0:01

This case is a one day old infant

0:03

who had congenital heart disease.

0:05

Um, all of the patients in our population

0:08

who have congenital heart disease undergo screening,

0:11

renal ultrasound, looking for concomitant renal anomalies.

0:14

Um, multiple congenital anomalies often go together.

0:17

So, um, we started

0:19

with renal ultrasound looking at the right kidney.

0:22

So here's a normal looking right kidney.

0:25

Um, we see some normal right adrenal gland

0:28

above this normal looking right kidney.

0:31

Um, this patient, um, uh, does have a little bit

0:35

of a small size of the right kidney,

0:38

four centimeters about is normal renal length

0:41

for a term infant.

0:43

And then we come, um, over to the left side of the kidney

0:46

and we have what looks to be normal

0:49

left reinform shape of the left kidney.

0:52

Um, as we continue imaging, there is, uh, sort

0:56

of an unusual appearance of the left adrenal gland.

1:00

However, so unlike the right adrenal gland that had, um,

1:04

a nice thin appearance

1:05

and we could see that Oreo cookie kind

1:07

of trilaminar appearance of the left adrenal gland.

1:11

Um, this looks a little bit large

1:13

and has some, uh, architectural distortion of that, uh,

1:17

left adrenal gland, uh, left adrenal gland area.

1:20

So, um, the concern anytime you have an abnormality

1:24

of your adrenal gland is, um, in a newborn period,

1:27

is this hemorrhage, so adrenal hematoma

1:30

or is this congenital neuroblastoma,

1:32

which can happen congenitally

1:34

and will involve the adrenal gland.

1:36

So if you can tell if there's blood flow

1:39

to the adrenal gland, that can be helpful

1:41

for distinguishing solid mass, which would lead you toward,

1:44

um, congenital neuroblastoma.

1:47

If you can't delineate blood flow, it could just be

1:49

that the, um, it's like not a particularly vascular, uh,

1:54

neuroblastoma or it could be, um, adrenal hemorrhage.

1:58

So the right thing to do in this patient,

2:00

number one is call the clinician

2:02

and tell them that you have an incidental finding

2:04

of something going on in that left adrenal gland.

2:07

This patient's kidneys are normal, thankfully,

2:09

as is the urinary bladder.

2:11

Um, they can do two things.

2:13

Number one, they will check, uh, urine catecholamines

2:16

to see if they are elevated, which we would expect

2:19

to see in the setting of, uh,

2:21

congenital neuroblastoma is elevated

2:23

urine catecholamine levels.

2:25

Number two, we can just get a follow-up ultrasound

2:28

to see if this abnormal kind

2:30

of enlarged heterogeneous appearance

2:32

of this left adrenal gland resolve spontaneously.

2:35

Um, if it's hematoma

2:37

or uh, adrenal hemorrhage, we will expect that

2:40

to involute over time.

2:42

If it's neuroblastoma, we might see a similar appearance

2:45

or it could enlarge in size as the, if,

2:48

if it's a neuroblastoma that grows.

2:50

So, uh, we'll recommend at a minimum follow up ultrasound in

2:53

this patient with a left adrenal lesion.

2:56

So two weeks later, this patient presented

2:59

For follow-up, uh, ultrasound to make sure that

3:01

that left adrenal, uh, area improved in appearance.

3:05

Um, you can tell they had a difficult time, uh,

3:08

examining this patient because she, uh,

3:10

we are using only our sector transducer.

3:12

We are starting with Doppler assessment

3:14

of the renal vasculature

3:16

because this was a patient with congenital heart disease

3:18

and so there were other concerns to be answered on this.

3:21

Um, ultrasound study.

3:23

We have normal arterial waveforms

3:25

that we've obtained from our main hepatic artery.

3:28

Um, they're actually a little bit high resistance in

3:30

appearance, uh, which could just be related

3:32

to postprandial state.

3:34

Um, our portal vein has normal antegrade flow,

3:37

as does our left portal vein

3:39

and our left, uh,

3:40

hepatic artery have pretty normal waveforms.

3:43

We'll continue through our, uh, uh,

3:46

very bidirectional hepatic venous flow.

3:48

So again, this, this patient has congenital heart disease

3:51

and maybe has an, um, an intrinsic intracardiac shunt

3:56

as the etiology of these very bidirectional, um,

3:59

reversal flow in, uh, um, during the, a prominent a wave

4:03

of this, uh, left of these hepatic veins.

4:07

We have a patent inferior vena cva.

4:11

Uh, what we see of our liver looks like normal genicity

4:14

normal morphology.

4:16

Our gallbladder is completely collapsed in this infant,

4:19

so it's hard to tell what's going on.

4:21

Our right kidney has a continued normal morphology

4:24

with no abnormal urinary tract dilatation.

4:27

The renal vasculature are,

4:29

is patent at the hilum moving along.

4:32

There's a Foley catheter in the completely, um, uh,

4:35

decompressed urinary bladder.

4:38

So we, we can't tell much

4:40

to our clinical colleagues about the urinary bladder

4:42

besides it's decompressed, their Foley catheter is working.

4:46

So we have a normal, uh,

4:48

normal spleen in the left upper abdominal quadrant

4:52

and then we'll try to see if we can find that, uh,

4:54

left adrenal abnormality that we saw on the prior study.

4:58

So we see left upper pole kidney here.

5:00

We have a pretty normal looking left adrenal gland

5:03

above the left kidney.

5:04

Um, thankfully our stenographer has switched

5:07

to the linear high frequency transducer

5:09

so we can see better detail as opposed to

5:11

that prior sector transducer.

5:13

So continued normal looking left kidney.

5:15

Um, we still have some G globular, um, sort

5:19

of heterogeneous, um, hypo material in the region of

5:24

that left adrenal gland,

5:26

but we don't see any internal color doppler flow.

5:29

Certainly there has been no interval enlargement

5:32

of this left adrenal mass like area.

5:35

And so in the absence of elevated urine catecholamines,

5:38

this is almost certainly going to be a left adrenal hematoma

5:41

or left adrenal hemorrhage related to birth trauma,

5:44

especially in this patient with congenital heart disease

5:47

who maybe had a little bit more of a tumultuous, um,

5:50

birth experience than other patients.

5:52

But we'll continue to follow this, um, through

5:55

until the size that it becomes smaller

5:57

or calcified, um, outright in this infant with um, uh,

6:02

just normal, essentially normal birth related left adrenal

6:05

hemorrhage.