GUT CASE INVESTIGATION

GUT CASE GUT CASE INVESTIGATIONINVESTIGATION

LECTURE 1LECTURE 1

Nephrolithiasis(renal stones)Nephrolithiasis(renal stones)

EpidemiologyEpidemiology Up to 10% by age 70, usu in 3Up to 10% by age 70, usu in 3rdrd to 4 to 4thth decade decade 4:1 M to F ratio4:1 M to F ratio More prevalent in the SouthMore prevalent in the South

Risk FactorsRisk Factors Hypercalcemic states, CrohnHypercalcemic states, Crohn’’s, stents, RTA, infection, s, stents, RTA, infection,

gout, hypercalciuria, hyperuricosuria, cystinuriagout, hypercalciuria, hyperuricosuria, cystinuria SymptomsSymptoms

Asymptomatic, flank pain, hematuriaAsymptomatic, flank pain, hematuria

CompositionCompositionOPAQUE OPAQUE contains calcium +/ phosphatecontains calcium +/ phosphate Calcium calculiCalcium calculi

Ca oxalate, Ca phosphateCa oxalate, Ca phosphate Struvite calculiStruvite calculi

Magnesium ammonium phosphate= triple phosphateMagnesium ammonium phosphate= triple phosphate

SEMI OPAQUE contains sulphurSEMI OPAQUE contains sulphur Cystine calculiCystine calculi

LUCENTLUCENT Uric acid stones;Xanthine Uric acid stones;Xanthine Matrix (coagulated mucoid material)Matrix (coagulated mucoid material)

CT Imaging of StonesCT Imaging of Stones

Essentially all renal and ureteral calculi have high Essentially all renal and ureteral calculi have high

attenuation on non-contrast CTattenuation on non-contrast CT (all but matrix stones (all but matrix stones have atten of > 100HU)have atten of > 100HU)

CT has sensitivity of 97% and specificity of 96%CT has sensitivity of 97% and specificity of 96% Can also see hydronephrosis, hydroureterCan also see hydronephrosis, hydroureter, renal , renal

enlargement, or perirenal strandingenlargement, or perirenal stranding Must differentiate from phlebolithMust differentiate from phlebolith which is a which is a

calcified blood clot in a pelvic vein.calcified blood clot in a pelvic vein.(appearance: (appearance: round/ovoid, smooth, central lucency, in true pelvis)round/ovoid, smooth, central lucency, in true pelvis)

NephrolithiasisNephrolithiasis

Images: BIDMC, Dept of Radiology, 2001.

Radio opaque stone in calyx

HydronephrosisHydronephrosis

Dilated urine filled pelvis

Stent

HydroureterHydroureter


Stent

Obstructive Uropathy Obstructive Uropathy Radiologic AssessmentRadiologic Assessment

Anatomy: Urinary TractAnatomy: Urinary Tract

http://www.urostonecenter.com/images/p1.gif

CortexCortex

MedullaMedulla

Superior Superior OperculumOperculum

Inferior Inferior OperculumOperculum

PelvisPelvis

CalyxCalyx

FornixFornix

Renal CapsuleRenal Capsule

PapillaPapilla

Unequivocal Obstructive Unequivocal Obstructive UropathyUropathy

= = Urinary tract obstructionUrinary tract obstruction

Unequivocal: clear etiologyUnequivocal: clear etiology Obstruction may be at any Obstruction may be at any

site within GU tractsite within GU tract Evidence of post-renal Evidence of post-renal

failurefailure Variable presentation Variable presentation

based on etiologybased on etiology

Sign: Hydronephrosis = dilatation of renal pelvis and ureters

Pathophysiology of Obstructive Pathophysiology of Obstructive UropathyUropathy

Initial increase in ureteral peristalsis & pelvic muscle hypertrophy

Mechanical or functional obstruction

Back up of urine flow = increased renal pressure

Initial increase in renal blood flow

Decrease in renal blood flow

Increase in renal lymphatic flow

Muscle stretched & atonic Aperistalsis

Tubular dilatation

Dilatation of ureters and renal collecting duct system

Parenchymal Atrophy

Renal failure

Pathogenesis of unilateral hydronephrosis. Smith’s Urology p.181

Hydronephrosis

How Acute Obstruction leads to How Acute Obstruction leads to Dilatation and Decreased Tubular Dilatation and Decreased Tubular

FunctionFunction

PathologyPathology

http://www.smbs.buffalo.edu/pth600/IMC-Path/images/Year1/Hydronephrosis_Gross-_Robbins.jpg

Dilated pelvis & calyces, renal atrophy, cut surface

http://www.smbs.buffalo.edu/pth600/IMC-Path/y1case/y1ans21.htm#Obstructivelesionsintheurinarytract

Dilated renal pelvis (arrow), external view

Clinical Presentation: Obstructive Clinical Presentation: Obstructive UropathyUropathy

Renal insufficiencyRenal insufficiency Consider UTO in all patients with unexplained renal insufficiencyConsider UTO in all patients with unexplained renal insufficiencyUrine Output ChangesUrine Output Changes

AnuriaAnuria = complete bilateral UTO = complete bilateral UTOPartial obstruction Partial obstruction normal to elevated UO normal to elevated UO

Hyperkalemic renal tubular acidosisHyperkalemic renal tubular acidosisHypertensionHypertensionLab Abnormalities: normal, microscopic/gross hematuria, pyuria, azotemia, uremia, anemia (2/2 Lab Abnormalities: normal, microscopic/gross hematuria, pyuria, azotemia, uremia, anemia (2/2

chronic infection, ACD), leukocytosischronic infection, ACD), leukocytosis

Lower and Mid Tract (Urethra and Bladder)

Hesitancy in starting urinationLessened forceWeak streamTerminal dribblingHematuriaBurning on urinationCloudy urine (infection)Acute urinary retention

Upper Tract(Ureter and Kidney)

Flank pain radiating along ureter course (distension)

Gross hematuriaNausea/VomitingFever/ChillsBurning on urinationCloudy urine with infectionBilateral uremia

N/V/weight loss

Think Anatomically: Think Anatomically: Where is obstructionWhere is obstruction??

Systemic or

Distal etiology

Bilateral hydronephrosis

Proximal etiology

Unilateral hydronephrosis

Series: 53 of 380 patients

52/53 in lower 1/3 of the ureter.

Causes:

Ureteral stones 64%

Ureteral edema or lucent stones 30%

Neoplasms 4%

Inflammatory disease 2%

Chen et al., J Emerg Med, 1997: 15; 3. 339 – 343.

Most Common in Distal Ureter

Acute Obstruction and AnuriaAcute Obstruction and Anuria

Patients may die from acute Patients may die from acute renal failure with renal failure with oliguria/anuriaoliguria/anuria

Requires prompt Requires prompt recognition and possible recognition and possible surgical interventionsurgical intervention

CT examination: Postcontrast axial scan: The retroperitoneal giant tumor mass compresses the right ureter and causes hydronephrosis (arrows).

http://www.szote.u-szeged.hu/radio/panc/alep8c.htm

Acute complete, bilateral obstruction = Medical Emergency

DiagnosisDiagnosis

Early diagnosis and decompression is Early diagnosis and decompression is criticalcritical to to prevent renal failureprevent renal failure

Continue to Radiologic work-up

UltrasonographyUltrasonographyTest of Choice for Suspected Urinary Tract ObstructionTest of Choice for Suspected Urinary Tract Obstruction

Screening testScreening testIndications: Renal failure of unknown origin/Hematuria/Signs of UTO/UrolithiasisIndications: Renal failure of unknown origin/Hematuria/Signs of UTO/UrolithiasisSensitivity for detection of chronic obstruction: 90%Sensitivity for detection of chronic obstruction: 90%Sensitivity for detection of acute obstruction: 60%Sensitivity for detection of acute obstruction: 60%

Advantages: Advantages: No allergic/toxic complications of radiocontrast mediaNo allergic/toxic complications of radiocontrast mediaFast, inexpensiveFast, inexpensiveDiagnose other causes of renal disease in patient with renal insufficiency of unknown originDiagnose other causes of renal disease in patient with renal insufficiency of unknown origin

Polycystic Kidney DiseasePolycystic Kidney Disease

DisadvantagesDisadvantagesNonspecificNonspecificRarely identifies causeRarely identifies causeFalse positive rate: < 25% with minimal criteria (operator dependent)False positive rate: < 25% with minimal criteria (operator dependent)

Any visualization of collecting systemsAny visualization of collecting systemsFalse negative with acute obstruction, dehydration, sepsisFalse negative with acute obstruction, dehydration, sepsisBowel Gas decreases sensitivityBowel Gas decreases sensitivity

Ultrasound Ultrasound –– Normal Kidney Normal Kidney

Normal renal fat, no dilatation of collecting system, hyperechoic

Normal renal parenchyma, hypoechoic, normal function

Ultrasound Ultrasound –– Obstructive Obstructive UropathyUropathy

Compressed renal fat, hyperechoic

Renal parenchyma, hypoechoic

Dilated collecting duct, hypoechoic (fluid)

CT: normal renal parenchyma with CT: normal renal parenchyma with proximal stone, no obstructive proximal stone, no obstructive

uropathyuropathy

Kawashima et al., RadioGraphics 2004;24:S35-S54

Noncontrast CT

Enhancing calculus in interpolar portion of R Kidney

CT: Hydronephrosis due to CT: Hydronephrosis due to retroperitoneal fibrosis (soft tissue)retroperitoneal fibrosis (soft tissue)

CT (postcontrast): Giant retroperitoneal tumor mass compressing the right ureter, causing hydronephrosis with compression of renal parenchyma (arrows).

http://www.szote.u-szeged.hu/radio/panc/alep8c.htm

CT: Obstructive UropathyCT: Obstructive Uropathy

PACS, Courtesy of Dr. D. Brennan

CT (postcontrast):Obstructive left-sided uropathy with proximal ureteric stone

Dilated Renal Pelvis

Proximal Stone

IVU: Intravenous UrogramIVU: Intravenous UrogramIntravenous Pyelogram = Excretory UrogramIntravenous Pyelogram = Excretory Urogram

1.1. Scout film Scout film calculi? calculi?2.2. IV bolus of radiocontrast dye (ionic contrast) IV bolus of radiocontrast dye (ionic contrast) 3.3. Series of plain films demonstrate kidneys, ureters, urinary Series of plain films demonstrate kidneys, ureters, urinary

bladderbladder4. Upright film post-void to evaluate for obstruction4. Upright film post-void to evaluate for obstruction

AdvantagesAdvantagesAnatomyAnatomyPathology LocationPathology LocationRough indicator of function bilaterallyRough indicator of function bilaterallyLow false positive rateLow false positive rateDetects associated conditionsDetects associated conditions

Papillary necrosis Papillary necrosis intralumenal filling defect intralumenal filling defectCaliceal blunting from previous infectionCaliceal blunting from previous infection

DisadvantagesDisadvantagesCumbersome Cumbersome Requires radiocontrastRequires radiocontrastNeed bowel prep with conventional IVUNeed bowel prep with conventional IVURadiation doseRadiation doseNeed cross-sectional imaging follow upNeed cross-sectional imaging follow up

CT UrographyCT Urography

Evaluate urinary tract for flow defectsEvaluate urinary tract for flow defects

Noncontrast Scout first: UrolithiasisNoncontrast Scout first: Urolithiasis

Coronal reconstructions: visualize entire urinary tractCoronal reconstructions: visualize entire urinary tract

Advantages over Conventional IVUSpeedSensitive to renal parenchyma abnormalitiesSimultaneous evaluation of both renal parenchyma and urinary tractCross-sectional imaging

DisadvantagesRadiation doseIonic Contrast reactions/cannot be used in patients in renal failure

Kawashima et al., RadioGraphics 2004;24:S35-S54

Normal CT UrogramNormal CT UrogramCT Urography

Total Body Opacificantion

Nephrogram

Pyelogram



Nephrogram

Pyelogram



Nephrogram

Pyelogram



Nephrogram

Pyelogram

Pt. JL, PACS, Courtesy of Dr. AC Kim



Nephrogram

Pyelogram



Nephrogram

Pyelogram



Nephrogram

Pyelogram

Contraindications for IVU/CTUContraindications for IVU/CTUHistory of allergy to IV contrastHistory of allergy to IV contrast

Bronchospasm, laryngeal edema, anaphylactic shockBronchospasm, laryngeal edema, anaphylactic shockMay use with history of minor allergic reactions with preprocedural steroids, antihistamines May use with history of minor allergic reactions with preprocedural steroids, antihistamines

(diphenhydramine) 12 hours prior to study(diphenhydramine) 12 hours prior to study

Renal insufficiencyRenal insufficiencyPregnancyPregnancy = relative contraindication (radiation exposure) = relative contraindication (radiation exposure)

MR Urogram can be usedMR Urogram can be usedLikewise: children Likewise: children minimize radiation doses minimize radiation doses

Pts taking oral hypoglycemicsPts taking oral hypoglycemics (metformin) should stop taking meds prior to study (metformin) should stop taking meds prior to studyMay resume after renal function is confirmed normalMay resume after renal function is confirmed normalRisk of lactic acidosisRisk of lactic acidosis

Must be Physician-Supervised- Contrast reactions- Minimize no. of images - Minimize radiation- May use Fluoroscopy

MR UrographyMR Urography

A. A. Unenhanced MR urographyUnenhanced MR urography Heavily T2 weighted Heavily T2 weighted

B. B. Gadolinium-enhanced excretory MR urographyGadolinium-enhanced excretory MR urographyC. C. Excretory MR urography + diureticExcretory MR urography + diuretic

10 mg furosemide IV 10 mg furosemide IV Gadopentetate dimeglumineGadopentetate dimeglumine

AdvantagesAdvantages: : Distinguishes adjacent Distinguishes adjacent soft tissuesoft tissue abnormalities abnormalitiesWith Gadolinium: functional informationWith Gadolinium: functional informationNo ionic contrast No ionic contrast OK in renal failure OK in renal failureNo radiation No radiation children, pregnancy women children, pregnancy women

DrawbacksDrawbacksHigh costHigh costLow sensitivity in detecting calcificationsLow sensitivity in detecting calcificationsTime intensiveTime intensiveMetallic implants/Foreign Body = ContraindicationsMetallic implants/Foreign Body = Contraindications

Blandino et al., AJR 2002; 179: 1307 -1314

Sagittal contrast-enhanced excretory MR urography obstructing right

sided papillary TCC

Excretory Urogram/CTU/MRUExcretory Urogram/CTU/MRUAcuteAcute Obstruction Obstruction

Kidney minimally enlargedDense Nephrogram • Preferential absorption of Na and

water from diseased tubules = concentration of contrast

Delayed appearance of contrast in collecting system

= delayed functionPoor concentration of contrast in the

collecting tubulesNo ureteral dilatation acutely

Ureters not tortuous

Mild Moderate Marked

http://asia.elsevierhealth.com/home/sample/pdf/314.pdf

Excretory Urogram/CTU/MRU Excretory Urogram/CTU/MRU ChronicChronic Obstruction Obstruction

Progressive dilation of collecting system and ureters/tortuous

Urectasis = dilated ureterDecrease number of nephrons 6-12 weeks: irreversible loss of renal

function“Shell nephrogram” parenchymal atrophy

Collecting system: blunt calyces/forniceal angles

Partial Complete

Blandino et al., AJR 2002; 179: 1307 -1314

Calyceal Clubbing

Patient JL Patient JL –– Bladder Mass Bladder Mass

Left Bladder mass surrounding UO

Diagnosis:

57 yo M with known Bladder CA with left hydronephrosis secondary to left bladder cancer.

Management

Foley placement for immediate decompression. Pt urinated following catheter removal and was cleared for d/c

Urology consult for possible stent placement

Renal Cystic DiseaseRenal Cystic Disease

Very commonVery common 50% of pts over age of 50 50% of pts over age of 50 Assoc w/ many syndromes, etiology Assoc w/ many syndromes, etiology

unknown, probably arise from obstructed unknown, probably arise from obstructed tubules or ductstubules or ducts

Most commonly asymptomaticMost commonly asymptomatic Rarely, may have hematuria, HTN, cyst Rarely, may have hematuria, HTN, cyst

infection, or mass effectinfection, or mass effect

CT Characteristics of CT Characteristics of Simple CystsSimple Cysts

Smooth, imperceptible cyst wallSmooth, imperceptible cyst wall Sharp demarcation from surrounding renal Sharp demarcation from surrounding renal

parenchymaparenchyma Water attenuation (<15 HU), homogenous Water attenuation (<15 HU), homogenous

throughout lesionthroughout lesion Non-enhancingNon-enhancing Simple cysts are w/o septations or calcificationSimple cysts are w/o septations or calcification May have slight elevation of adjacent renal May have slight elevation of adjacent renal

parenchyma parenchyma Beak sign Beak sign

Type I Simple CystType I Simple Cyst

Bird Beak Sign


Simple Cyst

Aortic aneurysm

Inferior vena cava with filters

Type IV Cystic NeoplasmType IV Cystic Neoplasm


Complex renal mass infiltrating lvc

Conditions Associated with Conditions Associated with Multiple CystsMultiple Cysts

Autosomal Dominant PCKDAutosomal Dominant PCKD Autosomal Recessive PCKDAutosomal Recessive PCKD Acquired Cystic Disease (hemodialysis Acquired Cystic Disease (hemodialysis

pts)pts) Von-Hippel-Lindau diseaseVon-Hippel-Lindau disease Tuberous SclerosisTuberous Sclerosis Medullary Sponge KidneyMedullary Sponge Kidney

Benign MassesBenign Masses

CystsCysts AngiomyolipomaAngiomyolipoma Oncocytoma (via epithelial cells of prox tubule)Oncocytoma (via epithelial cells of prox tubule) Renal Adenoma Renal Adenoma Mesoblastic Nephroma (hamartomatous tumor, usu Mesoblastic Nephroma (hamartomatous tumor, usu

present at birth)present at birth) HemangiomaHemangioma Various Renal Pelvic Tumors(papilloma, angioma, Various Renal Pelvic Tumors(papilloma, angioma,

fibroma)fibroma) HematomaHematoma

AngiomyolipomaAngiomyolipoma

Hamartomas containing fat, smooth muscle, and Hamartomas containing fat, smooth muscle, and blood vesselsblood vessels

Usually asymptomatic, but may spontaneously Usually asymptomatic, but may spontaneously bleedbleed

Large AMLs resected or embolizedLarge AMLs resected or embolized Multiple AMLS usually Associated w/ tuberous Multiple AMLS usually Associated w/ tuberous

sclerosissclerosis On CTOn CT *fat attenuation in mass*, strong *fat attenuation in mass*, strong

contrast enhancement (RCCs rarely contain fat), contrast enhancement (RCCs rarely contain fat), no Ca2+ no Ca2+

AngiomyolipomaAngiomyolipoma


Note fat content

Malignant MassesMalignant Masses

Renal Cell CancerRenal Cell Cancer Transitional Cell CancerTransitional Cell Cancer WilmWilm’’s Tumor s Tumor Nephroblastomatosis (multiple rests of Nephroblastomatosis (multiple rests of

embryologic metanephric blastoma)embryologic metanephric blastoma) LymphomaLymphoma Metastases (lung, breast, colon, melanoma)Metastases (lung, breast, colon, melanoma)

Renal Cell CaRenal Cell Ca

Most common primary renal malignancy (85% of Most common primary renal malignancy (85% of primary renal tumors)primary renal tumors)

Assoc w/ smoking, family hx, age, Von Hippel-Assoc w/ smoking, family hx, age, Von Hippel-Lindau, Acquired Cystic Disease/chronic dialysis, Lindau, Acquired Cystic Disease/chronic dialysis,

phenacetin abusephenacetin abusePresentation: Hematuria, flank pain, wt loss, palp Presentation: Hematuria, flank pain, wt loss, palp

mass, fever, anemia, paraneoplastic syndromesmass, fever, anemia, paraneoplastic syndromes liver enzymes w/o metsliver enzymes w/o mets Stauffer syndrome Stauffer syndrome

CT characteristicsCT characteristics

VariableVariablefrom complex cyst to large, from complex cyst to large, heterogeneous renal massheterogeneous renal mass

Generally enhancingGenerally enhancing May have calcificationsMay have calcifications May have hemorrhage and central necrosisMay have hemorrhage and central necrosis Usually no fatUsually no fat

Renal Cell CaRenal Cell Ca


RCCRCC


Renal Trauma

Anatomy of the Kidney

Be suspicious of renal injury with broken ribs

Renal blood supply

Renal arteries

Renal veins

IVC

Ureter

2

Anatomy of the Kidney

3

10-20% of trauma pts. have GU involvement

45% of GU trauma is renal

20-30% of renal trauma pts. have associated abdominal injury

•

•

•

Prevalence of Renal Trauma

4

Mechanisms of Renal Trauma

Blunt trauma (80%): MVA, falls, assaults

Penetrating trauma (20%): gunshot, stabbing, impalement

Predisposing factors: preexisting renal conditions (tumors, hydronephrosis), children, associated abdominal injuries

•

•

•

5

Clinical Presentation of Renal Trauma

Gross or microscopic hematuria (absent in 5%)

Flank pain/ecchymosis

Hemodynamic instability

Presence of other abdominal injuries

•

•

•

•

6

Patient 1: An illustration of imaging modalities

• 18 yo male sustained stab wound to R flank

• P=180, BP 130/80, Hct 36

• CXR nl.

• Why image and with which modality?

7

Indications for Imaging

• Gross hematuria

• Microscopic hematuria with hemodynamic instability

• Persistent microscopic hematuria

• Significant MOI

8

Radiologic Imaging of Renal Trauma

CT with IV contrast

• Gold standard, high sensitivity

• Immediate and delayed post-contrast images to view collecting system

• Images abdomen and retroperitoneum

• Allows diagnosis and staging

• Not for hemodynamically unstable pts.9

Patient 1: CT with IV Patient 1: CT with IV contrastcontrast

Peri-renal hemorrhage

Normal attenuating kidney

10

Patient 1: CT with IV contrast

Contrast extravasation

11

Renal laceration with extravasation of contrast

Retroperitoneal hematoma

Patient 1: CT with IV contrast

12

Intravenous pyelography

Extravasation of contrast from R kidney

Image from Trauma.org

• Inadequate for grading renal injury

• Used in unstable pts prior to surgery to identify functioning contralateral kidney

• Unable to evaluate abdomen and retroperitoneum

Radiologic Imaging of Renal Trauma Cont.

13

Renal Angiography

Devascularization of L kidney

Image fromTrauma.org

• Delineates vascular injury (intimal tears, pseudoaneurysm, AV fistula)

• Use when CT equivocal and continued hemorrhage

• Use for endovascular repair (embolization, stenting)


14

Renal ultrasound

• Bedside US in ED allows evaluation of abd/pelvic injury/fluid accumulation

• High false neg. rate for renal injury

• Used in areas without CT, or for follow up


kidney

Subcapsular hematoma

15

• 17 yo unrestrained driver MVA c/o RLQ pain

• VSS

• Hct 45.7, BUN 15, Cr 1.2

• CXR, cervical, lumbar, pelvic plain films nl.

• CT demonstrates renal laceration

• How severe? How manage?

Patient 2: An Illustration of Injury Staging

16

Grade I Contusion: Microscopic or gross hematuria, urological studies normal

Hematoma: Subcapsular, nonexpanding without parenchymal laceration

Grade II Hematoma: Nonexpanding perirenal hematoma confined to renal retroperitoneum

Laceration: <1cm parenchymal depth of renal cortex without urinary extravasation

AAST Organ Injury Scale - Renal Injury

Grade I and II injuries managed conservatively (observation, serial Hct)Grade I and II injuries managed conservatively (observation, serial Hct) 17

Grade III Laceration: >1cm depth of renal cortex, without collecting system rupture or urinary extravasation

Grade IV Laceration: Parenchymal laceration extending through the renal cortex, medulla and collecting system

Vascular: Main renal artery or vein injury with contained hemorrhage

AAST Renal Injury Scale Cont.

Grade III and IV injuries are now managed conservatively Grade III and IV injuries are now managed conservatively 18

Grade V Laceration: Completely shattered kidney

Vascular: Avulsion of renal hilum which devascularizes kidney

AAST Renal Injury Scale Cont.

Surgery! Salvage vs. nephrectomy Surgery! Salvage vs. nephrectomy

Image from www.trauma.org

19

Renal Trauma Conclusions

• CT with contrast

• Look for renal trauma in pts with abdominal trauma and significant MOI

• Grade severity of injury

• 80-90% renal injuries treated conservatively with remarkable resolution!•

• Injuries requiring surgery: vascular injury, shattered kidney, expanding hematoma

23

Imaging in the Imaging in the Evaluation of Female Evaluation of Female

InfertilityInfertility

InfertilityInfertility

Inability to conceive after one year of Inability to conceive after one year of intercourse without contraceptionintercourse without contraception

EpidemiologyEpidemiology Affects 1 in 7 American couplesAffects 1 in 7 American couples

Rate has been stable over the past 50 yearsRate has been stable over the past 50 years

Advances in assisted reproductive technologies Advances in assisted reproductive technologies (ART) has increased interest in infertility (ART) has increased interest in infertility treatmenttreatment

Infertility - CausesInfertility - CausesMale Factor Male Factor –– 40% 40%

AzoospermiaAzoospermiaSperm defect or dysfunctionSperm defect or dysfunctionChronic IllnessChronic Illness

Female FactorFemale Factor –– 40%40%Advanced ageAdvanced ageAnovulatory cyclesAnovulatory cyclesCongenital anomaliesCongenital anomaliesAcquired structural defectsAcquired structural defectsEndocrine abnormalitiesEndocrine abnormalities

Combined Factors – 10% Unexplained – 10%

Infertility Infertility –– Radiologic Evaluation Radiologic Evaluation Largely focuses on female factor infertilityLargely focuses on female factor infertility

Several congenital and acquired conditions affect Several congenital and acquired conditions affect female reproductive functionfemale reproductive function

Complete evaluation of the female reproductive tract Complete evaluation of the female reproductive tract must include cervical, uterine, endometrial, tubal, must include cervical, uterine, endometrial, tubal, peritoneal, and ovarian factorsperitoneal, and ovarian factors

Menu of TestsMenu of Tests

Hysterosalpingogram (HSG)Hysterosalpingogram (HSG) Ultrasound (US)Ultrasound (US) Sonohysterogram (SHG)Sonohysterogram (SHG) Magnetic Resonance Imaging (MRI)Magnetic Resonance Imaging (MRI)

HSGHSG

HysterosalpingogramHysterosalpingogram Historically the mainstay in infertility imagingHistorically the mainstay in infertility imaging

Indications: evaluation of uterine cavity and Indications: evaluation of uterine cavity and patency of tubespatency of tubes

Limitations: does not aid in characterization of Limitations: does not aid in characterization of uterine wall or ovarian pathologyuterine wall or ovarian pathology

UltrasoundUltrasound Test of choice for imaging the female pelvisTest of choice for imaging the female pelvis

No radiation exposureNo radiation exposure

Indications: evaluation of ovarian, uterine wall, and Indications: evaluation of ovarian, uterine wall, and adnexal pathologyadnexal pathology

Limitations: additional imaging may be needed for Limitations: additional imaging may be needed for pre-surgical characterization and localization of pre-surgical characterization and localization of pathologypathology

MRIMRI

Excellent soft tissue characterizationExcellent soft tissue characterization

Indications: guides interventional radiology Indications: guides interventional radiology and surgical management of infertility by and surgical management of infertility by

identifying size, number, and location of identifying size, number, and location of pathologypathology

Female Reproductive TractFemale Reproductive Tract

www.ethal.org.my/.../ 181rmgUterus.html

CervixCervixCervical StenosisCervical Stenosis

Narrowing of the cervix due Narrowing of the cervix due to adhesions or scarringto adhesions or scarring

Patients complain of painful Patients complain of painful or absent periodsor absent periods

Complication of cone Complication of cone biopsybiopsy

Blocks entry of spermBlocks entry of sperm

Fallopian Tube

vary

Ovary

Uterus

AdhesionsCervix

Vagina

www.drkline.com/ risks.html

Cervical StenosisCervical StenosisHSG Findings:

•Internal os < 1mm

•Inability to advance catheter •Non-opacified uterine cavity

BIDMC, PACSVaginaCervical Stenosis

Normal HSG

UterusUterus

SynechiaeSynechiae FibroidsFibroids PolypsPolyps Congenital AnomaliesCongenital Anomalies

SynechiaeSynechiae

Asherman SyndromeAsherman Syndrome

Intrauterine adhesions caused by trauma, infection, or Intrauterine adhesions caused by trauma, infection, or instrumentationinstrumentation

Healing granulation tissue forms bridges across the cavityHealing granulation tissue forms bridges across the cavity

Infertility may result from obliteration of the cavity or Infertility may result from obliteration of the cavity or obstruction to implantationobstruction to implantation

SynechiaSynechia

HSG findingsHSG findings::

Filling DefectFilling Defect

LinearLinear

IrregularIrregular

SynechiaBIDMC, PACS

SynechiaSynechia

US Findings:US Findings:

EchoicEchoic

LinearLinear

Extends from Extends from one wall to one wall to opposite wallopposite wall

Synechia

FibroidsFibroids Benign, smooth muscleBenign, smooth muscle

tumors of the uterustumors of the uterus

Found in 20-30% of Found in 20-30% of reproductive aged womenreproductive aged women

Affects fertility by Affects fertility by interfering with interfering with implantationimplantation

FibroidsFibroidsHSG FindingsHSG Findings

Scalloped endometrial lining

FibroidsFibroids

US FindingsUS Findings::HypoechoicHypoechoic mass mass

May be submucosal, May be submucosal, intramural, or subserosalintramural, or subserosal

Uterine enlargement or Uterine enlargement or distortion may be seendistortion may be seen

Fibroid

Ultrasound aids in characterization of fibroids.

FibroidsFibroids

BIDMC, PACS

MRI aids in:

• characterization and localization of uterine wall pathology

•pre-surgical planning

Fibroids

Uterine AnomaliesUterine AnomaliesA defect in the embryologic development of A defect in the embryologic development of

the Mullerian system can cause congenital the Mullerian system can cause congenital uterine anomaliesuterine anomalies

There are 7 classifications of anomaliesThere are 7 classifications of anomalies

All can be identified by imagingAll can be identified by imaging

Uterine AnomaliesUterine Anomalies

Normal Class II - Unicornuate

Class III - Didelphys Class IV - Bicornuate

Class V - Septate Class VII - DESClass VI - Arcuate

http://www.emedicine.com/radio/topic738.htm


Bicornuate:

• Indented fundus but otherwise normal uterine wall• No affect on fertility• No infertility treatment necessary

Septate:

• Fibrous band projecting from fundus into uterine cavity • Interferes with implantation• Surgical removal increases fertility

http://www.emedicine.com/radio/topic738.htm

Two classes must be differentiated in the infertility work-Two classes must be differentiated in the infertility work-upup::


Irregularly shaped uterine cavity on HSG MRI

BIDMC, PACS


The irregularly shaped uterus seen on HSG andThe irregularly shaped uterus seen on HSG and

MRI in the previous slides was determined to beMRI in the previous slides was determined to be

an arcuate (class VI) uterus. It is on the spectruman arcuate (class VI) uterus. It is on the spectrum

of bicornuate and is believed to be a normalof bicornuate and is believed to be a normal

variant with no affects on fertilityvariant with no affects on fertility . .

Fallopian TubesFallopian Tubes

ObstructionObstruction Pelvic Inflammatory DiseasePelvic Inflammatory Disease FibroidsFibroids EndometriosisEndometriosis AdhesionsAdhesions Tubal spasmTubal spasm


Fimbria

Ampulla

Isthmus

Infundibula


Left Proximal Obstruction Right Proximal Obstruction

Peritoneal CavityPeritoneal Cavity

AdhesionAdhesion EndometriosisEndometriosis Post surgicalPost surgical Post infectionPost infection

Difficult to image directly but an irregular pattern Difficult to image directly but an irregular pattern of dye overflow on HSG may raise suspicionof dye overflow on HSG may raise suspicion..

OvariesOvaries EndometriosisEndometriosis Polycystic Ovary Syndrome (PCOS)Polycystic Ovary Syndrome (PCOS)

Ovarian stroma

Bilateral Endometriomas

EndometriosisEndometriosis

US Findings:

•Round

•Symmetric

•Hypoechoic cysts

•Low-level echoes

•Persistent

PCOSPCOSUS Findings of PCOUS Findings of PCO::

BilateralBilateral

Round, echogenic ovariesRound, echogenic ovaries

10-1210-12 small folliclessmall follicles

PCOS is a clinical diagnosis. US findings of polycystic ovaries is neither necessary nor sufficient, but in the right clinical setting may be indicative of the diagnosis.

EW is 9 weeks pregnant today.

Early OB Ultrasound at 7 weeks 4 days.

GUT CASE INVESTIGATION

Documents

renal enlargement

renal atrophy

dilatation of renal

renal blood flowincrease

renal blood flowdecrease

renal pelvis arrow

renal lymphatic flowmuscle

urinary tracthttp