Eduardo Kaiser Ururahy Nunes Fonseca

Avaliação ultrassonográfica da dor inguinoescrotal: uma revisão baseada em imagens para o ultrassonografista

: Emergencies involving the inguinal region and scrotum are common and can be caused by a plethora of different causes. In most cases, such conditions have nonspecific symptoms and are quite painful. Some inguinoscrotal conditions have high complication rates. Early and accurate diagnosis is therefore imperative. Ultrasound is the method of choice for the initial evaluation of this vast range of conditions, because it is a rapid, ionizing radiation-free, low-cost method. Despite the practicality and accuracy of the method, which make it ideal for use in emergency care, the examiner should be experienced and should be familiarized with the ultrasound findings of the most common inguinoscrotal diseases. On the basis of that knowledge, the examiner should also be able to make an accurate, direct, precise report, helping the emergency room physician make decisions regarding the proper (clinical or surgical) management of each case. Here, we review most of the inguinoscrotal conditions, focusing on the imaging findings and discussing the critical points for the appropriate characterization of each condition.Emergencies involving the inguinal region and scrotum are common and can be caused by a plethora of different causes. In most cases, such conditions have nonspecific symptoms and are quite painful. Some inguinoscrotal conditions have high complication rates. Early and accurate diagnosis is therefore imperative. Ultrasound is the method of choice for the initial evaluation of this vast range of conditions, because it is a rapid, ionizing radiation-free, low-cost method. Despite the practicality and accuracy of the method, which make it ideal for use in emergency care, the examiner should be experienced and should be familiarized with the ultrasound findings of the most common inguinoscrotal diseases. On the basis of that knowledge, the examiner should also be able to make an accurate, direct, precise report, helping the emergency room physician make decisions regarding the proper (clinical or surgical) management of each case. Here, we review most of the inguinoscrotal conditions, focusing on the imaging findings and discussing the critical points for the appropriate characterization of each condition.

Gut signature sign in enteric duplication cysts

Enteric duplication cysts, rare congenital anomalies that can appear at any point in the gastrointestinal tract, have a broad differential diagnosis. They are thought to result from an abnormal recanalization of the intestine during embryonic development, and more frequently affect the ileum [1, 2]. These cystic masses often are assessed by ultrasonography. Sonograms facilitate lesion characterization by depicting a parietal stratification pattern similar to that of the normal intestine—a characteristic appearance known as ‘‘gut signature.’’ It refers to a hyperechoic inner layer, representing the mucosa, surrounded by a hypoechoic external layer, representing the muscular layer (Figs. 1, 2) [1, 2]. Although the gut signature sign is considered relatively specific for enteric duplication cysts, these lesions do not always have this classic appearance. Cysts of other origin, such as ovarian, Meckel diverticulum, or mesenteric also can present a layered wall that could simulate this sign [1].

Lead pipe sign in ulcerative colitis

A particular imaging feature that helps in the differentiation between UC and CD is the pattern of bowel wall involvement: the first tends to be limited to the superficial layers in a continuous fashion, while the latter tends to present transmural involvement, interweaving healthy mucosa and inflamed areas [1]. Hypertrophy of muscularis mucosae secondary to continuous regeneration promotes loss of haustration and reduction of the usual colon caliber. Fat proliferation due to chronic inflammation also can contribute to this pattern of continuous colonic involvement [2]. Classically described on barium enema exams (Fig. 1) almost a century ago [3], this appearance of smooth, ahaustral contour was compared to a water or gas pipe (Figs. 1, 2), and later also applied to computed tomography enterography and Magnetic Resonance enterography (Figs. 3, 4). Despite its correlation with UC, the ‘‘Lead Pipe’’ can also be found in other forms of inflammatory bowel diseases, and even in CD. It occasionally accompanies infectious colitides such as tuberculosis and amebiasis, and can be a sign of cathartic colon. The lead pipe sign, while not is not disease-specific, provides an indicator of chronic colonic pathology [1–4].

The draped aorta sign of impending aortic aneurysm rupture

aneurysm rupture Eduardo Kaiser Ururahy Nunes Fonseca , Adham do Amaral e Castro, Amanda de Vasconcelos Chambi Tames, Eduardo Matarolo Jayme, Omir Antunes Paiva, Luis Ricardo Sokolowski Imaging Department, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, São Paulo 05652-901, Brazil Imaging Department, Hospital Municipal do M’boi Mirim Dr. Moysés Deutsch, Estrada do M’boi Mirim, 5203, São Paulo 05868-160, Brazil

Thickening of the greater auricular nerve in leprosy: clinical correlation by ultrasound

http://dx.doi.org/10.1590/0100-3984.2017.0001 Alinne Christina Alves Pires1, Diogo Costa Oliveira2, Marcelo Souto Nacif2, Marcelo Fontalvo Martin1, João Maurício Canavezi Indiani1 1. Unidade de Radiologia Clínica (URC), São José dos Campos, SP, Brazil. 2. Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil. Correspondence: Dra. Alinne Christina Alves Pires. Unidade de Radiologia Clínica. Rua Teopompo de Vasconcelos, 245, Vila Adyana. São José dos Campos, SP, Brazil, 12243-830. E-mail: alinnechrispires@gmail.com. which supply segments of the small bowel in the area of the hernia defect. In the case described here, MDCT revealed laterally insinuated loops clustered in the region of the mesocolic fossa, with no significant distension or injury of the jejunal loops. The addition of contrast could increase the diagnostic accuracy of the radiological examinations. Laparoscopic repair is a safe and effective method for the management of cases of Broesike hernia. However, because the patient described here was at prohibitive surgical risk, we opted for clinical monitoring. At this writing, the patient has been followed at our facility for over six months, without any worsening of her symptoms.

Overuse of the hip external rotators: greater trochanter apophysitis in the karate kid

Lucas Samuel Perinazzo Pauvels1, Felipe Welter Langer1, Daiane dos Santos1, Carlos Jesus Pereira Haygert1 1. Department of Radiology and Imaging Diagnosis, Universidade Federal de Santa Maria (UFSM), Santa Maria, RS, Brazil. Correspondence: Dr. Felipe Welter Langer. Universidade Federal de Santa Maria – Departamento de Radiologia e Diagnóstico por Imagem. Avenida Roraima, 1000, Camobi. Santa Maria, RS, Brazil, 97105-900. E-mail: felipewlanger@gmail.com. the presence of multiple accessory spleens and duplication of left-sided structures illustrate the polysplenia syndrome. Classical findings in HS include cardiac malpositioning, septal defects, bilateral bilobed or trilobed lungs, midline liver, intestinal malrotation, and abnormal spleen development. Intestinal malrotation can lead to gut volvulus and ischemia, whereas complete asplenia predisposes to bacterial infections and sepsis. Up to 75% of patients with polysplenia have significant cardiac malformations, namely endocardial cushion defects, double-outlet right ventricle, left heart obstruction, and anomalous venous return. The severity of congenital heart disease remains a main determinant of the long-term prognosis of HS patients—even after surgical repair of congenital heart disease, patients are prone to developing arrhythmias, thromboembolism due to right atrium enlargement, and progressive systolic dysfunction. In conclusion, HS is a complex syndrome that has remarkable phenotypic variability and is a challenge to manage. Patients with HS are prone to develop potentially life-threatening complications, which should be promptly diagnosed and managed. Therefore, imaging studies are critical in evaluating these patients, because they delineate the spectrum of possible cardiac and extracardiac involvement in HS and associated complications. REFERENCES

Correction to: ‘‘Bunch of grapes’’ in complete hydatidiform mole

The original version of this article contained a mistake in the co-author’s first name. The co-author name should read as “Mariana Athaniel Silva Rodrigues” instead of “Marina Athaniel Silva Rodrigues”. It is now corrected with this erratum.

Keyhole sign in posterior urethral valve

Posterior urethral valves refer to a male-only congenital abnormality characterized by a membrane in the posterior portion of urethra resulting from the fusion or prominence of plicae colliculi in the verumontanum region that can lead to varying degrees of urinary obstruction [1]. Ultrasound plays an important role in characterizing this condition, revealing a classic configuration known as the keyhole sign: dilatation of the bladder and hypertrophy of the walls producing a rounded shape, accompanied by dilation of the proximal portions of the urethra, creating a keyhole-like contour (Figs. 1, 2) [2]. This finding also can be seen with prenatal ultrasonography, though with variable accuracy [3]. A similar appearance can be identified by voiding cystogram studies, which would depict a thickened and dilated bladder, associated with a dilated proximal urethra and a normal distal urethra (Fig. 3).

Daughter cyst sign in ovarian cysts

Ovarian lesions account for most of the abdominal masses in female neonates [1]. Imaging plays a key role in its adequate characterization, as it allows the differentiation between cystic and solid lesions as well as may define its origin. The daughter cyst sign is a useful finding to properly characterize an abdominal cystic lesion as an ovarian cyst (Fig. 1). This classic sign was first described in 2000 [1], and has specificity and positive predictive value of 100% in the characterization of a lesion as of ovarian origin. The morphology of the daughter cyst sign could be compared to the conceptual illustration of tangent

The interface sign

Ascites and pleural effusions represent abnormal accumulations of fluid in the peritoneal and intrathoracic cavity, respectively and are common findings on chest and abdominal computed tomography (CT). These conditions sometimes share the same etiologies, sometimes even coexisting in the same patient. When they occur separately, their differentiation by CT images is not always straightforward, as free fluid tends to accumulate in posterior and lateral pleural recesses and around the liver and spleen in patients lying supine [1]. However, there are some classic CT findings that aid in correct characterization [1, 2]. One classic sign described for this differentiation is the interface sign: in ascites, there is a direct contact of the free peritoneal fluid with the liver and/or spleen, leading to a sharp interface between the fluid and these organs. In pleural effusion, however, both liver and spleen are separated from the fluid in the thorax by the diaphragmatic crus, generating an ill-defined interface. It is noteworthy, however, that although helpful, the interface sign should not be considered isolated, as it may sometimes be misleading [1, 2]. This sign was able to correctly classify 80% of these two fluid collections in its original series [2] (Figs. 1 and 2).