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GUT CASE INVESTIGATION. LECTURE 1. Nephrolithiasis(renal stones). Epidemiology Up to 10% by age 70, usu in 3 rd to 4 th decade 4:1 M to F ratio More prevalent in the South Risk Factors

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Gut case investigation



Nephrolithiasis renal stones

Nephrolithiasis(renal stones)

  • Epidemiology

    • Up to 10% by age 70, usu in 3rd to 4th decade

    • 4:1 M to F ratio

    • More prevalent in the South

  • Risk Factors

    • Hypercalcemic states, Crohn’s, stents, RTA, infection, gout, hypercalciuria, hyperuricosuria, cystinuria

  • Symptoms

    • Asymptomatic, flank pain, hematuria



OPAQUE contains calcium +/ phosphate

  • Calcium calculi

    • Ca oxalate, Ca phosphate

  • Struvite calculi

    • Magnesium ammonium phosphate= triple phosphate

      SEMI OPAQUE contains sulphur

  • Cystine calculi


  • Uric acid stones;Xanthine

  • Matrix (coagulated mucoid material)

Ct imaging of stones

CT Imaging of Stones

  • Essentially all renal and ureteral calculi have high attenuation on non-contrast CT(all but matrix stones have atten of > 100HU)

  • CT has sensitivity of 97% and specificity of 96%

  • Can also see hydronephrosis, hydroureter, renal enlargement, or perirenal stranding

  • Must differentiate from phlebolithwhich is a calcified blood clot in a pelvic vein.(appearance: round/ovoid, smooth, central lucency, in true pelvis)



Radio opaque stone in calyx

Images: BIDMC, Dept of Radiology, 2001.



Dilated urine filled pelvis





Images: BIDMC, Dept of Radiology, 2001.

Obstructive uropathy radiologic assessment

Obstructive Uropathy Radiologic Assessment

Anatomy urinary tract

Anatomy: Urinary Tract

Renal Capsule


Superior Operculum





Inferior Operculum


Unequivocal obstructive uropathy

Unequivocal Obstructive Uropathy

= Urinary tract obstruction

Unequivocal: clear etiology

  • Obstruction may be at any site within GU tract

  • Evidence of post-renal failure

  • Variable presentation based on etiology

Sign: Hydronephrosis = dilatation of renal pelvis and ureters

Pathophysiology of obstructive uropathy

Pathophysiology of Obstructive Uropathy


Mechanical or functional obstruction

Back up of urine flow = increased renal pressure

Tubular dilatation

Initial increase in renal blood flow

Decrease in renal blood flow

Increase in renal lymphatic flow

Initial increase in ureteral peristalsis & pelvic muscle hypertrophy

Muscle stretched & atonic  Aperistalsis

Dilatation of ureters and renal collecting duct system

Parenchymal Atrophy

Renal failure

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

How acute obstruction leads to dilatation and decreased tubular function

How Acute Obstruction leads to Dilatation and Decreased Tubular Function



Dilated pelvis & calyces, renal atrophy, cut surface

Dilated renal pelvis (arrow), external view

Clinical presentation obstructive uropathy

Clinical Presentation: Obstructive Uropathy

Lower and Mid Tract

(Urethra and Bladder)

Upper Tract

(Ureter and Kidney)

Renal insufficiency Consider UTO in all patients with unexplained renal insufficiency

Urine Output Changes

Anuria = complete bilateral UTO

Partial obstruction  normal to elevated UO

Hyperkalemic renal tubular acidosis


Lab Abnormalities: normal, microscopic/gross hematuria, pyuria, azotemia, uremia, anemia (2/2 chronic infection, ACD), leukocytosis

Hesitancy in starting urination

Lessened force

Weak stream

Terminal dribbling


Burning on urination

Cloudy urine (infection)

Acute urinary retention

Flank pain radiating along ureter course (distension)

Gross hematuria



Burning on urination

Cloudy urine with infection

Bilateral uremia

N/V/weight loss

Think anatomically where is obstruction

Think Anatomically: Where is obstruction?

Proximal etiology

Unilateral hydronephrosis

Series: 53 of 380 patients

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


Ureteral stones 64%

Ureteral edema or lucent stones 30%

Neoplasms 4%

Inflammatory disease 2%

Most Common in Distal Ureter

Systemic or

Distal etiology

Bilateral hydronephrosis

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

Acute obstruction and anuria

Acute Obstruction and Anuria

Acute complete, bilateral obstruction

= Medical Emergency

Patients may die from acute renal failure with oliguria/anuria

Requires prompt recognition and possible surgical intervention

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



Early diagnosis and decompression is critical to prevent renal failure

Continue to Radiologic work-up



Test of Choice for Suspected Urinary Tract Obstruction

Screening test

Indications: Renal failure of unknown origin/Hematuria/Signs of UTO/Urolithiasis

Sensitivity for detection of chronic obstruction: 90%

Sensitivity for detection of acute obstruction: 60%


No allergic/toxic complications of radiocontrast media

Fast, inexpensive

Diagnose other causes of renal disease in patient with renal insufficiency of unknown origin

Polycystic Kidney Disease



Rarely identifies cause

False positive rate: < 25% with minimal criteria (operator dependent)

Any visualization of collecting systems

False negative with acute obstruction, dehydration, sepsis

Bowel Gas decreases sensitivity

Ultrasound normal kidney

Ultrasound – Normal Kidney

Normal renal parenchyma, hypoechoic, normal function

Normal renal fat, no dilatation of collecting system, hyperechoic

Ultrasound obstructive uropathy

Ultrasound – Obstructive Uropathy

Renal parenchyma, hypoechoic

Dilated collecting duct, hypoechoic (fluid)

Compressed renal fat, hyperechoic

Ct normal renal parenchyma with proximal stone no obstructive uropathy

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

Noncontrast CT

Enhancing calculus in interpolar portion of R Kidney

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

Ct hydronephrosis due to retroperitoneal fibrosis soft tissue

CT: Hydronephrosis due to retroperitoneal fibrosis (soft tissue)

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

Ct obstructive uropathy

CT: Obstructive Uropathy

Dilated Renal Pelvis

Proximal Stone

CT (postcontrast):

Obstructive left-sided uropathy with proximal ureteric stone

PACS, Courtesy of Dr. D. Brennan

Ivu intravenous urogram

IVU: Intravenous Urogram

Intravenous Pyelogram = Excretory Urogram

  • Scout film  calculi?

  • IV bolus of radiocontrast dye (ionic contrast)

  • Series of plain films demonstrate kidneys, ureters, urinary bladder

    4. Upright film post-void to evaluate for obstruction



    Pathology Location

    Rough indicator of function bilaterally

    Low false positive rate

    Detects associated conditions

    Papillary necrosis  intralumenal filling defect

    Caliceal blunting from previous infection



    Requires radiocontrast

    Need bowel prep with conventional IVU

    Radiation dose

    Need cross-sectional imaging follow up

Ct urography

CT Urography

Evaluate urinary tract for flow defects

Noncontrast Scout first: Urolithiasis

Coronal reconstructions: visualize entire urinary tract

  • Advantages over Conventional IVU

    • Speed

    • Sensitive to renal parenchyma abnormalities

    • Simultaneous evaluation of both renal parenchyma and urinary tract

    • Cross-sectional imaging

  • Disadvantages

    • Radiation dose

    • Ionic Contrast reactions/cannot be used in patients in renal failure

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

Normal ct urogram

Normal CT Urogram

CT Urography

Total Body Opacificantion



Normal ct urogram1

Normal CT Urogram

CT Urography

Total Body Opacificantion



Normal ct urogram2

Normal CT Urogram

CT Urography

Total Body Opacificantion



Normal ct urogram3

Normal CT Urogram

CT Urography

Total Body Opacificantion



Normal ct urogram4

Normal CT Urogram

CT Urography

Total Body Opacificantion



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

Normal ct urogram5

Normal CT Urogram

CT Urography

Total Body Opacificantion



Normal ct urogram6

Normal CT Urogram

CT Urography

Total Body Opacificantion



Contraindications for ivu ctu

Contraindications for IVU/CTU

History of allergy to IV contrast

Bronchospasm, laryngeal edema, anaphylactic shock

May use with history of minor allergic reactions with preprocedural steroids, antihistamines (diphenhydramine) 12 hours prior to study

Renal insufficiency

Pregnancy = relative contraindication (radiation exposure)

MR Urogram can be used

Likewise: children  minimize radiation doses

Pts taking oral hypoglycemics (metformin) should stop taking meds prior to study

May resume after renal function is confirmed normal

Risk of lactic acidosis

Must be Physician-Supervised

- Contrast reactions

- Minimize no. of images

- Minimize radiation

- May use Fluoroscopy

Mr urography

MR Urography

Sagittal contrast-enhanced excretory MR urography obstructing right sided papillary TCC

A. Unenhanced MR urography

Heavily T2 weighted

B. Gadolinium-enhanced excretory MR urography

C. Excretory MR urography + diuretic

10 mg furosemide IV

Gadopentetate dimeglumine


Distinguishes adjacent soft tissue abnormalities

With Gadolinium: functional information

No ionic contrast  OK in renal failure

No radiation  children, pregnancy women


High cost

Low sensitivity in detecting calcifications

Time intensive

Metallic implants/Foreign Body = Contraindications

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

Excretory urogram ctu mru acute obstruction

Excretory Urogram/CTU/MRUAcute Obstruction

Mild  Moderate  Marked

  • Kidney minimally enlarged

  • Dense Nephrogram

  • Preferential absorption of Na and water from diseased tubules = concentration of contrast

  • Delayed appearance of contrast in collecting system

  • = delayed function

  • Poor concentration of contrast in the collecting tubules

  • No ureteral dilatation acutely

  • Ureters not tortuous

Excretory urogram ctu mru chronic obstruction

Excretory Urogram/CTU/MRU Chronic Obstruction

Partial  Complete

Calyceal Clubbing

Progressive dilation of collecting system and ureters/tortuous

Urectasis = dilated ureter

Decrease number of nephrons

6-12 weeks: irreversible loss of renal function

“Shell nephrogram” parenchymal atrophy

Collecting system: blunt calyces/forniceal angles

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

Patient jl bladder mass

Patient JL – Bladder Mass


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


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

Urology consult for possible stent placement

Left Bladdermass surrounding UO

Renal cystic disease

Renal Cystic Disease

  • Very common 50% of pts over age of 50

  • Assoc w/ many syndromes, etiology unknown, probably arise from obstructed tubules or ducts

  • Most commonly asymptomatic

  • Rarely, may have hematuria, HTN, cyst infection, or mass effect

Ct characteristics of simple cysts

CT Characteristics of Simple Cysts

  • Smooth, imperceptible cyst wall

  • Sharp demarcation from surrounding renal parenchyma

  • Water attenuation (<15 HU), homogenous throughout lesion

  • Non-enhancing

  • Simple cysts are w/o septations or calcification

  • May have slight elevation of adjacent renal parenchyma  Beak sign

Type i simple cyst

Type I Simple Cyst

Bird Beak Sign

Aortic aneurysm

Inferior vena cava with filters

Simple Cyst

Images: BIDMC, Dept of Radiology, 2001.

Type iv cystic neoplasm

Type IV Cystic Neoplasm

Complex renal mass infiltrating lvc

Images: BIDMC, Dept of Radiology, 2001.

Conditions associated with multiple cysts

Conditions Associated with Multiple Cysts

  • Autosomal Dominant PCKD

  • Autosomal Recessive PCKD

  • Acquired Cystic Disease (hemodialysis pts)

  • Von-Hippel-Lindau disease

  • Tuberous Sclerosis

  • Medullary Sponge Kidney

Benign masses

Benign Masses

  • Cysts

  • Angiomyolipoma

  • Oncocytoma (via epithelial cells of prox tubule)

  • Renal Adenoma

  • Mesoblastic Nephroma (hamartomatous tumor, usu present at birth)

  • Hemangioma

  • Various Renal Pelvic Tumors(papilloma, angioma, fibroma)

  • Hematoma



  • Hamartomas containing fat, smooth muscle, and blood vessels

  • Usually asymptomatic, but may spontaneously bleed

  • Large AMLs resected or embolized

  • Multiple AMLS usually Associated w/ tuberous sclerosis

  • On CT *fat attenuation in mass*, strong contrast enhancement (RCCs rarely contain fat), no Ca2+



Note fat content

Images: BIDMC, Dept of Radiology, 2001.

Malignant masses

Malignant Masses

  • Renal Cell Cancer

  • Transitional Cell Cancer

  • Wilm’s Tumor

  • Nephroblastomatosis (multiple rests of embryologic metanephric blastoma)

  • Lymphoma

  • Metastases (lung, breast, colon, melanoma)

Renal cell ca

Renal Cell Ca

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

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

  • Presentation: Hematuria, flank pain, wt loss, palp mass, fever, anemia, paraneoplastic syndromes

  • liver enzymes w/o mets Stauffer syndrome

Ct characteristics

CT characteristics

  • Variablefrom complex cyst to large, heterogeneous renal mass

  • Generally enhancing

  • May have calcifications

  • May have hemorrhage and central necrosis

  • Usually no fat

Renal cell ca1

Renal Cell Ca

Images: BIDMC, Dept of Radiology, 2001.

Gut case investigation


Images: BIDMC, Dept of Radiology, 2001.

Gut case investigation

Renal Trauma

Gut case investigation

Anatomy of the Kidney

Renal blood supply

Renal arteries



Renal veins

Be suspicious of renal injury with broken ribs


Gut case investigation

Anatomy of the Kidney


Gut case investigation

Prevalence of Renal Trauma

10-20% of trauma pts. have GU involvement

45% of GU trauma is renal

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


Gut case investigation

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


Gut case investigation

Clinical Presentation of Renal Trauma

Gross or microscopic hematuria (absent in 5%)

Flank pain/ecchymosis

Hemodynamic instability

Presence of other abdominal injuries


Gut case investigation

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?


Gut case investigation

Indications for Imaging

  • Gross hematuria

  • Microscopic hematuria with hemodynamic instability

  • Persistent microscopic hematuria

  • Significant MOI


Gut case investigation

Radiologic Imaging of Renal Trauma

CT with IV contrast

  • Gold standard, high sensitivity

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

  • Allows diagnosis and staging

  • Images abdomen and retroperitoneum

  • Not for hemodynamically unstable pts.


Patient 1 ct with iv contrast

Patient 1: CT with IV contrast

Normal attenuating kidney

Peri-renal hemorrhage


Gut case investigation

Patient 1: CT with IV contrast

Contrast extravasation


Gut case investigation

Patient 1: CT with IV contrast

Renal laceration with extravasation of contrast

Retroperitoneal hematoma


Gut case investigation

Radiologic Imaging of Renal Trauma Cont.

Intravenous pyelography

  • Unable to evaluate abdomen and retroperitoneum

  • Inadequate for grading renal injury

Image from

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

Extravasation of contrast from R kidney


Gut case investigation

Radiologic Imaging of Renal Trauma Cont.

Renal Angiography

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

  • Use when CT equivocal and continued hemorrhage


Devascularization of L kidney

  • Use for endovascular repair (embolization, stenting)


Gut case investigation

Radiologic Imaging of Renal Trauma Cont.

Renal ultrasound

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

Subcapsular hematoma

  • High false neg. rate for renal injury

  • Used in areas without CT, or for follow up



Gut case investigation

Patient 2: An Illustration of Injury Staging

  • 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?


Gut case investigation

AAST Organ Injury Scale - Renal Injury

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

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


Gut case investigation

AAST Renal Injury Scale Cont.

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   

Grade III and IV injuries are now managed conservatively


Gut case investigation

AAST Renal Injury Scale Cont.

Grade V Laceration: Completely shattered kidney

Vascular: Avulsion of renal hilum which devascularizes kidney

Image from

Surgery! Salvage vs. nephrectomy


Gut case investigation

Renal Trauma Conclusions

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

  • CT with contrast

  • Grade severity of injury

  • Injuries requiring surgery: vascular injury,

  • shattered kidney, expanding hematoma

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


Imaging in the evaluation of female infertility

Imaging in the Evaluation of Female Infertility



Inability to conceive after one year of intercourse without contraception



  • Affects 1 in 7 American couples

  • Rate has been stable over the past 50 years

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

Infertility causes

Male Factor – 40%


Sperm defect or dysfunction

Chronic Illness

Female Factor–40%

Advanced age

Anovulatory cycles

Congenital anomalies

Acquired structural defects

Endocrine abnormalities

Infertility - Causes

Combined Factors – 10%

Unexplained – 10%

Infertility radiologic evaluation

Infertility – Radiologic Evaluation

  • Largely focuses on female factor infertility

  • Several congenital and acquired conditions affect female reproductive function

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

Menu of tests

Menu of Tests

  • Hysterosalpingogram (HSG)

  • Ultrasound (US)

  • Sonohysterogram (SHG)

  • Magnetic Resonance Imaging (MRI)

Gut case investigation




  • Historically the mainstay in infertility imaging

  • Indications: evaluation of uterine cavity and patency of tubes

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



  • Test of choice for imaging the female pelvis

  • No radiation exposure

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

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

Gut case investigation


  • Excellent soft tissue characterization

  • Indications: guides interventional radiology and surgical management of infertility by identifying size, number, and location of pathology

Female reproductive tract

Female Reproductive Tract 181rmgUterus.html



Cervical Stenosis

  • Narrowing of the cervix due to adhesions or scarring

  • Patients complain of painful or absent periods

  • Complication of cone biopsy

  • Blocks entry of sperm

Fallopian Tube






Vagina risks.html

Cervical stenosis

Cervical Stenosis

  • HSG Findings:

  • Internal os < 1mm

  • Inability to advance catheter

  • Non-opacified uterine cavity

Normal HSG

Cervical Stenosis





  • Synechiae

  • Fibroids

  • Polyps

  • Congenital Anomalies



Asherman Syndrome

  • Intrauterine adhesions caused by trauma, infection, or instrumentation

  • Healing granulation tissue forms bridges across the cavity

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



HSG findings:

  • Filling Defect

  • Linear

  • Irregular





US Findings:

  • Echoic

  • Linear

  • Extends from one wall to opposite wall




  • Benign, smooth muscle

    tumors of the uterus

  • Found in 20-30% of reproductive aged women

  • Affects fertility by interfering with implantation



Scalloped endometrial lining

HSG Findings



Ultrasound aids in characterization of fibroids.

US Findings:

  • Hypoechoic mass

  • May be submucosal, intramural, or subserosal

  • Uterine enlargement or distortion may be seen




  • MRI aids in:

  • characterizationand localization of uterine wall pathology

  • pre-surgical planning



Uterine anomalies

Uterine Anomalies

  • A defect in the embryologic development of the Mullerian system can cause congenital uterine anomalies

  • There are 7 classifications of anomalies

  • All can be identified by imaging

Uterine anomalies1

Uterine Anomalies

Class II - Unicornuate


Class III - Didelphys

Class IV - Bicornuate

Class VII - DES

Class V - Septate

Class VI - Arcuate

Uterine anomalies2

Uterine Anomalies

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

  • 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

Uterine anomalies3

Uterine Anomalies

Irregularly shaped uterine cavity on HSG  MRI


Uterine anomalies4

Uterine Anomalies

The irregularly shaped uterus seen on HSG and

MRI in the previous slides was determined to be

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

of bicornuate and is believed to be a normal

variant with no affects on fertility.

Fallopian tubes

Fallopian Tubes


  • Pelvic Inflammatory Disease

  • Fibroids

  • Endometriosis

  • Adhesions

  • Tubal spasm

Fallopian tubes1

Fallopian Tubes





Fallopian tubes2

Fallopian Tubes

Left Proximal Obstruction

Right Proximal Obstruction

Peritoneal cavity

Peritoneal Cavity


  • Endometriosis

  • Post surgical

  • Post infection

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



Polycystic Ovary Syndrome (PCOS)




  • US Findings:

  • Round

  • Symmetric

  • Hypoechoic cysts

  • Low-level echoes

  • Persistent



Ovarian stroma

Gut case investigation


US Findings of PCO:

  • Bilateral

  • Round, echogenic ovaries

  • 10-12 small 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.

Gut case investigation

EW is 9 weeks pregnant today.

Early OB Ultrasound at 7 weeks 4 days.

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