kub and ivp

KUB’s and IVP’s

Kristopher R. Carlson

2009

KUB

• Kubota Corporation

• Knoxville Utilities Board

• Kidneys, Ureters, Bladder

• Katholieke Universiteit Brabant

KIDNEYS, URETERS, BLADDER

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

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.

KUB, how to look at em.

• Get a System.

• #1 = Name and Date!!!

• Quality, penetration, pt position

• OutsideIn, vs. InsideOut

• Look at everything.

Anatomy, the basics

Anatomy

PSOAS• Position

• Size

• Orientation

• Axis

• Symmetry

Position

• Normally T12-L3

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

Size

• Normal adult • 10-13cm

• Children• Use normogram

Orientation and Axis

Bones

• Fractures• Vertebral Bodies pelvis, etc..

• Metastases• Lytic or blastic lesions

• Absence of bones• Sacral agenesis

• Diastasis• Symphysis, SI joints

Vertebrae

Pelvic Fractures

Mets

Not METS

Missing bones

Extra Bones

Stones

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

• Course of ureters• Lateral transverse processes

• Other Stones / Calcifications

Masses

• Renal contour

• Soft tissue densities

• Psoas shadows

• Displacement of normal structures

Colonic hydatid cyst

Gases

• Bowel gas• Distribution / location

• Gas filled fluid collections

• Gas in the wrong place

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

Abnormal Calcifications / Objects

• Multiple?

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

• Accidental• Bullets, swallowed items!

• Projectional• Clothing, body piercings

Whew…..Had enough?

IVP’s?

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

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

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

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

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

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%

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

Scout Film

• KUB as discussed

Early Nephrogram Films

• Most dense at 30 seconds to 1 minute

• Evaluates renal parenchyma

• PSOAS• Masses• Dromedary Hump• Fetal Lobulations

Tomograms• Increase sensitivity

for space occupying lesions

• Midplane in view of L2 vertebral bodies in focus

• Immediate detects parenchyma

• Delayed detects collecting system

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

• 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

Stones

Tumors

Other stuff

Trauma

Trauma IVP

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

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