0:00

This is Pediatrics week 2 case number four

0:03

and the diagnosis were considering is duplex.

0:06

Kidney with ectopic your

0:09

read-a-roll insertion.

0:11

The image you see in front of you is the initial image of a

0:14

renal and bladder ultrasound beginning with an image

0:17

of the bladder and you can see not only is there

0:20

anechoic urine within this urinary bladder but a

0:23

structure here that is definitely not urine within the

0:26

urinary bladder. Could it be a hematoma? Could it

0:29

be a stone? It's not shadowing. Could it

0:32

be something else entirely? Let's progress through the

0:35

Study and try to understand what's going on. Here's some

0:38

more bladder images with this structure again. Here we

0:41

go in lateral or longitudinal position.

0:44

So Superior is here

0:47

and inferior down here.

0:50

We're looking again at the bladder. We're not really seeing any

0:53

other abnormalities in it, but we

0:56

are seeing this structure in on higher resolution view.

0:59

We're seeing not only is it echogenic but

1:02

it's centrally anechoic. It almost looks like

1:05

a cyst within the bladder the

1:08

cystic space assist within a cyst. What

1:11

could this be? Let's keep on looking through at our renal images.

1:14

Here's an longitudinal image

1:17

of the kidney. You can see some medullary pyramids here

1:20

and here that are slightly more hypochoic than

1:23

this more echogenic cortex of

1:26

the kidney at the lower pole the architecture

1:29

of the kidney. It's fairly reassuring at

1:32

the upper pole we have this

1:34

Vague hypoechoic area

1:37

what's going on there? Let's keep looking you can see we've measured

1:40

the upper and lower poles of the kidney to get a longitudinal length

1:43

of the kidney and here on the Doppler signal.

1:47

There's an interesting oblique separation between

1:50

the blood flow to these

1:53

areas of the lower pole of the kidney and the

1:56

blood flow to this upper area of the kidney. So this

1:59

is almost a separation between the two parts of the kidney.

2:03

These are trans views. I'm going to keep scrolling through. We're not

2:06

seeing a lot of hydronephrosis here on the

2:09

left. Kidney. We're seeing a very similar oblique

2:12

echogenic line separating the lower Pole

2:15

from the upper pole except in this case. The upper

2:18

pole is very distorted. The

2:21

architecture is almost gone and what looks like

2:24

a cyst remains and as we scroll through that

2:27

left kidney we can see just a further evidence of

2:30

blood flow to a relatively normal lower

2:33

pole and a very abnormal upper pole. And anytime

2:36

you see dramatic differences in what's going

2:39

on with the upper pole versus the lower pole of the kidney. You

2:42

should consider a duplex collecting system, which is in fact

2:45

what's going on here?

2:47

Probably bilateral duplex kidneys, but the left side

2:50

has some problems much more so than the

2:53

right side.

2:54

And it turns out that when there's a duplex collecting

2:57

system. There is a concern not just

3:00

for abnormal separation of

3:03

the drainage of the kidney usually duplication

3:06

of the ureters all the way down to the bladder, but that

3:09

upper pull ureter inserts ectopically.

3:12

So the normal insertion of

3:15

the ureters the ortho topic Ortho is

3:18

Latin for straight the orthotopic insertion.

3:22

Is where we expect it to be the ectopic insertion

3:25

tends to be medial and inferior and

3:28

is frequently Complicated by

3:31

a your reader seal right at the insertion on

3:34

the bladder which can look like a cyst within the bladder recall at

3:37

the very beginning of our study. That's exactly what we

3:40

were looking at. So now we're going to switch over and we're

3:43

going to look at a voiding system urethrogram a fluoroscopic Imaging

3:46

study of the urinary tract

3:49

to try to identify what's going on with these duplex

3:52

ureters. Is there obstruction. Why does

3:55

the upper pull of the kidney look cystic on that

3:58

ultrasound exam. So here we are with our florescopic Imaging

4:01

we're going to infuse contrast into the

4:04

bladder and then we're going to watch as the pressure

4:07

builds within the bladder to see what happens here. We've

4:10

got a nicely full bladder. Here's our fully catheter at the

4:13

midline. We see some Loops of bowel up here. No problem there.

4:16

We want to know what's going on with the ureters and

4:19

pretty quickly. We're starting to see reflux on

4:22

both.

4:22

the right and the left

4:25

Both of these have somewhat of a

4:28

drooping appearance. And this is the so-called

4:31

drooping Lily sign of duplicated collecting

4:34

systems where the lower ureter the normally

4:37

inserted ureter refluxes and

4:40

the ectopic ureter that goes up to that

4:43

upper pole. Remember how cystic it looked on the ultrasound that's obstructed.

4:46

That's what caused that your reader a

4:49

seal in the bladder and as we follow through and

4:52

look at these images of the refluxing contrast, we

4:55

can see one ureter and now we can actually see a

4:58

little bit into the second ureter as well. So both of those

5:01

ureters on the left are seen one of them is quite tortuous. That's

5:04

the lower pole there quite a bit of reflux. And

5:07

then we see this big cystic space. That's what's left

5:10

of the upper Pole.

5:12

And that is the obstructed and dysplastic left

5:15

upper kidney which ends

5:18

in an ectopic your reader a seal

5:21

on the bladder. So this is duplex collecting system.

5:24

Remember the upper pole obstructs the lower

5:27

Pole refluxes.

5:29

And the upper pole is the one that's more likely to become dysplastic because

5:32

of that obstruction because of the your reader

5:35

is sealed that's frequently associated with it. I'm just going to

5:38

scroll through to the end of the study here as we get down to

5:41

the final images. We can see contrast still refluxing

5:44

into that lower pole and upper pole on

5:47

the left and we can see the insertion of

5:50

one of the ureters.

5:52

And this vague structure within the

5:55

bladder a filling defect you might say that's the ureterocio from

5:58

the ectopic ureter.

6:00

That's the end of the case.