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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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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

Pathology Tubular Function

Dilated pelvis & calyces, renal atrophy, cut surface

Dilated renal pelvis (arrow), external view

Clinical presentation obstructive uropathy
Clinical Presentation: Obstructive Uropathy Tubular Function

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: Tubular FunctionWhere 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 Tubular Function

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).

Diagnosis Tubular Function

Early diagnosis and decompression is critical to prevent renal failure

Continue to Radiologic work-up

Ultrasonography Tubular Function

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 Tubular Function– Normal Kidney

Normal renal parenchyma, hypoechoic, normal function

Normal renal fat, no dilatation of collecting system, hyperechoic

Ultrasound obstructive uropathy
Ultrasound Tubular Function– 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 tissue)

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 tissue)

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 tissue)

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 tissue)

CT Urography

Total Body Opacificantion



Normal ct urogram1
Normal CT Urogram tissue)

CT Urography

Total Body Opacificantion



Normal ct urogram2
Normal CT Urogram tissue)

CT Urography

Total Body Opacificantion



Normal ct urogram3
Normal CT Urogram tissue)

CT Urography

Total Body Opacificantion



Normal ct urogram4
Normal CT Urogram tissue)

CT Urography

Total Body Opacificantion



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

Normal ct urogram5
Normal CT Urogram tissue)

CT Urography

Total Body Opacificantion



Normal ct urogram6
Normal CT Urogram tissue)

CT Urography

Total Body Opacificantion



Contraindications for ivu ctu
Contraindications for IVU/CTU tissue)

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 tissue)

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/MRU tissue)Acute 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 tissue)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 tissue)– 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 tissue)

  • 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 tissue)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 tissue)

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 tissue)

Complex renal mass infiltrating lvc

Images: BIDMC, Dept of Radiology, 2001.

Conditions associated with multiple cysts
Conditions Associated with tissue)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 tissue)

  • 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

Angiomyolipoma tissue)

  • 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+

Angiomyolipoma tissue)

Note fat content

Images: BIDMC, Dept of Radiology, 2001.

Malignant masses
Malignant Masses tissue)

  • 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 tissue)

  • 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 tissue)

  • 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 tissue)

Images: BIDMC, Dept of Radiology, 2001.

RCC tissue)

Images: BIDMC, Dept of Radiology, 2001.

Renal Trauma tissue)

Anatomy of the Kidney tissue)

Renal blood supply

Renal arteries



Renal veins

Be suspicious of renal injury with broken ribs


Prevalence of Renal Trauma tissue)

10-20% of trauma pts. have GU involvement

45% of GU trauma is renal

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


Mechanisms of Renal Trauma tissue)

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

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

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


Clinical Presentation of Renal Trauma tissue)

Gross or microscopic hematuria (absent in 5%)

Flank pain/ecchymosis

Hemodynamic instability

Presence of other abdominal injuries


Patient 1: An illustration of imaging modalities tissue)

  • 18 yo male sustained stab wound to R flank

  • P=180, BP 130/80, Hct 36

  • CXR nl.

  • Why image and with which modality?


Indications for Imaging tissue)

  • Gross hematuria

  • Microscopic hematuria with hemodynamic instability

  • Persistent microscopic hematuria

  • Significant MOI


Radiologic Imaging of Renal Trauma tissue)

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 tissue)

Normal attenuating kidney

Peri-renal hemorrhage


Patient 1: CT with IV contrast tissue)

Contrast extravasation


Patient 1: CT with IV contrast tissue)

Renal laceration with extravasation of contrast

Retroperitoneal hematoma


Radiologic Imaging of Renal Trauma Cont. tissue)

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


Radiologic Imaging of Renal Trauma Cont. tissue)

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)


Radiologic Imaging of Renal Trauma Cont. tissue)

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



Patient 2: An Illustration of Injury Staging tissue)

  • 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?


AAST Organ Injury Scale - Renal Injury tissue)

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)


AAST Renal Injury Scale Cont. tissue)

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


AAST Renal Injury Scale Cont. tissue)

Grade V Laceration: Completely shattered kidney

Vascular: Avulsion of renal hilum which devascularizes kidney

Image from

Surgery! Salvage vs. nephrectomy


Renal Trauma Conclusions tissue)

  • 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!


Infertility tissue)

Inability to conceive after one year of intercourse without contraception

Epidemiology tissue)

  • 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 tissue)– 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 tissue)– 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 tissue)

  • Hysterosalpingogram (HSG)

  • Ultrasound (US)

  • Sonohysterogram (SHG)

  • Magnetic Resonance Imaging (MRI)

HSG tissue)

Hysterosalpingogram tissue)

  • 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

Ultrasound tissue)

  • 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

MRI tissue)

  • 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 tissue) 181rmgUterus.html

Cervix tissue)

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 tissue)

  • HSG Findings:

  • Internal os < 1mm

  • Inability to advance catheter

  • Non-opacified uterine cavity

Normal HSG

Cervical Stenosis



Uterus tissue)

  • Synechiae

  • Fibroids

  • Polyps

  • Congenital Anomalies

Synechiae tissue)

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

Synechia tissue)

HSG findings:

  • Filling Defect

  • Linear

  • Irregular



Synechia tissue)

US Findings:

  • Echoic

  • Linear

  • Extends from one wall to opposite wall


Fibroids tissue)

  • Benign, smooth muscle

    tumors of the uterus

  • Found in 20-30% of reproductive aged women

  • Affects fertility by interfering with implantation

Fibroids tissue)

Scalloped endometrial lining

HSG Findings

Fibroids tissue)

Ultrasound aids in characterization of fibroids.

US Findings:

  • Hypoechoic mass

  • May be submucosal, intramural, or subserosal

  • Uterine enlargement or distortion may be seen


Fibroids tissue)

  • MRI aids in:

  • characterizationand localization of uterine wall pathology

  • pre-surgical planning



Uterine anomalies
Uterine Anomalies tissue)

  • 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 tissue)

Class II - Unicornuate


Class III - Didelphys

Class IV - Bicornuate

Class VII - DES

Class V - Septate

Class VI - Arcuate

Uterine anomalies2
Uterine Anomalies tissue)

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 tissue)

Irregularly shaped uterine cavity on HSG  MRI


Uterine anomalies4
Uterine Anomalies tissue)

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 tissue)


  • Pelvic Inflammatory Disease

  • Fibroids

  • Endometriosis

  • Adhesions

  • Tubal spasm

Fallopian tubes1
Fallopian Tubes tissue)





Fallopian tubes2
Fallopian Tubes tissue)

Left Proximal Obstruction

Right Proximal Obstruction

Peritoneal cavity
Peritoneal Cavity tissue)


  • Endometriosis

  • Post surgical

  • Post infection

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


Endometriosis tissue)

Polycystic Ovary Syndrome (PCOS)


Endometriosis tissue)

  • US Findings:

  • Round

  • Symmetric

  • Hypoechoic cysts

  • Low-level echoes

  • Persistent



Ovarian stroma

PCOS tissue)

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.

EW is 9 weeks pregnant today. tissue)

Early OB Ultrasound at 7 weeks 4 days.