outline - siriraj hospital · outline •introduction to ... - 10- min or other delayed images -...
TRANSCRIPT
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Outline
• Introduction to imaging modalities of the urinary system
• Case base learning of common diseases in urinary tract
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Outline
• Introduction to imaging modalities of the urinary system
• Case base learning of common diseases in urinary tract
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Diagnostic Investigations in Urinary System
• PLAIN KUB
• EXCRETORY UROGRAPHY
• RETROGRADE PYELOGRAPHY
• ULTRASOUND
• COMPUTED TOMOGRAPHY
• MAGNETIC RESONANCE IMAGING
• ANGIOGRAM
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• PLAIN RADIOGRAPHY: PLAIN KUB
• EXCRETORY UROGRAPHY
• RETROGRADE PYELOGRAPHY
• ULTRASOUND
• COMPUTED TOMOGRAPHY (CT)
The general used investigations in
urinary tract system
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PLAIN RADIOGRAPHY
Density levels
1. Air density
2. Fat density
3. Soft tissue/fluid/water density
4. Bone/calcific density
5. Metallic density
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PLAIN KUB
• Renal shadows
• Psoas shadows
• Bladder shadow
• Calcification
• Bony structure
• Other soft tissue structures: liver/spleen, abnormal mass
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STAGHORN STONE
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VESICAL STONE
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Excretory Urography
• Intravenous pyelography: IVP• Intravenous urography: IVU• Advantages
-Anatomy: kidney and collecting system-Excretory function-Obstructive uropathy
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Excretory Urography
• Scout image
• Dynamic study
- 1-min film / 5-min of both kidneys
- 10- min or other delayed images
- full bladder image
• Post-void image
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Normal Pyelogram (IVP 5 min)
renal papilla
minor calyx
renal papilla
major calyx
renal pelvis
ureter
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NORMAL IVP
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Excretory Urography
1. Anatomy: Renal size, shape, axis and position
2. Excretory function: normal, delay, poor, no excretion
3. Obstructive uropathy: hydronephrosis, hydroureter
4. Distortion or destruction of collecting system
5. Filling defect in pelvocalyceal system, ureter or bladder
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A 55-year-old man with hematuria
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Retrograde Pyelography (RP)
• Direct injection of contrast medium into pelvicalyceal system or ureters via the catheter
• Demonstrates pelvicalyceal system and ureters
• Limitations
- invasive technique: cystoscope
- cannot evaluate renal function
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Retrograde Pyelography
Indications
• Evaluate collecting system in patients with hematuria
• Findings on IVP, US, or CT are not clear
• Poor renal excretion
Contraindication
• Urinary tract infection
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ULTRASOUND (US)
• Safe and cheap
• Portable
• No radiation
• No intravenous contrast medium
• Advantages for patients with renal failure, children and pregnancy
• Limitation to evaluate renal function or obese patient
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KIDNEY
Normal sonographic finding
• Shape: bean shape
• Size: 9-12 cm. in long axis
• Echogenicity:
- Renal parenchyma: hypoecho and 1 cm in thickness
- Central part or renal sinus: hyperecho
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HYDRONEPHROSIS
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CHRONIC RENAL DISEASE
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NORMAL BLADDER
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Color-Doppler Ultrasound
• Evaluate renal vascular disease
- Renal artery
- Renal vein
• Evaluate tumor vascularization
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Color-Doppler Ultrasound
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COMPUTED TOMOGRAPHY (CT)
Indications
• Detection and characterization of adrenal gland,
KUB system and pelvic organ
• Evaluate retroperitoneal disease
• Staging tumor and follow up after treatment
Limitations
• Pregnancy: radiation
• Renal insufficiency/failure : CT need IV contrast
medium administration
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Renal cell carcinoma
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CT Urography (CTU)
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CT ANGIOGRAPHY (CTA)
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Outline
• Introduction to urinary tract
• Case base learning of common disease in urinary tract
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Hematuria
Causes of hematuria
• Stone
• Tumor
• Infection
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Case 1 : A 46-year-old woman with right colicky pain and hematuria
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Urinary calculi
• Opaque stones : calcium oxalate, carbonate, phosphate
• Poor density stones : uric acid, xanthine, cystine
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Urinary calculi
Plain KUB / IVP
• Location: calyx, renal pelvis, ureter, bladder
• Shape: staghorn, round/oval (ureteric stone), lamellation (vesical stone)
IVP
• Severity and location of obstruction
• Renal function
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Semiopaque vesical stones
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Differential diagnosis
Filling defects in collecting system
• blood clot
• tumor
• stone
• fungal ball
• polyp
• air bubble
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Urinary calculi
Ultrasound
• Diagnosis of non-opaque stone
echogenic material with acoustic shadow
• Severity and location of obstruction
• Renal size and cortical thickness
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Vesical stone
Renal stone with hydronephrosis
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Urinary calculi
CT scan Lt.renal stone
Lt.renal stone
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Quiz : Renal or extrarenal calcification?
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Quiz : Renal or extrarenal calcification?
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Quiz : Renal or extrarenal calcification?
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Extra-urinary calcific shadows
1. Calcified costal cartilage2. Calcified mesenteric LN3. Calcified iliac and splenic vessels4. Phleboliths5. Gallstones, CBD, and cystic duct stones6. Transverse process of L-spine7. Intestinal content8. Calcified appendicolith9. Pancreatic calcification
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Case 2 : A 50-year-old woman with underlying DM presented with fever and sepsis
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Case 2 : A 50-year-old woman with underlying DM and present with fever and sepsis
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Emphysematous pyelonephritis
• Rare, life-threatening condition
• Severe pyelonephritis with gas-producing organism (Gram-neg. bacilli: E.coli)
• Elderly diabetic patient (DM 87 – 89 %)
• Clinical symptoms & signs : chills, fever, flank pain, lethargy, confusion, septicemic shock
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Emphysematous pyelonephritis
IVP• Gas bubbles in renal bed, upper renal collecting
system• Renal enlargement • Delayed or absent renal excretion• Obliteration of the renal pelvis CT• Investigation of choice • Intraparenchymal, intracalyceal, intrapelvic gas
and extension into perinephric space
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Case 3: Spot diagnosis ?
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Renal Tuberculosis: Typical Findings
• Early : difficult to detect due to miliary tubercles in renal parenchyma
• Moderate : minimal irregularity of pyramid, fornix or isthmus
: destruction of papilla
: isthmus stenosis due to fibrosis
: deformity of pelvicalyceal system
: cavity (caseous material & necrosis)
: reduction in renal size
• Severe : nephrocalcinosis (putty calcification)
: autonephrectomy
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Case 4: Spot diagnosis ?
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HORSESHOE KIDNEY
• Most common renal anomaly (1:400 live birth)
• Male : female = 2:1
• Midline connection may be by functioning renal perenchyma or fibrotic band
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Case 5: Diagnosis ?
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Case 5: Diagnosis ?
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SIMPLE CYST
• The most common renal masses ~ 65-70 % of cases
• Occur in patients > 50 years old
• Solitary or multiple
• Bilateral cysts: less common
• Size: variable
• No symptom, incidental finding
• Serous containing
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SIMPLE CYST
US
• well defined, smooth wall
• anechoic
• posterior enhancement
CT
• homogeneous water density
• thin septation may be identified
• no enhancement
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Case 6: A 60-year-old man with hematuria
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Renal cell carcinoma (RCC)
• Most common primary malignant renal tumor in adults
• Male : female = 2.5:1• Age : 50-70 years
Increased incidence • Tobacco• Acquired cystic disease of uremia• Hemodialysis
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Renal cell carcinoma (RCC)
Clinical presentation:
•Classic triad:
gross hematuria (60%)
flank pain (50%)
palpable renal mass (<10%)
•Distant metastases: lung, bone, liver and brain
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Renal cell carcinoma (RCC)
IVP
• distortion, enlarged renal portion
• displaced / obliterated collecting system, filling defect
• diminished function
• soft tissue mass
US : Hyperechoic mass with inhomogeneityCT : Hypervascular renal mass
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Case 7: What is it?
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Case 8: What is type of calcification?
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Which cases did you learn today?
1.Calculous disease D/D calcification on plain KUB
2.Infection – bacterial, TB
3.Renal cystic disease
4.Congenital anomaly - horseshoe kidney
5.Renal tumor
6.Calcified ovarian dermoid/uterine fibroid myoma
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REFERENCES
1. Armstong P, Rockall A, Wastie M. Diagnostic imaging. 6th ed. Williston: Wiley Blackwell; 2009
2. Dunnick R, Sandler C, Newhouse J. Textbook of Uroradiology. 5th ed. Lippincott Williams & Wilkins; 2013