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KUB’s and IVP’s Kristopher R. Carlson 2009
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Page 1: KUB and IVP

KUB’s and IVP’s

Kristopher R. Carlson

2009

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KUB

• Kubota Corporation

• Knoxville Utilities Board

• Kidneys, Ureters, Bladder

• Katholieke Universiteit Brabant

KIDNEYS, URETERS, BLADDER

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A little physics• Closer to film = smaller• Closer to beam = larger

• Radiation vs background:• CXR= 0.01 - 1.30 mSv. = 5-15d• AXR - 0.12 - 9.90 mSv. = 2-3m• IVP = 3 mSv = 0.5-1.5 years• CT abdomen = 10 mSv + = 3-5 years• Coast to Coast Airplane Ride = 0.01mSv

www.Radiologyinfo.org, www.hps.org

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KUB = Kidneys, Ureters, Bladder

• Adequacy• Adrenals to 2cm below pubic

symphysis

• Bones, Stones, Masses, Gasses

• Abnormal Calcifications• Renal, ureteral, gallstones, tumors, etc.

• Foreign Objects• It’s amazing what people can do with

things and their orifices.

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KUB, how to look at em.

• Get a System.

• #1 = Name and Date!!!

• Quality, penetration, pt position

• OutsideIn, vs. InsideOut

• Look at everything.

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Anatomy, the basics

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Anatomy

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PSOAS• Position

• Size

• Orientation

• Axis

• Symmetry

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Position

• Normally T12-L3

• R lower than L• R = L1 – L3• L = T12 – L2/3

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Size

• Normal adult • 10-13cm

• Children• Use normogram

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Orientation and Axis

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Bones

• Fractures• Vertebral Bodies pelvis, etc..

• Metastases• Lytic or blastic lesions

• Absence of bones• Sacral agenesis

• Diastasis• Symphysis, SI joints

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Vertebrae

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Pelvic Fractures

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Mets

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Not METS

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Missing bones

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Extra Bones

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Stones

• Overlying kidney/ureter/bladder• Kidneys• PSOAS mnemonic• Position, Size, Orientation, Axis, Symmetry

• Course of ureters• Lateral transverse processes

• Other Stones / Calcifications

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Masses

• Renal contour

• Soft tissue densities

• Psoas shadows

• Displacement of normal structures

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Colonic hydatid cyst

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Gases

• Bowel gas• Distribution / location

• Gas filled fluid collections

• Gas in the wrong place

• Free air• Hemi diaphragms.• Better with upright CXR

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Abnormal Calcifications / Objects

• Multiple?

• Foreign bodies• Iatrogenic • surgical clips, IUDs, IVC filters

• Accidental• Bullets, swallowed items!

• Projectional• Clothing, body piercings

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Whew…..Had enough?

IVP’s?

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IVP = IntraVenous Pyelogram

• Timed series of images of the abdomen after administration of 50-100mL IV contrast.• Scout Film• Early Nephrogram Films• Tomograms• Excretion Films

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Pre-Exam Considerations

• Bowel prep?• Useful in the chronically constipated• No randomized study to prove effective

• Hydration• Increased contrast if dehydrated• Increased risk of injury

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Contrast Media

• Ionic (high osmolar) Contrast Media• Hypaque, Conray, Renograffin• Hypertonic to serum by 5 to 7 fold

• Low Osmolar Contrast Media• Omnipaque, Visipaque• 50% reduction in osmolality

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Contrast Media• Indications for Low Osmolar Contrast• Previous reaction to contrast• History of Asthma or Allergy• History of Cardiac Disease or Dysfunction• Generalized Debilitation• Blood Dyscrasias• Risk of Aspiration• Age < 1 year

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Adverse effects of contrast• Chemotoxic• Nephrotoxicity• Nonoliguric• Creatinine peaks in 3-5 days• Risk 1 in 1000-5000 if no risk factors• Risk factors: renal insufficiency, DM, CHF,

hyperuricemia, proteinuria, multiple doses of contrast• Metformin (Glucophage) overdose causes

lactic acidosis withhold for 48 hours after contrast

• Anaphylactoid / Idiosyncratic

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Adverse effects of contrast• Anaphylactoid / Idiosyncratic• Mild: metallic taste, warmth, sneezing, coughing,

mild hives no treatment• Moderate: vomiting, severe hives, HA, palpitations,

facial edema• Severe: hypotension, bronchospasm, laryngeal

edema, pulmonary edema, LOC

• Idiosyncratic rxns for ionic contrast = as high as 12%, most mild.

• Tx with Antihistamine = mild, Epi or beta agonist = severe.

• Non-ionic = 3%

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Contrast “Allergic”?

• Consider non-allergenic imaging\

• Prophylaxis:• Prednisone = 50mg PO x 3 doses• 13hrs, 7hrs, 1hr before dose. AND…..

• Benadryl 50mg PO 30 min prior to dose• Other regiments exist.

Maddox, T. Adverse Reactions to Contrast Material: Recognition, Prevention, and Treatment AFP. Oct 2002.http://www.aafp.org/afp/20021001/1229.html

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Scout Film

• KUB as discussed

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Early Nephrogram Films

• Most dense at 30 seconds to 1 minute

• Evaluates renal parenchyma

• PSOAS• Masses• Dromedary Hump• Fetal Lobulations

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Tomograms• Increase sensitivity

for space occupying lesions

• Midplane in view of L2 vertebral bodies in focus

• Immediate detects parenchyma

• Delayed detects collecting system

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Excretion Films• 2 or 3 between 5 and 15 minutes• Need to see collecting system, ureters and

bladder• Oblique views may help to evaluate filling

defects or calcifications• Prone views distend the distal ureter• Upright films may help to evaluate for

renal ptosis, cystoceles, layering stones• Post void films help assess bladder outlet

obstruction

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• Kidney• 7-9 papillae, each

cupped by a minor calyx

• Each minor calyx narrows to form an infundibulum

• Minor calyces coalesce to form 2-3 major calyces

• Major calyces coalesce to form the renal pelvis

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Stones

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Tumors

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Other stuff

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Trauma

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Trauma IVP

• Useful in emergent situations on the table:• 2 mL / kg IV given intraoperatively• Image x 1 at 10 minutes

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Summary

• KUB’s and IVP’s provide rapid, low risk, low radiation way to assess a variety of complaints and pathologies.

• Be systematic

• Bones, Stones, Masses, Gases

• PSOAS

• Be aware of contrast and radiation