Kub Radio Lab Trans

OS 214: Renal Module Radio Lab Exam

Imaging Skills

Outline I. II.

Kidneys Calculi and Obstructive Uropathy Acute Renal Parenchymal Diseases

III. I.

Plain Pelvic Film

KIDNEYS

A.

REVIEW OF NORMAL ANATOMY • The left kidney is situated higher than right kidney (because of the liver on the right) • The outer cortex contains the glomeruli • The medullary pyramids contain the collecting tubules • Urine flows from the tubules to the calyxes to the pelvis to the ureter • role of radiology here is to document the pathologies of the kidney

B.

PLAIN AND CONTRAST X-RAY

1.

Plain KUB • • • 2.

Intravenous Pyelogram (IVP) • used to visualize the collecting system • look for sign of retention, pelvic abnormalities, if bladder itself has problems A.

Flank Stripe

• • • • •

The two white lines are the PSOAS lines. If they are obliterated, suspect retroperitoneal masses. The flank stripe is the border of the body; this is the fat layer of the skin. Give dulcolax, castor oil to remove excess fecal matter that would interfere with renal visualization. In Plain KUB, the entire pelvis should be visible as compared to the plain abdomen x-ray where the hemi diaphragm should be visible.

Roentgenographic examination of the urinary tract may begin with a plain film of the abdomen, exposed with the patient in a supine position, that includes the kidneys and the ureteral and bladder areas. This “scout” film, which must be obtained before contrast medium is given to determine if the hyperechoicity is due to the contrast or because of other reasons (a calcification for example), KUB film examination reveals the renal shadows and permits assessment of the size, shape, and position of the kidneys.

|

Pelvic ring is visualized Renal shadows & psoas lines are visible In a plain abdominal film, the hemidiaphragms have to be fully visualized.

Requirements for IVP: 1. Evaluate renal function  get the serum BUN and creatinine to be assured that the contrast material will be excreted 2. History  Diabetes, HTN  inquire about the allergy history of the patient to foresee allergic reactions to the contrast material that will be used  to know what to look for in the IVP 3. Preparation  Should have good bowel preparation because fecal matter can super impose on the renal image

B. Types of contrast: 1.

2.

Ionic  

more allergenic hyperosmolar (gives a burning feeling when given intravenously)  cheaper (~P400) Non-ionic  hypoallergenic  less osmolar  more expensive (~P1500)

Mace: Hi 2012. Exam na bukas. Wala pa akong naalala sa mga binasa ko. Hehe. Jan, Nani, salamat sa Kornets. Brent, wag ka na mainsulto. Tamad lang talaga ako mag-aral. Kung mabibigay ko lang sayo oras ko. Hehe. Pero ayoko eh. Masarap magbasa ng Harry Potter ulit o manood ng House Page 1 of 5

Jab, Erena, Bill, Kenneth

OS 214: Renal Module Radio Lab Exam

Imaging Skills

C.

IVP Procedure 1. Plain film/Scout film



visualize pelvis (collecting system and ureters are opacyfying)

5. Contrast at 10 minutes

 

calcific densitiesstone used as reference figure

2. Inject Contrast Material

3. Film at 3 minutes  

6.    

contrast has reached the pelvocalyceal system, ureters this is the time to look for stones in these areas Film at 15 minutes whole abdomen profile kidneys are still visualized ureters are likewise opacified bladder is starting to fill

7. Full bladder film at 20 minutes kidneys and upper collecting system (including the calyces) visualized  the contrast in the cortex and the medulla is seen 4. Film at 5 minutes 

|

Page 2 of 5

Jab, Erena, Bill, Kenneth

OS 214: Renal Module Radio Lab Exam

Imaging Skills

• • •

Calcific Density

D. Bladde r

C.

|

 

full bladder has very smooth borders “dapat bilog na”

8.   

Post-void film to check urinary retention <50 cc you can still see some degree of contrast in various areas of the GU system

ULTRASOUND • can measure length, width and height of the kidney • how is it done? --- supine or prone position • Characteristics: o Hypoechoic – black (ex. Air) o Isoechoic – gray (ex. Soft tissues like liver) o Hyperechoic – white (ex. Bone and stones)

The right kidney can be scanned with the patient in a supine or decubitus position (left side down) with longitudinal, transverse, and coronal images. Similarly, the left kidney can be imaged with similar views and the right side down. Occasionally, a prone position may prove useful. The best images are obtained with the patient’s respiration suspended; frequently, the end of partial or full inspiration brings the kidney into better view.

CT SCAN • CT examination of the kidneys is tailored to the specific clinical indication. • In general, there are three broad categories in which CT examination is used:  The most common indication for CT of the kidneys is a morphologic examination for potential renal mass after an ultrasound, IVP, or other examination. This protocol can also be applied when searching for potential renal trauma or infection.  Suspicion of urinary tract stones; this examination is called CT urography. CT urography has been shown to be highly accurate in the evaluation of suspected ureteral and renal stones in the setting of acute flank pain.  for visualization of renal vasculature •

CT Scan Procedure: 1. Check if all lab results are normal 2. Position patient 3. Do Plain study 4. Inject contrast material 5. Repeat scan immediately

Page 3 of 5

Jab, Erena, Bill, Kenneth

OS 214: Renal Module Radio Lab Exam

Imaging Skills

•

F.

VOIDING CYSTOURETHROGRAM

•

E.

X-Ray while Voiding

•

urethral rupture: Leaks of urine, extravasation of dye

•

neurogenic bladder: diagnosed only when other diseases have been ruled out to cause cystitis

RETROGRADE PYELOGRAM • done when it is not possible to give IV contrast e.g. trauma patients • when creatinine levels are high but it is imperative to view the lower collecting system

•

|

Normal Retrograde Pyelogram: The area in the ureter which looks like stenosed is just having some pulsations so the flow of the contrast is at intervals.

Catheter is inserted through the urethra, then dye is released.

G. RENAL ANGIOGRAM • Shows how may renal arteries and veins you have • useful for stenting procedures: a. RENAL ARTERY STENOSIS b. Hypertension will disappear quickly after stenting Page 4 of 5

Jab, Erena, Bill, Kenneth

OS 214: Renal Module Radio Lab Exam

Imaging Skills

• • • •

3.

•

Normal Renal Angiogram

Renal Artery

horseshoe kidney are prone to calculi so always follow up ectopic kidney: kidney reaches the pelvic area pelvic kidneys are a risk for UTI pregnancy may be a problem: prone to hydronephrosis and can make labor very difficult

VESICO-URETERAL REFLUX • more common in children • reflux increases risk for infection • when a patient voids, urine should not go up the collecting system • several grades • if you have infected urine—you can develop pyelonephritis or chronic pyelo • UTI: female babies of greater risk than males • Males with UTI are less common but incidence is usually connected to some renal abnormality.

Vesicoureteral reflux in children is usually caused by abnormal anatomy of the vesicoureteral junction. Normally, the ureters enter the bladder at a shallow angle and proceed in the bladder submucosa before emptying into the bladder. This arrangement creates a valve mechanism that allows antegrade flow of urine without reflux. If abnormal anatomy is present, usually a shortened submucosal course of the ureter, vesicoureteral reflux is common. Reflux often spontaneously resolves as the child ages because of the lengthening of the submucosal portion of the ureter. In general, the worse the reflux at the time of diagnosis, the less likely it is to resolve spontaneously and therefore the more likely it is to require surgical intervention.

H.

ABNORMALITIES OF THE KIDNEY 1.

Ptotic Kidney

• • 2.

|

Infection is the most common adult cause of vesicoureteral reflux, which is also found occasionally in patients with lower-urinary-tract obstruction. The obstructive lesions include posterior urethral valves, urethral stricture, and median bar enlargement of the prostate. Neurologic disorders that result in neurogenic bladder dysfunction,

4.

FEMALE GENITO-URINARY TRACT • wiping from back to front after bowel movements may force germs into urethra

5.

ACUTE PYELONEPHRITIS • various imaging modalities show normal findings! • nuclear scan provides earlier detection

1 kidney goes down more than 2 vertebral bodies; “the drooping lily” prone to having obstruction & thus infection

CONGENITAL MALROTATIONS/ECTOPIA Horseshoe and Pelvic kidney

Page 5 of 5

Jab, Erena, Bill, Kenneth