Ultrasound Spleen with Dr. Alka Singhal | Medality / MRI Online Radiology Course

Hello and welcome to noon conference hosted by modality. Noon conference connects the global radiology community through free live educational webinars that are accessible for all as an opportunity to learn alongside top radiologists from around the world. Today we are honored to welcome Dr. Ala Singal for a lecture entitled ultrasound spleen. Dr. Dr. Singal is an associate director of radiology at Madant Menic City Hospital Delhi NCR India and has over 28 years of experience in radiology. She's authored several publications and talks for leading national and international conferences and is the author of the Atlas of Parathyroid ultrasound. At the end of the lecture, please join her in a Q&A session where she will address questions you may have on today's topic. Please remember to use that Q&A feature to submit your questions so we can get to as many as we can before our time is up. With that we are ready to begin today's lecture. Dr. Singhol please take it from here. >> Thank you. And so today's ultrasound topic is ultrasound of the spleen. Now spleen is a very it's a very simple topic I think as we all would recall during ultrasound what do we do with the spleen evaluation? We simply see whether it's there or not and what's the size and if at all maybe is there any focal pathology but trust me paying a little more attention to it it's such a vital organ to do the scan and if we do it diligently we can actually evaluate the eeology of the spleenic enlargement and pathology and let's understand how so okay so it's often called the forgotten an organ of the abdominal scan. So we do a routine abdominal scan but okay as we do liver we focus so much of time attention for the liver gallbladder pancreas kidneys and all the other organs but spleen has not been given that much attention however recently so spleen elasttography and contrast ultrasound and routine evaluation is getting more and more important and especially our imaging technology has really improvised and the way we look at this Explain the amount of findings that we are able to observe. In cases of diffuse pathological changes and focal pathological changes both are immense. So more is visible to the eye more is being diagnosed on ultrasound. Let's see. So of course like for any other pathology any part of the body we will be uh evaluating under continal anomalies infections benign and neoplasm and other non-neoplastic and miscellaneous conditions right so [sighs and gasps] let's see to begin with of course anatomy defines everything so we say spleen is the largest organ of the lymphatic system of course sizes vary and the healthy adult spleen. So why we use the word is healthy and adult and spleen because the size varies with the population. So size varies with the age, size varies with the uh with the health of the patient. So it's a very important window to the direction in which the clinical uh diagnosis is there lie. Where is it located? As we all know it's located in the left highondrium. posterior to the spenic fracture in the stomach making an interior approach almost invariably unsuccessful due to an overlying bowel gas because the stomach is sitting right interior. So you do need to rotate the patient a bit in the cubitus position and scan from a little posterior approach and that way we see it nicely. A little breath hold is very helpful but not too much. That's we will understand why because then the plural gas also obscures it in the lung space. Now as we all know spleen is a very vascular organ and what's [clears throat] the blood supply? It receives a blood supply from the spleenic artery which is a branch of the cedi axis and the intrappleenic branches to north anastimos or communicate with one another. There is no intrplenic collateral flow. So what that practically means that in fact would be common in case of any blockage to any particular vessel that area of the spleen is rendered avascular and under goes infact. So without collateral flow the spleen is at an increased risk for infection that must always be remembered and especially we see a lot of where I work a lot of CLT patients with chronic liver disease and really enlarged spleen and that's a common cause of an intraabdominal emergency and pain and presentation as well and the spleenic vein the draining vein unites with the superior mentric vein posterior to the neck of the pancreas to form the hippatic portal vein And evaluation of the vascule is equally important to exclude any thrombus and any other aneurysm or any other pathology in the arterial venus vascule. Right? So like we discussed spleen is located in the left upper quadrant and it's readily examined in several positions. often you may need to really work around and we will also know uh a study in the flexibility or the mobility study that we will do for wandering spleen that we do need to rotate the patient. We need to put the patient in various positions to see if there is any change in the position of the spleen with the deicitus and and any shift in the position if there is any one brain splane and of course the transducer we use the routine 3.5 MHz transducer rarely for in children where very superficial any abnormality any focal pathology fungal infection when you really want to evaluate the detail the target appearance of lesion then we can go up if we can go up with a higher frequency transducer it's definitely gives us more clarity and more accuracy in the diagnosis right so that's about the transducer so approach like I said is the left lateral and costal is always the best in supine position and so the gas will bal is usually interior to the spleen and gentle respir respiration is frequently more successful than the deeper inspiration because otherwise the lung bases come downwards and obscure the spleen altogether. So you would have noticed beginners often find it challenging to find spleen because of the over inspiration at times. So the goal is to direct that unobstructed ultrasound beam between the lower intercostal spaces towards the spleen along its midaxis. So we can have the full cranio cordal measurement of the spleen from upper to the lower pole. So that's the probe placement and that's the image that you would be accordingly creating and that's very uh supportive in the accurate measurement. Right? [gasps] Now what does this bean parent normally look like? So as we all know it's like a homogeneous smooth diffused hypoquic eos right and the shape it's very nice smooth rounded outer margin and a nodular slightly nodular indulating inner margin and at times you may see accessory spleen as we will shortly evaluate. So also a difference between the spleen and the liver is that you may you need you need lesser TGC gain settings because uh the t uh the there's not much beam attenuation in the spleen as compared to the liver and uh that's an important tip to know and sometimes you of course you may have droardia and situs invertus. So the location of the spleen instead of being on the left side it may be on the other side. So of course how do you identify the liver is with the portal vein and the CBD inside but if you look at the spleen there wouldn't be any portal vein and CBD there would be just hilar vessels which are branching into the spleen parenchima and each of these is an end artery there are no inter collateral or anastasmosis between them. So to be able to differentiate between the liver and spleen is also a important task like not to misinterpret which organ are you looking at right of course. So so we will also whenever we need to do the doctor studies we look at the flow and diameters of the spleenic vein and document them. So just to orientation of the anatomy when we describe the lesion. So we have this is the outer surface as we can see here at the laser pointer. Okay. So that's the outer surface that's the inner surface or the medial surface of the hilum that's closely aparting the pancreatic tail. So many times a window to the pancreas the pancreatic tail can also be achieved through the spleen as a because that's a nice solid organ and the pancreatic tail is sitting there. Sometimes we can have pancreatitis where we may not have much changes in the head and the body but just in pathology in the tail region or any uh intra intra pancreatic accessory spleen or any other pathology. So using spleenic uh uh window to evaluate the pancreas is another great ultrasound skill that you can use. [snorts] Right. So of course you'll see the spleenic pain and you can see this the upper pole that's the lower pole and that's and that can also change depending upon how you've labeled your orientation in the ultrasound machine. So obviously you will have to remember that how you planned it all out but that's the nature most people use. So the vascule the Doppler we will always study. So oh it's like I said the spleen provides also an acoustic window to the upper port of the left kidney. the left adrenal and the tail of the pancreas. So to evaluate these organs also this is a very nice window to use. Okay. So of course we can also demonstrate the haler vessels. All right. [gasps] So the first and the foremost thing or maybe for most people the only thing that we do is screen is it there or not and what does it measure and is there any focal abnormality to let's put it simple way and then first we see the size and then we see the focal abnormality. Let's first come to the size. Of course, for the size, it definitely comes you have actually demonstrated the organ completely because if you only get part of the organ in your field of view and if you measure that you'll obviously not be documenting the full's complete size and that would not be an accurate estimation of the size of the spleen. So going back to my previous image. So, demonstration of a nice lower pole in the image. Demonstration of a nice upper pole in the image and then putting your calipers on. So, I could actually uh have a little wider sector width if that's possible or allow that before I can do my length measurement. Okay. So, just to remember that. So, demonstration of a nice upper and lower pole is very important when we proceed with the length measurement. Okay. So of course spleen size and shape are both variable like I discussed. So what is the length of the spleen which is the inferior the pole to the superior pole and usually below 12 cm is considered within normal limits but of course we have to look at the age body size of the patient. You can have a lean thin young female and you can have a large bodybuild patient. Of course, the spreading size would be different, right? Of course, the length is an adequate indicator for most purposes and provides a useful baseline for monitoring changes in disease status. So, routinely we only take one measurement but 7 cm in transverse or 12 cm in the length is a upper limit of the normal. Now the spleen as aging happens it it goes down the size it increases in the ch it is up in the childhood and then it goes smaller in the elderly the spleen enlarges downwards and medially. So sometimes in chronic liver disease especially so because the left lobe of liver is also gone under hypertrophy and the spleen is alo also enlarged cranial cordally. So you have to be and the ecotexture of the parent uh may have a resemblance. So be careful in observing which organ are you measuring. So of course spleen will grow downwards into and it pushes the left kidney into the pelvic often you will find that. So that's like a spleen which is nicely elongated. That's just the direction and that's the placement of the caliber. A nice demonstration of the dome of diaphragm is very helpful and it is very convincing that you have actually included the whole of the spleen there. Right? So that's when you see the hilum then that is the point which is confirming that you are if that's the three-dimensional volume of the organ that you are in the right plane to measure that because many times you see the spleen images which are not showing the hila vessels and a measurement for the longitudinal axis has been made that would not be correct. So you must show demonstrate the higher upper pole and lower pole and then you do the length measurement and that's the width measurement. You can do the depth and the width as well. Right? So that's the length measurement. That's again some certain examples. It's a case of chronic liver disease where we do see a lot of varices in the uh medial part of the spleen. Another approach which I don't adopt is what literature says you could use a panoramic view or extended field of view to measure the length of the spleen especially in cases of large spleen when you cannot accommodate or include it all in one frame. However, of course it there will be a lot of ri shadowing and it's technically a little challenging especially because you need breath holding and maneuvering of a transducer. But yes, perhaps that's another option to do it for those who are skilled with their MSK work and really love to do anoromic views. right now the spleen size especially because in children uh before 12 years of age so we we follow normograms the ch uh the percentiles like there are norm for the various ages that if it falls within the 3 to 97% of percentile that's the median splein velocity so this is a paper that has been published uh by uh by aims uh in India. So that's the which is pertaining to Indian population. So that we routinely follow to evaluate for the spleenic size as compared to the age the median size and then we uh give the dimension whether it's enlarged or not enlarged for a 5year-old, 6 year old, 7 year old and of course it's also got the sizes for the uh liver as well. Okay. Now, so like we discussed what are the causes for spleen omegaally. Now after we have seen the spleen size of course when we are evaluating any patient for an ultrasound scan we are usually going to be first looking at the clinical history as why did the patient come to us? What is the clinical presentation? So that will obviously give us an idea as to what are we looking at? Is there any slee? Is there any s uh chronic liver disease? Is there any renal disease? Is there any infection? Is there any gastroenterthritis? So that will give you as a cue the patient's running fever. Are we looking at biogenic infection or what are the causes? So the various conditions causing diffuse enlargement of the spleen including congestive hypoplastic inflammatory infection and filerative causes. So ultrasound will not be definite but you can still give a direction to the possible ethology of the diagnosis right so broadly four categories infection CD portal habitation or hematological disorders and neoplastic conditions so let's look at this in more detail okay so broadly like I said the categories are congestive causes as in liver cerosis codal hypertension and congestive cardiac failure. Infections which could be acute infections such as infectious monucleiosis. chronic such as millary tuberculosis uh inflammatory causes such as sarcoidosis and SLE and then neoplastic lymphoma is a very common cause leukemia and metastasis and of course myop proliferative disorders extra metal hemopois as it's happening in siri and storage diseases and many other cases which will also lead to spleenic enlargement what do we see so if it's Spleenomeally due to portal hypertension. Of course, we will see associated viruses, dilated spleenic vein, dilated spleen portal junction and maybe varises all over in the abdomen at the sitski sides in the ligamentum ties leal ligament ligamentum uh falsify ligament and vein and all the other areas. So also what happens in this the inferior margin is like a rounded it's not like a sharp one. descending below and medial to the left kidney viruses are seen associated changes of chronic liver disease would be seen in the liver maybe pathologies and so that you can see [sighs] right so we will look at more specific causes as we come here now what about the conal abnormalities of the speed let's look at the big broad heading because that we do come across in our everyday scanning and these often cause diagnostic dilemmas in unless proved otherwise. Let's put it that way. Simple. So what are these? Common ones are the accessory spleen also known as splitulus or a small spenic nodule. Common sites are the spleenic hilum and they could also be intraancriatic like especially within the pancreatic tail region. They could be in the other sides the less common sides anywhere in the mental. So intraancriotic accessory spleen could be there and then we could also have wandering spleen which is basically hyper mortality of the spleen. So we it's spleen uh is seen in uh beyond the left hypochondrium in the other areas in the abdomen and of course that can also enlarge that can undergo pathological changes and that is also liable to torsion and other pathologies as we shall see soon right so let's understand them each so accessory spleen of course arises from a failure of the embriionic spleen and arch to fused and then extreme lovation that separates spenic tissue is formed and this is very common. So 10 to 30% of individuals which is fairly common usually found around the tail of the around the spicilum or in the ligaments in the pancreatic tail or sometimes in the pancreatic parenime ultrasound you will see well circumscribed hypocoic homogeneous like same equexture as this be the best part is that's your reflection and the mirror upon usually 1 cm or less or so maybe but rarely seen more than 3 cm right so that is the characteristic and of course the common sites as I explained already are the uh highlighter region then you can have the tail of the pancreas and less often you can see them in the spinocolic ligament the greater momentum misentry anywhere in the pelvis as well right so uh the percentages commonly of course is 75% is spinic high and the rest the lesser lesser percentages at the other sides. How does it look like? Like we see. So in here we have a this is the normal spleen and that's the well definfined rounded hypercoid well circumscribed area. Echogenicity is quite matching that of the spleenic paraga that is the confirmatory that is the schematic diagram to show how an intraaran creatic accessory spleen would look like. So a welldefined hypocoic nodular lesion which is in the spleen. So it's not now the our commonest differential of course here would be a pancreatic mass a pancreatic primary pathology and definitely uh we would be doing a contrast CCD abdomen to prove it or a contrast ultrasound to prove it but on a gray scale a lesion that looks as similar ecoenist as of spenic parenta can be uh the spenic spelankulus is in the differential diagnosis. another case of a pancreatic uh intraarent pancreatic uh splankus that we can see here. So the why do we need to observe and document them because they also enlarge under the same circumstances which cause pedome and they were also hypertrophy in postpinctomy patients. So observing making a note of them and documenting health in differential diagnosis and giving explanation to find and seen on imaging. So we can use our Doppler and the circulation of the splankus derives from the main splenic artery and drains into the main splenic vein. So when you trace the blood supply that can help you in differentiation. And what is the importance? Importance is of course not to mistate them from lymph nodes, not to mistate them from an adrenal lesion and not to mistake them from a mass in the tail of pancreas. So conversely, so if it's a mass in the tail of pancreas and you mistake as a splankus, of course that's not going to be a good news. The left adrenal mass and you mistake it as spraining, that's also not good. And there's a lymph node enlargement in the abdomen that may be required in sampling. You cannot label that as plas. So these three differential diagnosis are very important and of course each has their own characteristic identification. Lymph nodes would have their high vascularity and hypocoic rounded appearance that you can identify. Adrenal nodule will have its either it's a lipo lipoid or hypocoic or some hetrogenous parenma or typically located at the upper pole. the shape and other pathology will give you a cue. Mass in the pal of the pancreas again you observe where the vascule and the feeding is coming to it. A splenulus will derive its vessel vasculature from the spleenic artery. So if you evaluate and patiently scan you may be able to demonstrate the connectivity and give a differential diagnosis. Next coming to wandering spleen. Now the name sounds very weird. Spleen is going on wandering or it's ectopic in location or where it is. So basically what this refers to when the spleen migrates from its normally fixed posterolateral location in the left upper abdomen to other areas in the abdomen. So condition can be both conidal and acquired. And why it happens? because there's there's a lack of normal anchoring by the gastrosplenic and the gastroenal ligaments. So ultrasound is a valuable modality to diagnose this and to evaluate its complications including if there is any torsion or impaction in that case right. So of course in torsion and infaction we will look at infaction which will come up in later and torsion you'll see always a twisted pedicle and loss of vascule or supply in the organ and you'll see demonstrate a twisted pedicle and a world cool sign right of a lot or something and in fact you'll see a veg shaped area hypervascular zone right uh watershed uh area. So in particular most important is like a realtime ultrasound helps test the spleenic hypermobility and the vascular cortical abnormalities right now. How do we test for spenic hypermobility? Let's see. So basically you have the patient in leftus. The spleen normally just stays there on the upper side. Right? But if the spleen gravitates to a dependent area on the right side of the abdomen or to the pelvis or to any other area that means there is not much anchorage with the gastrosplenic and the lead recommends right. So unlike in the static stem so what happens is you position the patient in the right decipitus observe the spleen physically migrating to the dependent positions within the abdomen. So this by this we can track the spleen's gravitational shift and its migratory nature and we can confirm if it's absent from its normal quadrant and it's freely moving. Right? So two things you will need to establish that it's actually left its quadrant and it is moving. Okay? Right? So this is a case where we see the spleen which is uh uh which is uh not a nice pointed rounded shape. It's like a flattened shape and it's enlarged and citrogenous and it's descending down and it's uh it presented with acute abdomen and there's torsion and eskeeia of the wand screen. So uh we have to evaluate the vascularity right treat uh diagnosis is confirmatory is by CCT abdomen and treatment is by spleenopaxi which is uh reposition the spleen and to prevent the portion and pre preserve its function. So that was about the cenital anomalies right. Moving on to the next a section of abnormalities that we see very commonly for which we are actually sought to evaluate as to what it is especially fungal infections we see very commonly not very commonly but we see in transplant recipients or imunompromised patients. Biogenic absesses in spleen are less frequently seen as compared to liver. we see more uh amic abapsis and uh other absesses but you can see them in the screen as well. Tubercular millary tuberculosis and tubercular absis again in endemic areas can be seen. Of course parasitic infection and hydrated cysts are very common in endemic areas and of course in Asia they are common right. So pyogenic absis like anywhere in the body you can see solitary and multiple variable thick sized or anoic hypericid cyst without any flow. Same for fungal infection you'll see small target shaped like nodules microapsises less than 1 cm usually tubercular are small meary nodules and parasitic hydrated cyst would have variable all stages depending upon what stage of the hydrated cyst you are looking at clear or with folding membranes undulating membranes floating sand or a calcified hydrated cyst right let's understand in details so what do we have here we have Bacterial infections we have spenic abscesses for bacterial infections we what are the common causes infectious spread is usually through the bloodstream 75% cases or through trauma or through spenic infaction. So a rendered avascular area is of course susceptible to infection right. So like we discussed uh it can be single or multiple. If we have poorly defined onto hypergoic or any cystic masses of course like an absess like a cyst the characteristic as we've discussed in ultrasound basis there's a posterior acoustic enhancement and of course we at times post intervention or otherwise you can see some air bubbles and shadowing as well. So basically a hetrogenous ragged margins hypercoic lesion with some peripheral vascularity that may be seen definitely aspiration and relieving the pressure definitely supports in the healing. You can have absesses with some septi and loilulation as well and aspiration release the fever symptomatology and escurative fungal infections usually are seen in immunompromised people. Again you see these hypoquic nodular areas. However, if you observe them closely they will each show a central echogenic dot as well. So that's what's we call a target appearance. like we see an echogenic area. So this is about the layering pattern. So fungal infections typically occur in imuninompromised people and with neutropenia and commonly caused by candida aspergillosis and cryptocus. Fungal infection appear as microapsis usually less than a cm and almost always less than 2 cm. Candida can show bull eye or wheel within a wheel pattern consisting of layers of necrosis, inflammation and fibrosis. Right? See here this we there are some absesses in the spleen uh in the liver as well along with multiple absesses in the spleen. So this is characteristic appearance is the target appearance. You can use a higher frequency transducer to demonstrate this classic picture. So that way you know that you're not looking at me nodules or any other sarcoidosis nodules or any other pathology. Coming to next tuberculosis. So microacterial spleenic involvement can develop in disseminated milary tuberculosis. Of course what do we see on ultrasound is multiple hypercodules absesses can form and of course there is spleenic enlargement associated with this. There would be liver enlargement. There would be multiple abdominal lymph nodes and you can haveitis you can have gerital tuberculosis and findings in various other parts of the body. So basically what you will see is hypercoic nodules in the sple and which are demonstrated both ultrasound and CT and associated other findings in this abdomen. Next you can also have sarcoidosis which is basically a diffused bleeding enlargement and again mentric lymph nodes FNA and other imaging is diagnostic. All right. So you can have illdefined nodules which often just show up. Right. Now coming to the more important area of hydrated cyst. Basically parasitic infections. Commonly we are concerned about hydrated cyst because hydrated sphenic hydrated liver hydrated is another one of the indications for liver transplant and we do keep on seeing them very frequently. So uh which shows that it's still communicable and it's uh it's still uh endemic in certain parts of the world and uh what we see on ultrasound of course it depends on the stage of the cyst and the associated complications. What you see is anoic fluid fil cyst and if you see any debris floating any any indulation in the internal membrane floating membranes any sand sometimes you can see very classic like you know picture appearances really really this is like a hydrated cyst you can see the cyst and you can see the floating indulating membranes with it again the floating indulating membranes that you can see you sometimes you can see classes the daughter's chicises and the sand and all the other appearances within. So all these are classic appearances and u of course these patients will require treatment uh to prevent uh the disease from spreading and localizing it. So other cysts that you can see which has just simple cyst to epidermoid spin cyst or any other simple cyst calcific or any other cyst you just have to document them and uh they may not be belonging to any specific infection or any other category but yes documentation is required and um rarely they may undergo secondary hemorrhage or infection and then you can have internal debris and thicker walls right and Other parasitic infection could be par gonmiais where again you can find hetrogenous solid h solid cystic hypooric areas. Again this diagnosis would be non-specific on ultrasound and it's predominantly a hystopathological diagnosis. Right? So along with that hydrocyst and other paracetic diseases would often be seen spread in the abdomen. Right? So you can see nodular pathol in other areas of the abdomen as well. Okay. Now coming to the neoplasms. So the benign neoplasms the commonly that we see him in tuma which we see and don't see kind of the simple common less than cm typical hypercoic nodules that we see which are incidental. Of course we see atypical heimomas where we are the lesion is uh appearing hypercoic and shows maybe some vascularity some features and of course the CT is required to confirm and exclude other pathologies and then we know it's a hema that's been labeled and then it's constantly coming to us for for a followup. We can see hematomas where we see homogeneous iso to hypercoic lesions which are hypervascular. We can see lympangoma. The classic appearance of lymphoma is the echogenic lines that we see in any part of the body multilocular cyst. And if there are any soft tissue nodules they may show some vascularity and let's see so the commonly the heimas is simple that we see commonly soft small soft tissue hypercoic areas similar to what we see in the liver and larger lesions may undergo may be seen like this. Again this is the lesion but of course triple phase CT the flow characteristics confirm the heava diagnosis hematas so rare it's basically an appearance of a sleen within a spleen what it says is it's malformed spiny tissue caused by post-traumatic scar nodular hyperplasia or hypoplastic nodules typically appears as a single well-defined homogeneous isoquic or hyperquic nodule mass or a mass on ultrasound. So the key finding is there is hypervascularity in it is which is reflected as a hypervascular pattern on ultrasound and it is confirmed on cross. Look at the intense enhancement and intense hypervascularity of the lesion. Right? So that's confirmatory. Now coming to the next the lymphopolerative disorders. Lymphoma of course is the most common malignant disease and approximately 3% of spleenic malignancies are lymphas. So what is lympantioma? So benign slow growing continal neoplasm seen in childhood. Basically you see a multilocular cystic lesion located in the subcapsular area of the spleen may contain intraocular intraocular ecoenic debris hyperquid septations and thin neural calcifications. Right? So that's the kind of classic appearance that you can see like a honeycomb or a sponge-like anyway spaces and of course size and followup is required. No treatment as such is given. So you can see them as multiloculated cystic mass and these can be big huge as well. Right. Coming to the next entity which is SA antiscent sclerosing angtoid nodular transformation. So basically it's a nonoplastic vascular lesion which shows multiple angic metal nodules interspersed with hyper strand. So ba uh you see vascularity in the nodule and of course you can only suggest a diagnosis confirmed by CT right. So a hypoic nodule the classic vascularity pattern is demonstrated either on a contrast ultrasound or on a contrast CCT abdomen. Coming to the next the malignant masses the lymphoma metastasis and angio saroma. So spenic lymphoma as we say is the one of the commonest malignancy diffuse infiltration you can just have spenic enlargement or you can have focal nodular pathology. Often you can see along with enlargement illdefined hyperacquic nodules throughout the parenma. You can also have focal nodular masses in the spleenic parenma. So, so you can have meary nodules. So, differentiation between milary tuberculosis again is clinical or hystopathological. Coming to the next clinic metastasis. Metastasis is uncommon, rare. However, lymphoma is common. And other malignancies that metastasize to spleen are melanoma, cancers of breast, ovary, colon, lung and prostate. So most metastasis occur as solitary or multiple nodules while approximately 50% are hypercoid. This varies according to the primary tumor and hypercoidic especially from melanoma and colon cancer mixed eco cystic and target appearances are also seen most of the metastases are avascular on color after ultrasound there isn't any vascularity that we are able to demonstrate on ultrasound right so and associated findings for malignancy you will see metastasis elsewhere in the body by the time you have metastasis So that kind of supports you in confirming the diagnosis or giving a hint to as to what you're looking at. So majority of the colon metastasis and others are hypercoidic. Coming to next angio saroma which is a primary uh non-hemopoic malignant neoplasm of the spleen develops from the endometrial lining of the blood vessels on the spleen. So it's seen as well defined hetrogenous solitary or multiple nodules of masses with hemorrhage or necrotic changes and spenomeally interusative cases. So you can demonstrated an increased blood flow in the solid component but not always right. So coming to the next the cystic lesions the cystic lesions they what develops in the spleen they could be just simple congenital cyst there could be some pseudo cyst and in fact that developed as an in fact to begin with but later can become necro and cystic so that could also look like cyst and then of course you can see gamma antibodies and piosis very commonly seen spinic in fact. Now what does it look like? The classic appearance is if the speed that's the outer surface you'll have the veg the base of the triangle is at over there and the triangular the aets is usually at the hilum right so that kind of an orientation if you find a W shapeology that really looks like a triangular with a base towards the capsule outer capsule of the spleen and vascular connectivity with the spelic kila that is quite quite suggestive of a in part right so underlying hemolytic anemia as inle and other pathologies cods and other things are predisposing liations ultrasound changes like whenever the in fact has happened it takes some time before the paranka alters for you to be able to appreciate the difference the in the uh and the line the watershed line right so you do see a wedge-shaped hyperquake area and a lack of flow and it can give a mass-like appearance, irregular mahogens or a not multilotular mortal appearance in that scenario diagnosis can be a dilemma right and chronic stages uh or long-term it shrinks ecoenity increases and there can be a fibrosis issues right so this is a case of spina that I just recently saw so you see that's the spleen and you see this This is the capsular lesion which is got the base over there and it's like uh reaching up to the hilum. So it's a classic in the central part of the spleen we have a wedshaped hypergoic hetrogenous area which is really characteristic of a spleenic impact. So again you can see there is a capsular contour that is dropping at the sight of the impact. So you can classically demonstrate that yes that is of [clears throat] course that's the spleen measurement that's been enlarged and that's the size of the inf 3 into 4 in 3 cm that's in the other orientation that we demonstrate. We attempt to demonstrate the blood vascularity. You see some flow outside but not within the area that you're talking about. So that kind of confirms the diagnosis, right? You can see. Okay. All right. So that was another case. That's a different case. Another case where we have in fact the whole of the lower pool area here. Gamma candy bodies. Commonly we see tiny ecoenic bright dots cedotic not as bright as it's seen in the image that's a very classic picture. So of course you can see in various uh situations of congestive hematomey cle cell disease hemolytic anemas lemadoma hemocromattosis blood transfusion and various other situations. So tiny dot-like calcifications that you can spot on spinic piliosis which is rare pathology and is characterized by cinosodal like dilotation formation of multiple cyst like cavities within the parenma so rarely seen in the liver common in the uh common in the liver less often seen in the spleen but that's what it looks like basically you have poorly defined hypergoic nodules again it we can only give differential diagnosis some calcified spin cy that you can see they these could be hydrated we don't know but we just document them the way we see in fact we've already discussed what are the causes that you can see we can see there's a band sign like the echogenic strand this hypergoic lines that we see in the impact tissue that is classic of in park so if you can identify that then you don't need to really think on the lines of an S you you know it that you're dealing with an impart see this kind of a white ecoenic line appearance that's that's the appearance of the uh coral snake right so you can identify the spenic in part coming to the last two topics little bit of spleen elastigraphy and contrast ultrasound so of course elastigraphy of the spleen is coming up more and more and uh of course uh more meta analysis is needed before we can actually understand that how much it can predict but yes it has a place in chronic liver disease in predicting the complications and um it is being uh done we doing a research work on the liver and spleen elasttoraphy together as a non-invasive tool to assess the complications of uh CLD uh including viruses and other parameters and correlating with lab parameters. So because the spleen is highly vascular, stiffness closely reflects changes in pressure throughout the abdomen. So what is the rule? Primarily of course diag spleen stiffness measurements are highly accurate and often outperform liver stiffness indirect measurements and they support in predicting isopial viruses. there support in monitoring the liver pipe process. So how do we do it? There are we can do it shear or we can do it as an RP tool as an absolute velocity measurement. So and we can give the measurement in kpa the kilopascal or in meters/ second. And of course beans uh stiffness values are higher um in cerosis and total hypertension compared to normal population. So what it says is that of course it's an operator dependent modality and of course reproducibility is a question at the moment. However, it is a promising tool and uh it may it may add value to the esophagoscopy and screening modality for detecting the size and the presence of esophasial viruses. Coming to contrast ultrasound, we do a lot of work on liver liver contrast ultrasound. However, screen contrast of course uh is usually honestly uh sought when there is an impaired renal function and we do not want to give a uh CT contrast. So we can use ultrasound contrast as another uh diagnostic tool to evaluate any focal nodular pathology of which we want to assert in the pattern. The pattern is the same as evaluating a focal lesion for the liver and the enhancement pattern for any infectious biogenic absis would be peripheral enhancement for any cysts simple cyst they do not enhance for any uh melant nodules they hyper uh they show rapid enhancement and rapid wash out. So with that uh background understanding we try and use the CUS for lesion characterization. Benign lesions typically show enhancements similar uh to the normal spenic tissue hypoenhancement uh is seen with them. Trauma is a very important role for this. So you see um uh you can identify lacerations and subcapsular hematomas and active bleeding right at the bedside in unstable patients when you can't do a CT. So there is a great role of CUS in trauma infactions there is a great role in predicting and of course in benign lesion excluding benign lesions and leaving them the way they are. So heas and hematimas we can see uh this just a summary of the key points of course which we've already covered and what I wanted to cover now is the spleen trauma injuries are common uh from sports and various other factors you instantly the patient is first sent for a vast scan so you see fresh blood and absence of free fluid however does not rule out any spenic injury and we have to evaluate the spenic texture any laceration or hypergoic regions presenting hematoma may be present. So laceration is basically a tear and rupture is rupture of the capsule and hematoma is just a hematoma for a peric capsular hematoma. So of course there are five grades by the American classification. So grade one is a small subcapsular hematoma, grade two, grade three and grade four. We'll come to that. So various causes are uh most common is of course trauma but a predisposing condition of enlarged spleen due to various causes is really increases the vulnerability uh to rupture. So basically what do we see on ultrasound you can see there is some altered eco texture it's not smooth. So why is that happening? That is because of an edematous tissue and there could be subcapsular hematoma lacerations with branching stellate appearance like liberally shattered or a torn organ hemoperonium fluid with eos that you see now the American association of surgery of trauma has created this devices system which uh we will just learn and laceration is a tear and rupture is a bursting of the organs's outer capsules. So that's what's a laceration. It's just a sheer tear in it. And rupture is like a rupture of the capsule at a focal point. Right? So what is grade one? Subcapsular hematoma less than 10% surface area or less ration less than a cm. Grade two is 10 to 50 cm% of surface area hematoma or hematoma less than one or less ration less than 1 to three. Then grade three these are the ones which are three four and five often requires celctomy where is there is an intraarent primal hematoma more than 5 cm or more than 50% surface area has hematoma and of course grade four and five have got injury to the vascular picle or there's sheer multiple ruptures of so here what it looks on ultrasound you see a lesseration here you see a lesseration and you see that that's what you see on color At rupture you see there's a sh there's a te like a stellate like a star kind of an appearance the capsules irregular margins that you can see we can do contrast a word so you can indicate it in various studies you can see lesions that don't enhance or that's the normal enhancement that you see arterial and in the venus phase there's a arterial phase you'll see the early arterial vascular enhancement and then in the venus the space there's a homogeneous diffuse enhancement of the organ. So that's just how piogenic absis is presenting on a contrast ultrasound. So it's enhancing on the rim and there's no central enhancement. So we are wanting to exclude if it's a malignancy or a metastasis but that's not what it is. So it's just a uh pyogenic absis. So to conclude remember the pitfalls of course. So like I talked about the left lo of liver like I talked about the introspic masses like I talked about the spinuli like I talked about the normal tail of the pancreas and a left adrenal mass. So remember these do not mistake them for vice versa. And really I thank you. I really really thank you all for your presence for all your attention for all the learning for creating this great space. Thank you MRI online. I'm really really grateful to all of you. Thank you. Thank you so much for that lecture Dr. Singhal. That was great. We don't have any questions in the Q&A box yet, but I can wait for one minute to see if something comes in. >> Sometimes it takes a second. >> Hope you all like it and get some value out of the session. The out would be great. And yeah, do put in your comments. So I do see some appreciations. Thank you for the great talk and insightful session. Thank you so much. That is wonderful. And yeah, okay you thank you for your presence and listening. Uh there's one thing how large can be piosis? I haven't personally seen but the literature uh would say probably I would say 3 to 5 cm that would be my my guess. I haven't seen large leations as such. Thank you and yeah thank you for your question. So next is when do you cause pleenomeally? I call like especially if it's a child uh depending on what age it is I follow the I follow the pediatric uh paper that I talked about uh sent out by as all India institute of medical sciences that's that's what most people here use for our Indian population uh that's the median percentiles that we use so we call it more than 12 cm because because otherwise in a normal healthy adult, we don't normally see uh 12 plus or 13. There's usually some chronic inflammation or something to match up to. 14 is not more than 14. I would call it more than 12. [clears throat] So yeah that would be my answer to the question that you put in the chat by Annabel and yeah so please share us your experience on biopsy or efficacy of spicy lesions. So rarely is it sought as a diagnostic dilemma to solve? Why would you biopsy a knee lesion when you can't treat when you really need a sample to treat the pathology or you can't get a diagnosis. So example if you have fungal infections multiple fungal absesses so you may require a samples to if you want to tailor match the antibiotic and if you have a like a say hydrated you wouldn't put a needle in if you are thinking of any uh malignancies or uh there would be a systematic systematic uh presentation that will hint you to the diagnos nosis much before you really need to put a needle in uh in spleen for a sampling and of course do remember spleen is a highly vascular organ. So FNA of a spleen is less frequently done and it's less frequently required per se. I would say put put through we can always sample if it's required. Uh says normaly in adults is 12 to 14. Yeah because 12 to 14 it's written because sometimes if you if I have a very large built patient so I may give it a consideration like I said. So for a normal a median or a lower median build I usually take it as 12 but if I have a really large body habitus I would let go 14 up to 14 also as normal. So again I think that's where the differences come to because spleen size is really age and body h and you know the distribution of the population and the BMI index. It's a lot factors to be accountable for. Uh so question is can it be smaller than normal? Can a normal spleen not be visible due to gaps? uh question of course uh spleen can be smaller in elderly population spleens that I you would see in lean thin small build 70 year old 80 year old you might just find barely a 5 cm or a 4 cm kind of a spleen. So that is very normal finding and can a normal spleen not be visible due to gas? Yes, of course, it can be obscured by balgases. That's why I really paid attention on the scanning technique for that. So, do not over inspirate and hold uh just a light breathe to just push the diaphragm a little bit low so you can see it but not push the lung too low so that it itself secures the spleenic window. So that's the intention. So if you remember that it will make it simple. Question for purposes of annual checkup med life age person if length is 12 cm you sign out as normal size. If length is 12 up to 12 I wouldn't uh I wouldn't quote it as abnormal. So normal uh if it's more than 12 even if it's 12.5 I'll call it as borderline spleen. And of course if it's more than 13 I would label it as spin vigory. This is how I use in my everyday practice. Thank you. So next is thank you Dr. Single. Is it possible to detect spenic artery dilotation calcification abnormality before the hilosone? Yes of course the vessels are there. So that that is actually a part of chronic liver disease doppler. So then we do evaluate the vessels very well. So we have to take the vessels right from the spicilum. Uh the doppler evaluation for CLT starts to evaluate the artery and the vein from spenic highum to the SPJ then the porta and you evaluate the hippatic artery and the portal vein and all that cell. So that's the hippatilary dropler. So it includes the spleen at the far end and the vascule and then the SPJ and you go into the liver and the branching and the hypatic veins and portal vein and the hypatic artery. So yes of course you can evaluate that. There are some more questions in the chat. So question is yeah I think a lot of gas that we've covered and we'll check up. Yeah I think we have covered the questions both in the chat and in the Q&A. Yes. Thank you. >> Thank you so much. Yes, you got everything. I appreciate you staying on for a couple minutes and getting those. Thank you so much for your lecture, Dr. Single. We always love having you here. And yes, thank you for everyone for participating in this new conferences conference and asking such great questions. You can access a recording of today's conference and all our previous noon conferences by creating a free account. We will also email out a link to the replay later today. Be sure to join us next week on Thursday, July 16th at 12 p.m. Eastern where Dr. Omar Neimar will deliver a lecture entitled benign and malignant breast calcifications. You can register for that at medality.com and follow us on social media for updates on future new conferences. Thanks again for learning with us and have a great day.