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KUB is variously called as plain film or scout film. It is done preliminary to IVP Since IV contrast can hide the calculi (same xray density as contrast) it serves as the film of reference for all subsequent films done after injection of contrast material.
KUB is variously called as plain film or scout film. It is done preliminary to IVP Since IV contrast can hide the calculi (same xray density as contrast) it serves as the film of reference for all subsequent films done after injection of contrast material.
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KUB is variously called as plain film or scout film. It is done preliminary to IVP Since IV contrast can hide the calculi (same xray density as contrast) it serves as the film of reference for all subsequent films done after injection of contrast material.
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Attribution Non-Commercial (BY-NC)
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Скачайте в формате DOC, PDF, TXT или читайте онлайн в Scribd
May aggravate renal failure Kidney Ureter Bladder : KUB KUB is variously called as plain film or scout film. It is done preliminary to IVP. Difference in x-ray attenuation between the kidneys and the enveloping perirenal fat in plain films provides a crude index of renal anatomy and pathologic changes Retrograde Pyelogram Preliminary to IVP Like IVP, retrograde pyelography relies on Since IV contrast can hide the calculi (same x- contrast medium to produce detailed X-ray ray density as contrast) it serves as the film of images of the urinary tract. reference for all subsequent films done after Utility injection of contrast material. Defines ureters and collecting systems Good to pick up calcifications. Observe for While newer diagnostic techniques have calcification over kidney, ureters, bladder replaced this test for many functions, regions and rest of the abdomen retrograde pyelography may still yield better Can identify distended bladder definition of the upper urinary tract, particularly the ureter and kidney collecting Can identify abdominal and pelvic masses. syst Observe renal outline for size and mass Indications density. Commonly performed when IVP produces an Incidental non diagnostic findings on KUB may inadequate picture. Useful to study urinary alert the physician to the possibility of urinary tract obstruction when further clarification of tract injury nature of ureteral obstruction is required In trauma fracture of vertebrae, ribs or pelvis It also complements cystoscopy while alerts you to GU tract injury. investigating a patient with hematuria or Psoas obliteration and concavity of spine recurrent or suspected cancer. towards the side of pathology. Detects small lesions in the collecting system Abnormal air collections suggestive of renal or E.g. Transitional cell carcinoma peri-renal abscess Limitations Contrast complications Intravenous Pyelogram (IVP) May aggravate an existing urinary tract IVP is a radiological test that uses contrast to infection or triggering one from the outline the kidneys, ureters and bladder. catheterization. Also known as intravenous urogram Utility Voiding cystourethrogram (VCUG) Useful for evaluating the anatomy of the Children with urinary tract infections. kidneys, ureters and bladder One can detect function when no contrast is Reflux is detected if contrast is seen to excreted flow in retrograde fashion up the absence of renal function . ureters from the bladder. absence of perfusion to a kidney Pelvic trauma where rupture of the bladder or urethra is suspected. Useful to identify urinary tract obstruction Useful to evaluate reno-vascular disease If the bladder is ruptured, Common indications extravasation of contrast will be seen Renal colic outside the bladder in the pelvis or Hematuria abdomen. Recurrent urinary tract Infections If urethra is ruptured, there is Suspected reno-vascular hypertension extravasation into the perineum Disadvantages Patients with suspected bladder outlet Labor and time intensive – it may take up to 6 obstruction hours to complete in the severe obstruction Obstructions or strictures or injury of It requires placement of an intravenous line. the urethra can be seen on the x-rays taken during voiding. Requires a bowel preparation for optimal Limitations results Insertion of the catheter is painful. Involves intravenous injection of potentially allergic and mildly nephrotoxic contrast While conventional voiding cystograms are still necessary to evaluate the male urethra for Nonionic contrast agents have lowered the posterior valves and bladder trauma, the incidence of adverse reactions. majority of reflux studies today are done IVP's are not useful in patients with renal effectively with radionuclide cystography. dysfunction. Newborns rarely have sufficient renal ULTRASOUND concentrating ability to allow the kidneys to be seen on an x-ray. 2 The use of high-frequency sound waves to Most young children require sedation to produce real-time images, provides a simple undergo a CAT scan. and painless way to examine the kidney, CAT scans are relatively expensive bladder, prostate and scrotum Advantages MRI Non-invasive test MRI is as good as CT or better in characterizing Requires no preparation lesions of kidney and prostate. No pain Because of its ability to show soft tissues in Provides accurate anatomic information, exquisite detail, MRI can detect disease and including dimensions evaluate renal vasculature and inferior vena No radiation risk cava Avoiding the potential allergic and toxic MRI can delineate a cyst from a solid mass. complications of contrast media. In can identify the spread of kidney cancer into Can be used on individuals with poor kidney the renal vein, inferior vena cava and perirenal function in whom contrast cannot be given area (Staging). No complications Indication Can be done at bedside When contrast CT cannot be done Relatively economical exam MRI is useful to evaluate vascular lesions Utility Disadvantages Helpful in defining renal, bladder and prostate Expensive anatomy Limited availability MRI has limited applicability for the urinary It is the test of choice to exclude Urinary tract tract since the non-specificity of its signals obstruction makes it ineffective in detecting calcifications US can, in the majority of cases, diagnose and bladder abnormalities. hydronephrosis. Patients with pacemakers, aneurysm clips, ear Good for evaluating Kidney size implants and metallic pieces in vital body Good to distinguish between cysts and solid locations cannot be imaged safely mass. Good to localize kidney for biopsy ADRENALS Common indications Adrenal Adenoma Renal mass / Abdominal mass Incidence in the population is 2-8% Renal colic Diagnosis is often made as an incidental Recurrent Urinary tract infections finding on CT examination. Chronic renal failure In patient with no known primary, an adrenal Acute glomerulonephritis mass is almost always a benign adenoma Hematuria In a patient with a known neoplasm, especially lung cancer, an adrenal mass is problematic Renal CT and diagnosing a metastasis versus an CT scanning combines X-rays and computer to adenoma is critical for prognosis produce precisely detailed cross-sectional CT findings images of the genito urinary system. Size greater than 4 cm tend to be metastases Utility or adrenal carcinoma A CT scan is helpful in delineating the Heterogeneous appearance and characteristics of anatomy and function irregular shape are malignant of Kidneys characteristics Three-dimensional reconstructions of Homogeneous and smooth are benign the kidney and blood supply provide characteristics. "road maps" for planning surgeries. Intracellular lipid in adenoma results in INDICATION low attenuation on CT Ultra fast CT is considered preferable to KUB Little intracytoplasmic fat in metastases results for detection of suspected stones in high attenuation on non-enhanced CT If ultrasound evaluation is equivocal for a cyst, Non-enhanced CT (NECT) or is suggestive of malignancy Threshold 10 HU In evaluating solid abdominal masses Sensitivity 79%, specificity 96% Hematuria Contrast-enhanced CT (CECT) Local staging of cancer Kidney to allow Because majority of CT examinations in definitive surgical management if needed oncology use IV contrast, the % Renal artery and vein evaluation washout is useful after 10 minutes. DISADVANTAGES Adenomas have greater than 50% Requires placement of an intravenous line for washout after 10 minutes IV contrast. Washout can also be used on adrenal Exposes patient to radiation. masses that measure > 10 HU on NECT Contrast toxicity or allergy Alternative is to do MR or PET 3 they are usually round or oval masses Adrenocortical carcinoma with an attenuation similar to that of rare malignancy with a poor prognosis. the liver reported incidence: 2 cases per million Larger lesions frequently demonstrate persons. necrosis, hemorrhage, and fluid-fluid tumors frequently are large, measuring 4-10 levels. cm in cross-sectional diameter. As a result, they often appear arise from the adrenal cortex inhomogeneous. bilateral in up to 10% of patients. Calcification is rare, but it is reported Approximately 50-80% are functional tumors, with most causing Cushing syndrome. KIDNEYS Endocrine syndromes associated with adrenocortical Acute Pyelonephritis carcinoma Etiology Cushing syndrome o Inflammation of the renal parenchyma and Virilization and precocious puberty renal pelvis due to an infectious source o Most often secondary to an ascending lower Feminization urinary tract infection from gram-negative Primary hyperaldosteronism bacteria CT findings E. coli Large mass (>4 cm) Klebsiella Central necrosis or hemorrhage Proteus Heterogeneous enhancement Pseudomonas. Invasion into adjacent structures o Exception is S. aureus, which is spread Venous extension into the renal vein or inferior hematogenously vena cava Pathologic Causes o Vesicoureteral reflux Adrenal metastases o Obstruction in the collecting system usually Unilateral adrenal mass or enlargement due to a calculus Small masses (<1 cm) - Adenoma, Complications ganglioneuroma, hyperplasia, metastasis, and o Abscess pheochromocytoma o Emphysematous pyelonephritis Large masses (>4 cm) - Carcinoma of Most often occurs in diabetics adrenal cortex; cyst or pseudocyst; hematoma; Can produce gas in the collecting infection; inflammation (eg, tuberculosis, system and renal parenchyma. histoplasmosis); metastasis (eg, lung or breast Radiographic Imaging Findings related); myelolipoma; neuroblastoma, o Enlarged kidneys (U/S and CT) ganglioneuroblastoma, or ganglioneuroma; o Hydronephrosis (U/S and CT) pheochromocytoma (eg, multiple endocrine o Wedge shaped areas of low attenuation neoplasia) secondary to decreased perfusion (CT) o Loss of the ability to distinguish the Bilateral adrenal enlargement corticomedullary border (CT) Common causes - Hemorrhage (eg, in infants, o Perinephric stranding (CT) trauma, bleeding disorder), histoplasmosis, hyperplasia, metastasis (eg, lung or breast Emphysematous Pyelonephritis related), neuroblastoma, and tuberculosis Acute, fulminant, necrotizing infection of kidney and Uncommon causes - Addison disease, perirenal tissues associated with gas formation which adenomas, amyloidosis, carcinomas (eg, may be life-threatening multiple, primary), infection (ie, others), lymphoma, pheochromocytoma (multiple • Organism endocrine neoplasia), and Wolman disease (eg, o E. coli (vast majority of cases) familial xanthomatosis) o Klebsiella pneumoniae (9%) CT findings o Proteus mirabilis appear as focal masses or distortion of the o Pseudomonas contour of the adrenal gland. o Enterobacter smaller than 3 cm may be homogeneous. o Candida Larger lesions may have central necrosis or o Clostridia (exceptionally rare) hemorrhage. These lesions are heterogeneous • Location and may have thick enhancing rims. They may o Most are unilateral also invade contiguous organs such as the o 5-7% bilateral kidneys. Attenuation values of less than 10 HU on • Types unenhanced o Type I (33%) • Streaky or mottled gas in Pheochromocytomas interstitium of renal CT parenchyma radiating from large tumors (often >3 cm), medulla to cortex 4 • Crescent of subcapsular or Traumatic avulsion of renal perinephric gas artery • No fluid collection (= no Surgery effective immune response) o Embolism • Prognosis in this type is poor Cardiac origin (69% mortality) • Rheumatic heart • disease with o Type II (66%) arrhythmia • Bubbly and/or loculated o Atrial fibrillation intrarenal gas (infers presence • Myocardial infarction of abscess) • Prosthetic valves • Renal and/or perirenal fluid • Myocardial trauma collection • Left atrial or mural • Gas within collecting system in thrombus almost all • Myocardial tumors • CT findings • Subacute bacterial o Most reliable and sensitive modality endocarditis o Mottled areas of low attenuation • extending radially along the pyramids o Extensive involvement of kidney and Catheters perinephric space • Angiographic catheter o Air extending through Gerota’s fascia manipulation into retroperitoneal space • Umbilical artery o Occasionally gas in renal veins catheter above level of • Ultrasound findings renal arteries o High-amplitude echoes within renal o Arterial thrombosis sinus and/or renal parenchyma Arteriosclerosis associated with "dirty" shadowing Thrombangitis obliterans • "Comet tail" reverberations Polyarteritis nodosa o Kidney may be completely obscured by Syphilitic cardiovascular large amount of gas in perinephric disease space (DDx: surrounding bowel gas) Aneurysms of the aorta or renal o Gas may be confused with renal calculi artery Sickle cell disease Renal Infarction o Sudden complete renal vein thrombosis • Thrombotic disease usually affects larger o vessels • Lobar Renal Infarction o Includes main renal artery o Early signs o Patients with thrombotic disease usually present with hypertension or Focal attenuation of collecting renal insufficiency system o Usually results from atherosclerosis • Tissue swelling But, blunt abdominal trauma Focally absent nephrogram may cause intimal tears with • Triangular with base at subsequent dissection and cortex thrombosis o Late signs • Emboli can affect vessels of various sizes Normal or small kidney(s) depending on the size of the emboli Focally atrophied parenchyma o Renal artery emboli usually come from with normal interpapillary line cardiac source Cortical atrophy and irregular o Embolic disease usually produces acute scarring are seen as late symptoms sequelae Sudden onset of flank pain o CT Hematuria Subtle renal infarcts are best Proteinuria demonstrated on CT Fever Appear as wedge-shaped, Leukocytosis cortically based, hypodense areas • Causes • Triangular in shape with o Trauma widest part at the cortex (base of infarct) Blunt abdominal trauma 5 Non-perfused area Much more common in corresponding to vascular females division o Angiomyolipoma associated with Renal swelling may also be tuberous sclerosis (in 20%) seen Angiomyolipoma occurs in 80% Cortical rim sign of patients with tuberous • Entire kidney is sclerosis nonenhancing except • Commonly large for the outer 24 mm of • Usually bilateral cortex, which are • Usually multiple perfused by capsular branches May be only evidence of tuberous sclerosis Mean age of incidence: teens Equal incidence in males and females o US • Imaging findings Focally increased echogenicity o Mostly small lesions <5 cm in diameter Color flow Doppler aids in diagnosis of o Many have a large exophytic renal artery thrombosis component (25%) • There is absence of an o Calcifications not common (6%) intrarenal arterial signal o Plain film findings • Tardus parvus waveform is Mass of fat lucency is lesion is seen if incomplete occlusion or large enough collateral supply o CT findings Nuclear medicine Well-marginated, cortical- • Nuclear imaging shows a based, heterogeneous tumor photopenic area corresponding predominantly of fat density to the region of ischemia or (<-20 HU) infarction Variable enhancement (smooth • Chronic Renal Infarction muscle, vessels) o Pathology • US findings o Highly echogenic tumor due to high fat All elements of kidney atrophied with replacement by content interstitial fibrosis o Less echogenic areas due to hemorrhage, necrosis, dilated calyces Normal or small kidney with smooth contour Kidney, Trauma Grading Globally atrophied parenchyma • Grade 1 Diminished or absent contrast o Hematuria with normal imaging studies material density o Contusions o US o Nonexpanding subcapsular hematomas Increased echogenicity (by 17 • Grade 2 days) o Nonexpanding perinephric hematomas Angiomyolipoma confined to the retroperitoneum o Superficial cortical lacerations less than • Benign mesenchymal tumor of kidney 1 cm in depth without collecting • Rare system injury • Histopathology • Grade 3 - Renal lacerations greater than 1 cm o No true capsule in depth that do not involve the collecting o Commonly bleed system o Tumor composed of fat, smooth • Grade 4 muscle, aggregates of thick-walled o Renal lacerations extending through blood vessels the kidney into the collecting system • Types o Injuries involving the main renal artery o Isolated angiomyolipoma is most or vein with contained hemorrhage common (80%) o Segmental infarctions without Usually solitary associated lacerations Unilateral (80% on right side) o Expanding subcapsular hematomas Not associated with tuberous compressing the kidney sclerosis • Grade 5 Mean age of incidence: 40s o Shattered or devascularized kidney 6 o Ureteropelvic avulsions • Hydronephrosis (83% sensitive, 94% specific) o Complete laceration or thrombus of the • Perinephric fluid (82% sensitive, 93% specific) main renal artery or vein • Ureteral dilatation (90% sensitive, 93% specific) Nephrolithiasis/Urolithiasis • Soft-tissue rim sign (good positive predictive • Passage of a urinary stone is the most common value with a positive odds ratio of 31:1) cause of acute ureteral obstruction KUB -Conventional radiography is often performed as a ULTRASOUND preliminary examination in patients with abdominal - on sonograms, stones are demonstrated as bright pain possibly resulting from urinary calculi echogenic foci with posterior acoustic shadowing. - Stones are visualized fairly well with US in the kidneys and the distal ureter at or near the UVJ, especially if • Stones are often found at key points of dilatation is present. narrowing such as the UPJ, the ureterovesical - US is good for the visualization of complications such junction (UVJ), and the point at which the as hydronephrosis (or other signs of obstruction); ureter crossing the iliac vessels. An addition however, some patients with acute obstruction have site is on the right side where the ureter passes little or no dilation. through the root of the mesentery. • Calcium stones as small as 1-2 mm can be seen. Cystine stones as small as 3-4 mm may be depicted, but uric acid stones are usually not seen unless they have become calcified. Acute obstructive uropathy - is a commonly encountered condition, occurring in both inpatient and outpatient settings. - The most common cause for acute obstructive IVP uropathy is an impacted calculus. In 70% of patients, - useful for confirming the exact location of a stone the level of obstruction is at the ureterovesical within the urinary tract. IVU depicts anatomic junction; in the remainder of patients, the ureteropelvic abnormalities such as dilated calyces, calyceal junction or mid ureter are the points where calculi tend diverticula, duplication, UPJ obstruction, retrocaval to lodge. ureter, and others that may predispose patients to - Most calculi (90%) contain calcium, combined with stone formation or alter therapy oxalate and/or phosphate. - When a stone causes acute obstruction, an - Magnesium ammonium phosphate (struvite) stones obstructive nephrogram may be present. This may be are the next most common type, and are observed prolonged and hyperopaque, with increasing opacity most frequently laminated with calcium apatite. They over time. The nephrogram of acute obstruction is form in the alkaline environment created by urease- usually homogeneous, but may also be striated or splitting bacteria, especially Proteus species, and occasionally not visible on radiographs. commonly produce the staghorn appearance of the - Other signs include delayed excretion, dilatation to pelvocalyceal system. the point of obstruction, or blunting of the calyceal - Uric acid stones are less common, These stones, fornices. Immediately after the passage of a stone, along with the less common xanthine and matrix residual mild obstruction or edema can be detected at calculi, appear radiolucent on plain radiographs. the UVJ. Delayed images may be needed to opacify to Cystine stones are less opaque than calcium stones the point of the obstruction, but using gravity to and may be difficult to demonstrate on plain position the more opaque and more distal contrast radiographs. material–laden-urine is also possible by placing the patient in a prone or erect position. IMAGING CT SCAN CT SCAN - Unenhanced helical CT has both a high sensitivity of -With a sensitivity of 94-97% and a specificity of 96- 95-98% and a high specificity of 96-100% in detecting 100%, ureteral calculi in the acute setting. Both calcified and - helical CT is the most sensitive radiologic examination noncalcified calculi may be identified, along with the for the detection, localization, and characterization of location and size of the stone. urinary calcifications - Secondary signs of obstructive uropathy, including - CT scans frequently depict non-obstructing stones hydronephrosis, perinephric and periureteral stranding, that are missed on IVU. as well as ureterectasis, are well demonstrated on CT. - CT is faster and no contrast agent is needed in most patients. ULTRASOUND - CT easily differentiates between non-opaque stones In the evaluation of acute flank pain, ultrasound (US) is and blood clots or tumors (compared with IVU, which limited primarily to pregnant patients. While US may depict only a filling defect). demonstrates renal calculi, it is poor at detecting - helical CT is better than US or IVU in detecting other ureteral stones causes of abdominal pain CT may depict the following: • Stones in the ureter The hallmark of obstruction on US is the presence of hydronephrosis. Prominent anechoic structures within • Enlarged kidneys 7 the renal sinus represent a dilated pelvocalyceal Intravenous urography system. Renal calculi also may be demonstrated as Intravenous urography (IVU) is also limited in depicting echogenic foci with or without shadowing. This finding RCCs. Large lesions, which can distort the renal contour depends on the size of the calculi, with smaller stones or the collecting system, may be detected. blending into the echogenic renal sinus. Ureteral calculi Findings of RCC are nonspecific and include and ureterectasis are detected less often. While UPJ - mass effect on the collecting system, and UVJ stones may be observed, mid ureteral stones - distortion of the renal contour, are extremely difficult to detect. - enlargement of a portion of the kidney, and - calcifications. KUB - most RCCs are less attenuating than surrounding The plain abdominal radiograph or KUB film has long renal parenchyma. been the initial imaging study of choice in patients - Renal vein invasion may be inferred if contrast presenting with symptoms of acute flank pain material excretion by the affected kidney is poor or absent. Alternatively, this finding may result from extensive involvement of the kidney or ureteral While 90% of stones contain calcium, the sensitivity of obstruction caused by mass effect. plain films has been reported at only 50-60%, with a specificity of 70%. CT SCAN - On initial nonenhanced CT scans, RCCs may appear Most noncalcified stones, blood clots, and most other as isoattenuation, hypoattenuation, or intraluminal obstructive causes are radiolucent; hyperattenuation relative to the remainder of the therefore, they are not seen on abdominal radiographs. kidney. Calcifications may be present and are usually In trauma, the presence of pelvic fractures and soft amorphous and internal, although rimlike calcifications tissue mass in the abdomen or pelvis may alert the can also be present. radiologist to the possibility of ureteral injury, a rare - On contrast-enhanced CT scans, RCC is usually solid, complication, or obstruction from a large hematoma. and evidence of necrosis is often present. Sometimes RCC is a predominantly cystic mass, with thick septa and wall nodularity. RCC may also appear as a completely solid and highly enhancing mass. Renal Cell Carcinoma - Staging of RCC, which can be performed by using CT - the most common primary renal malignant neoplasm or MRI, includes the assessment of ipsilateral or in the adult. contralateral adrenal involvement, direct extension into - It accounts for approximately 85% of renal tumors adjacent organs, enlargement of retroperitoneal lymph and 2% of all adult malignancies. nodes, invasion of the ipsilateral renal vein (with or - RCC is more common in men than in women (ratio, without extension into the inferior vena cava), and 2:1), and distant metastatic disease (liver, bone, lungs). - it most often occurs in patients aged 50-70 years. Retrocrural, subcarinal, or mediastinal lymph nodes can also be enlarged. RCCs can be staged by using the American Joint ULTRASOUND: Committee on Cancer TNM classification, as follows: On sonograms, RCC can be isoechoic, hypoechoic, or hyperechoic relative to the remainder of the renal • Stage 1 RCCs are 7 cm or smaller and confined parenchyma. - Smaller lesions with less necrosis are to the kidney. more likely to be hyperechoic. • Stage 2 RCCs are larger than 7 cm but still - Isoechoic tumors are detected only by distortion of the renal contour, focal enlargement of a portion of the organ confined. kidney, or distortion of the central sinus fat. • Stage 3 tumors extend into the renal vein or - For the workup in RCC, US is used primarily to vena cava, involve the ipsilateral adrenal gland differentiate solid masses from simple cysts and to and/or perinephric fat, or have spread to one visualize the internal architecture of lesions more local lymph node. effectively than can be accomplished by using CT or • Stage 4 tumors extend beyond the Gerota MRI. fascia, to more than one local node or have distant metastases URINARY BLADDER Bladder cystitis Findings: - is defined as inflammation of the urinary bladder Plain radiography from any cause. Plain radiographic findings are often unrevealing in -female individuals, especially those younger than 50 patients with RCC unless the mass contains detectable years, are affected more often than male individuals calcification or is large enough to distort the normal -. The high incidence in women is due to the short renal contour. Plain radiography has no role in the length of the urethra and its proximity to the anus. primary search for RCC or in the follow-up observation of patients with RCC because of its limited sensitivity ULTRASOUND: and specificity. - The bladder appears sonographically normal in most cases but may show thickening of its wall due to edema. 8 - The bladder mucosa is normally less than 2 mm thick when measured at full distension and less than 5 mm thick when nondistended.