KUB Radio Lab Trans

OS 214: Renal Module

Radio Lab ExamImaging Skills

| Jab, Erena, Bill, Kenneth

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Outline

I. KidneysII. Calculi and Obstructive UropathyIII. Acute Renal Parenchymal DiseasesIV. BladderV. Adrenal Glands

I. 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

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.

Plain Pelvic Film

Pelvic ring is visualized Renal shadows & psoas lines are visible In a plain abdominal film, the hemidiaphragms

have to be fully visualized.

2. Intravenous Pyelogram (IVP) used to visualize the collecting system look for sign of retention, pelvic

abnormalities, if bladder itself has problems

A. 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 IVP3. Preparation

Should have good bowel preparation because fecal matter can super impose on the renal image

B. Types of contrast:1. Ionic

more allergenic hyperosmolar (gives a burning

feeling when given intravenously) cheaper (~P400)

2. Non-ionic hypoallergenic less osmolar more expensive (~P1500)

C. IVP Procedure 1. Plain film/Scout film

Flank Stripe

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calcific densitiesstone used as reference figure

2. Inject Contrast Material

3. Film at 3 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

visualize pelvis (collecting system and ureters are opacyfying)

5. Contrast at 10 minutes

contrast has reached the pelvocalyceal system, ureters

this is the time to look for stones in these areas

6. 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

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

Calcific Density

Bladder




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C. 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.

D. 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 normal2. Position patient3. Do Plain study4. Inject contrast material

5. Repeat scan immediately




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E. 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

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

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.

F. VOIDING CYSTOURETHROGRAM

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

G. RENAL ANGIOGRAM Shows how may renal arteries and veins you

have useful for stenting procedures:

a. RENAL ARTERY STENOSISb. Hypertension will disappear quickly after

stenting




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Normal Renal Angiogram

H. ABNORMALITIES OF THE KIDNEY

1. Ptotic Kidney

1 kidney goes down more than 2 vertebral bodies; “the drooping lily”

prone to having obstruction & thus infection

2. CONGENITAL MALROTATIONS/ECTOPIA Horseshoe and Pelvic kidney 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

3. 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.

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, congenital anomalies such as ectopic ureter, and other anomalies of the distal ureter and trigone may also produce reflux.

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

Renal Artery Stenosis

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