not

00:35:38

been changed. Yes, this is the default value.

00:35:41

to be normal, the parenchyma

00:35:43

should not be changed What does this mean is not

00:35:46

changed parenchyma This means that we

00:35:48

see all three elements that are now

00:35:51

drawn here And that we see the pyramid

00:35:54

once related to the medulla and

00:35:58

that we also see cortical substance 2

00:36:01

indicated by the letter k Yes and

00:36:07

we see areas between the pyramids, these are the

00:36:11

spaces, what are they

00:36:14

called, Bertinet's columns

00:36:18

or renal columns? Yes, these are three

00:36:23

elements that should be clearly

00:36:25

distinguishable when you look. If you

00:36:28

don't see them, then you are talking about. What is the

00:36:30

echostructure of the parenchyma changed?

00:36:34

Well, that's how we can

00:36:39

here manually Sign or

00:36:43

specifically

00:36:45

insert, let's say due to the lack of

00:36:48

clear cortical-cerebral differentiation,

00:36:51

this is the most common situation Yes, cortical-

00:36:53

cerebral

00:36:55

differentiation visually,

00:36:58

you can't see a separate pyramid,

00:37:00

but you have to Why Because the echogenicity

00:37:03

we said is

00:37:07

different if I succeed Now

00:37:09

I'll try to

00:37:11

paint them over or let's do it on the

00:37:15

next slide, I'll take

00:37:20

a new one

00:37:23

and draw the same contours again

00:37:39

to do

00:37:43

it like

00:37:51

this, I'm now trying to choose a color so that

00:37:55

it approaches what you see in

00:37:58

echography and

00:38:00

now I'm drawing the

00:38:15

pyramids a little low, I've done it,

00:38:20

correcting everything - they are located more

00:38:23

peripherally, let’s go

00:38:41

in here, it’s like this,

00:38:52

yes Okay, we painted over the

00:38:55

next

00:38:57

structure like this, it’s a pyramid, now I’ll draw

00:39:01

another one, I’ll paint

00:39:28

it over too, and next

00:39:35

to it I’ll draw another

00:39:49

one, and finally the last one

00:39:53

on the side closer to the pole closer, the pins

00:39:58

are often located like this almost

00:40:11

horizontally and what I would like to

00:40:13

emphasize here is that this image already

00:40:17

resembles echographic

00:40:28

truth, the pyramids are darker, they are

00:40:32

discretely different from one

00:40:34

another, and the

00:40:38

echogenicity of the Bertin column is no

00:40:42

different from the pyramid, but it turns out that the

00:40:44

Bertin column is nothing more than a

00:40:46

pyramid that penetrates here like a cortical a

00:40:49

substance that penetrates between the

00:40:51

pyramids Yes, and therefore the color does not change

00:40:54

cheat when we talk about the absence of core

00:40:58

differentiation, then this color scheme,

00:41:01

if I may say so, in the B mode of

00:41:04

the image of the pyramids and parenchyma, it

00:41:09

becomes

00:41:10

indistinguishable, it becomes solid and does not

00:41:14

mean that it is homogeneous but does not allow you to

00:41:17

see as a rule,

00:41:20

certain elements of heterogeneity appear there due to

00:41:23

what due to some areas we

00:41:26

describe them then and due to the lack of

00:41:29

cortical-cerebral differentiation and we can

00:41:32

simply additionally indicate, separated by a comma,

00:41:38

zones of irregular shapes of

00:41:43

different

00:41:50

echogenicity, this assessment of the echostructure

00:41:54

for us is

00:41:58

but Next item echogenicity

00:42:01

of the parenchyma, look, it is indicated as

00:42:04

average, but it is implied that

00:42:08

we mean the

00:42:10

echogenicity of the cortex and pillars,

00:42:14

yes, that is, we are not focusing on the

00:42:16

pyramids, but on what is compared with the

00:42:19

adjacent liver pankh,

00:42:23

what we compare names cortical, yes, that is, this is

00:42:27

what we have it depicted here in gray

00:42:32

Yes,

00:42:35

finally we go down further. The next

00:42:38

point that we must evaluate

00:42:41

is

00:42:47

sinus, a concept that is not always

00:42:50

used in

00:42:53

echography about the collecting-pelvis

00:42:59

attempt to replace the term sinus. This is not

00:43:03

entirely correct. Why is a sinus a

00:43:06

depression in the area of the hilum of the kidney inside

00:43:10

this organ and in the sinus there are

00:43:13

several structural elements located at once: the

00:43:22

collecting-pelvic tissue and adipose tissue, the

00:43:29

structure of the collecting-nocturnal complex and its

00:43:33

images are changing,

00:43:36

modifying this will definitely be

00:43:38

reflected to one degree or another

00:43:44

on the

00:43:45

image of the sinus,

00:43:49

which means Look, by default

00:43:52

our sinus is not

00:43:56

filled That is, you can Calmly this

00:43:58

skip yes this line in situations

00:44:02

if there are no pathological

00:44:05

changes in

00:44:07

its shape and

00:44:10

structure, most often this happens due

00:44:14

to situations when

00:44:21

signs of incomplete or complete

00:44:25

doubling appear, so please, it means I’ll

00:44:29

cancel it now, I want to draw now in

00:44:32

white like this,

00:44:34

yes

00:44:41

Here so And now if I change it a little,

00:44:44

maybe it’s not completely white Or

00:44:47

maybe Like this, yes like this yes yes Well, yes, a

00:45:09

spray can And now I don’t need a spray can yet

00:45:12

because I want these

00:45:15

linear fragments to be

00:45:25

noticeable, which I want to draw your attention

00:45:29

to what I just

00:45:31

drew, that in this

00:45:34

case the sinus is like this, this is a

00:45:38

structure of increased echogenicity located

00:45:40

deeper than the

00:45:43

pyramids, it is not united, it is

00:45:47

divided into two

00:45:48

fragments and that the same parenchyma protrudes between these

00:45:51

two fragments.

00:45:55

Yes, it divides the sinus into two fragments,

00:45:58

upper and lower.

00:46:01

And this is For us, there is always a suspicion of

00:46:05

doubling of the pyelocaliceal system, that

00:46:07

is, in essence, this is a variant of

00:46:10

kidney doubling, which is not very

00:46:12

rough, it is impossible to prove this absolutely on an ultrasound,

00:46:15

we only indicate these indirect

00:46:18

signs Yes, but this is very important

00:46:21

in what situations when the pressure is on

00:46:32

some situations when he is persistently treated

00:46:37

for this pressure and

00:46:39

it

00:46:43

reacts completely unpredictably to this treatment

00:46:45

yes because of What Because if there

00:46:49

is a splitting of the calyceal nocturnal

00:46:52

complex, then this is often accompanied by the

00:46:54

appearance of two ureters

00:46:57

that connect somewhere distally and the

00:47:00

vascular bed will also be

00:47:04

not

00:47:06

typical not of a typical nature of the structure

00:47:09

Yes, the splitting of the main

00:47:11

branches of the renal artery will

00:47:15

occur differently, additional

00:47:17

aberrant arteries appear and they can conflict with each other,

00:47:21

compressing each other and this leads to

00:47:26

certain

00:47:28

disorders, which are often associated, in addition to

00:47:30

all other symptoms, let's say with

00:47:33

the problem of arterial hypertension Yes, and

00:47:36

in this case, we can simply

00:47:38

indicate here, for example,

00:47:40

that the

00:47:42

splitting of

00:47:43

the sinus occurs due to the

00:47:51

split parenchymal septum, here it is specifically worthwhile to have an

00:47:54

extra floor

00:47:57

behind the complete parenchymal septum,

00:48:00

let’s take a look at how it will

00:48:02

look

00:48:05

in the text of the

00:48:07

report, the parenchyma is changed due to the

00:48:10

lack of a clear cortical medullary

00:48:12

differentiation and irregularly shaped zones of

00:48:15

varying

00:48:16

echogenicity parenchyma thickness 20 mm yes

00:48:20

As for they

00:48:27

indicated that it is

00:48:37

split in the

00:48:43

thickness of the sinus and parenchyma itself Yes, under

00:48:48

normal conditions

00:48:51

this ratio

00:48:57

approaches

00:49:00

2: one or o to one Yes, but often

00:49:06

there is an

00:49:07

increase in the

00:49:10

amount of adipose tissue in the sinus

00:49:14

and then the ratio of sinus parenchyma

00:49:18

increases to a value of 3: this alone is

00:49:21

one

00:49:23

of the symptoms of sinus fibrolipoma, yes,

00:49:26

that is, the relationship between

00:49:31

these values of the thickness of the parenchyma and the sinus

00:49:35

here

00:49:36

will also be a reflection of the situation associated

00:49:40

with a deviation from the normal

00:49:44

picture. If

00:49:47

the sinus is not a

00:49:55

split complex and then I’m removing

00:50:01

these designations that I just

00:50:05

made. Please note that I

00:50:09

didn’t take a spray can here, but drew it in

00:50:13

such a way as to emphasize that

00:50:17

normally this tissue is connective and

00:50:21

fibrous in the sinus.

00:50:24

It always contains a different amount of

00:50:28

Svetka elements of the fibrous

00:50:31

type of a fibrous nature and that means it

00:50:35

will contain these small

00:50:37

hyperechoic linear echo signals, that

00:50:39

is, they are always present in the sinus,

00:50:41

how to interpret them? If they do not

00:50:45

contain any shadow behind them, they have a

00:50:48

linear shape, then this is a normal

00:50:50

structural

00:50:51

element; this is a reflection of those structures

00:50:55

that are fibrous in nature and

00:50:59

they always overlap in the sinus on the

00:51:09

collecting pelvis

00:51:21

Well, as a

00:51:25

rule, so the

00:51:28

color again I want to choose, let's say

00:51:31

this Yes completely I want to fill in And who is

00:51:35

this circle

00:51:40

oval so that it is filled in you still

00:51:43

need to click

00:51:48

Yes so Yeah

00:51:59

more

00:52:04

Okay, I've drawn one oval now

00:52:08

another

00:52:11

now

00:52:15

I I’ll try to pull it away now, but it did

00:52:30

n’t work out very well, then I’ll draw a

00:52:34

third one here, some other fourth one. I

00:52:37

ask you to remember what from that echogram.

00:52:41

Well, more precisely, from that

00:52:44

video of the study of the kidneys. We met

00:52:48

with two explanations of these ahoge or

00:52:51

hygen

00:52:52

structures, od this is enough.

00:52:56

We can always do it easily check

00:52:58

by turning on the

00:53:00

CDK they are usually of small diameter

00:53:03

But like this they are regularly mixed

00:53:06

with

00:53:26

we will consider Yes,

00:53:28

its apex can open in this

00:53:31

direction Yes, in this case it has a

00:53:35

characteristic boundary there that was

00:53:38

noticeable in that view and

00:53:42

this is the second normal explanation

00:53:46

associated with this situation now The

00:54:00

next point that we must

00:54:02

reflect is the echo structure of the

00:54:08

sinus in silence, if it is not changed,

00:54:12

then we can not report anything about this point at all

00:54:21

or indicate that it is simply not

00:54:24

changed Yes, the echo is changed, but quite

00:54:29

often we Naturally encounter a

00:54:31

pathological situation and then due to

00:54:34

what it can be

00:54:36

changed, here are the

00:54:39

symptoms that are most

00:54:42

often found in violations of the

00:54:46

structure of the sinus, firstly, a diffuse

00:54:48

increase in echogenicity yes. What can

00:54:50

be characteristic most often for sinus

00:54:53

fibrolipoma, the egen

00:54:56

increases But then the

00:55:01

ratio of sinus thickness and parenchyma

00:55:05

and sinus, as if recaptured of

00:55:13

their typical

00:55:22

location, permanently

00:55:26

related

00:55:32

to Is it possible to see salt

00:55:39

inclusions in the

00:55:45

pelvicalyceal design there are no absolutely

00:55:48

clear answers Yes, because it

00:55:50

depends on the type of salt inclusions, yes, that

00:55:54

is, what specific salts

00:55:56

And most importantly, there is

00:55:58

an acoustic behind them shadow or not, as a rule,

00:56:02

if these are salt inclusions, then they have

00:56:15

outlines that are

00:56:17

quite close to

00:56:22

round, I want to say,

00:56:43

now I have drawn something

00:56:45

closer

00:56:47

to

00:56:49

this, a circle or an irregular but

00:56:54

non-linear shape,

00:57:26

very small shadow

00:57:31

paths and when you always see

00:57:34

some kind of hyperaggregation,

00:57:56

there are no

00:57:59

reliable signs that this

00:58:03

inclusion is associated with salt fragments

00:58:07

no everything else the signs are unreliable

00:58:11

they can

00:58:14

be speculative but not

00:58:21

often conclusive. The presence of such

00:58:25

shadow paths is

00:58:27

determined by the size of the accumulations and they

00:58:31

can gather into larger

00:58:34

conglomerates

00:58:36

and

00:58:39

form some kind of complex that

00:58:42

already has a clearly defined path. What

00:58:45

if one or two such formations

00:58:48

Separately, paths are located next to them

00:58:49

No, it is a question of converting

00:58:51

quantity into quality, how many of

00:58:54

these inclusions are there? If they

00:58:56

gather in clusters of a large nature,

00:58:59

then a shadow path inevitably appears behind them.

00:59:02

If not, then we treat

00:59:06

this with great skepticism. Yes, I don’t

00:59:08

regard it them as some kind of salt

00:59:12

inclusions is another sign that

00:59:15

allows

00:59:17

us to regard some hygen inclusions

00:59:22

as

00:59:23

salt. If even there

00:59:27

they are generally

00:59:31

so pinpoint that

00:59:34

separately located elements are

00:59:36

not differentiated from each other,

00:59:40

we understand that urine

00:59:42

comes out

00:59:45

of the collecting ducts where

00:59:48

they open nephrons at the top of the pyramids

00:59:51

That is, if

00:59:55

these are pyramids, then this is where the

01:00:00

urinary tubules open,

01:00:03

which then ended up in the Lesser Calyx,

01:00:06

here we have it now. The Lesser Calyx is not

01:00:08

drawn, but suddenly if you see

01:00:18

that like this,

01:00:31

small hyperaggregations appear along the periphery of the narrowed part of the pyramid,

01:00:59

framing itself the contour

01:01:04

has repeated the configuration of the pyramid Yes, this is

01:01:08

most often not in one but in

01:01:10

several pyramids at once, so we closely

01:01:14

look and see that they somehow

01:01:17

rise here as a rule. They do not

01:01:20

go above the middle

01:01:23

level of the length of the pyramid. Why are

01:01:27

they located where the

01:01:29

Small

01:01:31

calyx is attached and here in this case, these are also

01:01:34

signs of salt inclusions

01:01:38

on the periphery of the pyramids,

01:01:41

which will force

01:01:44

us to interpret this as

01:01:50

signs of target inclusions in the sinus and

01:01:54

kidney parenchyma, that is, then we

01:01:57

must conclude that these are salt

01:02:00

inclusions in the sinus and kidney parenchyma, this is

01:02:09

what we have now designated about the

01:02:12

echostructure of the sinus in our picture

01:02:15

is associated with pathological manifestations,

01:02:21

these fragments of gene inclusions with a shadow

01:02:25

should be interpreted in this case

01:02:28

as salt inclusions as microliths even

01:02:32

if they are larger than TH mm yes

01:02:34

If up to three, then it’s simply better to

01:02:37

designate them as salt inclusions

01:02:40

And what else may often be included

01:02:46

in this image of the sinus some kind of

01:02:51

hypoechoic rounded or let's directly

01:02:54

emphasize water or incorrectly

01:02:56

ovoid formations. Let's draw

01:02:59

these. I again take

01:03:11

the brush here

01:03:14

Yes, okay and Here, for example,

01:03:20

I draw such a structure

01:03:32

and to paint over it is not from here Yes yes And with the

01:03:37

same color That's the same

01:03:43

Yes, but like this you didn't paint over everything

01:03:46

Well, because the white went over it too

01:04:06

I of course can try now to take

01:04:09

another

01:04:21

tool back,

01:04:37

it's easier, but I didn't want that at first

01:04:39

Why did I want to emphasize

01:04:41

I’ll now try to do this one more time,

01:04:43

that the structure of these formations is

01:04:47

incorrectly ovoid, and most often they

01:04:51

have outlines

01:05:00

approximately like this, and they are aquatic, but nevertheless,

01:05:15

their Whites do not shrink; whites do not shrink; a

01:05:20

separate object is

01:05:53

I did a lot of

01:05:54

computer graphics in

01:05:57

vector mode. And in this I haven’t contacted my pet for a long time, I

01:06:00

didn’t draw on the board

01:06:02

Why Because on the board we would have

01:06:04

all the colors inverted, yes, but here I

01:06:07

wanted to choose those colors that you

01:06:09

actually see on the monitor screen But

01:06:13

this is a diagram and what is wrong with these three

01:06:16

ovoid structures I

01:06:19

I wanted to depict

01:06:23

sinus cysts, these sinus cysts are a

01:06:26

very

01:06:28

characteristic and typical

01:06:32

thing that needs to be differentiated from

01:06:35

two other signs from parenchymal

01:06:39

cysts

01:06:46

and from the expansion of the pyelocaliceal

01:06:52

complex, you are

01:06:55

now in the sinus and there is every reason to

01:06:58

think that, for example, if you come across

01:07:01

this structure But if it is larger in

01:07:03

size, for example, I will draw twice as

01:07:05

large, that this is a large

01:07:07

cup How do we tear them off? Let's

01:07:11

first

01:07:15

differentiate parenchymal

01:07:18

cysts. Parenchymal cysts are

01:07:21

always round,

01:07:25

they appeared in the parenchyma, it is clear that they are

01:07:28

located in the parenchyma a little

01:07:30

further from the plane in which we are looking.

01:07:32

Yes, beyond the plane the screen is further from

01:07:36

us, then this cyst is still

01:07:40

projected here if it is parenchymal and

01:07:42

superimposed on the image of the sinus, but

01:07:45

its outline will be absolutely smooth and

01:07:48

absolutely round due to the fact that it

01:07:51

develops in the parenchyma, it must

01:07:56

push the parenchyma in all directions.

01:07:58

I specifically

01:08:05

jump over the difference between a pair of ovarian

01:08:09

cysts and ovarian cysts, and a pair of varia

01:08:12

cysts are also

01:08:15

always ovoid, and ovarian cysts, but while they are

01:08:19

small in size, not more than 5 cm, yes,

01:08:23

they are more round, yes, that

01:08:26

is, there is some kind of analogy here:

01:08:28

parenchymal cysts should be the

01:08:30

spheroid is spherical in shape and the

01:08:34

sinus cyst has this irregular ovoid

01:08:36

shape, this is how we

01:08:39

differentiate

01:08:42

parenchymal cysts by origin, they are

01:08:45

completely different parenchymal cysts -

01:08:48

this is

01:08:50

the result of the

01:08:52

lack of opportunities for the

01:08:55

developing

01:08:58

urinary accumulation to exit into

01:09:00

that part of the nephron that is connected to the

01:09:04

loop or then the collecting

01:09:06

ee opens into the collector tube and

01:09:10

due to this, a cyst is formed. Yes, which

01:09:13

means sinus cysts

01:09:17

are usually just an accumulation of fluid

01:09:20

of lymphoid origin, as they are from the

01:09:23

lymph, most often of a lymphoid nature

01:09:25

in

01:09:27

origin, usually as a result of such

01:09:30

microtrauma associated with the discharge of the

01:09:32

pechino. So they come off and the structures nearby are

01:09:39

uh the sinus suffers in this case, small

01:09:43

lymphatic vessels can rupture and

01:09:45

form something like

01:09:48

lymphatic swelling. If you want a not

01:09:50

quite correct shape, irregular

01:09:53

incorrectly ovoid, and

01:09:57

uh, another such implicit less obvious

01:10:01

differential diagnostic sign

01:10:03

that parenchymal cysts they will not

01:10:08

disappear anywhere, they can only

01:10:12

uh can rupture Yes, and fluid can

01:10:20

leak out of them, but while they are small, this

01:10:24

practically does

01:10:26

not happen,

01:10:28

and sinus cysts disappear in some cases, yes, that

01:10:32

is, this may

01:10:35

not be such a factor all the time if

01:10:38

they are not large cysts, if they are

01:10:41

small cysts, they

01:10:43

can sometimes go away and disappear on their own

01:10:47

cup

01:10:55

complex Here, first of all, again in terms of

01:10:57

shape, but you need to

01:11:08

draw it out in detail for yourself. Now I’ll try

01:11:12

to draw a small cup here first,

01:11:34

and if not then fill in the black one, how to

01:11:38

do it this way I draw

01:11:40

Yes, and then I want the middle to be

01:11:45

black, the middle is black

01:11:49

Yes, well here we need to finish closing Yes

01:11:54

close

01:11:56

so yes yes Yeah now

01:11:59

aliv filling and Black

01:12:04

lard is not not Lar one black

01:12:10

ha Hi Ko

01:12:46

I just drew an image of a small

01:12:48

cup, it is fundamentally important that you

01:12:51

notice that it seems to hug the

01:12:57

top of the pyramid so it sits on it

01:13:04

like breast pump on the nipple yes This is

01:13:09

fundamentally how it works, yes there

01:13:11

is a fornical mechanism that

01:13:13

forces urine not to

01:13:15

flow out actively in this most passive way

01:13:18

and this is the outline that is

01:13:22

drawn on top we

01:13:26

can distinguish it visually in 90% of small cups

01:13:30

Yes if we just

01:13:32

look at how it comes out, this

01:13:35

is the outline

01:13:38

that surrounded the top of the pyramid

01:13:43

like a cup of a breast pump. Yes,

01:13:47

it will be clearly

01:13:50

visible. And now the next one I will draw a

01:13:55

similar

01:14:02

structure

01:14:09

and the more expanded such

01:14:15

small cups are, the less

01:14:19

it is possible to distinguish

01:14:35

salt inclusions inside, this is practically

01:14:37

already then it will be

01:14:46

impossible. I paint it exactly the same way.

01:14:49

Here we are, hugging the small cup at the top of the

01:14:54

pyramid. We can clearly

01:14:58

see this configuration.

01:15:02

I first chose white for the

01:15:07

periphery of

01:15:13

these cups because in fact,

01:15:16

sometimes it is possible to distinguish their wall there,

01:15:20

but this does not

01:15:23

always happen and if not, then we

01:15:25

see like this how two small cups here

01:15:29

merge into one

01:15:41

large one, this example is quite

01:15:46

clear and what follows is the

01:15:57

pelvis yes. In order to demonstrate the same thing to you,

01:16:00

I will now take the

01:16:05

example of a specific patient, woman ri, in

01:16:10

my opinion years with such pronounced

01:16:13

retrocervical endometriosis

01:16:17

and this retrocervical endometriosis

01:16:21

gave way

01:16:26

and led to a secondary expansion of the

01:16:29

pyelocaliceal

01:16:31

system

01:16:38

and here

01:16:43

it is and where it is,

01:16:47

you see a transabdominal

01:16:51

scan now the bladder

01:16:53

Yes the uterus And here is a hyperechoic

01:16:56

round

01:16:57

structure behind the isthmus of the uterus

01:17:00

isthmus and at the border of the cervix this is

01:17:04

retrocervical

01:17:05

endometriosis Now I’ve switched to transverse

01:17:08

scanning Yes, here it is

01:17:09

retrocervical endometriosis

01:17:20

Oh well,

01:17:25

now it’s

01:17:29

just the left

01:17:31

kidney, maybe even Let’s turn off

01:17:34

the light and

01:17:36

look at these visual small cups

01:17:40

Here’s one, here’s the

01:17:41

second one big as you and I

01:17:44

drew in that picture, yes And here the

01:17:47

same thing, this is already

01:17:50

big and these large cups

01:17:52

open into the khanka, yes,

01:17:55

that is, the configuration of these areas

01:17:58

is very characteristic and you can

01:18:04

directly see how they cover the pyramids,

01:18:08

but the pyramid is already here it is often

01:18:11

impossible to consider because,

01:18:13

due to prolonged suffering, they

01:18:16

disrupt cortical-brain differentiation

01:18:19

and we cannot distinguish an individual

01:18:26

pyramid.

01:18:27

Yes, that

01:18:31

means I remember. Yesterday we had such a

01:18:35

perfect example, but in a place

01:18:38

where it was impossible to record on video, that

01:18:41

is, there simply was not all devices

01:18:42

make it possible to record this perfectly

01:18:45

And there was at the same time such

01:18:51

a combination often happens,

01:18:56

such as for example here,

01:18:59

plus Multiple sinus cysts, there were

01:19:03

many of them

01:19:05

and these or large ones, quite

01:19:10

large ones,

01:19:13

plus if such a sinus cyst

01:19:16

becomes very large, it does not

01:19:19

fit inside the

01:19:21

sinus and then it is located next to the

01:19:25

pelvis, that is, it needs to go

01:19:29

beyond the inner part of the sinus, it is

01:19:31

already located partially outside the

01:19:35

organ, and in this case it acquires

01:19:38

the name parapelvic cyst, we can

01:19:41

say that a parapelvic cyst

01:19:43

is a type of sinus cyst, but

01:19:46

when it is

01:19:47

large, it is usually more than 3

01:19:51

cm and not fitting in the sinus so large

01:19:56

it is forced to go beyond And

01:19:58

when it comes out you understand that

01:19:59

the gates of the kidneys They are, uh,

01:20:01

like this door Yes, if you don’t fit, then you wo

01:20:06

n’t fit through them,

01:20:08

yes, that is, you have to adapt to you and

01:20:10

not the doors Yes, and

01:20:12

uh the cyst,

01:20:15

uh, shrinking, deforms the

01:20:20

uh pelvis and secondarily intensifies or

01:20:26

even provokes hydronephrosis,

01:20:29

yes, that is, these large sinus cysts Going

01:20:34

beyond the sinus itself From the hilum, the kidneys

01:20:38

get a new name, they become

01:20:40

parapelvical and one of the problems is

01:20:43

if we don’t see the

01:20:46

parapelvical from the dilated pelvis

01:20:49

but it is necessary, yes, that is, we differentiate the pelvis

01:20:52

on this basis, that if it is

01:20:55

so large, then most often

01:20:57

large calyces are associated with it, we

01:20:58

can examine these large calyces Yes,

01:21:01

and the second means the situation is this,

01:21:10

and the fact that this is a large parapelvic

01:21:13

cyst will

01:21:17

compress the pelvis itself and secondarily

01:21:22

lead to the expansion of

01:21:26

large small calyces to form

01:21:28

hydronephrosis

01:21:30

Yes And yesterday we had a patient

01:21:33

who had all these three signs clearly

01:21:35

expressed, but unfortunately this

01:21:38

was impossible to write down and therefore I will not show you today

01:21:41

Multiple sinus cysts

01:21:45

plus dilatation of the collecting pelvis

01:21:48

systems are more pronounced than here in this

01:21:51

example, a

01:22:02

large parapelvic

01:22:04

cyst 60 mm in length, it was already ovoid in

01:22:09

shape and quite naturally without placing

01:22:13

pressure, this is progressive

01:22:16

hydronephrosis, before this I had it

01:22:19

about 8 months ago and the degree of

01:22:22

hydronephrotic

01:22:24

worsened, yes, that is, this leads to a

01:22:27

gradual to gradual

01:22:29

progression of

01:22:45

the process, which means the pelvicalyceal

01:22:49

system, by default, it is not

01:22:53

dilated normally; there is no expansion of the

01:22:55

pelvicalyceal system. In what

01:22:58

cases can we normally see the pelvis?

01:23:06

see neither large nor small cups

01:23:08

in which case can we normally see the

01:23:11

pelvis and what size does it come in? yes, in

01:23:14

principle, somewhere up to 15-18 mm it can

01:23:18

be normal visualize the pelvis with a

01:23:21

full bladder yes

01:23:26

the patient came for a gynecological

01:23:28

examination using a transabdominal sensor

01:23:31

in order to watch, they force her to

01:23:34

sit there for 40-45 minutes, she

01:23:39

can’t stand it at all and the overflowing Bubble,

01:23:41

which is now more than 500 ml,

01:23:44

quite naturally leads to the fact that the

01:23:46

outflow from the pelvis is difficult, she will

01:23:48

visualize you sent her then

01:23:50

to urinate if Look again at the kidney

01:23:53

maybe it would still be there, but after half an hour it wo

01:23:55

n’t be there; the pelvis is dilated, yes, that

01:23:58

is, immediately after the urine is drained, it

01:24:01

may still be present, but uh. Because

01:24:08

when the bladder is dilated with a volume of

01:24:11

more than 500 ml, it is quite natural that this

01:24:16

makes it very difficult for urine to pass out

01:24:18

within the parenchyma itself kidneys yes

01:24:21

Therefore, by the time she got from the toilet to

01:24:23

your office, filling is already happening there again.

01:24:26

Yes, and the bladder is already

01:24:29

filled there with at least

01:24:32

8090 milliliters and the same thing, the pelvis

01:24:36

could still not empty completely, well, in half an hour it won’t

01:24:38

remain there, that is, on its own

01:24:41

pelvis only the pelvis can be visible,

01:24:44

while you normally will not see

01:24:47

the ureter and normally you will not see either

01:24:50

large or small calyces, that is, it is

01:24:51

fundamentally important for us

01:24:53

to agree here that

01:24:55

we normally do not see the ureter and we do not

01:24:59

see either large or small calyces,

01:25:07

we can see the pelvis

01:25:08

therefore, it means that under normal conditions, by

01:25:11

default, it is filled here as the

01:25:13

collecting-pelvis system is not

01:25:20

expanded, it can be

01:25:22

expanded. Maybe from a hanka and then we

01:25:26

indicate its diameter, let’s say

01:25:30

up to 20 mm, yes, and then we will indicate what happened

01:25:34

after the cci, after the urine was deflated or

01:25:38

not, yes then yes, if we saw it, there are

01:25:40

no other signs, then by

01:25:42

decree we can indicate that

01:25:45

it is a pelvicalyceal

01:25:48

system, tree-like,

01:25:55

maximum, then the diameter is indicated at the

01:25:57

pelvis, the maximum diameter of the cups,

01:25:59

but here we mean large cups

01:26:01

Yes, small ones are of secondary

01:26:03

importance Yes,

01:26:07

and this should

01:26:12

be reflected in the appropriate

01:26:15

paragraph we go down below

01:26:19

what in the room should be

01:26:24

differentiated, so it is not dilated, that

01:26:26

is, these are two manifestations of the same situation connected with each

01:26:31

other,

01:26:34

yes, the ureter is normal.

01:26:38

We don’t see because it is not dilated,

01:26:42

then it is not

01:26:44

differentiated, remember that the ureter is a

01:26:46

long structure, yes, that is, it

01:26:48

begins from the gate of the kidneys, it has a long

01:26:51

abdominal section and then it descends,

01:26:54

which also has about

01:26:57

8-12

01:26:59

cm, the next pelvic section and then

01:27:02

it has an intramural

01:27:04

section and therefore we always remember that the

01:27:07

intramural section opens

01:27:12

in the triangle of the bladder with

01:27:17

the mouth and therefore when Any suspicions,

01:27:20

we definitely need to check again to see

01:27:22

if the bladder is enlarged.

01:27:26

Yes, yesterday too. We had a boy, our

01:27:31

student, maybe he will come again if

01:27:34

we write it down here, we’ll see,

01:27:39

20, in my opinion, 2 years old with

01:27:44

urolithiasis, he says that from school

01:27:49

Yes, I recently for the first time in my life I saw uh a

01:27:54

stone in the thirty-second week in the fetus,

01:27:56

yes, a stone in the

01:28:01

ureter, yes. That is, in principle, this is

01:28:04

such a violation of the

01:28:10

exchange of salts that can

01:28:13

lead to such things and what was the situation

01:28:16

there, he was

01:28:20

dilated. the pelvis was dilated, the large

01:28:23

and small calyces were dilated

01:28:27

and

01:28:29

the ureter was dilated at the

01:28:32

level of 5 cm in length, that is, we could

01:28:35

trace it to the 5 cm of the abdominal

01:28:39

section, starting with the pelvis. And then no, the

01:28:42

ureter is lost and everything is always difficult

01:28:44

to look at.

01:28:45

Yes,

01:28:47

but that’s always Then the question is If it is 5 cm

01:28:52

lived and then is

01:28:54

there some kind of obstruction,

01:28:57

yes, if there is one, it can usually be

01:29:01

seen if it is an overlying stone, it

01:29:04

gives a shadow and can be seen. It happens, but

01:29:08

here this was not visible, he had a

01:29:11

history of plastic ureter in childhood,

01:29:13

yes, that is there seems to be a bunch of

01:29:15

accompanying complications, but

01:29:17

nevertheless, here is an example of the fact that

01:29:21

the ureter is visible at some point. This is

01:29:25

usually the proximal

01:29:29

part of the

01:29:30

pelvis at the

01:29:33

abdominal level of the ureter. And

01:29:36

then it may not always be noticeable;

01:29:39

we can clearly differentiate this reason with the help of ultrasound;

01:29:54

is located by default if

01:29:57

it is located we indicate where the

01:30:01

concrement always

01:30:03

has an acoustic shadow If you do not

01:30:06

see the acoustic shadow Whatever the

01:30:08

structure is, you cannot

01:30:11

unambiguously interpret it As a

01:30:12

concrement and therefore If I, for example,

01:30:15

see Here now I am drawing such a supposed

01:30:20

concrement

01:30:43

Well, I drew that - something similar to a

01:30:47

calculus but without an acoustic

01:30:51

shadow, we measured its dimensions,

01:30:54

we determined its

01:30:56

location, but no matter how much we turn

01:31:01

the sensor, no matter how much we turn the patient

01:31:04

from side to side, we will not

01:31:07

see the shadow; we

01:31:09

have no reason to unambiguously

01:31:12

interpret it as a

01:31:16

calculus, then we indicate suspicion

01:31:19

on a

01:31:20

calculus with a weak or no

01:31:22

acoustic shadow and such and such a

01:31:24

localization as a suspicion, but we

01:31:27

cannot make it clear. And if this is a true

01:31:31

calculus, he

01:31:43

always has such a dorsal acoustic

01:31:46

shadow, it is always there, that is, this is precisely what

01:31:49

serves as evidence of the calculus,

01:31:54

so we must be quite

01:31:56

critical to other people's conclusions,

01:31:59

overdiagnosis of

01:32:01

urolithiasis, we will

01:32:04

say, according to the

01:32:07

conclusions, it is a fairly common

01:32:09

phenomenon. Yes, it is not always that we

01:32:15

see an acoustic shadow, also at what

01:32:19

size is a salt inclusion that has a shadow,

01:32:22

call a calculus there larger than 4 mm, yes

01:32:26

up to 4 mm is better, uh Call it simply

01:32:31

microlite or large salt inclusion with an

01:32:34

acoustic shadow

01:32:44

Yes, and finally, as for the

01:32:58

mobility of the kidney, we evaluate it, is it

01:33:03

preserved, limited or

01:33:06

is it

01:33:08

pathological when comparing the

01:33:09

horizontal and

01:33:13

vertical positions, we remember we just saw During

01:33:17

this study how the kidney moves back and

01:33:20

forth yes With every inhalation and exhalation and

01:33:25

this this is just a

01:33:27

normal

01:33:29

reaction of the kidney to breathing,

01:33:35

but in a vertical position the

01:33:38

kidney should not move if the patient

01:33:40

gets up and

01:33:42

we compare the position with the initial one. It

01:33:45

should not move. Yes, they

01:33:53

mentioned it to you when they talked

01:33:57

about the liver and the fact that the ratio most

01:34:02

convenient for assessment is the upper one poles

01:34:06

in relation to the contour of the diaphragm Yes, and

01:34:10

we talked about the fact that the kidney can

01:34:14

descend yes And for us In this case,

01:34:19

very often it is also a

01:34:21

differential diagnostic

01:34:23

sign of how to separate nephroptosis from

01:34:27

dystopia and in order to show this, I will

01:34:31

then show you

01:34:37

several pictures directly

01:34:40

with the image the

01:34:42

drugs themselves that allow you to

01:34:47

see where the

01:34:52

renal artery comes from the abdominal aorta in a

01:34:55

typical place and the typical place is

01:34:59

immediately below the

01:35:01

artery of the terika superior Yes,

01:35:06

when we look for the pancreas we

01:35:08

always look and immediately below it the

01:35:11

renal arteries should come off. And if

01:35:13

the renal the artery does not originate there, but

01:35:17

more distally. It doesn’t matter where more distally in the

01:35:20

lumbar region or in the pelvic region, but in the pelvic region

01:35:22

this means no longer from the abdominal

01:35:24

aorta, but from the common iliac artery or

01:35:27

external iliac artery or

01:35:29

internal it happens differently,

01:35:31

then we are talking about dystopia, that is,

01:35:34

the basis in

01:35:36

order to call an abnormally located kidney

01:35:40

dystopic, the

01:35:45

basis for this is the visualization of the

01:35:49

renal artery in an atypical place,

01:35:52

which means it does not depart half a centimeter lower

01:35:55

than the

01:35:58

mesenteric artery by 5-7 cm or even from the

01:36:01

iliac artery, common external or

01:36:04

internal, that is, if it departs

01:36:07

from the iliac arteries we are talking about

01:36:09

pelvic dystopia if it extends from the

01:36:11

abdominal aorta just lower we are then

01:36:14

talking about lumbar dystopia yes that

01:36:17

is, this is a differential diagnosis between

01:36:19

dystopia and nephroptosis it is clear that dystopia

01:36:22

is always a born

01:36:25

situation and nephroptosis is an

01:36:28

acquired situation Yes quite

01:36:31

often associated with losing weight there

01:36:33

with weight loss due to illnesses and so

01:36:44

on Well, as for space-occupying

01:36:47

formations, this is the

01:36:49

next point,

01:36:54

too, and a very common situation is when we

01:36:57

say that the position of the

01:37:00

kidney, look at the clinostatic one,

01:37:18

this should be indicated, that is, as for

01:37:23

the position of the kidney, it often

01:37:27

differs like this lying and standing and then if it is

01:37:31

significantly different We will point out here

01:37:33

that this mobility is excessive or

01:37:37

pathological mobility of the kidney in this case it

01:37:39

will be in the case of pathological or or

01:37:49

excessively always and always not, dystopia

01:37:55

may be one, not necessarily both, it

01:38:00

is important that dystopia is always associated

01:38:03

with atypical origin of the

01:38:06

renal artery Uh-huh

Description:

Лекция для врачей курса первичной переподготовки по ультразвуковой диагностике в медицинском институте БФУ им. И.Канта (г. Калининград)

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How can I download an audio track (music) to MP3 "Ультразвуковая анатомия и эхосемиотика структурных изменений почек"?

The most convenient way is to use the UDL Client program, which supports converting video to MP3 format. In some cases, MP3 can also be downloaded through the UDL Helper extension.

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This feature is available in the UDL Helper extension. Make sure that "Show the video snapshot button" is checked in the settings. A camera icon should appear in the lower right corner of the player to the left of the "Settings" icon. When you click on it, the current frame from the video will be saved to your computer in JPEG format.

What's the price of all this stuff?

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