Beyond the Scan - Dr Maniruzzaman

27/05/2026

21/05/2026

🧠 Emphysematous Pyelonephritis
Sometimes the artifact tells the story.

👨‍⚕️ What I observed:
A middle-aged woman came with constant severe loin pain for the last few days, associated with high-grade fever.

🔍 The scan:

• Enlarged swollen right kidney
• Mild right-sided hydronephrosis due to periureteric inflammatory edema
• Multiple echogenic air foci within the right kidney casting dirty / ring-down artifact
• Fine floating internal debris within the urinary bladder

🧠 My insights:

The swollen edematous kidney immediately suggested severe infective pathology.

The key finding was the presence of multiple echogenic foci producing dirty posterior acoustic ring-down artifact.

Air within the renal parenchyma should never be mistaken for calculi.

There was no obstructing stone or mass along the visualized course of the ureter & surrounding periureteric inflammatory edema explained the mild hydronephrosis.

The constant severe pain, fever and toxic appearance did not fit simple renal colic..

✅ Impression:
Right-sided emphysematous pyelonephritis causing mild hydronephrosis.

📌 Takeaway:
Air bubbles within the kidney can mimic stones on ultrasound.
Recognizing dirty shadowing / ring-down artifact and correlating with the clinical picture is the key.

💬 Would you confidently differentiate air from stone on ultrasound at first glance?

— Beyond the Scan, into Clinical Thinking

17/05/2026

🧠 Case : Multifocal liver lesions…not metastasis!!

👨‍⚕️ What I observed:

A 55-year-old diabetic lady came with history of severe upper abdominal pain and high-grade fever a few weeks earlier.
She arrived with multiple previous imaging reports:
• One ultrasound suggested multiple hepatic lesions, likely secondary deposits
• CT upper abdomen reported CLD with multiple focal hepatic lesions possibly metastatic.
• Another ultrasound described coarse liver echotexture with multiple SOLs in both lobes
• Upper GI endoscopy was normal

No proper blood work was available to me initially.

She later returned after 3 weeks for follow-up ultrasound after undergoing core biopsy / aspiration from one hepatic lesion following my first report.

🔍 The scan:

• Multiple small to moderate-sized cystic lesions in both lobes of the liver
• Internal echogenic debris within the lesions
• Few lesions with tiny air bubbles
• Mild fatty change in liver
• Biliary sludge within gallbladder

🧠 My insights:

On the first visit though previous reports suggesting secondary lesions, the overall pattern kept pushing my thoughts toward multifocal liver absces as the lesions were predominantly cystic and avascular with internal debris and echogenic fluid contents and tiny air bubbles, alongside high-grade fever, severe abdominal pain.

On follow-up after 3 weeks, the lesions appeared partially resolving and a few evolved into antibioma formation.

The later FNA / biopsy findings supported my initial impression.

✅ Impression:
Multifocal hepatic abscesses in resolving stage with few antibiomas.

💬 Would you initially lean toward metastasis or infective etiology in this case

— Beyond the Scan, into Clinical Thinking

17/05/2026

🧠 Severe loin pain. Fever.
Any guess??

14/05/2026

🧠 Case: Trickier than It looked

👨‍⚕️ What I observed:

A middle-aged ill-looking man came with upper abdominal pain for the last few months.
The pain was not severe though he described an episode of moderate pain about a month earlier.
He had no history of fever.
Investigations showed mildly raised blood counts and previous imaging suggested a hepatic abscess.

🔍 The scan:

• A well-defined complex cystic lesion in the right lobe of the liver
• Posterior acoustic enhancement
• Intra-mural nodular wall thickening with almost no vascularity
• No visible septations
• Organized internal debris

🧠 My insights:

At first glance, the lesion shouted to be an abscess but not convincingly enough to silence the questions.

Why no fever?
Why no severe throbbing pain?

The avascular mural nodular structures immediately made me think of a retracted clot.
My initial differentials included:

👉 Hemorrhagic hepatic cyst
👉 Necrotic metastasis
👉 Biliary cystadenoma / cystadenocarcinoma

Necrotic metastases usually show at least some peripheral vascularity.
Cystadenoma and cystadenocarcinoma more commonly show internal septations and mural nodules in cystadenocarcinoma often demonstrate mild vascularity.
The mobile echogenic internal debris further favored hemorrhagic content.
The absence of septation made hemorrhagic hepatic cyst the leading impression in this case.

✅ Impression:
Solitary moderate-sized complex hepatic cyst, likely hemorrhagic in nature.

📌 Follow-up:

A few days later, the patient underwent USG-guided aspiration.
Approximately 75 ml of blood-mixed clear fluid was aspirated and sent for histopathology.
Reports are still pending.

💬 Would you lean toward hemorrhagic cyst first, or keep cystic neoplasm higher in the differential here?

— Beyond the Scan, into Clinical Thinking

11/05/2026

🧠 Case: Sometimes Budd-Chiari whispers before it shouts.

👨‍⚕️ What I observed:

A middle aged male came with severe abdominal distension.
He was a known case of chronic liver disease with previous history of EVL.
The patient appeared very restless and was in respiratory distress.

🔍 The scan:

• Shrunken cirrhotic liver with grossly coarse echotexture
• Irregular hepatic margins
• Gross ascites
• Prominent Spleen with dilated splenic vein
• Dilated portal vein with non-occlusive thrombus in the main portal vein
• IVC appeared patent

On careful focused venous assessment:

• Echogenic thrombus noted within few terminal branches of the right and middle hepatic veins
• Doppler confirmed absent flow within those involved branches

🧠 My insights:

Gross ascites with portal venous thrombosis in a cirrhotic patient always pushes me toward a more careful evaluation of the hepatic venous system.
The patient was extremely restless, making detailed venous assessment difficult.
At first glance the main hepatic veins and IVC appeared patent, but on careful focused scanning a few small terminal branches of the right and middle hepatic veins appeared echogenic.
Doppler confirmed the suspicion.
Sometimes Budd-Chiari syndrome does not begin with major venous occlusion-- sometimes the smaller branches whisper first.

✅ Impression:
Chronic liver disease with Budd-Chiari syndrome, associated non-occlusive portal venous thrombosis and gross ascites.

📌 Takeaway:
In cirrhotic patients with gross ascites and portal venous thrombosis, hepatic veins deserve meticulous evaluation -even when the major veins appear patent.

💬 Would you stop after seeing a patent IVC and major hepatic veins, or continue searching the smaller branches?

— Beyond the Scan, into Clinical Thinking

10/05/2026

🧠 Trickier than it looks… what would you call it?

Almost avascular complex hepatic lesion.
Mild pain. No fever.

💬 Drop your thoughts in the comments.

My insights will follow soon.

10/05/2026

🧠 Case : Suspicious findings, loud differentials — what would be your first impression?

👨‍⚕️ What I observed:

A 52-year-old healthy-looking patient with good body build came with mild upper abdominal discomfort.
No remarkable previous history. Blood work was largely unremarkable.

🔍 The scan:

• A small well-defined mildly irregular and heterogeneous hypoechoic lesion at the body of the pancreas
• Almost isovascularity on Doppler
• Main pancreatic duct not dilated
• No surrounding lymphadenopathy detected

🧠 My insights:

Pancreatic soft tissue lesions always deserve careful attention.
A focal hypoechoic pancreatic lesion with mildly irregular margin immediately raises concern for a neoplastic process.
Pancreatic adenocarcinoma crossed my mind first, as these lesions appeaed hypoechoic with irregular borders and show hypo / isovascularity on Doppler,
A neuroendocrine tumor also remained an important consideration However, neuroendocrine tumors are usually more well-circumscribed and often hypervascular and homogeneous at early stage.

I also considered focal inflammatory pathology or pancreatic adenoma, though adenomas are generally more encapsulated and tend to be hypervascular.

✅ Impression:
Small non-invasive pancreatic body mass — possibly malignant pancreatic growth, though benign neuroendocrine tumor remains a consideration.

💬 What would be your first differential in this case?

— Beyond the Scan, into Clinical Thinking

**Check the first comment for the video

10/05/2026

🧠 Case : A quiet ureter can still carry a stone.

👨‍⚕️ What I observed:

A young male came with a history of severe pain in the left lower abdomen radiating to the groin a few days back.
He arrived with a normal KUB X-ray and a previous normal ultrasound of the KUB region.
Patient complained of no further pain following that episode.

🔍 The scan:

• Two small calculi in the left lower ureter
• Left ureter and pelvicalyceal system not dilated
• Urinary bladder appeared normal
• Right kidney appeared normal

🧠 My insights:

A history of severe loin-to-groin pain immediately made me think of ureteric colic.
The normal KUB X-ray initially raised two possibilities in my mind:
👉 spontaneous stone expulsion
👉 or a radiolucent ureteric stone
Despite the absence of hydronephrosis or ureteric dilatation the clinical history kept pulling my attention back toward the ureter.

On careful focused scanning of the lower ureter, two small stones became visible.

Sometimes the pain resolves before the stone leaves.

✅ Impression:
Left-sided non-dilated lower ureteric calculi.

📌 Takeaway:

In cases of classic loin-to-groin pain, the ureter always deserves extra attention — even when there is no dilatation.

**Check the first comment for the video

💬 Would the absence of hydronephrosis make you less suspicious of ureteric stones in this case?

— Beyond the Scan, into Clinical Thinking