Definition — Liver Calcification (Hepatic Calcification):
Deposition of calcium salts within the hepatic parenchyma or within focal hepatic lesions. Calcifications may be dystrophic (in necrotic or treated tumours), granulomatous (healed infection), parasitic, vascular, or related to prior surgery/trauma. Sonographically calcifications appear as brightly echogenic foci; large calcifications cast posterior acoustic shadowing while tiny microcalcifications may create comet-tail or reverberation artifacts.
Sonographic features — Liver Calcification:
Appearance: Bright echogenic foci within the liver parenchyma or within lesions. Dense calcifications produce strong posterior acoustic shadowing; microcalcifications may cause comet-tail/reverberation artifacts.
Location & distribution: Solitary or multiple; segmental, lobar or diffuse distribution. Note relation to bile ducts, vessels, prior surgical sites or focal lesions.
Associated lesion: Calcification within a mass may indicate dystrophic change (treated or necrotic tumour), healed abscess, hydatid cyst (inactive), or calcified metastasis (eg mucinous primaries).
Doppler: Calcified foci are avascular; assess surrounding tissue for increased vascularity which may indicate active inflammation or viable tumour.
Acoustic shadowing vs enhancement: Dense calcifications cast shadowing; biliary or gas artifacts may mimic shadowing — correlate with patient history and other imaging.
Comet-tail/reverberation: Typical of small intraparenchymal calcifications or biliary microstones and helpful to distinguish from surgical clips or gas.
Mimics: Surgical clips, gallstones in an intrahepatic duct, phleboliths, gas — cross-check prior imaging (CT/X-ray) to confirm true calcification.
Clinical relevance: Calcification usually indicates chronicity/healing. New calcification within a lesion requires further characterisation to exclude treated tumour vs progressing disease.
Reporting tips: Document number, size, segmental location (Couinaud), presence/absence of posterior shadowing, relation to adjacent structures, and comparison with prior imaging.
Case Study — 1: Hepatic Calcification/Solitary Calcified Granuloma:
48-year-old female with intermittent right upper quadrant discomfort. No fever. History of prior pulmonary tuberculosis.
Ultrasound:
Single 10–12 mm intensely echogenic focus in segment IV with posterior acoustic shadowing; no surrounding hypoechoic halo, no internal vascularity.
Interpretation:
Appearance most consistent with a healed calcified granuloma. Recommend correlation with prior chest imaging and clinical history; no evidence of active infection or viable tumour on ultrasound.
Ultrasound Report — Line
Liver shows a solitary 12.22 mm echogenic focus in segment IV with strong posterior acoustic shadowing — appearance consistent with hepatic calcification/old granuloma. No adjacent mass or intra-lesional vascularity identified. Background liver echotexture within normal limits. Recommend correlation with prior CT or radiographs to confirm chronicity.
Conclusion
Focal hepatic calcification in segment IV, most likely a healed granuloma. No sonographic evidence of active abscess or viable tumour.
Recommendation
Correlate with prior imaging (non-contrast or contrast CT) to confirm calcific density and chronicity.
If calcification is new or associated with a mass, obtain contrast-enhanced CT for full characterisation.
If infection suspected clinically (fever, raised inflammatory markers), consider CT and clinical management; aspiration only if abscess suspected and accessible.
Right kidney shows A tiny echogenic foci in the mid calyx , consistent with microlithiasis. No significant hydronephrosis noted.
Left kidney demonstrates a single echogenic calculus measuring ~3.7 mm in the mid calyx with posterior acoustic shadowing and twinkle artifact on Doppler. No associated hydronephrosis observed.
Most hepatic calcifications are asymptomatic and incidental findings.
If due to active abscess — RUQ pain, fever, leukocytosis and raised CRP.
Mass effect symptoms only when associated with large lesion.
Diagnostic Strategy
Identify echogenic focus and characterise artifact (shadowing vs comet-tail).
Use Doppler to confirm lack of internal vascularity.
Compare with prior imaging (CT or radiographs) — CT is gold standard to confirm mineral density.
If infection suspected, correlate with labs (CBC, CRP) and treat/aspirate as indicated.
Risk Factors
History of granulomatous disease or endemic infections.
Prior hepatic abscess, parasitic disease, or liver trauma.
Prior hepatic tumour treatment (ablation, chemo) leading to dystrophic calcification.
Metastatic disease from calcifying primaries (less common).
Declaration:
I, R. K. Mouj, declare that the material presented in this document titled "Liver Calcification — Sonographic Guide" has been prepared for educational purposes. Patient data should be anonymised and clinical correlation is required.
Author: ____________________ Name: R. K. Mouj [Radio-imaging Technologist] Supervisor / Guide: Department radiologist Department: Radiology Institution: ____________________ Date: 25-09-2025
"Every cyst tells a story — knowing the benign from the sinister is the art of ultrasound."
Gall bladder sonography — Table of Contents (Topic-wise)
Contents (Topic-wise)
Agenesis of Gallbladder
Gallbladder not visualized despite adequate scanning and patient repositioning; normal biliary tree — features consistent with gallbladder agenesis. Conclusion: Gallbladder agenesis suspected — correlate with MRCP if clinically indicated. Recommendation: Clinical correlation and/or cross-sectional imaging (MRCP) to confirm agenesis and assess biliary anatomy.
Definition — Hepatic Simple Cyst:
A benign, developmental, non-parasitic cystic lesion of the liver lined by cuboidal epithelium, usually containing clear serous fluid. Sonographically, it appears as a well-defined, anechoic lesion with thin, imperceptible walls, posterior acoustic enhancement, and without internal septations, solid components, or vascularity. Typically asymptomatic and incidentally detected, but large cysts may cause mass effect symptoms. Differentiation from hydatid cyst or cystic neoplasm is important in relevant clinical contexts.
Sonographic features — Hepatic Simple Cyst:
Size & shape: Usually round or ovoid, variable in size (few mm to several cm), with smooth and well-defined margins.
Wall characteristics: Thin, imperceptible wall without irregularity, calcification, or nodularity.
Internal contents: Anechoic (completely echo-free) fluid content without septations or internal echoes.
Vascularity: No internal vascularity on color Doppler imaging.
Distribution: May occur singly or as multiple simple cysts; usually asymptomatic and found incidentally.
Case Study — 1: Hepatic Simple Cyst:
Mrs. S., 54 years old, female, presented for routine health check-up with nonspecific abdominal bloating. She had no history of jaundice, fever, weight loss, or liver disease. No history of alcohol intake or prior abdominal surgery. No relevant family history.
Clinical Examination:
Patient afebrile, no pallor or icterus. Abdomen soft, non-tender, no palpable hepatomegaly, no ascites. No stigmata of chronic liver disease. General and systemic examination unremarkable.
Laboratory Findings:
CBC: Hb 12.8 g/dL, WBC 6,400/µL, Platelets 220,000/µL.
LFT: Bilirubin 0.8 mg/dL, AST 28 U/L, ALT 32 U/L, ALP 86 U/L, Albumin 4.2 g/dL.
INR 1.0. Serum AFP within normal limits. Viral markers (HBsAg, anti-HCV) negative.
Ultrasound Examination:
Transabdominal ultrasound performed using 3.5–5 MHz convex probe.
A well-defined anechoic round cyst in the right hepatic lobe (segment V/VII) measuring 67 x 46 mm.
Imperceptible thin wall, no septations or mural nodules.
Prominent posterior acoustic enhancement.
No internal vascularity on color Doppler.
Ultrasound Report — Hepatic Simple Cyst:
A solitary, well-circumscribed, thin-walled anechoic lesion with posterior acoustic enhancement, measuring 67 x 46 mm in the righ hepatic lobe, without septations, solid component, or vascularity. No intrahepatic biliary dilatation or additional focal hepatic lesion seen. Findings consistent with a Hepatic Simple Cyst.
Conclusion:
Benign hepatic simple cyst. No features to suggest parasitic, neoplastic, or complicated cyst.
Recommendation:
No active intervention required. Symptomatic management if bloating persists. Follow-up ultrasound only if lesion enlarges or symptoms develop.
Causes / Etiology — Hepatic Simple Cyst:
Congenital biliary microhamartomas with cystic dilatation.
Embryological maldevelopment of intrahepatic bile ducts.
Non-parasitic, non-neoplastic origin.
Symptoms / Clinical Features — Hepatic Simple Cyst:
Most are asymptomatic and discovered incidentally.
Large cysts may cause abdominal fullness, discomfort, or early satiety.
Rarely, pain due to cyst hemorrhage, rupture, or infection.
Diagnostic Strategy — Hepatic Simple Cyst:
Ultrasound: Anechoic, thin-walled, well-defined, posterior enhancement, no septa or nodules.
CT/MRI: Simple fluid attenuation/signal, no enhancement.
Differentiation: Important to exclude hydatid cyst, cystic neoplasm, or abscess in symptomatic or atypical cases.
Declaration:
I, R. K. Mouj, hereby declare that the material presented in this document titled "Hepatic Simple Cyst: Definition, Sonographic Features, Case Studies, and Risk Assessment" has been prepared and compiled by me for educational purposes only. It is intended for learning, training, and academic reference. Sources and references have been acknowledged where appropriate.
Ethics / Patient Data Statement: Any patient images, case material, or ultrasound examples included here are for academic use only, anonymised, and used with ethical consideration.
Author: ____________________ Name: R. K. Mouj [Radio-imaging Technologist] Supervisor / Guide: Department radiologist Department: Radiology Institution: ____________________ Date: 16-09-2025
"Every cyst tells a story — knowing the benign from the sinister is the art of ultrasound."
Bilingual Quiz - Hepatic Simple Cyst Sonography
Note: Select English to answer in English, या हिंदी चुनें तो प्रश्नों के उत्तर हिंदी में दीजिए।
Definition — Massive Hepatocellular Carcinoma (Massive HCC):
A large primary malignant hepatic neoplasm occupying a substantial portion of one hepatic lobe (or the whole liver) and commonly >5 cm in diameter, often showing heterogeneous echotexture, central necrosis or cystic change, irregular margins, arterialised internal vascularity on Doppler, and may be associated with portal or hepatic vein invasion or satellite nodules. Correlate with serum AFP and cross-sectional multiphasic imaging.
Sonographic features — Massive HCC:
Size & shape: Typically a large (>50 mm, often many cm) solitary mass with irregular, lobulated margins. May produce palpable hepatomegaly and distortion of hepatic contour.
Echotexture: Heterogeneous echotexture is common — mixed hypoechoic and hyperechoic areas due to viable tumour, necrosis, haemorrhage or fatty change. Central cystic/necrotic zones may be present producing complex internal echoes.
Internal architecture: Thick internal septations, mural nodularity or solid mural components; layering of blood products may produce fluid-fluid levels in subacute haemorrhage.
Capsule / pseudocapsule: A peripheral hypoechoic or echogenic rim (pseudocapsule) may be seen; capsule retraction suggests scarring or treated lesion.
Vascularity (Colour/Power Doppler): Prominent internal arterialised flow and chaotic intralesional vessels are typical — early arterial phase supply and lower-resistance waveform on spectral Doppler. Presence of internal flow helps differentiate solid tumour from simple cyst or avascular collection.
Vascular invasion: Contiguous echogenic or hypoechoic filling defect in the portal or hepatic vein with internal vascularity (on colour Doppler) suggests tumour thrombus rather than bland thrombus. Look for loss of normal venous flow and expansion of the vessel calibre.
Contrast-enhanced ultrasound (CEUS) patterns: Typical HCC enhancement pattern on CEUS — arterial phase hyperenhancement (rapid wash-in) followed by washout in the late portal/late phases (timing and degree of washout correlate with lesion grade). CEUS is useful when CT/MRI contraindicated or to characterise indeterminate lesions on B-mode US.
Elastography: Focal area of increased stiffness compared with surrounding parenchyma; elastography adds supportive information but is not diagnostic on its own.
Associated findings: Background cirrhosis (coarse, nodular liver), splenomegaly, portal hypertension, ascites. Satellite nodules or multifocal lesions may be present.
Complications visible on US: Tumour rupture with hemoperitoneum (free fluid with internal echoes), biliary obstruction if centrally located, and spontaneous intralesional haemorrhage producing echogenic clot/heterogeneous areas.
Size progression / growth pattern: Rapid increase in size over serial exams, new vascularity or new satellite nodules suggests aggressive behavior — compare with prior imaging where available.
Common pitfalls / mimics: Abscess (systemic sepsis, peripheral hyperemia, gas artifacts), necrotic metastasis (clinical history of other primary), focal nodular hyperplasia (FNH) or haemangioma (typical Doppler/CEUS features differ). Use clinical correlation, AFP and cross-sectional multiphasic CT/MRI to resolve uncertainty.
Practical reporting tips: Always record lesion segment (Couinaud segment), maximal three-dimensional size (AP × transverse × craniocaudal in mm), number of lesions, relation to major vessels, presence/absence of portal/hepatic vein thrombus, ascites, background liver appearance and comparison with prior studies.
Case Study — 1: Single Massive HCC:
Mr. R., 61 years old, male, known chronic hepatitis B carrier with compensated cirrhosis, presented with progressive right upper quadrant pain, abdominal fullness, and early satiety for the past 6 weeks. He reported unintentional weight loss of 8 kg and intermittent low-grade fever without rigors. No history of alcohol intake in the last 10 years. No prior liver surgery or oncological treatment.
Clinical Examination:
Patient afebrile (37.9 °C), mildly icteric. Abdomen distended with a firm, irregular hepatomegaly palpable 8 cm below the right costal margin, tender to deep palpation. No clinically detectable ascites. No splenomegaly. No stigmata of advanced portal hypertension. Performance status ECOG-1.
Laboratory Findings:
CBC: Hb 11.2 g/dL, WBC 7,800/µL, Platelets 128,000/µL.
LFT: Bilirubin 2.1 mg/dL, AST 98 U/L, ALT 82 U/L, ALP 310 U/L, Albumin 3.0 g/dL.
INR 1.4. Serum AFP markedly elevated at 2,450 ng/mL.
HBsAg positive, anti-HCV negative. Renal function normal.
Ultrasound Examination:
Transabdominal ultrasound performed with a 3.5–5 MHz convex probe.
Right lobe shows a large heterogeneous hypoechoic mass in segments V–VIII. with lobulated margins and central necrosis.
Colour Doppler demonstrates chaotic intralesional arterial flow with evidence of early venous shunting.
Ultrasound Report — Single Massive HCC:
Liver shows a large heterogeneous hypoechoic mass lesion in the right lobe (segments V–VIII) measuring 114x92 mm, with lobulated margins, central necrosis and prominent intralesional arterial flow on colour Doppler. Right portal vein demonstrates an intraluminal echogenic filling defect with internal vascularity, consistent with tumour thrombus. Background liver is coursed in appearance. No significant ascites.
Conclusion:
Large heterogeneous hepatic mass with arterialised vascularity and portal vein tumour thrombus — findings are most consistent with a Single Massive Hepatocellular Carcinoma (HCC).
Recommendation:
Triphasic contrast-enhanced CT or MRI liver for staging and treatment planning. Correlation with serum AFP. Multidisciplinary team (MDT) review (hepatology / oncology / surgery) advised for management decision — surgical resection vs locoregional therapy (TACE/ablation) vs systemic therapy. Assess transplant eligibility if criteria are met.
Case Study — 2: Multiple Massive HCC:
Mr. K., 69 years old, male, known case of chronic hepatitis C with established cirrhosis, presented with progressive abdominal distension, dull right upper quadrant pain, early satiety, and significant weight loss (10 kg over 2 months). He also complained of intermittent low-grade fever and generalized fatigue. No prior history of hepatic surgery or locoregional therapy. Alcohol abstinent for the last 12 years.
Clinical Examination:
Patient mildly icteric, afebrile (37.5°C). Abdomen distended with massive hepatomegaly, firm irregular liver palpable up to 12 cm below the right costal margin, crossing midline. Shifting dullness positive indicating ascites. Mild splenomegaly. No pedal edema. ECOG performance status 2.
Laboratory Findings:
CBC: Hb 10.4 g/dL, WBC 9,600/µL, Platelets 102,000/µL.
LFT: Bilirubin 3.5 mg/dL, AST 132 U/L, ALT 97 U/L, ALP 410 U/L, Albumin 2.7 g/dL.
INR 1.6. Serum AFP markedly elevated at 5,800 ng/mL.
Anti-HCV positive, HBsAg negative. Renal function preserved.
Ultrasound Examination:
Transabdominal ultrasound performed with a 3.5–5 MHz convex probe.
Multiple large heterogeneous masses identified in both hepatic lobes.
The dominant right lobe mass (segments V–VIII) measures 85 × 56 mm with central necrosis and lobulated margins.
A left lobe lesion (segments II–III) measures 35 x 32 mm.
Several satellite nodules present bilaterally.
Colour Doppler shows chaotic arterialised intralesional flow with arterioportal shunting.
Right portal vein shows intraluminal echogenic thrombus with internal vascularity — consistent with tumour thrombus.
Background cirrhotic liver with coarse echotexture and nodular surface.
Moderate ascites and splenomegaly (131 mm) present.
Ultrasound Report — Multiple Massive HCCs:
Liver appears cirrhotic with coarse, nodular echotexture. Multiple large heterogeneous masses are noted in both hepatic lobes, the dominant lesion in the right lobe (segments V–VIII) measures 85 x 65 mm, and another large lesion in the left lobe (segment II–III) measures 35 × 32 mm. Additional satellite nodules are seen in both lobes. Lesions are predominantly hypoechoic with central necrotic areas and irregular lobulated margins. Colour Doppler shows prominent chaotic arterial flow within the dominant masses. Right portal vein shows intraluminal echogenic filling defect with internal vascularity, consistent with tumour thrombus.
Conclusion:
Multifocal massive hepatocellular carcinoma involving both lobes of the liver, with vascular invasion (portal vein tumour thrombus) in a cirrhotic background.
Recommendation:
Triphasic contrast-enhanced CT or MRI liver for staging and treatment planning. Correlation with serum AFP. Multidisciplinary team (MDT) review advised to assess options — liver transplantation (if within criteria), locoregional therapy (TACE/TAE), systemic therapy, or palliative care depending on tumour burden, vascular invasion, and hepatic reserve.
Causes / Etiology — Massive HCC:
Chronic hepatitis B infection with cirrhosis — most frequent cause of massive solitary HCC.
Chronic hepatitis C infection with long-standing cirrhosis.
Alcohol-related cirrhosis in advanced disease stages.
Metabolic dysfunction–associated steatohepatitis (NASH) with fibrosis/cirrhosis, increasingly common cause.
Aflatoxin B1 exposure leading to aggressive, large single tumours.
Declaration:
I, R. K. Mouj, hereby declare that the material presented in this document titled "Massive Hepatocellular Carcinoma (HCC): Definition, Sonographic Features, Case Studies, and Risk Assessment" has been prepared and compiled by me for educational purposes only. It is intended for learning, training, and academic reference, and not for submission toward any formal degree or qualification. Sources and references used have been acknowledged where appropriate. This is my own original work. This thesis has not been submitted, either in whole or in part, for a degree at this or any other university. All sources and contributions from other authors have been clearly acknowledged and cited in the references. Where material from other authors has been used, permission has been obtained and is indicated in the text or figure captions.
Ethics / Patient Data Statement: Any patient images, clinical data, or case material included in this thesis have been used in accordance with applicable ethical guidelines and with appropriate consent or institutional approval. All identifying patient information has been removed or anonymised.
Author: ____________________ Name: R. K. Mouj [Radio-imaging Technologist] Supervisor / Guide: Department radiologist Department: Radiology Institution: ____________________ Date: 15-09-2025
"Learning never stops — every question answered brings you one step closer to mastery, and every mistake is a doorway to deeper understanding."
Definition — Post-caesarean Haematoma: A localized collection of blood that forms at or near the cesarean incision (subcutaneous, between uterine layers, or in the pelvis) due to bleeding from surgical vessels or inadequate haemostasis. It may present as a palpable tender mass, expanding uterine size, persistent anaemia, or delayed haemodynamic instability and can act as a nidus for infection if not resorbed or evacuated.
Definition — Septic Collection (Post-caesarean Abscess/Collection): An infected fluid collection (abscess or infected seroma/haematoma) occurring in the wound bed, subcutaneous tissue, uterine incision plane, or pelvic spaces after cesarean delivery. It is characterized clinically by fever, wound erythema/tenderness, raised inflammatory markers, and may require antibiotic therapy and ultrasound-guided or surgical drainage.
Definition — Wound Disruption (Dehiscence/Evisceration): Partial or complete separation of the layers of the surgical incision after cesarean section — ranging from superficial wound dehiscence (skin/subcutaneous) to deep dehiscence involving fascia and uterine closure, and in severe cases evisceration. Presents with wound gaping, serosanguinous discharge, pain or visible bowel/uterine edges, and requires prompt surgical assessment and management.
Uterus appears bulky in size (103x39x69mm) and shows Complex, multiloculated hypoechoic collection with internal mobile echoes and no peripheral hyperaemia on colour Doppler at the wound/uterine incision plane /parametrium measuring, 44.2 x 24.3 mm comunicating with endometrial cavity The endometrial cavit containig slightely hypo to hetrogeneus colection. — findings favour an infected collection/abscess.
Conclusions: Findings favour infected collection/abscess.(Post-caesarean sepsis). Recommendation: image-guided aspiration for culture and CT Pelvis
Case Study — Post-caesarean Sepsis:
Mrs. S., 28 years old, G2P2, underwent an emergency lower segment caesarean section (LSCS) 28 days ago for prolonged obstructed labour. The immediate postoperative period was uneventful, and she was discharged on day 4. On day 7, she developed fever, lower abdominal pain, and foul-smelling wound discharge. Symptoms worsened over 2 days with chills, malaise, and suprapubic tenderness. She was re-admitted on day 9.
Clinical Examination:
Patient febrile (38.9°C), tachycardic (pulse 112/min). Pfannenstiel incision erythematous with induration and purulent discharge. Uterus bulky and tender. No generalized peritonitis.
Ultrasound Examination:
Transabdominal ultrasound performed with a curvilinear probe (3.5–5 MHz).
Uterus appears bulky in size (103 × 39 × 69 mm).
At the uterine incision plane/parametrium: a complex, multiloculated hypoechoic collection measuring 44.2 × 24.3 mm with internal mobile echoes.
The collection communicates with the endometrial cavity, which also contains a small heterogeneous fluid collection.
No significant peripheral hyperaemia on colour Doppler.
Minimal free intraperitoneal fluid detected.
Right kidney: Moderate hydronephrosis with proximal hydroureter noted.
The right ureter is seen dilated up to the level of the ureterovesical junction (UVJ), where it is compressed/extrinsically obstructed by the adjacent parametrial infected collection/abscess.
Pathophysiological Explanation:
The infected post-caesarean collection located in the right parametrium exerts mass effect on the distal ureter at the UVJ. This results in impaired urinary drainage from the right kidney, leading to back pressure changes (hydronephrosis and hydroureter). Such obstruction may worsen sepsis by impairing urinary clearance and increasing risk of secondary urosepsis if untreated.
Ultrasound Impression:
Complex multiloculated hypoechoic collection with internal echoes and endometrial extension, associated with secondary right hydronephrosis due to UVJ obstruction by mass effect of the collection — consistent with infected collection/abscess (post-caesarean sepsis).
Related Ultrasound report lines — Post-caesarean sepsis / wound collections:
1. No collection detected: No sonographic evidence of wound, subcutaneous or pelvic fluid collection. Uterine incision appears intact with no focal defect. No free intraperitoneal fluid identified.
2. Subcutaneous haematoma (acute / subacute): Heterogeneous, predominantly echogenic collection in the subcutaneous plane at the Pfannenstiel incision measuring {{length}}×{{width}}×{{depth}} mm, with no internal vascularity on colour Doppler — appearances most consistent with haematoma.
3. Organ/uterine-incision haematoma / muscular plane collection: Well-defined complex collection deep to the fascia at the region of the uterine incision measuring {{size}} mm, variable internal echoes and layering; no internal Doppler flow. Correlate with haemoglobin trends and clinical status.
4. Infected collection / abscess: Complex, multiloculated hypoechoic collection with internal mobile echoes and peripheral hyperaemia on colour Doppler at the wound/uterine incision plane, measuring {{size}} mm — findings favour an infected collection/abscess. Recommend image-guided aspiration for culture and targeted drainage if clinically indicated.
5. Gas-forming infection (suggestive): Collection containing multiple echogenic foci with dirty posterior reverberation/dirty shadowing and ring-down artefact compatible with intralesional gas — highly suspicious for gas-forming infection. Urgent clinical correlation and surgical/infectious disease review advised.
6. Deep pelvic / parametrial abscess: Complex fluid collection in the anterior pelvic/pouch of Douglas region measuring {{size}} mm with internal echoes and peripheral vascularity, tracking towards the uterine incision — features consistent with deep pelvic abscess; cross-sectional imaging (CT/MRI) and image-guided drainage may be required.
7. Tracking collection / sinus to skin: Fluid collection in continuity with a superficial wound tract extending from the uterine incision to the subcutaneous layer/skin, suggestive of sinus/superficial to deep communicating infection.
8. Wound dehiscence with subfascial collection / evisceration risk: Fascial discontinuity at the prior incision with underlying subfascial fluid collection and visible bowel loops abutting the defect on dynamic Valsalva — concerning for deep wound dehiscence; urgent surgical review recommended.
9. Postoperative seroma / simple collection: Anechoic, avascular fluid collection in the subcutaneous plane consistent with seroma measuring {{size}} mm; consider conservative management or aspiration if symptomatic or infected.
10. Suggestion for image-guided management: Ultrasound-guided diagnostic aspiration and/or catheter drainage is feasible and recommended to obtain fluid for Gram stain/culture and to help source control; correlate with CBC, CRP and blood cultures prior to antibiotic therapy where possible.
11. Final summary sentence (template): Summary: {{one-line finding}}. Recommend clinical correlation (fever, WBC, CRP), review by obstetrics/surgery and consideration of image-guided aspiration/drainage and microbiology sampling.
Notes — technique / limitations: Exam performed with graded compression and colour Doppler. Small collections or deep retroperitoneal/loculated pockets may be better defined on contrast CT/MRI — correlation recommended if clinical suspicion persists despite negative ultrasound.
Post-caesarean Haematoma — Causes:
Poor haemostasis at the time of surgery (bleeding from uterine artery branches, subcutaneous vessels or superficial fascia).
Inadvertent vessel injury during entry or closure, multiple uterine incisions or difficult dissection.
Coagulopathy (pre-existing or acquired), antiplatelet/anticoagulant drugs.
Hypertension or sudden rise in blood pressure post-op.
Obesity, prolonged labour or emergency CS with friable tissues.
Placenta accreta spectrum (bleeding from placental bed) or retained placental tissue.
Local: increasing wound tenderness, swelling or a palpable, often tender mass near the incision.
Uterine enlargement or persistent lochia/bleeding; expanding abdominal girth if retroperitoneal/pelvic.
Systemic: falling haemoglobin, tachycardia, hypotension or signs of hypovolaemia if bleeding is significant.
Low-grade fever may occur; a chronic haematoma can later become infected.
Post-caesarean Haematoma — Diagnostic strategy:
Clinical assessment: inspection and palpation of wound, vital signs, serial haemoglobin/hematocrit.
Baseline labs: CBC, coagulation profile, type & crossmatch if significant bleeding suspected.
Ultrasound (transabdominal ± transvaginal) is first-line to identify and estimate size/location — acute haematoma may be relatively echogenic and become more complex/hypoechoic over time; no internal Doppler flow within organised clot.
CT abdomen/pelvis with contrast if ultrasound equivocal or to assess deep/retroperitoneal bleeding, expanding collection, or haemodynamic instability (useful for surgical planning).
If concern for infection of the haematoma, obtain blood cultures and consider image-guided aspiration for culture and sensitivity before/after starting antibiotics.
Urgent surgical review if expanding haematoma, hemodynamic instability, or suspicion of ongoing arterial bleeding.
Superficial wound infection that tracks deeper into fascial or pelvic planes.
Septic Collection — Symptoms / Clinical features:
Fever, chills and malaise; often persistent or recurrent fever despite usual postpartum care.
Local signs: wound erythema, induration, warmth, increased pain, purulent discharge or sinus formation.
Pelvic/heavy lower abdominal pain, tenderness, guarding if deep pelvic abscess.
Raised inflammatory markers (CRP, ESR) and leukocytosis on blood tests.
If severe, systemic sepsis with tachycardia, hypotension and organ dysfunction.
Septic Collection — Diagnostic strategy:
Clinical inspection of the wound and focused history (timing of fever, wound changes, antibiotic exposure).
Laboratory tests: CBC, CRP/ESR, blood cultures (if febrile/septic), wound swab for microscopy/culture if discharge present.
Ultrasound (first-line) to detect fluid collections in the subcutaneous tissue, uterine incision plane or pelvis — infected collections often appear complex with internal echoes; peripheral hyperemia may be seen on Doppler.
CT pelvis/abdomen with contrast for deeper, multiloculated or complex collections, to guide drainage and exclude other intra-abdominal sources.
Image-guided (US/CT) aspiration or drainage both diagnostic (culture) and therapeutic — obtain specimens before starting antibiotics if safe to do so.
Consult surgery/obstetrics for combined management (antibiotics ± drainage ± debridement); escalate urgently if signs of sepsis.
Early excessive strain on the wound or poor postoperative care/compliance.
Wound Disruption — Symptoms / Clinical features:
Visible separation of the incision edges, serosanguinous or purulent discharge from the wound.
Pain out of proportion, visible subcutaneous tissue or (in severe cases) bowel/omentum protruding through the wound (evisceration).
Fever if infected; local erythema and induration.
In deeper dehiscence, abdominal wall laxity, bulge on coughing or rising, and risk of secondary hernia formation.
Wound Disruption — Diagnostic strategy:
Immediate visual and bedside assessment of the wound — document extent, depth and presence of exposed viscera.
Wound swab for culture if discharge present; CBC and inflammatory markers to assess for systemic infection.
Bedside ultrasound can identify fascial plane separation, subcutaneous collections or occult deep fluid; useful for planning management.
CT abdomen/pelvis if deeper abdominal wall disruption is suspected or to assess intra-abdominal extension/evisceration not appreciated on exam.
Urgent surgical/obstetric evaluation for wound exploration, debridement and re-closure when indicated — evisceration is a surgical emergency.
Red flags (require urgent action): expanding or tense haematoma, hemodynamic instability, signs of peritonitis, visible evisceration, rapidly worsening sepsis, or failure to improve on conservative therapy — all warrant immediate surgical review and likely operative intervention.
Risk factors — Post-caesarean Haematoma:
Operative / surgical: inadequate haemostasis at closure, difficult dissection, multiple uterine incisions, long operative time, repeat CS, accidental vessel injury, use of anticoagulants/antiplatelets or intra-operative heparinization.
Obstetric / peripartum: emergency CS (esp. after prolonged or obstructed labour), placenta accreta/placenta praevia or retained placental tissue, prolonged second stage, uterine atony or heavy blood loss.
Post-op factors: vigorous coughing/straining, early physical strain, inadequate wound support or early anticoagulation therapy after delivery.
Perioperative / obstetric: emergency surgery, prolonged labour, repeated operations, blood transfusion, use of corticosteroids in labor.
Post-op mechanical strain: early heavy lifting, vomiting, severe coughing, constipation/straining.
Quick preventive notes: careful haemostasis and fascial closure, perioperative antibiotic prophylaxis, optimal BP and glycaemic control, minimising operative time where safe, good wound care instructions, thrombosis/bleeding risk assessment before starting postoperative anticoagulation, and early recognition of wound collections reduce the risk of these complications. (See cited reviews for details and local protocol guidance.)
Declaration:
I, R. K. Mouj, hereby declare that the material presented in this document titled "Post-caesarean Sepsis: Post-caesarean Haematomas, Septic Collections and Wound Disruptions" has been prepared and compiled by me for educational purposes only. It is intended for learning, training and academic reference, and not for submission toward any formal degree or qualification. Sources and references used have been acknowledged where appropriate. Its my own original work. This thesis has not been submitted, either in whole or in part, for a degree at this or any other university. All sources and contributions from other authors have been clearly acknowledged and cited in the references. Where material from other authors has been used, permission has been obtained and is indicated in the text or figure captions.
Ethics / Patient Data Statement: Any patient images, clinical data or case material included in this thesis have been used in accordance with applicable ethical guidelines and with appropriate consent or institutional approval. Identifying patient information has been removed or anonymised.
Author: ____________________ Name: R. K. Mouj [Radio-imaging Technologist] Supervisor / Guide:Department radiologist Department: Radiology Institution: ____________________ Date: 11-09-2025
"Learning never stops — every question answered brings you one step closer to mastery, and every mistake is a doorway to deeper understanding."
