ivu--dr juned a ansari
TRANSCRIPT
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INTRAVENOUS UROGRAPHY
PRESENTER : DR JUNED A ANSARI
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The Intravenous Urogram is the classic routine investigation of UroradiologyTechnically satisfactory IVU demonstrates clearly and completely both the renal parenchyma & the collecting system including the calyces, renal pelvis, ureters and the urinary bladder and gives an indication of their function
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1937-Berger made several recommendations•Routine tomography•High dose of contrast agents•Ureteral compression
Introduction of excretory urography 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.
Moses Swick
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INDICATIONS:Persistent or frank haematuriaRenal or ureteric calculiUreteric strictures or fistulasComplex urinary tract infection
CONTRAINDICATIONS:No absolute contraindicationRelative contraindications•Renal & hepatic failure•Multiple myeloma•Pregnancy•Previous reaction to contrast media•H/o allergy•Infancy •Thyroid disease•Diabetes
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PATIENT PREPARATIONPATIENT PREPARATION
Dehydration : Effective fluid restriction may produce a slightly detectable increase in urographic density but the nephrogram is uneffected, hence no longer considered applicable
Bowel preparation
Psychological preparation
Informed consent
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EXPOSURE FACTORSEXPOSURE FACTORS
Kv(p) 66-70mA Sufficiently high to allow short exposure timesFilm/Screen combination Medium speed
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Physiology of contrast excretion
I.V. injection Contrast media
Anion(I2)
Osmotically inert & non reabsorbable
Cation
Meglumine
Not reabsorbedby renal tubules
Sodium
Freely reabsorbed by renal tubules
Following bolus I.V. injection, very rapid plasma concentration is followed by rapid declineRapid mixing in vascular compartmentDiffusion into extravascular, extracellular spaceRenal excretion
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Extrarenal routes for contrast excretion:
Hepatic
Small bowel
Sweat
saliva
Tears
Gastric juice
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PROCEDUREPROCEDURE
Plain film of the abdomen (Scout film)•State of bowel preparation•Calcific density in the renal tract•Soft tissue masses•To observe the abdominal parieties•To check exposure factors & positioning
Oblique views
Contrast administration: bolus/infusion Dose: adults- 50ml of 350-370 strength water soluble contrast children-2-3ml/kg body wt.
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FILM SEQUENCEFILM SEQUENCE1-3 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
Upright post void Antero-posterior
Nephrotomography-whenever anatomic information is obscured
Role of delayed films- rule of eight
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Contraindications to ureteral compression:
Suspected or proven aortic aneurysm
Evidence of obstruction in early urogram films
Recent abdominal surgery
Severe hypertension
Abdominal pain on application of compression
Recent acute injury
Renal transplantation
Abdominal distension
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WHAT TO LOOK FOR IN IVUWHAT TO LOOK FOR IN IVU
Size, shape, position and axis of kidneysExternal cortex and inner medullaCalyceal systemRenal pelvis and ureteropelvic junctionUreterUretero-vesical junctionUrinary bladderRelation of ureter to spine and psoas muscle
RADIATION DOSE FROM IVU1,465 mR/projection for males1,047 mR for femalesTotal dose to the gonads / exam-751 mR –males 577 mR-females
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UROGRAPHIC INTERPRETATIONUROGRAPHIC INTERPRETATION
Nephrogram- Provides information regarding arterial perfusion of the kidney as well as the functional & structural integrity of the nephrons
•Vascular/ capillary/cortical nephrogram- due to distribution of contrast media in the cortical microvasculature
•Urographic/parenchymal nephrogram- due to entry of contrast in the proximal tubules
•Fading of contrast- continous flow of contrast in the tubules -reduced plasma conc. of C.M.
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NEPHROGRAPHIC PATTERNS
Immediate Faint Persistent Nephrogram
Due to severe impairment of Glomerular filtration
•Proliferative/necrotising disorders
•Renal vein thrombosis
•Chronic severe ischaemia
Immediate Dense Persistent Nephrogram
Due to unimpaired glomerular filtration
•Acute tubular necrosis
•Acute renal failure
•Acute on chronic renal failure
•Acute hypotension
Increasingly Dense Nephrogram
•Acute obstruction . Acute Pyelonephritis
•Acute Hypotension . Multiple Myeloma
•Acute tubular necrosis . Renal vein thrombosis
•Acute glomerulonephritis .Amyloid, Acute papillary necrosis
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Increasingly Dense Nephrogram
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Rim Nephrogram
•Severe hydronephrosis
•Acute complete arterial occlusion
Striated Nephrogram
•Acute ureteric obstruction
•Infantile polycystic disease
•Medullary sponge kidney
•Acute pyelonephritis
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Pyelogram
Value of compression
•In normally functioning kidneys, contrast is first seen in the calyces at 2 mins following bolus injection.
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UretersUreters begin to transport opacified urine about 3 mins post injectionMaximum ureteral filling occurs between 5-10 minutes.
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Bladder
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MINUTE SEQUENCE IVP
Evaluation of renovascular hypertension
Minimum series includes films at 1,2,3 minutes, post injection
Criteria
•Delayed visualisation of contrast in the collecting system on the affected side
•Decreased renal size
•Delayed washout of contrast
•Notching of the proximal ureter
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HIGH DOSE UROGRAPHY
Indicated for imaging the kidneys in patients with mild renal impairment
Prerequisites
.Adequate hydration
•Optimal metabolic & CVS condition
•Higher contrast medium dose
•Use of low osmolality agent
FINDINGS IN CRFReduced renal sizeParenchymal thinningNormal pevicalyceal anatomy
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ADVERSE REACTIONS
Minor reactions- flushing,arm pain, nausea, vomiting, headache, rigors and mild urticaria.
Intermediate reactions-•More severe degrees of the above mentioned symptoms•Moderate degrees of hypotension and bronchospasm
Severe life threatening reactions-•Severe manifestations of above symptoms•Severe bronchospasm•Unconsciousness•Laryngeal oedema•Pulmonary oedema•Severe cardiac dysaarrythmias•Cardiac arrest•Cardiovascular and pulmonary collapse
Death
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IVU findings in certain entitiesIVU findings in certain entities
Renal agenesis
U/L-Absent renal outline & U/L-Absent renal outline & pelvicalyceal system, pelvicalyceal system, 9999mmTcTc
DMSA most sensitiveDMSA most sensitive
B/L-Uncommon & B/L-Uncommon & incompatible with lifeincompatible with life
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Renal Ectopia
Failure of complete ascent of the kidney to its normal position
IVU- abnormally placed kidneys
Pancake kidney
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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
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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
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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
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Ureterocele
Contrast filled structure with a thin smooth radiolucent wall surrounded by contrast containing urine in the bladder- “Cobra’s head’ appearence
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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.
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Congenital HydronephrosisDue to functional obstruction at the pelvi-ureteral junctionAetiology- cong. Bands, adhesions, neuro muscular inco-ordination, abberent vesselsAdvanced cases• large soft tissue mass replacing the renal parenchyma•No opacification of collecting systemLesser degrees of obstruction• Nephrogram- thin rim of renal substance outlining the kidney•Later films – crescent shaped opacities produced by dilated stretched tubules surrounding the enlarged non opacified calyx•Delayed films – slow filling of calyces & renal pelvisMild forms•“Wine glass appearance”Mildest form- minimal deviation from the normal appearance
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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
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Medullary sponge kidney
Brush like linear striations in renal papillae
Enlargement of kidney
Renal calculi
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Acute urinary obstruction
Increasingly dense “obstructive” nephrogram
Moderate kidney enlargement
Delayed calyceal opacification
Minimal to moderate pelvicalyectasis
Standing column of the ureter
Spontaneous pyelosinous extravasation
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Chronic urinary obstruction
Kidney size -large(partial obstruction) -small(complete obst) Nephrogram density - normal or reduced Parenchymal thickness-
reduced Pyelogram-
Hydronephrosis Ureter-dilatation &
tortuosity -mucosal striations
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Renal Vein Thrombosis
Enlarged kidney with faint or absent Nephrogram
Pelvicalyceal filling maybe absent or the PCS stretched & compressed by oedematous renal parenchyma
Rarely, increasingly dense nephrogram, sometimes wiyh striation
Later stages- Renal atrophy
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Renal masses
Small SOL
Localised bulge with increased thickness of the renal substance
Deforms or displaces or distends a calyx
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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
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Renal tuberculosis
Early stage Irregularity or destruction of
one or more papillae
Later stage Calcification
Renal
Parenchymal
Punctate calcification
Calcification within caseous pyonephrosis
Proceeds to Tuberculous Autonephrectomy
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Cavities- irregular, communicates
with the collecting system
Fibrosis- leading to obstruction
- Hydronephrosis, hydrocalicosis
Bladder wall-Thickened and trabeculated
- small capacity bladder
Concentration of contrast medium is poor in proportion to the degree of obstruction
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Conclusion
“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.”
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