Diagnostic Ultrasound - Abdomen and Pelvis

Perigraft Fluid Collections
Diagnoses: Kidney Transplant
DIFFERENTIAL DIAGNOSIS
Ovarian Cysts
• Coexisting ovarian cysts may produce features
simulatinglymphoceles orhematomas, including
○ Functional cysts ±hemorrhage
○ Cystadenomas
○ Endometriomas
Renal Cyst
• Exophytic large renal cortical cyst may mimic PFC
Peritoneal Inclusion Cyst
• Also called peritoneal pseudocysts or inflammatory pelvic
cysts
• Variable appearance that can simulate hydro- or pyosalpinx,
paraovarian cysts, and malignant ovarian neoplasm
• Variable size; may be large, filling entire pelvis and
extending into abdomen
Penile Prosthesis Reservoir
• Diagnosis based on history and presence of tubing
Pseudomyxoma Peritonei
• Rare intraabdominal disease characterized by dissecting
gelatinous ascites and multifocal peritoneal deposits that
secrete mucin
• Originates from perforated appendiceal epithelial tumor,
which may be benign, borderline, or malignant
• Patients present with abdominal pain and distension
• Sonographically manifests as complex echogenic ascites
Tuberculous Peritonitis
• Associated with ascites that may be free or loculated,
anechoic, or contains fine fibrin strands
PATHOLOGY
General Features
• Etiology
○ Lymphoceles form when normal lymphatics are
disrupted during perivascular dissection or after
incomplete ligation of pelvic lymphatics
○ Urinomas result from urine leaks at ureterovesical
junction (UVJ) secondary to ischemia and necrosis of
distal ureter
○ Abscesses can be due to fungal or bacterial infection
○ Hematomas may develop from venous or arterial
bleeders, from surgical complications or bleeding
diathesis
• Associated abnormalities
○ Ureteral compression and hydronephrosis
○ Vascular compression with graft or leg edema or
ischemia
○ Compartment syndrome with graft dysfunction
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Lymphoceles: Majority asymptomatic
○ Urinomas: Pain, swelling, discharge from wound
○ Abscesses: Fever, abdominal pain, raised white cell count
○ Hematomas or seromas: Usually asymptomatic
• Other signs/symptoms
○ Lymphoceles: Palpable mass, leg pain, edema, impaired
renal function
Natural History & Prognosis
• Lymphoceles are usually slow growing, occurring within 1
year of transplantation
○ May recur after catheter drainage
○ Sclerotherapy after percutaneous aspiration and
drainage may reduce recurrence rate
• Urinomas require intervention
• Small hematomas and seromas resolve spontaneously
• Abscesses usually resolve following treatment
Treatment
• Most PFC are small and asymptomatic, require careful
observation only, and will resolve with single aspiration
• Aggressive treatment reserved for symptomatic PFC that
may result in allograft dysfunction
• Lymphoceles usually require no therapy unless
symptomatic
○ Noninfected: Open surgical drainage, percutaneous
aspiration ± sclerotherapy, and laparoscopic
marsupialization
○ Infected: Percutaneous drainage
• Urinomas: Short-term urinary diversion with nephrostomy
or ureteral stenting if small
○ Large, or those associated with complete disruption of
ureteroneocystostomy: Surgical reimplantation
○ Surgically not feasible: Long-term urinary diversion with
nephrostomy or ureteral stenting
• Abscesses: Percutaneous drainage followed by antibiotic
therapy
• Small hematomas and seromas usually require no therapy
○ Active bleeding requires surgery
DIAGNOSTIC CHECKLIST
Consider
• Definitive diagnosis established by needle aspiration
• Important to exclude obstructive uropathy
Image Interpretation Pearls
• Appearance, location, and occurrence of PFC after
transplantation are useful clues to diagnosis
SELECTED REFERENCES
1. Eufrásio P et al: Surgical complications in 2000 renal transplants. Transplant
Proc. 43(1):142-4, 2011
2. Irshad A et al: An overview of renal transplantation: current practice and use
of ultrasound. Semin Ultrasound CT MR. 30(4):298-314, 2009
3. Cosgrove DO et al: Renal transplants: what ultrasound can and cannot do.
Ultrasound Q. 24(2):77-87; quiz 141-2, 2008
4. Akbar SA et al: Complications of renal transplantation. Radiographics.
25(5):1335-56, 2005
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