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Ivu ppt

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Ivu ppt

  1. 1. Intravenous Urography Anoopkrishnan
  2. 2. Definition It is the radiographic examination of the urinary tract including the renal parenchyma, calyces and pelvis after the intravenous injection of the contrast media.
  3. 3. Intravenous Urography Use decreased significantly in recent years CT, US, MR is replacing Remains primary modality for visualization of pelvicalyceal system and ureter
  4. 4. Introduction of excretory urograpy was done in 1929, by American urologist Moses Swick. He injected an organically-bound iodide compound—later named Uroselectan—into a vein, taking X-rays as the material cleared the body through the urinary tract. 1937-Berger made several recommendations •Routine tomography •High dose of contrast agents •Ureteral compression Moses Swick
  5. 5. Terminology  Urogram Visualization of kidney parenchyma, calyces and pelvis resulting from IV injection of contrast.  Pyelogram Describes retrograde studies visualizing only the collecting system. So, IVP is misnomer, should be IVU
  6. 6. Cystography Describes visualization of the bladder Urethrography Visualization of urethra Cystourethrography Combined study to visualize bladder and urethra.
  7. 7. One more word about terminology…. Contrast is what we give intravenously. Dye is used on clothes and in cooking to change the color of things—it is not given IV to patients!
  8. 8. Indications American College of Radiology (ACR) guidelines published in 2010 To evaluate the presence or continuing presence of suspected or known ureteral obstruction. To assess the integrity of the urinary tract status post trauma. To assess the urinary tract for suspected congenital anomalies. To assess the urinary tract for lesions that may explain hematuria or infection Investigation of HTN in young adults not controlled
  9. 9. contraindications No absolute contraindication Relative contraindications Renal failure (raised serum creatinine level >1.5 mg/dL) Hepatorenal syndrome Previous allergy to the contrast agent/iodine Generalized allergic conditions  Multiple myeloma Pregnancy Infancy Thyrotoxicosis Diabetes
  10. 10. Advantages Clear outline of the entire urinary system so can see even mild hydronephrosis.  Easier to pick out obstructing stone when there are multiple pelvic calcifications. Can show non-opaque stones as filling defects.  Demonstrate renal function and allow for verification that the opposite kidney is functioning normally.
  11. 11. Disadvantages need for IV contrast material may provoke an allergic response multiple delayed films (Can take hours as contrast passes quite slowly into the blocked renal unit and ureter.) May not have sufficient opacification to define the anatomy and point of obstruction. Requires a significant amount of radiation exposure and may not be ideal for young children or pregnant women
  12. 12. Internal structure The parenchyma of the kidney is divided into two major structures: superficial is the renal cortex and deep is the renal medulla. Grossly, these structures take the shape of 8 to 18 cone-shaped renal lobes, each containing renal cortex surrounding a portion of medulla called a renal pyramid (of Malpighi).  Between the renal pyramids are projections of cortex called renal columns (of Bertin).
  13. 13. Nephrons, the urine-producing functional structures of the kidney, span the cortex and medulla. The tip, or papilla, of each pyramid empties urine into a minor calyx  minor calyces empty into major calyces, and major calyces empty into the renal pelvis, which becomes the ureter.
  14. 14. Relations of kidneys Superiorly, the suprarenal (adrenal) glands sit adjacent to the upper pole of each kidney On the right side, the second part of the duodenum (descending portion) abuts the medial aspect of the kidney On the left side, the greater curvature of the stomach can drape over the superomedial aspect of the kidney, and the tail of the pancreas may extend to overlie the renal hilum
  15. 15. The spleen is located anterior to the upper pole of left kidney and is connected by the splenorenal (lienorenal) ligaments Inferiorly to these organs, the colon typically rests anteriorly to the kidneys on both sides Posteriorly, the diaphragm covers the upper third of each kidney, with the 12th rib most commonly crossing the upper pole The kidneys sit over the psoas (medially) and the quadratus lumborum muscles (laterally)
  16. 16. Contrast High osmolar contrast media Low osmolar contrast media Iso osmolar contrast media
  17. 17. All currently used IRCM are chemical modifications of a 2,4,6-tri-iodinated benzene ring.  They are classified on the basis of their physical and chemical characteristics, including their chemical structure, osmolality, iodine content, and ionization in solution.  In clinical practice, categorization based on osmolality is widely used.
  18. 18. 2,4,6 tri iodinated compound i i i Carboxl HOCM Organic sidechain 3 5 variation various brands OH LOCM dissociates iodinated anion CationNa,meglumine monomer/dimer
  19. 19. HOCM High-osmolar contrast media (HOCM) are the oldest agents.  They are relatively inexpensive, but their utility is limited. They are monomers (single benzene ring) that ionize in solution with a valence of -1.  Their cation is either sodium or meglumine.
  20. 20. HOCM Diatrizoate –Na10%,Meg66%-Hypaque76 Iothalmate-Na66.8—Conray400 Diatrizoate –Na35% meg34.3%—Renovist Diatrizoate-Na10%meg66%--renografin76
  21. 21. LOCM major advance was the development of non ionic compounds. They are monomers that dissolve in water but do not dissociate.  Hence, with fewer particles in solution,
  22. 22. LOCM Hydrophilic Non-ionise Osmotic load<50% <complications
  23. 23. Iso -osmolar contrast media The most recent class of agents is dimers that consist of a molecule with two benzene rings (again, each with 3 iodine atoms) that does not dissociate in water(nonionic).
  24. 24. Dose of 200mg of iodine per pound body wt-dose of 20-30g. Injection completed within 60 sec-rapidly injecting as bolus with 50 ml syringes. Slow injections decrease side effects but provides less dense nephrogram Another method –drip infusion technique,infusion kit with 40-50g iodine delivered in 250-400ml fluid.
  25. 25. DRIP infusion Advantages  Nephrogram prolonged >diuresis—distends collecting system & ureter Collecting system—visualised longer time-more flexibility in filming Ureter compression not necessary Administration easy Disadvatages Overloads with more iodine Calyceal blunting Pyelosinus extravasation—pain  may produce CCF  increased Diuresis- decrease visualisation Initial vascular nephrogram not obtained
  26. 26. PREPARATION OF THE PATIENT Complete urine and blood examination to assess the renal function. The patient is given mild laxatives(1-2 oz castor oil) about twelve to twenty four hours before the proposed x-ray examination. (A night before the urographic examination) .Eliminates fecal material and reduces amount of gas in bowel. The patient is kept nil by mouth over night and is dehydrated by stopping the fluid intake. Most uroradiologist believe that with modern contrast media overhydration should be avoided but dehydration is unnecessary. In practice adviced omit fluids after 11pm,omit breakfast which decreases chance of vomiting and produce slight dehydration.
  27. 27. The dehydration helps in better concentration of the contrast and clearer x-ray pictures. The patient should not be dehydrated if suffering from renal failure as it may lead to severe fluid and electrolyte imbalance. Sensitivity to the dye (Hypaque or Urographin)checked. Necessary precautions are taken to avoid the allergic reactions. Take informed consent.
  28. 28. Physiology of contrast excretion Following bolus I.V. injection, very rapid plasma concentration is followed by rapid decline Rapid mixing in vascular compartment Diffusion into extravascular, extracellular space Renal excretion I.V. injection Contrast media Anion(I2) Osmotically inert & non reabsorbable Cation Meglumine Not reabsorbed by renal tubules Sodium Freely reabsorbed by renal tubules
  29. 29. Extrarenal routes for contrast excretion: Hepatic Small bowel Sweat  saliva Tears Gastric juice
  30. 30. Procedure requirements
  31. 31. Equipments: Medium powered X-Ray generator set-up, typical 40-60 kW. Basic tomography equipment. Abdominal compression equipment. Medium / Regular film screen combination in a variety of sizes.
  32. 32. Pads and immobilisation aids. Intravenous administration equipment: 50 ml syringe, filling needle, skin prep, sticky tape, Selection of needles, straight/'Butterfly' 16, 19, 21,23 gauge. Tourniquet or blood pressure cuff. Emergency drugs and equipment.
  33. 33. 57 09/06/14
  34. 34. Technique Venous access via the median antecubital vein is the preferred injection site because flow is retarded in the cephalic vein as it pierces the clavipectoral fascia. The gauge of the cannula/needle should allow the injection to be given rapidly as bolus to maximize the density of nephrogram. Upper arm or shoulder pain may be due to stasis of contrast in vein which may be relieved by abduction of the arm. 58 09/06/14
  35. 35. PROCEDURE Plain film of the abdomen (Scout film) •State of bowel preparation •Calcific density in the renal tract •Soft tissue masses •To observe the abdominal parities •To check exposure factors & positioning Oblique views- optional Contrast administration: bolus/infusion Dose: adults- 50ml of 350-370 strength water soluble contrast
  36. 36. Films Preliminary film:  Supine, full length AP of abdomen in inspiration.  The lower border of cassette is at the level of symphysis pubis and the x-ray beam is centred in the midline at the level of iliac crests.  To demonstrate bowel preparation, check exposure factor, and location of radiopaque stones or any radiopaque artifacts. 60 09/06/14
  37. 37. If necessary the position of overlying opacities may be further demonstrated by: Supine AP of renal areas, in expiration. The x-ray beam is centred in the mid-line at the level of lower costal margin Or 35° posterior oblique views, or, Tomography of the kidneys at the level of a third of the AP diameter of the patient (app.8-11 cm). The optimal angle of swing is 25-40°. The examination should not proceed until these films are reviewed by radiologist and claimed satisfactory. 61 09/06/14
  38. 38. Contrast media: Low osmolar contrast media (LOCM)- 300- 600mgI/ml Adult dose : 50-100ml Paediatric dose : 1ml/kg 62 09/06/14
  39. 39. FILM SEQUENCE 1-3 minutes Antero-posterior- film coned to the renal area 5 minutes Antero-posterior-film coned to the renal area Apply ureteral compression 10 minutes Antero-posterior Release compression “Flush”, “X” or “Release view”- - full length view at 20 minutes Upright post void Antero-posterior
  40. 40. Scout film Calculus Skeletal abnormality Intestinal gaspattern Calcifications Abdominal masses Foreign bodies
  41. 41. Contraindications to ureteral compression Evidence of obstruction on the 5-minute image Abdominal aortic aneurysm or other abdominal mass Severe abdominal pain Recent abdominal surgery Suspected urinary tract trauma Presence of a urinary diversion Presence of a renal transplant
  42. 42. WHAT TO LOOK FOR IN IVU Size, shape, position and axis of kidneys External cortex and inner medulla Calyceal system Renal pelvis and ureteropelvic junction Ureter Uretero-vesical junction Urinary bladder Relation of ureter to spine and psoas muscle RADIATION DOSE FROM IVU 1,465 mR/projection for males 1,047 mR for females
  43. 43. The size of the kidneys should be assesed during neprographic phase The normal kidney may range from 9 to13 cm in cephalocaudal length, with the left kidney inherently larger than the right by 0.5 cm and the kidneys slightly larger in men than in women Significant discrepancies (right kidney 1.5 cm larger than the left kidney,left kidney 2 cm larger than the right kidney) require explanation.
  44. 44. Pyelogram •In normally functioning kidneys, contrast is first seen in the calyces at 2 mins following bolus injection. Value of compression
  45. 45. On the 5-minute image, the nephrogram should be receding as the collecting system becomes opacified. On the 10-minute image, the pyelogram is the dominant urographic element. Alterations in this temporal sequence require explanation.
  46. 46. Visualization of the collecting system and renal pelvis can be augmented with the use of abdominal compression, Trendelenburg position, and other gravity maneuvers such as placing the patient with the side of interest in the ipsilateral posterior oblique position The appearance of the calices and renal pelvis should be examined closely
  47. 47. Early and mild obstruction is indicated by subtle rounding of the forniceal margins more severe and prolonged obstruction evidenced by progressive loss of the papillary impression and eventual clubbing of calices.
  48. 48. Ureters Ureters begin to transport opacified urine about 3 mins post injection Maximum ureteral filling occurs between 5-10 minutes.
  49. 49. At the release of compression, the bolus of contrast material– laden urine entering the ureters provides optimal visualization throughout their length Persistence of a standing column of contrast material on several images may indicate obstruction or ureteral ileus (nonobstructive dilatation). Medial deviation of the ureter should be considered when the ureter overlies the ipsilateral lumbar pedicle. lateral deviation should be considered when the ureter lies more than 1.5 cm beyond the tip of the transverseprocess, but comparison with the position of the contralateral ureter should always be made
  50. 50. Urographic image demonstrates acute medial deviation of the right ureter produced by an aneurysm of the internal iliac artery.
  51. 51. Ureteral filling defects may be single or multiple and can usually be attributed to luminal, mural, or extrinsic causes.
  52. 52. Urographic image shows multiple filling defects in the left renal pelvis and ureter.  Multifocal transitional cell carcinoma was confirmed in this case.
  53. 53. An absolute ureteral diameter exceeding 8 mm is considered a criterion for dilatation Asymmetry of ureteral caliber is a more significant finding. Early in its course, high-grade ureteral obstruction may be associated with only minimal ureteral dilatation. More chronic forms of obstruction and other chronic ureteral conditions are typically associated with greater degrees of ureteral dilatation
  54. 54. Bladder
  55. 55. By 15–30 minutes after the injection of contrast material, the bladder is often sufficiently filled, and the 15-minute KUB radiograph may be adequate for evaluation.  As the bladder distends with contrast the intraluminal contrast material should be spheric and smoothly marginated and the wall progressively less evident.
  56. 56. Bladder wall thickening and irregularity of the luminal contrast material associated with a bladder base defect is typical of changes of bladder outlet obstruction from prostatic disease. Contour abnormalities from cellule or diverticulum formation.
  57. 57. Bladder transitional cell carcinoma.  Bladder image shows a filling defect with a papillary configuration along the right bladder wall  Note the irregular distribution of contrast material  associated with the filling defect (“stipple sign”)
  58. 58. The postvoid image may also be helpful in evaluating patients with upper urinary tract dilatation. Persistence of the dilatation on the postvoid image suggests fixed obstruction, The postvoid image is most helpful in assessing residual volume.
  59. 59. Extravasation of contrast medium Local pain, erythema, swelling Usually resolve with local therapy Rarely, significant tissue necrosis and skin-sloughing occur (even with small amounts)  severe, may lead to compartment syndrome Severe edema, loss of pulses, necrosis More common with injection in hand or foot
  60. 60. Initial recommended treatment of extravasation  - Elevation of affected extremity above heart  - Ice packs (15-60min/3 times per day) - Close observation for 2-4 hrs
  61. 61.  Immediate plastic surgery consultation for the following indications Extravasated volume exceeds 100 cc of nonionic contrast Skin blistering Altered tissue perfusion Decreased capillary refill over or distal to injection site Increasing pain after 2-4 hours Change in sensation distal to site extravasation
  62. 62. Renal agenesis U/L-Absent renal outline & pelvicalyceal system, 99mTc DMSA most sensitive test. B/L-Uncommon & incompatible with life
  63. 63. Renal Ectopia Failure of complete ascent of the kidney to its normal position IVU- abnormally placed kidneys
  64. 64. Crossed fused renal ectopia  Two complete pelvicalyceal systems on one side usually one above the other  Ureter from the lower renal pelvis crosses the midline and enters bladder normally
  65. 65. Horseshoe kidney Kidneys placed lower than normal Malrotation of pelvis Lower pole calyces of both sides deviated towards midline Ureters have characteristic vaselike curve Pelvicalyectasis Renal calculi
  66. 66. Intravenous urogram (IVU) shows an altered renal axis with medially directed lower renal poles, which suggests horseshoe kidney. Also note the dilated collecting system of the left kidney, resulting from a uretero pelvic junction obstruction; this is a frequently associated finding
  67. 67. Duplex collecting system  Minor form – bifid renal pelvis  Ureteral duplication  Incomplete – ureters fuse in their course  Complete – 2 ureters open seperately in bladder, lower moiety inserted orthoptically & upper moiety ectopically  “Drooping lily” sign-obstructed upper moiety ureter, in a completely duplicated system, may produce downward and lateral displacement of the functional lower moiety collecting system,
  68. 68. Horse shoe kidney Duplex bilateral 134 09/06/14
  69. 69. Ureterocele Contrast filled structure with a thin smooth radiolucent wall surrounded by contrast containing urine in the bladder- “Cobra’s head’ appearence
  70. 70. Retrocaval ureter The ureter may have a sickle, S or reverse J appearance before crossing behind and medial to the IVC. The ureter descends medial to right lumbar pedicle. Proximal ureter is dilated.
  71. 71. Congenital Hydronephrosis  Due to functional obstruction at the pelvi-ureteral junction Aetiology- cong. Bands, adhesions, neuro muscular inco-ordination, abberent vessels Advanced cases • large soft tissue mass replacing the renal parenchyma • No opacification of collecting system Lesser degrees of obstruction • Nephrogram- thin rim of renal substance outlining kidney • Later films – crescent shaped opacities produced by dilated stretched tubules surrounding the enlarged non opacified calyx • Delayed films – slow filling of calyces & renal pelvis Mild forms •“Wine glass appearance” Mildest form- minimal deviation from the normal appearance
  72. 72. Grading of hydronephrosis Gr 1-dilatation of renal pelvis without dilatation of calices,prominent reflex of renal sinus without signs of parenchymal atrophy. Gr2-dilatation of renal pelvis and calices ,pelvicalyceal pattern is maintained,no signs of parenchymal atrophy Gr3-moderate dilatation of renal pelvis and calyces ,blunting of fornices and flattening of papillae,mild cortical thinning may be seen Gr4-gross dilatation of renal pelvis and calyces which appear ballooned ,loss of borders between renal pelvis and calyces,renal atrophy seen as cortical thinning.
  73. 73. The balloon on a string sign This sign refers to the appearance of a high and somewhat eccentric exit point of the ureter from a dilated renal pelvis and is a typical finding of ureteropelvic junction obstruction
  74. 74. PUJO
  75. 75. Polycystic kidneys  Autosomal dominant  Plain films- cyst calcification  IVU- enlarged kidneys with compression and displacement of calyces by intrarenal cyst  Autosomal recessive B/L symmetrical enlargement of kidneys Streaky nephrogram Calyces maybe distorted
  76. 76. Dromedary hump. Tomogram from excretory urography demonstrates a prominent cortical hump in the interpolar region of the left kidney.  On a compression image obtained in a later phase of the sequence, the hump is subtended by a normal collecting system element, indicating that it represents normal functioning tissue.
  77. 77. Bladder calculi 157 09/06/14
  78. 78. Medullar y sponge kidney  Brush like linear striations in renal papillae Enlargement of kidney Renal calculi
  79. 79. Renal masses Small SOL  Localised bulge with increased thickness of the renal substance  Deforms or displaces or distends a calyx
  80. 80. Medium sized lesions Localized or generalized enlargement of the kidneys Displacement or distortion of renal pelvis, ureter or adjacent structures Malrotation Very large lesions Non functioning kidneys Calycine spreading Visceral displacement
  81. 81. Bladder transitional cell carcinoma .  Bladder image shows a filling defect with a papillary configuration along the right bladder wall  Note the irregular distribution of contrast material  associated with the filling defect (“stipple sign”)
  82. 82. GU Tb-plain KUB Disparity in renal size on plain films may indicate early increase in size of the affected kidney due to caseous lesions or a shrunken fibrotic kidney of autonephrectomy. Calcifications are seen in 30% to 50% A characteristic diffuse, uniform,extensive parenchymal, putty-like calcification, forming a lobar cast of the kidney is seen with autonephrectomy Calculi may also be seen in the collecting system or ureter secondary to stricture formation.  Ureteral calcifications are rare and are characteristically intraluminal as opposed to the mural calcifications of schistosomiasis
  83. 83. . Bladder wall calcifications seen in late cases of bladder contraction.  Calcifications of the prostate and seminal vesicles are seen in 10% of cases . Plain film findings suggestive of tuberculosis may be seen in surrounding tissues such as erosions of the vertebral bodies or calcifications in a cold abscess of the psoas muscle.
  84. 84. GU Tb-IVU The most common findings being hydrocalycosis,hydronephrosis, or hydroureter due to stricture formation .  Early signs include the moth-eaten appearance of calyceal erosion and papillary irregularity- signs are best seen on early excretory films.
  85. 85. Cavitary lesions communicating with the collecting system are characteristic of TB.  These lesions eventually enlarge as parenchymal destruction ensues. Fibrotic distortion of the collecting system and ureter is also seen. Calyceal obliteration and amputation, hydrocalycosis, segmental or total hydronephrosis, and a shriveled reduced capacity renal pelvis may all be signs of renal tuberculosis
  86. 86. Scarring and angulation of the ureteropelvic junction (UPJ) may also occur, the so-called “Kerr’s kink” . Tuberculosis of the ureter is commonly seen as a rigid, straightened “pipe-stem” ureter also beaded, corkscrew appearance.  Ureterovesical junction obstruction is caused by tuberculous cystitis or strictures of the distal third of the ureter. secondary stone formation on top of this stricture . The cystogram films may show a small contracted bladder due to excessive fibrosis
  87. 87. “A tailored urographic study allowing optimal visualization of sequentially opacified portions of the urinary tract may provide diagnostic detail in certain portions of the urinary system beyond the current capabilities of other imaging modalities. This can be accomplished only with good technique, an understanding of the limitations of the procedure, and adherence to basic rules of interpretation. The ability to correlate urographic findings with those from other imaging modalities will remain an important skill until an ideal "global" urinary tract imaging technique emerges.”
  88. 88. The professors of forensic medicine, Derobert and Dehouve (who also was a radiologist), together with Wolfromm, an allergologist, wrote in 1964: “More patients died from lack of an IVU than patients died because they were submitted for an IVU” However,urography now faced the challenge of the alternative methods of US and CT, and the new generation of uroradiologists needed to develop strategies for using them optimally.
  89. 89. Thank you

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