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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

LECTURE 1


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


Composition

OPAQUE contains calcium +/ phosphate

  • Calcium calculi

    • Ca oxalate, Ca phosphate

  • Struvite calculi

    • Magnesium ammonium phosphate= triple phosphate

      SEMI OPAQUE contains sulphur

  • Cystine calculi

    LUCENT

  • Uric acid stones;Xanthine

  • Matrix (coagulated mucoid material)


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)


Nephrolithiasis

Radio opaque stone in calyx

Images: BIDMC, Dept of Radiology, 2001.


Hydronephrosis

Dilated urine filled pelvis

Stent


Hydroureter

Stent

Images: BIDMC, Dept of Radiology, 2001.


Obstructive Uropathy Radiologic Assessment


Anatomy: Urinary Tract

Renal Capsule

Calyx

Superior Operculum

Cortex

Medulla

Papilla

Pelvis

Inferior Operculum

Fornix

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


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

Hydronephrosis

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


Pathology

Dilated pelvis & calyces, renal atrophy, cut surface

Dilated renal pelvis (arrow), external view

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

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


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

Hypertension

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

Hematuria

Burning on urination

Cloudy urine (infection)

Acute urinary retention

Flank pain radiating along ureter course (distension)

Gross hematuria

Nausea/Vomiting

Fever/Chills

Burning on urination

Cloudy urine with infection

Bilateral uremia

N/V/weight loss


Think Anatomically: Where is obstruction?

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%

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 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).

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


Diagnosis

Early diagnosis and decompression is critical to prevent renal failure

Continue to Radiologic work-up


Ultrasonography

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%

Advantages:

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

Disadvantages

Nonspecific

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

Normal renal parenchyma, hypoechoic, normal function

Normal renal fat, no dilatation of collecting system, hyperechoic


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

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

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


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

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

    Advantages

    Anatomy

    Pathology Location

    Rough indicator of function bilaterally

    Low false positive rate

    Detects associated conditions

    Papillary necrosis  intralumenal filling defect

    Caliceal blunting from previous infection

    Disadvantages

    Cumbersome

    Requires radiocontrast

    Need bowel prep with conventional IVU

    Radiation dose

    Need cross-sectional imaging follow up


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

CT Urography

Total Body Opacificantion

Nephrogram

Pyelogram


Normal CT Urogram

CT Urography

Total Body Opacificantion

Nephrogram

Pyelogram


Normal CT Urogram

CT Urography

Total Body Opacificantion

Nephrogram

Pyelogram


Normal CT Urogram

CT Urography

Total Body Opacificantion

Nephrogram

Pyelogram


Normal CT Urogram

CT Urography

Total Body Opacificantion

Nephrogram

Pyelogram

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


Normal CT Urogram

CT Urography

Total Body Opacificantion

Nephrogram

Pyelogram


Normal CT Urogram

CT Urography

Total Body Opacificantion

Nephrogram

Pyelogram


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

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

Advantages:

Distinguishes adjacent soft tissue abnormalities

With Gadolinium: functional information

No ionic contrast  OK in renal failure

No radiation  children, pregnancy women

Drawbacks

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/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

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


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

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

Left Bladdermass surrounding UO


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

  • 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

Bird Beak Sign

Aortic aneurysm

Inferior vena cava with filters

Simple Cyst

Images: BIDMC, Dept of Radiology, 2001.


Type IV Cystic Neoplasm

Complex renal mass infiltrating lvc

Images: BIDMC, Dept of Radiology, 2001.


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

  • 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

  • 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

Note fat content

Images: BIDMC, Dept of Radiology, 2001.


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

  • 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

  • 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 Ca

Images: BIDMC, Dept of Radiology, 2001.


RCC

Images: BIDMC, Dept of Radiology, 2001.


Renal Trauma


Anatomy of the Kidney

Renal blood supply

Renal arteries

IVC

Ureter

Renal veins

Be suspicious of renal injury with broken ribs

2


Anatomy of the Kidney

3


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

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

  • Allows diagnosis and staging

  • Images abdomen and retroperitoneum

  • Not for hemodynamically unstable pts.

9


Patient 1: CT with IV contrast

Normal attenuating kidney

Peri-renal hemorrhage

10


Patient 1: CT with IV contrast

Contrast extravasation

11


Patient 1: CT with IV contrast

Renal laceration with extravasation of contrast

Retroperitoneal hematoma

12


Radiologic Imaging of Renal Trauma Cont.

Intravenous pyelography

  • Unable to evaluate abdomen and retroperitoneum

  • Inadequate for grading renal injury

Image from Trauma.org

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

Extravasation of contrast from R kidney

13


Radiologic Imaging of Renal Trauma Cont.

Renal Angiography

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

  • Use when CT equivocal and continued hemorrhage

Image fromTrauma.org

Devascularization of L kidney

  • Use for endovascular repair (embolization, stenting)

14


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

kidney

15


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?

16


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)

17


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

18


AAST Renal Injury Scale Cont.

Grade V Laceration: Completely shattered kidney

Vascular: Avulsion of renal hilum which devascularizes kidney

Image from www.trauma.org

Surgery! Salvage vs. nephrectomy

19


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!

23


Imaging in the Evaluation of Female Infertility


Infertility

Inability to conceive after one year of intercourse without contraception


Epidemiology

  • 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


Male Factor – 40%

Azoospermia

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

  • 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

  • Hysterosalpingogram (HSG)

  • Ultrasound (US)

  • Sonohysterogram (SHG)

  • Magnetic Resonance Imaging (MRI)


HSG


Hysterosalpingogram

  • 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

  • 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

  • Excellent soft tissue characterization

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


Female Reproductive Tract

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


Cervix

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

Ovary

vary

Uterus

Adhesions

Cervix

Vagina

www.drkline.com/ risks.html


Cervical Stenosis

  • HSG Findings:

  • Internal os < 1mm

  • Inability to advance catheter

  • Non-opacified uterine cavity

Normal HSG

Cervical Stenosis

Vagina

BIDMC, PACS


Uterus

  • Synechiae

  • Fibroids

  • Polyps

  • Congenital Anomalies


Synechiae

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

HSG findings:

  • Filling Defect

  • Linear

  • Irregular

Synechia

BIDMC, PACS


Synechia

US Findings:

  • Echoic

  • Linear

  • Extends from one wall to opposite wall

Synechia


Fibroids

  • Benign, smooth muscle

    tumors of the uterus

  • Found in 20-30% of reproductive aged women

  • Affects fertility by interfering with implantation


Fibroids

Scalloped endometrial lining

HSG Findings


Fibroids

Ultrasound aids in characterization of fibroids.

US Findings:

  • Hypoechoic mass

  • May be submucosal, intramural, or subserosal

  • Uterine enlargement or distortion may be seen

Fibroid


Fibroids

  • MRI aids in:

  • characterizationand localization of uterine wall pathology

  • pre-surgical planning

Fibroids

BIDMC, PACS


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 Anomalies

Class II - Unicornuate

Normal

Class III - Didelphys

Class IV - Bicornuate

Class VII - DES

Class V - Septate

Class VI - Arcuate

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


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

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


Uterine Anomalies

Irregularly shaped uterine cavity on HSG  MRI

BIDMC, PACS


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

Obstruction

  • Pelvic Inflammatory Disease

  • Fibroids

  • Endometriosis

  • Adhesions

  • Tubal spasm


Fallopian Tubes

Isthmus

Ampulla

Infundibula

Fimbria


Fallopian Tubes

Left Proximal Obstruction

Right Proximal Obstruction


Peritoneal Cavity

Adhesion

  • Endometriosis

  • Post surgical

  • Post infection

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


Endometriosis

Polycystic Ovary Syndrome (PCOS)

Ovaries


Endometriosis

  • US Findings:

  • Round

  • Symmetric

  • Hypoechoic cysts

  • Low-level echoes

  • Persistent

Bilateral

Endometriomas

Ovarian stroma


PCOS

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.

Early OB Ultrasound at 7 weeks 4 days.


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