Intravenous urography and its modifications.pptx 01
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This document provides an overview of intravenous urography (IVU) and its modifications. It discusses the anatomy of the urinary system, how IVU is performed including injection of contrast media and taking radiographic films at various time points, and modifications such as using compression. It also covers indications, contraindications, required materials, and complications. IVU involves injecting contrast media intravenously and imaging the urinary tract, but has been replaced by other modalities like ultrasound, CT, and MRI in many cases.
Intravenous urography and its modifications.pptx 01
- 1. INTRAVENOUS UROGRAPHY AND IT’S MODIFICATIONS Sujan karki BSc.Mit 2ND year NAMS,BIR HOSPITAL
- 2. Contents • Introduction • Urinary system anatomy • Procedure • Filming • Modification • Some anomalies and related images • Complications and aftercare • Conclusion • References
- 3. Introduction • IVU is the radiographic examination of urinary tract including renal parenchyma, calyces and pelvis after intravenous injection of contrast media • For decades intravenous urography has been the primary imaging modality for evaluation of the urinary tract. • In recent years, however other imaging modalities including ultrasonography(USG), computed tomography(CT), and magnetic resonance imaging(MRI) have been used with increasing frequency to compensate for the limitations of intravenous urography in the evaluation of urinary tract diseases. • Intravenous pyleogram is a misnomer as it implies visualization of the pelvis and calyces without parenchyma.
- 4. Introduction • Introduction of excretory urography was done in 1929,by American urologist Moses swick. • He injected an organically-bound iodide compound into a vein, taking X-rays as the material cleared the body through the urinary
- 5. Radiological investigations of urinary system There are 4 main radiological examinations : 1 IVU: Intravenous urography. 2-Ultrasonography 3-CT scan 4-Radioisotope scan. Others (not frequently used): MRI, arteriography, antegrade or retrograde pyelogram.
- 6. Some related terminologies • Urogram : Visualization of kidney parenchyma, calyces and pelvis resulting from IV injection of contrast. • Pyelogram :Describes retrograde studies visualizing only the collecting system • Cystography :Describes visualization of the bladder • Urethrography :Visualization of urethra • Cystourethrography :Combined study to visualize bladder and urethra.
- 7. Gross anatomy of urinary system • Consist of 2 kidneys, 2 ureter, 1 urinary bladder and 1 urethra. • After kidney filter the blood, they return most of the water and other solute to the blood stream. • The remaining water (urine), passes through the ureters and is stored in the urinary bladder.
- 8. Kidney Functions of kidney: 1)Excreatory functions 2)Regulatory functions 3)Endocrine functions 4)Metabolic functions
- 9. • The parenchyma of the kidney is divided into two major structures: • 1) Superficial is the renal cortex • 2) 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 as renal pyramid. • Between the renal pyramids are projections of cortex called renal columns. • 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 empty into the ureter.
- 10. Gross overview of nephron
- 11. Major sites of obstruction of urinary system • The ureter has constriction at five points: 1) Calyx 2)Ureteropelvic junction 2)Crossing of external/common iliac artery 3)Pelvic brim, arching over iliac vessels 4)Posterior pelvis (females) under broad ligament 5)Above intramuscular ureter/ vuj-most common • These are also sites of obstruction and stones impaction.
- 12. Indications • Screening of entire urinary tract especially in cases of heamaturia or pyuria • Differentiate function of both kidneys • Abnormalities of the ureter • Obstructive uropathy tract • TB of the urinary tract • Renal calculus • Potential of the renal doners • Surgery of urinary tract • Suspected renal injury • Renal colic or flank pain • Burning micturition
- 13. Indications in children • VATER anomalies. Renal anomalies are seen in the 90% of patients. • V: vertebral anomalies • A: anal atresia • TE: tracheoesophageal fistulas • R: radial ray hypoplasia, polydactyly and renal agenesis • Malformation of urinary tract, e.g. polycystic disease, PUJ obstruction etc. • Neurological disorders affecting urinary tract. • Anorectal anomalies. • Enuresis in the presence of bacteriuria. • History of recurrent urinary tract infection.
- 14. Contraindications Relative contraindications • Severe history of anaphylaxis previously carries 30% risk. • Renal failure (raised serum creatinine level >1.5 mg/dL). • Hepatorenal syndrome. Previous allergy to the contrast agent/iodine • Multiple myeloma. • Pregnancy. • Hyperthyroidism. • Diabetes. • Sickle cell anemia.
- 15. Contrast media • Contrast media are the pharmaceutical agents that are used for the enhancement of necessary visuals contrast in an image between the organ,vessels or tracts in which they are present and the surrounding tissue in the body . • Iodine is the main element which imparts radio opacity • Types Ionic or HOCM contain sodium or meglumine salts,they are water soluble, dissociates into anion and cation diatrizoic-acid-urograffin,angiograffin,urovision iothalmic acid –triovedeo conray 280 Non-ionic or LOCM do not dissociate in the body. Eg : mertrizamide, iohexol, (LOCM are more expensive then HOCM ,the only reason they haven’t replaced HOCM completely)
- 16. Contrast media • Low osmolar contrast media is used • Dose: 300-400 mg iodine equivalent/kg body weight • If 300mgI/ml, 2-3ml/kg for children, 1ml/kg for adult CM Dose: For adult: 1ml/kg body weight for concentration of 300mgI/ml The concentration can be increased upto 350mgI/ml if the patient is well hydrated. For Children(2-12 years) 1.5ml/kg body weight for concentration of 300mgI/ml For Infants(1month-2 years) 3ml/kg body weight for concentration
- 17. Preparation • Ask for any history of Diabetes mellitus, Renal insufficiency, Renal Disease, Allergy to drugs and any specific foods. • Nil per oral for at least 6 hours but patient can be hydrated . • Low residue diet, the day before the examination • Do not dehydrate the patient(dehydration is associated with the increased risk of nephrotoxicity) • Blood urea and creatinine value should be normal. • Bowel preparation: 1.Dulcolax is given 2-4 tablets at bedtime for 2 days prior to the I.V.U 2. Because colon should be empty for I.V.U • Take informed consent.
- 18. Radiation protection • ‘Pregnancy” rule should be followed. • If whole of the UT is to be visualized, no gonad shielding is possible for the females. • In males, the testes can be protected by placing a lead rubber sheet over upper thighs below lower edge of symphysis pubis
- 19. Required materials for the procedure • Fluoroscopy guided x-ray unit • Abdominal compression equipment. • Pads and immobilization aids. • Intravenous administration equipment: (50 ml disposable syringe, , skin prep, sticky tape) • ,18-20 gauze IV cannula. • Tourniquet or blood pressure cuff. • Emergency drugs and equipment.
- 20. Mode of injection • Contrast Media is usually give n as a I.V. bolus injection with in 30-60 seconds. • The density of the nephrogram is directly proportional to the plasma concentration of contrast media. • More iodine increases the density of the nephrogram. • Large Doses of Contrast Media increase diuresis which distends the collecting system thus Increasing the diagnostic information from the Urogram • Antecubital vein is mostly chosen for the administration of the contrast medium .
- 21. Procedure • Patient is placed in supine position with pelvis at cathode side of the tube. • A support is placed under patient’s knees to reduce lordotic curvature of lumbosacral spine and provide comfort. • A scout film is taken including the Kidneys,Ureters,Bladder and Urethral Regions on a large size film. • Contrast media is injected intravenously into a prominent vein in the arm. • Test injection of 1ml of contrast is given and patient is observed for 1 min to look for any contrast reactions. • Then the rest of the contrast is rapidly injected within 30-60 seconds.
- 22. FILMING TECHNIQUES • Low KV high mA(300-500)and short exposure should be used to get optimum image contrast. • Standard films taken • Preliminary X-Ray (KUB)/Scout film -14x17 • Immediate film - 10x12 • 5 minute film - 10x12 • 15 minute film – 14x17 • Full bladder - 14x17/10x12 • Post Void film – 10x12
- 23. PRELIMINAY FILM / SCOUT FILM • Ap of abdomen, before the contrast is given. • Scout film provides valuable information and sometimes indicates provable diagnosis. • Useful in assessing : 1) Calculus 2) Intestinal abnormalities 3) Intestinal gas pattern 4) Calcification 5) Abdominal mass 6) Foreign body
- 24. R
- 25. • Immediate film Ap of the renal areas, shows Nephrogram. i.e(the renal parenchyma opacified by the contrast medium in the renal tubules) • This film is exposed 10-14sec after the injection (approximate arm to kidney time).It aims to show the nephrogram at its most dense, i.e the renal parenchyma opacified by contrast medium in the renal tubule outline or possible masses
- 26. 5 min film • Ap of the renal areas, this film gives an initial assessment of pathology-specifically the prescence or absence of obstruction before administering compression. • A compression band is then applied positioned midway between the anterior superior iliac spine, i.e precisely over the ureters as they cross the pelvic brim. The aim is to produce pelvicalyceal distension. Compression contraindicated in: • 1) Renal trauma • 2) Large abdominal mass • 3) Abdominal aneurysm • 4) After abdominal surgery
- 27. • If 5 minute film shows dilated calyces or if calyces and pelvis are not adequately opacified, obstruction exists and compression band not be applied. • If compression band is applied a film is taken after 10 minutes , the film should shows centered kidneys to demonstrate distended collecting system and proximal ureter.
- 28. •15 minutes film 1)If compression is not applied film exposed in 15 min shows adequate distension of pelvicalyceal system and ureters. 2)If compression is applied then should be removed after satisfactory demonstration of pelvicalyceal system and film is exposed after releasing compression (release film) 3)Release film offers best chance of demonstrating ureters.
- 29. Full bladder film • It gives complete over view of the urinary bladder. • Bladder distension can be evaluated. • Contrast is filling the bladder or not • Bladder surface is smooth or rough • Is there any diverticlula, filling defect or prostate indentation?
- 30. Post Void film • Taken immediately after voiding it is used to assess for • 1) Residual urine • 2) Bladder mucosal lesions • 3) Diverticula • 4) Bladder tumour • 5) Outlet obstruction VUR Note: All films are taken expiratory phase only.
- 31. SPECIAL FILMS IN IVU • Oblique view: • 1. To project the ureter away to supine and to separate overlying radio opaque shadows mimicking calculi. • 2. Oblique views are also used for visualization of posterolateral aspects of bladder and for doubtful urethral masses. • Erect film: • 1. Provoke emptying of urinary tract. • 2. Demonstrate layering of calculi in cysts and abscesses. • 3. Detect urinary tract gas not seen in other films. • 4. Have optimum demonstration of renal ptosis, bladder hernia,cystole and areas of obstruction in ureter. • Prone film: • 1. Viewing of urethral areas not seen in supine films. • 2. Demonstration of renal ptosis and bladder hernia.
- 32. Oblique film
- 33. Delayed films • Delayed films in IVU are taken 1-24 hours after injection. Patients should always be instructed to void prior to delayed films so that a calculus in the distal ureter seen in the well. Usual sequence of delayed films is after 1 hr, 3hrs, 6hrs, 12hrs and 24hrs. • Delayed films are used in : • Cases of obstruction where early nephrogram is seen but collecting system is not seen • Long standing hydronephrosis in which renal parenchyma is seen but collecting system is not visualized until many hours later • Congenital lesions like non-visualized upper calyceal system with obstructed ureter
- 34. MODIFICATION OF UROGRAM • Diuretic Urograms • It is useful in PUJ obstruction in which furosemide is given intravenously to induce diuresis which distends the renal pelvis. • The film is taken 5-15 minutes after the administration of the diuretic. • I.V. furosemide is used to induce dieresis which distends the renal pelvis.
- 35. 2.Tailored Urogram: • It modifies the urograms to provide the information needed to include or exclude the clinical problem and tailor the Urogram for that. • The study is terminated as soon as the desired information is available. 3.Hypertensive Urogram : • It is also called minute sequence urograms. • The films are taken 1,2,3,5 minutes after injection of contrast media. • Although the findings are of value, IVU cannot be used for screening of hypertensives as there are any many positive and false negative results
- 36. 4.Drip infusion Urography • Contrast is given in 500 ml normal saline. • Now this procedure is not widely used. • Advantages: • Nephrogram persists for longer time • Enhanced dieresis from the additional contrast media and water volume will distend the collecting system • Collecting system is visualized for long times. • No significant increase the contrast reactions. • Administration is easy.
- 37. 5.Emergency Urography: • It is done in cases of urinary colic. • Film taken : • 1) KUB • 2) 15mins
- 38. In case of Pregnancy: • Rarely necessary to perform, however if necessary, • The collecting system in pregnancy is capacious and the ureter exhibit poor peristalsis therefore, a single full length preliminary film and a delayed full length around 30-45 min may be well enough in this case.
- 39. In case of children: • Films at 2 min (supine) and 7 min (prone) is taken after contrast administration. • Or a 2 min (renal area) , 5 min (renal area),and 15 min full length abdominal film. • Abdominal compression not used. • To improve visualization of left kidney child can be given a carbonated beverage. • The right kidney can be well seen through the liver in a 15-20 degree caudal tilted view.
- 40. IN CASE OF PATHOLOGY/ABNORMALITIES • In case of VUJ obstruction: Oblique film of bladder area of obstruction side can be taken. • Ectopic kidney: full film KUB region from immediate to last film. • Renal agenesis: full film KUB from immediate to last film can be taken with Delayed films upto 24 hours. • Bladder diverticulum: Which is an Abnormal pouch formed within bladder. Lateral film of bladder area can be taken. • Vesicovaginal fistula: lateral film of bladder area can be taken. • In case of Hypertension: Minute sequence urogram is performed where, Films taken at 1,2,3,5 mins after injection of contrast media
- 41. Congenital anomalies • Renal agenesis • Supernumerary kidney • Ectopic kidney (pelvic, intrathoracic) • Crossed ectopia • Horseshoe kidney • Duplex kidney • Ureterocele
- 42. Common congenital abnormalities of kidneys and urinary tract
- 43. Horseshoe kidney
- 44. Ectopic kidney
- 45. Hydronephrosis
- 48. Ureterocele
- 49. Importance of compression 5min film without compression Bilateral underfilled and poorly demonstrated collecting system 5 min film after compression is applied Bilateral distension of collecting system is improved
- 50. Value of fluoroscopy Fluoroscopic spot image demonstrate the entire luminal surface of the bladder
- 51. Haematoma 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.
- 52. Hemorrhagic cystitis • 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).
- 53. Complications • Due to CM: • Reactions due to CM: mild, moderate and severe. • Due to technique: • Incorrectly applied abdominal compression may produce intolerable discomfort or hypotension. • Swelling ,pain and infection during injection • Extravasation of CM
- 54. • AFTER CARE • 1) Observation for 6 hours • 2) Watch for late contrast reactions • 3) Prevention of dehydration • 4) In high risk patients-renal function test should be done to watch for deterioration
- 55. 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.
- 56. 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
- 57. CT Urography •It is the diagonostic examination that allows the study of the urinary tract. •Generally three phases are taken for ct urography- unenhanced, nephrogenic phase and excreatory phase •Nephrogenic phase is taken after 100seconds and delayed after 3-5 minutes from the start if IV contrast •Ct urography can also be combined with excreatory urography delayed phase to onfirm the excreation of kidneys.
- 58. • Advantages of CT urography: • It helps to depict any smaller calculi • Depiction of renal masses • Depication of the calcification and pheloboliths • Diseases of renal vessels can be depicted • Disadvatages: • More radiation than conventional radiography • Less spatial radiation than conventional radiaography • High cost
- 60. References • A handbook of radiological procdures • Radiopedia • Radiographics.com • Guide to radiological procedure (chapman and nakielny,s) • Images from google
- 62. Questions • What do you understand by intravenous urogram and intravenous pyleogram ? • In which condition compression is applied and when is it contraindicated? • what is the normal value of urea and serum creatinie? • What are the filming sequences of intravenous urogram ? • What are the modifications of intravenous urogram ?