Nitin IVP final

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That is a good presentation doctor

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LearningRadiology.com Intravenous Urography All the basics you need to know © Dr. Nitin Bhutada Junior resident 1 IGGMC NAGPUR

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Introduction 4 Radiological Anatomy 12 Contrast & Excretion Physiology 6 Routine procedure/filming sequence 13 Analysis of IVU 23 Films in Congenital anomaly 9 Recent advances in urography 5 Spotter

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Definition LearningRadiology.com It is the radiographic examination of the urinary tract including the renal parenchyma, calyces and pelvis after the intravenous injection of the contrast media.

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1923 discovery of principal of IVU Sodium iodide severe reaction 1928 Real debuted 1930 di-iodinated contrast 1955-3 rd generation(diatrizoate) 1977-4 th generation (Iopamidol) Use decreased significantly in recent years CT, US, MR is replacing Remains primary modality for visualization of pelvi calyceal system and ureter

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Indications : Investigation of Heamaturia. Renal and ureteric calculi (particularly prior to endourological procedures), ureteric fistulas and strictures and Complex infections.... tuberculosis Trauma. Suspected urinary tract pathology. Investigation of hypertension not controlled by medication in young adults.

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Contra Indications : General contra indications to iodinated contrast agents. Hepato renal syndrome, Thyrotoxicosis , Pregnancy, (Allow 28 days from childbirth) Blood urea raised above 12 mmol ./L. urography unlikely to be successful Sr creatinine 1.2mg%

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Radiological Anatomy LearningRadiology.com

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GROSS ANATOMY PARTS OK KIDNEY PARENCHYMA CORTEX – MICROSCOPIC CAPILLARIES AND URINIFEROUS TUBULES MEDULLA – MAINLY PYRAMIDS of Malpighi AND Column of Bertin COLLECTING SYSTEM CALYCES- ATTACHED TO PAPILLA (apex of pyramid) INFUNDIBULI and PELVIS : RENAL SINUS FATTY TISSUE PCS BLOOD VESSELS

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Collecting system: minor calyx(8-12), major calyx( 2-4 ), renal pelvis Renal sinus

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ANATOMY….

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SEGMENTAL ARTERIES INTERLOBAR ARTERIES ARCUATE ARTERIES INTERLOBULAR ARTERIES ANATOMY…

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SHAPE – BEAN SHAPED CONVEX LATERAL MARGIN LINEAR MEDIAL BORDER CONTOUR – SMOOTH REGULAR Renal size- 12-15cm in length Right kidney appears smaller than left Length of kidney approximates 3 ½ vertebral bodies In children, kidneys are proportionately larger (approx. 4 vertebral bodies)

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Renal position- Located in lumbar fossa Left kidney slightly higher than right one Upper pole of left kidney- T 11 -T 12 Upper pole of right kidney- T 12 -L 1 Lower limit of kidney is well above iliac crest, at the level of L 3 or L 3 -L 4 IV disc Medial border is parallel to psoas margin

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Renal axes- The kidneys are oblique in 3 planes Long axis points downwards & laterally upper pole being more medial than lower pole Lateral obliquity depends on amount of retroperitoneal fat & thickness of psoas muscle long axis downward and forward In transverse plane , axis is tilted backwards at about 30 deg upper pole more posterior than lower pole

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SHOWS INFINITE ANATOMICAL VARIATIONS. TWICE AS MANY TYPE OF PELVICALYCEAL VARIATIONS THAN THERE ARE INDIVIDUAL MINOR CALYCES – 8 TO 12 MULTIPLE PAPPILAE DRAIN INTO SINGLE CALYX MAJOR CALYCES –2- 4 OR MORE CONNECTS MINOR CALYCES TO RENAL PELVIS

Ureter : 

Ureter 30-34 cm diameter 2-8 mm 3 CONSTRICTIONS PUJ PELVIC BRIM AT ILIAC VESSELS CROSSING VUJ UPJ UVJ

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Lumbar Iliac Pelvic

Urinary bladder: 

Urinary bladder Ureter  posterolateral of UB Inferolateral : upon floor of pelvis Superior: covered with peritoneum

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FRONTAL VIEW – OVAL OR ROUND INFERIOR MARGIN BELOW PUBIC BONE OBLIQUE OR LATERAL VIEW – POST HEIGHT GREATER THAN ANTERIOR HEIGHT

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LearningRadiology.com Contrast & Excretion Physiology

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PHYSIOLOGY OF EXCRETION OF CONTRAST CONTRAST REACHES RENAL ARTERY IN 15 SECOND VASCULAR NEPHROGRAM COEXISTS WITH DIFFUSION OF CONTRAST LASTS FOR FEW SECONDS TO 1 MIN CONTRAST FREELY FILTERED BY GLOMERULI TOTAL BODY OPACIFICATION PHASE LASTS FOR 1 MIN CONTRAST IN PROXIMAL AND DISTAL TUBULES TUBULAR - DENSITY FADES EXCRETED CONTRAST IN PCS REACHES CALYCES BETWEEN 2 – 3 MIN PYELOGRAPHIC PHASE

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CONTRAST MEDIA TYPES IONIC OR HOCM - :CONTAIN NA OR MEGLUMINE SALTS Ex. Diatrizoic acid- Urograffin,Angiograffin,Urovision Iothalmic acid - Triovedeo Conary 280 Meg. 420 Na NONIONIC OR LOCM – :DO NOT DISSOCIATE IN BODY Ex. Metrizamide,Iohexol ( Omnipaque ), Iopromide ( Ultravist ), Iopamidol ( Iopamiro ) : MORE EXPENSIVE THAN HOCM (ONLY REASON THEY HAVENT REPLACED HOCM COMPLETELY ) IODINE IS MAIN ELEMENT WHICH IMPARTS RADIOOPACITY

CONVENTIONAL / HIGH OSMOLAR/ IONIC MONOMERS: 

CONVENTIONAL / HIGH OSMOLAR/ IONIC MONOMERS DIATRIZOATE GROUP w/v (g/100ml) Iodine mg/m l Viscosity Urograffin 60% Meg+ Na 76% Meg+ Na 52+8 66+10 292 370 4 8.9 Angiograffin Meglumine 65 306 5 Urovision Na: Meg 40:18 325 3.3

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THINK IN TERMS OF GMS OF IODINE RELATE DOSE TO BODY SIZE NORMAL DOSE 300MG I /KG BODY WT CAN BE DOUBLED IN RENAL FAILURE NEONATES, INFANTS AND CHILDREN - 600MG I/KG BODY WT 15 – 25 GM OF IODINE GIVEN IN ADULTS MAX 70 GM IODINE CAN BE GIVEN PAEDIATRICS WT DOSE UPTO 5.5 KG 4 ML/KG 5.5 TO 12.5 KG 25 ML 12.5 TO 23 KG 2 ML/KG 23 TO 46 KG 50 ML LOCM PREFERED IN INFANTS RENAL CARDIAC FAILURE DIABETES, MYELOMA, SICKLE CELL PREVIOUS REACTION Contain 18.5 gm in 50 ml

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ADVERSE EFFECTS IODINE EFFECTS –: MAY INDUCE HYPERTHYROIDISM PRODUCE SALIVARY GLAND ENLARGEMENT MINOR REACTION – INCLUDE NAUSEA VOMITTING SENSATION OF HEAT OR TINGLING,METALLIC TASTE DESIRE TO EMPTY BLADDER OR RECTUM, ARM PAIN DUE TO VENOUS SPASM USUALLY MILD AND TRANSIENT REQUIRE NO TREATMENT SKIN RASHES :DIFFUSE ERYTHEMA URTICARIA ANGIONEUROTIC EDEMA PRURITIS, SNEEZING AND RHINORRHEA Rx :ANTIHISTAMINE, STEROIDS BRONCHOSPASM AND LARYNGEAL EDEMA PARTICULARLY DUE TO MEGLUMINE Rx :ADRENALINE AMINOPHYLLINE OR SALBUTAMOL O2 STEROIDS

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ARRHYTHMIAS AND CARDIAC DISORDERS PULMONARY EDEMA RESPIRATORY AND CARDIAC ARREST And the most severe reaction… Death ~4/million A history of previous reaction to the administration of contrast media is the greatest single predictor of a contrast reaction

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LearningRadiology.com Routine procedure/ filming sequence

Patient History & preparation: 

Patient History & preparation Basic abdominal preparation, to clear fecal residue. Tab Dulcolax 2 HS + Enzar forte 1 tds 3 days prior PREPARATION NOT GIVEN IMPAIRED RENAL FUNCTION. MYELOMA. HYPERURICAEMIA NEWBORNS OR INFANTS DIABETICS Nil by mouth for 4-6 hours before the examination. Previous experience of iodinated contrast media. Blood urea levels (normal approx. 2.5-6.5 mmol ./L.) IF above 12 contraindicated ? Serum Creatinine (Should be less than 1.2 mg%) Patient wears cotton garment starch free USG report preferably the same day . Basic psychological preparation with reassurance and explanation of technique & written informed & valid consent Bladder emptied immediately before examination.

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Advantage Radiologist Best examination is tailored by vigilant radiologist and modified to answer clinical question No universally accepted filming sequence

Standard procedure for IVP: 

Standard procedure for IVP

Procedure in IGGMC MAYO HOSPITAL: 

Procedure in IGGMC MAYO HOSPITAL Control Nephrogram 5 min and 10 minutes compression Prone at 15 minutes Full bladder Post voiding film

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KUB RADIOGRAPH INCLUDE ENTIRE URINARY TRAT FROM UPPER POLE OF BOTH KIDNEYS TO URETHRAL MEATUS IN FEMALES AND PROSTATIC URETHRA IN MALES. CENTERING- LINE DRAWN THROUGH SPINOUS PROCESS MUST GO THROUGH SYMPHYSIS PUBIS AND BE IN MIDDLE OF FILM. ROENTGENOGRAPHIC QUALITY - JUDGED BY ADEQUATE VISUALIZA TION OF FOUR FUNDAMENTAL DENSITIES ( GAS, FAT, FLUID, BONE ) - VISUALIZATION OF PSOAS MARGIN IN PT WITH SUFFICIENT RETRO PERITONEAL FAT - FULL LENGTH FILM IN INSPIRATION - IF DOUBT ABOUT STONE PERSISTS OBLIQUE VIEWS OR TOMOGRAPHY Preliminary film , (14*17 inch) supine full A.P. abdomen to include lower border of symphysis pubis and diaphragm

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2 MINUTES AIM TO SHOW NEPHROGRAM 5 MIN – TO SEE IF EXCRETION IS SYMMETRICAL ASSESSING NEED TO MODIFY TECHNIQUE IF POOR OPACIFICATION, FURTHER INJ OF CONTRAST COMPRESSION BAND & 10 MIN FILM AIM – TO PRODUCE BETTER PC DISTENTION C/I – AFTER RECENT ABD SURGERY RENAL TRAUMA LARGE ABD MASS OBSTRUCTION IF 5 MIN FILM SHOWS PC DISTENTION

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5 min BEFORE COMPRESSION nephrogram AFTER COMPRESSION

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15MIN PRONE FILM –TO SHOW LOWER URETER as the heavy contrast laden urine will more readily gravitate to the site of the obstruction RELEASE FILM – CONED ON WHOLE ABDOMEN TO SHOW WHOLE URINARY TRACT

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POST VOID – TOASSESS BLADDER EMPTYING , TO DEMONSTRATE RETURN OF DILATED UPPER RACTS,BLADDER TUMOUR ,CONFIRM VUJ CALCULUS FULL BLADDER – FOR CAPACITY CONTOUR, EXTRISIC OR INTRINSIC FILLING DEFECT

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MODIFICATIONS AND ADDITIONAL VIEWS Plain films Additional oblique or tomograms To assist the location of potentially intra renal opacities. Nephrogram Thick slice tomogram To improve definition of the renal outlines Omit along with the 5 min film and take a solitary 3 min film To reduce radiation dose 5 min film Second injection of contrast improve opacification of the pelvicalyceal systems if inadequate 1 5 min release film Additional bladder views When the bladder is poorly filled on the release film delayed films small suspected calculus in the distal ureter may be confirmed with the appropriate oblique films

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D ELAYED FILMS : 3,6,12, 24 HRS FOR DELAYED OPACIFICATION IMMEDIATE AFTER MICTURATION FILM : FOR V-U REFLUX RAPID SEQUENCE UROGRAPHY : IN RENAL ARTERY STENOSIS FILMS 2, 4, 6 MIN , TO COMPARE RATE OF EXCRETION OF EACH KIDNEY FRUSEMIDE IVU : ADMINISTRATION OF 20 MG OF FRUSEMIDE IV AFTER 15 MIN FILM WITH FURTHER FILM 15 MIN LATER If suspected pelvi ureteric junction obstruction is being investigated and there is no evidence of this on the standard IVU, this manoeuvre is performed. To provoke Hydronephrosis and pain. It is rarely necessary if the patient is to be investigated with radionuclide renography . Before frusemide After frusemide

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ANALYSIS OF IVP LearningRadiology.com

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ANALYSIS OF KUB SKELETON - EVALUATION OF ALL BONES ELEMENT BY ELEMENT. PSOAS MARGIN- - DESCENDS OBLIQUELY AND LATERALLY FROM T12 TO ILIAC CREST VISUALIZED ONLY IF ADEQUATE RETROPERITONEAL FAT - USUALLY STRAIGHT CONVEX IN ATHLETIC MUSCULATURE FLUID COLLECTION IN PSOAS SHEATH ABSENCE OF PSOAS MARGIN – - LACK OF RETROPERITONEAL - SCOLIOSIS (OFTEN ONE SIDE) - FLUID COLLECTION IN RETRO PERITONEAL SPACE - RETROPERITONEAL TUMOURS - RETROPERITONEAL LN DISSECTION KIDNEYS - VISUALIZED ONLY IF ENOUGH PERIRENAL FAT

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INTESTINAL GAS- -MAY OVERLAP CHANGE IN SHAPE AND LOCATION IN DIFFERENT FILMS DISPLACED BY COMPRESSION CALCIFICATIONS OVER RENAL AREA - -TRUE LATERAL FILM OF KIDNEY (IPSILATERAL POST OBLIQUE) PROJECTS RENAL SHADOW BETWEEN PSOAS AND LIVER OR SPLEEN -ALSO STUDY DISPLACE MENT OF CALCIFICATION WITH INSPIRAION AND EXPIRATION AND / OR UPRIGHT FILM EXTRARENAL CALCIFICATIONS- CALCIFIED COSTAL CARTILAGE INRAHEPATIC CALCIFICATION GALLBLADDER STONES CHIP FRACTURE OF TRANSVERSE PROCES CALCIFICATIONS OF TAIL OF PANCREAS CALCIFICATION OF SPLENIC ARTERY PHLEBOLITH CALCIFIED SUPRARENAL GLAND

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URETERS- NORMALLY NOT VISUALIZED OPACITIES - INTRALUMINAL – URETERAL STONES INTRAMURAL - SCHISTOSOMIASIS GAS SHADOWS- CONFORM TO SHAPE OF URETERS WHEN GAS IN COLLECTING SYSTEM EXTRAURETERAL CALCIFICATIONS MAY PROJECT OVER COURSE OF URETERS BLADDER AND URETHRA NOT NORMALLY SEEN VISUALIZED ONLY IF RESIDUAL, CALCULI OR FOREIGN BODY MESNTERIC LN (MOBILE) - LUMBER LN (FIXED) CALCIFICATIONS OF ARTERIES PHLEBOLITHS

What is nephrogram? : 

What is nephrogram? Four phases of nephrogram occur sequentially- Spontaneous nephrogram - the non opacified kidney outlined by retroperitoneal fat visible on plane film Vascular nephrogram - due to opacification of intrarenal blood vessels Total body opacification - due to opacification of pre- & retro renal soft tissue in addition to vascular nephrogram Tubular nephrogram - due to opacification of intrarenal tubules Nephrogram is the opacification of renal parenchyma

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Vascular (Angiographic) nephrogram - occurs during passage of contrast material through the cortical microvasculature. * Short lasting seen within 30 sec of rapid IV bolus * Approx 80% of renal blood flows to the cortex, renal cortex looks much more radiodense as compared to medulla, hence C-M differentiation will be seen. *This is the criteria for successful vascular nephrogram . If C-M differentiation is not seen, the vascular nephrogram is inadequate & must be interpreted with great caution After injection of contrast medium 3 phases occur sequentially

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Tubular ( Urographic ) nephrogram - will appear after the contrast medium has been concentrated in PCT. *Density is greatest approx 1min of injection of IV bolus at which time peak plasma level is reached. * Radiodensity of medulla equals that of cortex hence it appears homogenous . *C-M junction is no longer visualized. Total body opacification phase- appears slightly later because of faster renal circulation time. It is well seen during the passage of the end of the bolus.

Value of nephrographic analysis: 

Value of nephrographic analysis Vascular nephrogram requires only intact vascular system. Hence it is an useful indicator of disturbance in blood flow to the kidney Tubular nephrogram permits accurate evaluation of fundamentals of renal radiology: kidney size, position, axis & contour.A normal tubular nephrogram requires 1.normal blood flow 2.structural & functional integrity of nephrons 3.unobstructed flow of filtrate through the tubules Failure to visualize nephrogram - Insufficient dose of contrast Acute or chronic renal failure End stage renal disease Absent kidney Renal artery thrombus / avulsion

Three abnormal time-density patterns are recognized: 

Three abnormal time-density patterns are recognized Immediate, faint & persistent nephrogram Increasingly dense nephrogram Immediate, dense & persistent nephrogram

Immediate, faint, persistent nephrogram: 

Immediate, faint, persistent nephrogram Peak density is seen on the first film exposed at the completion of injection of contrast. Density is disproportionate with amount of contrast material injected.Though faint persists for several hours . Pathogenesis : reduction in number of functioning nephrons ( immediate faint nephrogram ) severely impaired glomerular filtration low plasma clearance rate of contrast material ( persistent nephrogram ) High dose of contrast material is required to obtain nephrogram

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Seen in : Chronic glomerular disease Sudden loss of glomerular function- atheroembolic renal disease These diseases are often associated with a high urea load & impaired sodium reabsorption in PCT- also contribute to faintness of nephrogram . Immediate faint persistent nephrogram Chronic glomerulonephritis

Increasingly dense nephrogram: 

Increasingly dense nephrogram Faint to begin with Increasingly dense over a period of hours to days 10 min 4 hrs Increasingly dense nephrogram Distal ureteric calculus

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Seen in: Acute extrarenal obstruction Diminished perfusion pressure of kidney systemic hypotension severe RAS 3. Intratubular obstruction uric acid crystals myeloma casts acute papillary necrosis Acute renal vein thrombosis Acute glomerular disease Acute tubular necrosis

Immediate, dense, persistent nephrogram: 

Immediate, dense, persistent nephrogram As dense as normally expected to be at 1 minute The level of density persists rather than fading Often slightly increases over a period of time Seen in- Acute tubular necrosis * if this pattern sets in after an initially normal urogram , suggests contrast induced nephrotoxicity Acute bacterial nephritis * almost always unilateral Pathogenesis- has not been clarified unimpaired glomerular filtration ( immediate dense nephrogram ) diffusion of filtrate into interstit ium due to damaged tubules return of filtered material to the circulation ( persistent nephrogram )

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Immediate dense persistent nephrogram Acute tubular necrosis 10 min 12 hrs

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Inhomogeneous nephrogram - Striated nephrogram Patchy nephrogram Cortical rim nephrogram

Striated nephrogram (Sunburst nephrogram): 

fine linear bands of alternating lucency & density uniformly oriented in direction similar to that of tubules & collecting ducts Striated nephrogram (Sunburst nephrogram ) Seen in- Acute extrarenal obstruction Acute bacterial nephritis Acute pyelonephritis Renal contusion Autosomal recessive infantile polycystic kidney disease Medullary cystic disease Medullary sponge kidney

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inhomogeneous nephrogram consisting of patchy densities Seen in- Polyarteritis nodosa Scleroderma Necrotizing angiitis Patchy nephrogram

Cortical rim nephrogram: 

Cortical rim nephrogram Only the thin rim of peripheral cortex is opacified that is perfused by capsular Collateral arteries Reliable indicator of under perfusion of kidney Seen in- Infarction of kidney Renal vein thrombosis (some cases) Cortical rim sign in segmental RA occlusion

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At this stage the calyces, renal pelvis and part of the ureters will be visible. There is considerable anatomical variation in the number and pattern of the renal calyces. The nephrogram will be reduced but both kidneys should have the same density . 5 or 10 Minute FILM

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Normal interpapillary line of HUDSON . Drawing illustrates how the renal outline should closely paralleled by a line connecting the papillary tips (dotted line). Asses thickness of parenchyma Recognize scarring of parenchyma Weather abnormality involves entire kidney ( cortex,medulla , sinus, pcs ) Normal: 3-3.5 cm (polar), 2-2.5 cm ( interpolar ) Increase or indentation Congenital anatomic variation Decrease Post-inflammation or stone-related scarring Secondary to renal infarct.

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BLADDER PATHOLOGIES OVERLAPPING INTESTINES INTRAVESICAL GAS SOLID INTRAVESICAL FOREIGN BODY RADIOLUCENT BLADER CALCULI INTRAVESICAL BLOOD CLOTS INTRAMURAL LESIONS EXTRINSIC COMPRESSION BLADDER FILLING DEFECTS DUE TO Prostate enlargement Vaginal mass. Bladder image shows a bladder base defect (arrowheads) similar to that seen in males with prostatic disease ("female prostate" defect). In this case, the defect was associated with an anterior vaginal wall mass. Note the prominent uterine impression on the superior aspect of the bladder.

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Hematoma in a patient with pelvic trauma. Urographic image shows a pear-shaped bladder elevated out of the pelvis and elongated superiorly due to pelvic hematoma. Note the large filling defect within the bladder due to blood clot. Primary megaureter tapered narrowing of the left ureter at the ureterovesical junction (arrow) associated with dilatation of the distal third of the ureter , with minimal upper urinary tract obstructive changes.

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TUMOURS FROM POSTERIOR WALL (COMMON) TUMOURS FROM ANTERIOR WALL(LESS COMMON) PROJECTION OF CONTRAST FROM BLADDER OUTLINE DIVERTICULI FISTULAS Multiple bladder diverticula in a patient with a neurogenic bladder. Bladder image shows numerous bladder diverticula associated with wall thickening and irregularity of the intraluminal contrast material BLADDER TUMOURS

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LearningRadiology.com CONGENITAL ANAMOLIES & VARIATIONS

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RENAL DUPLICATION

HORSE SHOE KIDNEY : 

HORSE SHOE KIDNEY

UNILATERAL AGENESIS OF KIDNEY AND PELVI CALYCEAL COLLECTING SYSTEM : 

UNILATERAL AGENESIS OF KIDNEY AND PELVI CALYCEAL COLLECTING SYSTEM

PERSISTENCE OF FETAL LOBULATIONS : 

PERSISTENCE OF FETAL LOBULATIONS

ECTOPIC PELVIC KIDNEY : 

ECTOPIC PELVIC KIDNEY

CROSSED FUSED ECTOPIC KIDNEY : 

CROSSED FUSED ECTOPIC KIDNEY

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MALROTATED KIDNEYS PELVIS LATERAL PELVIS ANTERIOR

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Congenital bilateral hydronephrosis

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RETROCAVAL URETER

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SPOTTERS LearningRadiology.com

STAG HORN CALCULUS : 

STAG HORN CALCULUS

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patient should be evaluated immediately for the development of hypotension related to the procedure or as a reaction to contrast material administration 2 min.film demonstrates symmetric nephrograms and pyelograms . Renal size is normal 10-minute image, no pyelogram is evident. The nephrograms are persistent & kidneys are smaller.

HYDRONEPHROSIS: 

HYDRONEPHROSIS CALYCEAL BLUNTING AND LOSS OF PAPILLARY IMPRESSIONS DILATATION OF CALYCES

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The lower pole moiety has been displaced infero laterally by an upper pole hydronephrosis . This usually occurs due to obstruction of the upper pole moiety ureter at its orifice associated with ectopic insertion or a ureterocele . drooping lily sign on IVU

POLYCYSTIC KIDNEY : 

POLYCYSTIC KIDNEY SPIDER LEG DEFORMITY OF PCS

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RENAL MASSES LOCALIZED BULGE OF RENAL OUTLINE SPLAYING OR DISPLACEMENT OF CALICES LOSS OF RENAL CONTOUR ROTATION OF KIDNEY HODSONS LINE IS CURVED IN OPPOSITE DIRECTION OF BULGING RENAL OUTLINE

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FEATURES OF MALIGNANT MASSES PATHOGNOMIC SIGN – INVASION OF COLLECTING SYSTEM PRODUCING AMPUTATION OF CALYX OR INTRALUMINAL FILLING DEFECT SUGGESTIVE SIGNS – VASCULAR MASS -CALCIFICATION TUMOUR SHELL-IF WALL IS THICK AND IRREGULAR ABSENT MOBILITY WITH RESPIRATION AND CHANGE IN POSITION HODSONS LINE IS NORMAL NORMAL APPARENT BULGE OF LEFT KIDNEY DUE TO PRESSURE FROM SPLEEN WHICH MAY BE MISTAKEN FOR RENAL MASS PSEUDOTUMOUR DROMEDARY HUMP

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Longitudinal US image of the left kidney suggests hydronephrosis. Similar findings were seen in the right kidney. Renal sinus cysts Nephrotomogram obtained with compression shows narrowing and displacement of opacified collecting system elements and the renal pelvis bilaterally without hydronephrosis. This incongruity between US and urographic findings

ATROPHIC SMALL SMOOTH KIDNEY : 

ATROPHIC SMALL SMOOTH KIDNEY CAPE HANA Chronic glomerulo nephritis Arteriosclerosis Papillary necrosis Embolic disease Hypotension Alport syndrome Nephrosclerosis A mylodosis late

URETEROCELE: 

URETEROCELE COBRA HEAD APPEARANCE

SEGMENTAL RENAL ARTERY OCCLUSION : 

SEGMENTAL RENAL ARTERY OCCLUSION HYPODENSE AREA CORTICAL RIM SIGN

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SIMPLE CYST LARGE UNIFOCAL UNILATERAL Smooth margin BEAK SIGN

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Renal abscess Large unifocal unilateral Irregular shaggy margin

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. Pyelographic image shows central cavities within multiple papillae Papillary necrosis caused by analgesic abuse

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12 HOURS 10 MIN ACUTE OBSTRUCTION ASYMMETRIC NEPHROGRAM AND EXCRETION OF CONTRAST HIGH CONC AND INCREASING LY DENSE NEPHROGRAM (OBSTRUCTIVE NEPHROGRAM) DELAYED CALICEAL OPACIFICATION FROM MIN TO HOURS

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standing column of contrast material from the ureteropelvic junction to the ureterovesical junction on the right stone is impacted at the ureterovesical junction. Note also the edema in the right side of the interureteric ridge (arrow), which is normally less than 3 mm in thickness.

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Arterial aneurysmof the internal iliac artery. acute medial deviation of the right ureter

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Bladder image shows contrast material with a lobulated and irregular contour within the lumen of the bladder. The thickness of the bladder wall can be appreciated (arrows). Hemorrhagic cystitis

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chronically obstructed pelvi calyceal system is filled with calcifying caseous pus with complete renal parenchymaL destruction. RENAL TUBERCULOSIS calcifying pus in an obstructed dilated upper ureter .

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THANK YOU

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Transitional cell carcinoma. Urographic image shows multiple filling defects in the left renal pelvis and ureter. Note the "goblet" appearance of the contrast material below the lowest filling defect (arrow). This finding is typical of lesions that grow slowly into the lumen of the ureter. Multifocal transitional cell carcinoma was confirmed in this case.

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Ureteral tumor in a patient with persistent microscopic hematuria. (a) On a urographic image, a portion of the left ureter is not visualized. Note also the lack of proximal obstructive findings. (b) Fluoroscopic spot image reveals a filling defect in the opacified lumen (arrow). This proved to be a transitional cell carcinoma.

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Ureteral tumor in a patient with persistent microscopic hematuria. (a) On a urographic image, a portion of the left ureter is not visualized. Note also the lack of proximal obstructive findings. (b) Fluoroscopic spot image reveals a filling defect in the opacified lumen (arrow). This proved to be a transitional cell carcinoma.

RENAL CELL CARCINOMA LARGE UNIFOCAL UNILATERAL : 

RENAL CELL CARCINOMA LARGE UNIFOCAL UNILATERAL LOCALIZED BULGE ON LATERAL CONTOUR OF KIDNEY

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BOLUS INJECTION GIVES IMMEDIATE PEAK PLASMA LEVEL FOLLOWED BY RAPID DECLINE DUE TO – - VASCULAR MIXING - EXTRAVASCULAR DIFFUSION - RENAL EXCRETION (BY GFR ALONE) DIAGNOSTIC QUALITY OF IVU DEPENDS ON – 1. AMOUNT OF IODINE EXCRETED (UV) GFR = UV / P UV = GFR * P - ONLY P CAN BE ADJUSTED BY DOSE - GFR IS CONSTANT FOR A PERSON 2. VOL OF URINE FORMED TO DISTEND PCS ADEQUATE DISTENTION OBTAINED BY – - MECHANICAL COMPRESSION -TAKING ADVANTAGE OF DIURETIC EFFECT OF CONTRAST PHYSIOLOGY OF EXCRETION

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DIURETIC EFFECT OF UROGRAPHIC CONTRAST HOCM - POTENT DIURETIC - SPLITS FREELY INTO IODINE BEARING ANION AND CATION CATION – 1. SODIUM - LESS DIURETIC AS REABSORBED - SMALLER AMT OF URINE - HIGHER CONC OF CONTRAST 2. MEGLUMINE - MORE DIURETIC EFFECT - NOT REABSORBED SO WHEN HOCM USED NA SALTS PROVIDE GREATER CONCENTRATION LOCM - MARKEDLY LESS DIURETIC EFFECT - DECREASED URINE VOL - TRANSLATES INTO ENHANCED RADIODENSITY BUT LESS PCS DISTENTION - COMPENSATED- URETERAL COMPRESSION - DELAYED FILMING SEQUENCE

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PREPARATION OF PT WITH H/O PREVIOUS REACTION H/O ALLERGY INCREASES RISK OF SEVERE IDIOSYNCRATIC REACTION 5 FOLD H/O CURRENT OR REMOTE ASTHMA – 8 FOLD H/O PREVIOUS REACTION WITH CONTRAST –11 FOLD RISK FACTORS ARE VALID FOR LOCM ALSO THOUGH LESS THAN HOCM PROPHYLAXIS - REVIEW NEED FOR PROCEDURE 100 MG IV HYDROCORTISONE AT LEAST 12 HRS PRIOR MAINTAIN OPEN IV LINES READY FOR RESOSCITATION INJECTION OF TEST DOSE HAS IS NOT EFFECTIVE SCREEN ANTIHISTAMINICS NOT ACCEPTABLE AS EFFECTIVE PROPHYLAXIS

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THE BOLUS TECHNIQUE IV INJECTION OF CONTRAST IN 10 SEC OR LESS RADIOPAQUE COLUMN WILL GO THROUGH PULMONARY AND SYSTEMIC CIRCULATION AT SPEED DEPENDING ON CARDIAC OUTPUT FOUR PHASES OCCUR SEQUENTIALLY 1.SPONTANEOUS NEPHROGRAM - BEFORE CONTRAST ENTERS ARTERIAL CIRCULATION 2. VASCULAR NEPHROGRAM DURING PASSAGE THROUGH BLOOD VESSELS OF PARENCHYMA CORTEX AND COLUMNS OF BERTINI MORE VASCULAR THAN PYRAMIDS AND RENAL SINUSES SO C-M DIFFERENTIATION SEEN LASTS FOR FEW SECONDS

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DRIP INFUSION TECHNIQUE - INJECTION OVER 1 TO 5 MIN - NO TRUE VASCULAR NEPHROGRAM - MIXED NEPHROGRAM COMBINING EFFECT OF WHOLE BODY OPACIFICATION WITH TUBULAR NEPHROGRAM - NO ADVANTAGE OVER BOLUS TECHNIQUE

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INTERMITTENT OBSTRUCTION -PUJ IS NON OBSTRUCTIVE DURING NORMAL FLOW RATES BUT OBSTRUCTIVE DURING DIURESIS -RENAL PELVIC PRESSURE RISES AND CAUSES PAIN -PERFORMING IVU DURING PAINFUL EPISODE IS DIAGNOSTIC AS SIGNS OF OBSTRUCTION WILL BE DEMONSTRATED -IF PTS HISTORY IS S/O INTERMITTENT OBSTRUCTION BUT IVU IS NORMAL THEN .IV FUROSEMIDE GIVEN TO CAUSE DIURESIS AND INDUCE PAIN -IF PT DEVELOPS BOTH PAIN AND DISTENTION OF PCS THEN DIURESIS UROGRAM IS DEFINITIVE DIURESIS UROGRAM -