Os 214 - Renal Module - Imaging Of The Kub

Transcript

OS 214 Renal Module Dr. Fragante Exams 1 & 2, Lab Exam Imaging of the KUB • Lecture Outline: I. Introduction to KUB Imaging II. Renal Anatomical Abnormalities III. Infections IV. IV. Calculi and Obstructive Uropathy V. Renal Parenchymal Diseases VI. Urinary Bladder  VII. Adrenal Glands VIII. Renal Vascular Lesions IX. Appendix 2. Get the serum serum BUN and creati creatinin nine e to be assured that the contrast maaterial will be excreted History Diabetes, HPM Inqu Inquir ire e abou aboutt the the alle allerg rgy y hist history ory of the the patient patient to foresee foresee allergic allergic reactions reactions to the contrast material that will be used To know what to look for in IVP • • • Contrasts: o INTRO TO KUB IMAGING o • • • • Befo Before re usin using g imag imagin ing g moda modali liti ties es,, make make sure sure to perform a good history and physical examination (PE) first, first, as these will give you a working impression and guide you in choosing the appropriate modalities. The different modalities used for visualizing the KUB are: X-ray film o Intravenous pyelography (IVP) o Ultrasound (UTS) o Computerized tomography (CT) scan o Correlate imaging findings with renal function: serum BUN and creatinine results, urinalysis Take note also of comorbidities, eg. diabetes mellitus, hypertension Ionic – hyperallergenic and hyperosmolar (so may may caus cause e pain pain)) but but chea cheape per; r; give gives s a burning feeling when given intravenously Non-ionic Non-ionic – hypoallerge hypoallergenic nic and low osmolar  but more expensive IVP Procedure • Scout film (no contrast yet)  film 3 minutes after  contrast  after 10 minutes  during full bladder   post-void (see Fig. 39 in appendix) 1. Plain Film/Scout Film Calcific densities  stones Used as reference figure 2. Inject Contrast Material 3. Film at 3 minutes Kidneys Kidneys and upper collecting collecting systems systems visualized The The cont contra rast st in the the cort cortex ex and and the the medulla is seen 4. Film at 5 minutes Visualize pelvis (collecting system and ureters are opacyfying)] 5. Contrast at 10 minutes Contrast Contrast has reached reached the pelvocalceal pelvocalceal system, ureters This This is the time time to look for stones 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 minutes Full bladder has very smooth borders “dapat bilog na” 8. Post-void Film To check urinary retention < 50 cc You can can stil stilll see see some some degr degree ee of  cont contra rast st in vari variou ous s area areas s of the the GU system • • • • A. KUB X-ray film • Advi Advise se pati patien entt to have have empt empty y bowe bowell (eg. (eg. take take Dulcolax first) to visualize the outlines of the kidneys and the psoas • • LK RK • • Psoas lines • • • • • • • • C. Ultrasound Figure 1. Normal KUB film, showing the psoas lines and the outlines of the kidneys. Note that the right kidney (RK) is normally lower than the left (LK). B. Intravenous Pyelography • • Seri Series es of film films s with with cont contra rast st mate materi rial al to bett better  er  visualize the urinary system To see if there is retention of urine Requirements for IVP 1. Eval Evalua uate te rena renall func functi tion on 05 March 2009 | Thursday Page 1 of 9 patty.nina.ad.aoo OS 214 Renal Module Dr. Fragante Exams 1 & 2, Lab Exam Imaging of the KUB Figure 2. Sagittal (left) and tranverse (right) views of the kidney through through ultrasonog ultrasonography raphy.. The outer hypoechoic hypoechoic area area denote denotes s the renal renal parenc parenchym hyma, a, while while the inner  inner  hypere hyperecho choic ic area area denote denotes s the renal renal pelvis pelvis (colle (collecti cting ng system). D. CT scan • • • • Has more detail than the other modalities, but more expensive, of course (see Fig. 38 in appendix). Patient is scanned in the supine or decubitus position. Occasionally, Occasionally, a prone position may prove useful. The best best image images s are obtain obtained ed with with the patien patient’ t’s s respiration suspended; frequently, the end of partial or  full inspiration brings the kidney to better view Allows us to see cortex, medulla, and renal drainage ANATOMICAL ANATOMICAL ABNORMALITIES A. Ptotic Kidney Kidney is descended by at least two vertebrae levels; during standing position Prone to having obstruction and infection • • Figure 4. Horseshoe kidney (left) and pelvic kidney (right). C. Vesico-ureteral Reflux Urine goes back (reflux) to the kidneys; patients are prone to nephritis Reflux increases risk for infection Results in dilatation of the collecting system • • • Figure 5. Vesiculo-ureteral reflux. Black arrows points to the reflux (right). Figure Figure 3. Ptoti Ptotic c right right kidney kidney – notice notice that it is almost almost completely at the level of the pelvis. Nasa House, MD. ‘tong condition na ‘to! Hehe. INFECTIONS A. Acute Pyelonephritis Pyelonephritis • B. Horseshoe Kidney, Pelvic Kidney • • • Horseshoe kidney – lower poles of the kidneys are connected  malrotation of kidneys Patien Patients ts with with this this are prone prone to infect infection ions, s, o stones and malignancies Pelvic kidney – at the level of the pelvis already (even if not during standing position); prone to UTI Pregnancy may be a problem: prone to hydronephrosis and can make labor ver y difficult • • NORMAL NORMAL findings findings in almost almost all variou various s imagin imaging g modalities! (daw, sabi sa lecture ni Ma’am…) Nuclear scan provides earlier detection Risk factor: stones Figure Figure 6. KUB film showing “acute “acute pyelonephrit pyelonephritis”. is”. Left kidney is shown to be larger than the right. 05 March 2009 | Thursday Page 2 of 9 patty.nina.ad.aoo OS 214 Renal Module Dr. Fragante Exams 1 & 2, Lab Exam Imaging of the KUB Figure 7. Ultrasound (left) and CT scan (right) showing “acute pyelonephritis” (pointed by their respective arrows). Enla nlargem rgeme ent of the kidn kidney ey is due to ede edema of  inflam inflammat mation ion.. Areas Areas of avascu avascular larity ity are due to toxic toxic secretions which cause constriction B. Chroni Chronic c Pyelon Pyeloneph ephrit ritis, is, Renal Renal Absces Abscess, s, Renal Renal Tuberculosis • • Chro Chroni nic c pye pyelone loneph phri riti tis s – may hav have cort cortic ical al irregularities or scarring Atrophied kidney and cortical abnormalities If not treate treated, d, renal renal absces abscess s forms forms (201 (2011 o trans) Figure 10. KUB film (left) and CT scan (right) with foci of  renal tuberculosis, shown by white arrows. Multiple calcific densities are seen. CALCULI AND OBSTRUCTIVE UROPATHY A. Stones and Calculi • • • • • Uric acid stones – intake of beans, beer, meat, oats Calcium stones – from salty foods (junk food! Chippy!) Stones form in the calyx, then may go down to the renal pelvis and then to the ureter ( ouch…) For female females: s: get calciu calcium m from from milk, milk, not calcium calcium tablets (2011 trans) Stag Stagho horn rn calc calcul ulii – ston stones es can can occu occupy py an enti entire re collecting collecting system, system, conforming conforming to the pelvocalic pelvocaliceal eal system (2011 trans); thus the “reindeer configuration” Figure 8. Cortical scarring, which can be a sign of chronic pyelonephritis. Distance at poles should not be differ by greater than 2 mm. Figure Figure 11. Renal Renal calcul calculi, i, as shown shown by arrows arrows (white (white calcified structures). Figure 9. Ultrasound (left) and CT scan (right) showing renal abscess. In UTS the abscess is hypoechoic and in CT scan it is dark. It happens happens when you do not treat your  chronic pyelonephritis. 05 March 2009 | Thursday Page 3 of 9 patty.nina.ad.aoo OS 214 Renal Module Dr. Fragante Exams 1 & 2, Lab Exam Imaging of the KUB Figure 15. Ureteral stones as seen in plain and contrast films films using using retrog retrograd rade e pyelog pyelograp raphy hy (RPG). (RPG). Notice Notice the discontinu discontinuation ation of the contrast because of obstruction obstruction by the stones. B. Hydronephro H ydronephrosis sis There is dilatation of the collecting system because of  a chronic obstruction May be uni- or bilateral If not treated then there can be infection and then pus formation • • • Plain Contrast Figure 12. Staghorn calculi in both plain and contrast films. They can occupy a hole collecting collecting system. They conform to the configuration of the pelvocaceal system. Figure 16. Hydronephrosis. Ur  Figure 13. Renal calculi as shown in UTS. The stones are hyperechoic, with shadowing behind them (2011 trans). PC Patty, Nina, AD, Aoo : hi Jelly A’s! Hi JollyB’s! =) pus/debris Figure 17. UTS showing hydronephrosis. Note the muchdilated pelvis, and the thinned out parenchyma. PCS – pelvicaliceal system; Ur – ureter. C. Ureteral Stricture Stones and inflammation are more common causes because can lead to fibrosis, leading to stricture • Figure Figure 14. CT-st CT-stono onogra gram m showing showing the stones stones.. This This is requested when X-ray is not enough (2011 (2011 trans). Plain Contrast Figure 18. Ureteral stricture. RENAL PARENCHYMAL DISEASE 05 March 2009 | Thursday Page 4 of 9 patty.nina.ad.aoo OS 214 Renal Module Dr. Fragante Exams 1 & 2, Lab Exam Imaging of the KUB A. Acute Renal Parenchymal Disease (2011 (2011 trans) Pati Patien ents ts are are edem edemat atou ous, s, asce asceti tic c beca becaus use e glomeruli are unable to filter  Enlarged kidneys on UTZ Echogenic ball-like kidney • the the • • Figure 21. Wilm’s tumor or nephroblastoma in UTS (left) and CT scan (right). LM Figure 19. UTS showing acute renal parenchymal disease. The areas are hyperechoic because of inflammation. B. Masses/Tumors and Cysts (2011 trans) Renal cysts – most common in the elderly Fluid-filled and can cause obstruction if large o enough Seen as “fraying of the collecting system” o May cause obstruction o • • Renal tumors may metastasize to nearby organs such as the liver and spleen; first symptom is hematuria (painless) • Wilm’s tumor/nephroblastoma – more common in the pediatric population; may occupy the whole kidney; diffused, multiply masses Diff Diffus use e mali malign gnan anci cies es – beca becaus use e of canc cancer ers s like like lymphomas • SM Figure Figure 22. CT scan images showing renal cell carcinoma (left, (left, with arrows arrows)) and organ organ metast metastase ases s (LM – liver  liver  metastasis, SM – splenic metastasis). Figure 23. UTS (left) and CT scan (right) showing diffuse malignancies (eg. lymphomas). Figure 20. Cysts, as shown in IVP (left), UTS (upper right) and CT scan (lower right). Cysts in IVP are white. 05 March 2009 | Thursday URINARY BLADDER • Normal filled UB: very smooth borders, like a balloon • Normal post-void UB: not more than 50cc of urine left; if more than 50cc, then UB is more prone to infection Page 5 of 9 patty.nina.ad.aoo OS 214 Renal Module Dr. Fragante Exams 1 & 2, Lab Exam Imaging of the KUB Figure 24. Normal filled UB (left and middle) and normal post-void UB (right). A. Cystolithiasi C ystolithiasis s (2011 trans) Stones of the UB; calcific, rounded/ovoid opacity that have the same density as bone and may look like eggs Capacity of UB is decreased; there ma y also be reflux • • • • • • Patient becomes more prone to cystitis Usuall Usually y lamel lamellat lated; ed; lamell lamellae ae repres represent ent times times of  deposition, just like in “tree rings” Mves with changes in position Uually smooth borders but can be mulitlobulated Enlarged prostate Figure Figure 27. Enlargem Enlargement ent of the prosta prostate, te, leadin leading g to UB obstruction and cystitis. Patients have poor stream due to retention UTZ is used to evaluate prostate • • C. Emphysematous Cystitis Characterized by infection of UB and UB wall with gas-forming organisms (2011 trans); thus, there is air  outlining the wall of the bladder  “Mickey Mouse” appearance because of diverticula • • Plain Contrast D. Chronic Cystitis UB may become become fibrotic, fibrotic, and have vesico-ureter vesico-ureteral al reflux Can lead to chronic renal parenchymal disease • • E. Contracted Bladder  • UB capacity approximately only 20cc; “one drink of  iced tea, ihi na agad ” • Treat Treated ed with with bladde bladderr augmen augmentat tation ion (2011 (2011 trans) trans);; “neobladder”, attached to ileal segment UB Div Figure 25. Plain and contrast films showing cystolithiasis. UB Div Figure 28. Emphysematous cystitis. Note the outline of ai in the UB wall (shown by arrows) and the “Mickey Mouse” appearance (UB Div – UB diverticula). VUR Figure 26. UB calculi with blood clots, as sho wn in UTS. B. Pros Prosta tati tic c Enla Enlarg rgem emen entt Obstruction/Cystitis with with Chro Chroni nic c Blad Bladde der  r  Figure Figure 29. Chroni Chronic c cystiti cystitis: s: with with vesico vesico-ur -urete eteral ral reflux reflux (VUR), as shown in contrast film (left), and with thickened 05 March 2009 | Thursday Page 6 of 9 patty.nina.ad.aoo OS 214 Renal Module Dr. Fragante Exams 1 & 2, Lab Exam Imaging of the KUB bladder wall (white lining of the UB located in the center), as shown in CT scan (right). Figure 32. Bladder extrophy. The ureters are dilated, and the symphysis pubis widened. G. UB Malignancy There is a change from “full moon” to “half/crescent moon” UB wall may be eaten up (2011 trans) Risk factor: smoking and alcohol intake Most common: transitional cell CA • • • • Figure 30. Normal findings in UTS (top images), compared to findings of cystitis in UTS (bottom images). The normal UB has smooth smooth walls, walls, while the cystit cystitic ic UB has rough rough edges. Figure 33. UB malignancy as shown in CT scan (left) and contrast film (right), where the “crescent moon” is very evident. ADRENAL GLANDS A. Adrenal Gland Hyperplasia Figure 31. Contracted bladder. F. Post-traumatic Bladder Extrophy UB not only descends, but goes out (2011 trans) There is widening of the symphysis pubis; also, there is bilateral dilatation of the collecting systems (also ureters) Due Due to pelv pelvic ic frac fractu ture res, s, moto motorcy rcycl cle e acci accide dent nts, s, horseback riding May involve urethras in males (2011 trans) • • • • Figure Figure 34. CT scans showing normal adrenal gland (left) (left) and hyperplastic adrenal gland (right). B. Pheochromocytoma Pheochromocytoma Tumors Tumors of the adrenal adrenal medulla, medulla, resulting resulting in increase in catecholamine production Hypertension is one manifestation As oppo oppose sed d to adre adren nal glan gland d hype hyperp rpllasia asia,, pheochromocy pheochromocytom toma a look like round masses; in the former, the original shape is somewhat retained (2011 trans) • • • 05 March 2009 | Thursday Page 7 of 9 patty.nina.ad.aoo OS 214 Renal Module Imaging of the KUB Dr. Fragante Exams 1 & 2, Lab Exam Before Stenting After Stenting Figure 37. The left angiogram shows renal artery stenosis, while the right angiogram shows the effect of stenting (no more stenosis). Figure 35. Pheochromocytoma, as seen in UTS (left) and CT scans (right). RENAL VASCULAR LESIONS • Renal angiography – used for visualizing the vascular  tree of the kidneys; aside from locating lesions, this is also used in screening for organ transplants Philippines has one of the highest rates of  o kidney transplantation APPENDIX Figure 36. Normal renal angiogram. Figure 38. CT scans of the normal kidney. 05 March 2009 | Thursday Page 8 of 9 patty.nina.ad.aoo OS 214 Renal Module Dr. Fragante Exams 1 & 2, Lab Exam Imaging of the KUB 3 min 10 mins Scout Post-void Full bladder  Figure 39. Series of IVP contrast films: scout film (no contrast yet, left), 3 minutes after injection (top middle), after 10 minutes (top right), full bladder (bottom right) and post-void bladder (bottom middle). 05 March 2009 | Thursday Page 9 of 9 patty.nina.ad.aoo