OS 214: Renal Module

Imaging Skills Radio Lab Exam

Outline

I. Kidneys Plain Pelvic Film

II. Calculi and Obstructive
Uropathy
III. Acute Renal
Parenchymal Diseases

I. KIDNEYS

A. REVIEW OF NORMAL ANATOMY

• The left kidney is situated higher than right
kidney (because of the liver on the right)
• The outer cortex contains the glomeruli
• The medullary pyramids contain the collecting
tubules
• Urine flows from the tubules to the calyxes to the
pelvis to the ureter
• role of radiology here is to document the
pathologies of the kidney

B. PLAIN AND CONTRAST X-RAY

1. Plain KUB
• Pelvic ring is visualized
• Renal shadows & psoas lines are visible
• In a plain abdominal film, the hemidiaphragms
have to be fully visualized.

2. Intravenous Pyelogram (IVP)

• used to visualize the collecting system
• look for sign of retention, pelvic
abnormalities, if bladder itself has problems

A. Requirements for IVP:

1. Evaluate renal function
Flank Stripe  get the serum BUN and creatinine
to be assured that the contrast
material will be excreted
2. History
 Diabetes, HTN
 inquire about the allergy history of
the patient to foresee allergic
reactions to the contrast material
that will be used
• The two white lines are the PSOAS lines.  to know what to look for in the IVP
• If they are obliterated, suspect retroperitoneal 3. Preparation
masses.  Should have good bowel
• The flank stripe is the border of the body; this is preparation because fecal matter
the fat layer of the skin. can super impose on the renal
• Give dulcolax, castor oil to remove excess fecal image
matter that would interfere with renal
visualization. B. Types of contrast:
• In Plain KUB, the entire pelvis should be visible 1. Ionic
as compared to the plain abdomen x-ray where  more allergenic
the hemi diaphragm should be visible.  hyperosmolar (gives a burning
feeling when given intravenously)
Roentgenographic examination of the urinary tract may
 cheaper (~P400)
2. Non-ionic
begin with a plain film of the abdomen, exposed with the
patient in a supine position, that includes the kidneys and the  hypoallergenic
ureteral and bladder areas. This “scout” film, which must be  less osmolar
obtained before contrast medium is given to determine if the  more expensive (~P1500)
hyperechoicity is due to the contrast or because of other
reasons (a calcification for example), KUB film examination
reveals the renal shadows and permits assessment of the Mace: Hi 2012. Exam na bukas. Wala pa akong naalala
size, shape, and position of the kidneys. sa mga binasa ko. Hehe. Jan, Nani, salamat sa Kornets.
Brent, wag ka na mainsulto. Tamad lang talaga ako
mag-aral. Kung mabibigay ko lang sayo oras ko. Hehe.
Pero ayoko eh. Masarap magbasa ng Harry Potter ulit o
manood ng House
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Jab, Erena, Bill, Kenneth
 OS 214: Renal Module
Imaging Skills Radio Lab Exam

C. IVP Procedure
1. Plain film/Scout film

 visualize pelvis (collecting system and

ureters are opacyfying)

5. Contrast at 10 minutes
 calcific densitiesstone
 used as reference figure

2. Inject Contrast Material

3. Film at 3 minutes

 contrast has reached the pelvocalyceal

system, ureters
 this is the time to look for stones in these
areas

6. Film at 15 minutes
 whole abdomen profile
 kidneys are still visualized
 ureters are likewise opacified
 bladder is starting to fill

7. Full bladder film at 20 minutes

 kidneys and upper collecting system

(including the calyces) visualized
 the contrast in the cortex and the medulla is
seen
4. Film at 5 minutes

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Jab, Erena, Bill, Kenneth
 OS 214: Renal Module
Imaging Skills Radio Lab Exam

• The right kidney can be scanned with the patient

in a supine or decubitus position (left side down)
with longitudinal, transverse, and coronal images.
• Similarly, the left kidney can be imaged with
similar views and the right side down.
Occasionally, a prone position may prove useful.
• The best images are obtained with the patient’s
Calcific respiration suspended; frequently, the end of
Density partial or full inspiration brings the kidney into
better view.

D. CT SCAN
• CT examination of the kidneys is tailored to the
Bladde specific clinical indication.
r • In general, there are three broad categories in
which CT examination is used:
 The most common indication for CT of the
kidneys is a morphologic examination for
potential renal mass after an ultrasound, IVP,
or other examination. This protocol can also
be applied when searching for potential renal
trauma or infection.
 Suspicion of urinary tract stones; this
 full bladder has very smooth borders
examination is called CT urography. CT
 “dapat bilog na” urography has been shown to be highly
accurate in the evaluation of suspected
ureteral and renal stones in the setting of
8. Post-void film acute flank pain.
 to check urinary retention  for visualization of renal vasculature
 <50 cc
 you can still see some degree of contrast in
various areas of the GU system • CT Scan Procedure:
1. Check if all lab results are normal
2. Position patient
3. Do Plain study
4. Inject contrast material
C. ULTRASOUND 5. Repeat scan immediately
• can measure length, width and height of the
kidney
• how is it done? --- supine or prone position
• Characteristics:
o Hypoechoic – black (ex. Air)
o Isoechoic – gray (ex. Soft tissues like
liver)
o Hyperechoic – white (ex. Bone and
stones)

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Jab, Erena, Bill, Kenneth
 OS 214: Renal Module
Imaging Skills Radio Lab Exam

• Normal Retrograde Pyelogram: The area in the

ureter which looks like stenosed is just having
some pulsations so the flow of the contrast is at
intervals.

F. VOIDING CYSTOURETHROGRAM

• X-Ray while Voiding

• urethral rupture: Leaks of urine, extravasation
of dye

E. RETROGRADE PYELOGRAM
• done when it is not possible to give IV contrast
e.g. trauma patients
• when creatinine levels are high but it is
imperative to view the lower collecting system

• neurogenic bladder: diagnosed only when other

diseases have been ruled out to cause cystitis

G. RENAL ANGIOGRAM
• Shows how may renal arteries and veins you
have
• useful for stenting procedures:
• Catheter is inserted through the urethra, then dye
a. RENAL ARTERY STENOSIS
is released.
b. Hypertension will disappear quickly after
stenting

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Jab, Erena, Bill, Kenneth
 OS 214: Renal Module
Imaging Skills Radio Lab Exam

• horseshoe kidney are prone to calculi so

always follow up
• ectopic kidney: kidney reaches the pelvic
area
• pelvic kidneys are a risk for UTI
• pregnancy may be a problem: prone to
hydronephrosis and can make labor very
difficult

3. VESICO-URETERAL REFLUX
• more common in children
• reflux increases risk for infection
• when a patient voids, urine should not go up
the collecting system
• Normal Renal Angiogram • several grades
• if you have infected urine—you can develop
pyelonephritis or chronic pyelo
• UTI: female babies of greater risk than males
Renal • Males with UTI are less common but
Artery incidence is usually connected to some renal
abnormality.

Vesicoureteral reflux in children is usually caused by

abnormal anatomy of the vesicoureteral junction.
Normally, the ureters enter the bladder at a shallow
angle and proceed in the bladder submucosa before
emptying into the bladder. This arrangement creates
a valve mechanism that allows antegrade flow of
urine without reflux. If abnormal anatomy is present,
usually a shortened submucosal course of the ureter,
vesicoureteral reflux is common. Reflux often
spontaneously resolves as the child ages because of
the lengthening of the submucosal portion of the
ureter. In general, the worse the reflux at the time of
diagnosis, the less likely it is to resolve
spontaneously and therefore the more likely it is to
require surgical intervention.

Infection is the most common adult cause of

vesicoureteral reflux, which is also found
occasionally in patients with lower-urinary-tract
obstruction. The obstructive lesions include posterior
urethral valves, urethral stricture, and median bar
H. ABNORMALITIES OF THE KIDNEY enlargement of the prostate. Neurologic disorders
that result in neurogenic bladder dysfunction,
1. Ptotic Kidney
4. FEMALE GENITO-URINARY TRACT
• wiping from back to front after bowel
movements may force germs into urethra

5. ACUTE PYELONEPHRITIS
• various imaging modalities show normal
findings!
• nuclear scan provides earlier detection

• 1 kidney goes down more than 2 vertebral

bodies; “the drooping lily”
• prone to having obstruction & thus infection

2. CONGENITAL MALROTATIONS/ECTOPIA
Horseshoe and Pelvic kidney

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Jab, Erena, Bill, Kenneth