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OS 214 Renal Module Dr.

Fragante
Imaging of the KUB Exams 1 & 2, Lab Exam

Lecture Outline: • Get the serum BUN and creatinine to be


assured that the contrast maaterial will be
I. Introduction to KUB Imaging excreted
II. Renal Anatomical Abnormalities
III. Infections 2. History
IV. Calculi and Obstructive Uropathy • Diabetes, HPM
V. Renal Parenchymal Diseases • Inquire about the allergy history of the
VI. Urinary Bladder patient to foresee allergic reactions to the
VII. Adrenal Glands contrast material that will be used
VIII. Renal Vascular Lesions • To know what to look for in IVP
IX. Appendix
Contrasts:
o Ionic – hyperallergenic and hyperosmolar (so
may cause pain) but cheaper; gives a
INTRO TO KUB IMAGING burning feeling when given intravenously
o Non-ionic – hypoallergenic and low osmolar
• Before using imaging modalities, make sure to but more expensive
perform a good history and physical examination
(PE) first, as these will give you a working impression IVP Procedure
and guide you in choosing the appropriate modalities. • Scout film (no contrast yet)  film 3 minutes after
• The different modalities used for visualizing the KUB contrast  after 10 minutes  during full bladder 
are: post-void (see Fig. 39 in appendix)
o X-ray film
o Intravenous pyelography (IVP) 1. Plain Film/Scout Film
o Ultrasound (UTS) • Calcific densities  stones
o Computerized tomography (CT) scan • Used as reference figure
• Correlate imaging findings with renal function: serum 2. Inject Contrast Material
BUN and creatinine results, urinalysis 3. Film at 3 minutes
• Take note also of comorbidities, eg. diabetes mellitus, • Kidneys and upper collecting systems
hypertension visualized
• The contrast in the cortex and the
A. KUB X-ray film medulla is seen
• Advise patient to have empty bowel (eg. take 4. Film at 5 minutes
Dulcolax first) to visualize the outlines of the kidneys • Visualize pelvis (collecting system and
and the psoas ureters are opacyfying)]
5. Contrast at 10 minutes
• Contrast has reached the pelvocalceal
system, ureters
• This is the time to look for stones in
LK these areas
RK 6. Film at 15 minutes
• Whole abdomen profile
• Kidneys are still visualized
Psoas • Ureters are likewise opacified
• Bladder is starting to fill
lines 7. Full bladder film at 20 minutes
• Full bladder has very smooth borders
• “dapat bilog na”
8. Post-void Film
• To check urinary retention
• < 50 cc
• You can still see some degree of
contrast in various areas of the GU
system

C. Ultrasound

Figure 1. Normal KUB film, showing the psoas lines and


the outlines of the kidneys. Note that the right kidney (RK)
is normally lower than the left (LK).

B. Intravenous Pyelography
• Series of films with contrast material to better
visualize the urinary system
• To see if there is retention of urine

Requirements for IVP


1. Evaluate renal function

05 March 2009 | Thursday Page 1 of 9


patty.nina.ad.aoo
OS 214 Renal Module Dr. Fragante
Imaging of the KUB Exams 1 & 2, Lab Exam

Figure 2. Sagittal (left) and tranverse (right) views of the


kidney through ultrasonography. The outer hypoechoic
area denotes the renal parenchyma, while the inner
hyperechoic area denotes the renal pelvis (collecting
system).

D. CT scan
• Has more detail than the other modalities, but more
expensive, of course (see Fig. 38 in appendix).
• Patient is scanned in the supine or decubitus position.
Occasionally, a prone position may prove useful.
• The best images are obtained with the patient’s
respiration suspended; frequently, the end of partial or
full inspiration brings the kidney to better view
• Allows us to see cortex, medulla, and renal drainage

ANATOMICAL ABNORMALITIES Figure 4. Horseshoe kidney (left) and pelvic kidney (right).
A. Ptotic Kidney C. Vesico-ureteral Reflux
• Kidney is descended by at least two vertebrae levels; • Urine goes back (reflux) to the kidneys; patients are
during standing position prone to nephritis
• Prone to having obstruction and infection • Reflux increases risk for infection
• Results in dilatation of the collecting system

Figure 5. Vesiculo-ureteral reflux. Black arrows points to


the reflux (right).

Figure 3. Ptotic right kidney – notice that it is almost INFECTIONS


completely at the level of the pelvis. Nasa House, MD.
‘tong condition na ‘to! Hehe. A. Acute Pyelonephritis
• NORMAL findings in almost all various imaging
B. Horseshoe Kidney, Pelvic Kidney modalities! (daw, sabi sa lecture ni Ma’am…)
• Horseshoe kidney – lower poles of the kidneys are • Nuclear scan provides earlier detection
connected  malrotation of kidneys • Risk factor: stones
o Patients with this are prone to infections,
stones and malignancies
• Pelvic kidney – at the level of the pelvis already (even
if not during standing position); prone to UTI
• Pregnancy may be a problem: prone to
hydronephrosis and can make labor very difficult

Figure 6. KUB film showing “acute pyelonephritis”. Left


kidney is shown to be larger than the right.

05 March 2009 | Thursday Page 2 of 9


patty.nina.ad.aoo
OS 214 Renal Module Dr. Fragante
Imaging of the KUB Exams 1 & 2, Lab Exam

Figure 7. Ultrasound (left) and CT scan (right) showing


“acute pyelonephritis” (pointed by their respective arrows).
Enlargement of the kidney is due to edema of
inflammation. Areas of avascularity are due to toxic
Figure 10. KUB film (left) and CT scan (right) with foci of
secretions which cause constriction
renal tuberculosis, shown by white arrows. Multiple calcific
densities are seen.
B. Chronic Pyelonephritis, Renal Abscess, Renal
Tuberculosis
• Chronic pyelonephritis – may have cortical CALCULI AND OBSTRUCTIVE
irregularities or scarring UROPATHY
• Atrophied kidney and cortical abnormalities
o If not treated, renal abscess forms (2011 A. Stones and Calculi
trans) • Uric acid stones – intake of beans, beer, meat, oats
• Calcium stones – from salty foods (junk food! Chippy!)
• Stones form in the calyx, then may go down to the
renal pelvis and then to the ureter (ouch…)
• For females: get calcium from milk, not calcium
tablets (2011 trans)
• Staghorn calculi – stones can occupy an entire
collecting system, conforming to the pelvocaliceal
system (2011 trans); thus the “reindeer configuration”

Figure 8. Cortical scarring, which can be a sign of chronic


pyelonephritis. Distance at poles should not be differ by
greater than 2 mm.

Figure 11. Renal calculi, as shown by arrows (white


calcified structures).

Figure 9. Ultrasound (left) and CT scan (right) showing


renal abscess. In UTS the abscess is hypoechoic and in
CT scan it is dark. It happens when you do not treat your
chronic pyelonephritis.

05 March 2009 | Thursday Page 3 of 9


patty.nina.ad.aoo
OS 214 Renal Module Dr. Fragante
Imaging of the KUB Exams 1 & 2, Lab Exam

Figure 15. Ureteral stones as seen in plain and contrast


films using retrograde pyelography (RPG). Notice the
discontinuation of the contrast because of obstruction by
the stones.

B. Hydronephrosis
• There is dilatation of the collecting system because of
a chronic obstruction
• May be uni- or bilateral
• If not treated then there can be infection and then pus
formation

Plain Contrast
Figure 12. Staghorn calculi in both plain and contrast films.
They can occupy a hole collecting system. They conform
to the configuration of the pelvocaceal system.

Figure 16. Hydronephrosis.

Ur
Figure 13. Renal calculi as shown in UTS. The stones are
hyperechoic, with shadowing behind them (2011 trans).
PC
Patty, Nina, AD, Aoo : hi Jelly A’s! Hi JollyB’s! =) S

pus/debris

Figure 17. UTS showing hydronephrosis. Note the much-


dilated pelvis, and the thinned out parenchyma. PCS –
pelvicaliceal system; Ur – ureter.

C. Ureteral Stricture
• Stones and inflammation are more common causes
because can lead to fibrosis, leading to stricture
Figure 14. CT-stonogram showing the stones. This is
requested when X-ray is not enough (2011 trans).

Plain Contrast

Figure 18. Ureteral stricture.

RENAL PARENCHYMAL DISEASE

05 March 2009 | Thursday Page 4 of 9


patty.nina.ad.aoo
OS 214 Renal Module Dr. Fragante
Imaging of the KUB Exams 1 & 2, Lab Exam

A. Acute Renal Parenchymal Disease (2011 trans)


• Patients are edematous, ascetic because the
glomeruli are unable to filter
• Enlarged kidneys on UTZ
• Echogenic ball-like kidney

Figure 21. Wilm’s tumor or nephroblastoma in UTS (left)


and CT scan (right).

LM
Figure 19. UTS showing acute renal parenchymal disease.
The areas are hyperechoic because of inflammation.

B. Masses/Tumors and Cysts (2011 trans)


• Renal cysts – most common in the elderly
o Fluid-filled and can cause obstruction if large
enough
o Seen as “fraying of the collecting system”
o May cause obstruction
• Renal tumors may metastasize to nearby organs such
as the liver and spleen; first symptom is hematuria
(painless)
• Wilm’s tumor/nephroblastoma – more common in the
pediatric population; may occupy the whole kidney;
diffused, multiply masses SM
• Diffuse malignancies – because of cancers like
lymphomas
Figure 22. CT scan images showing renal cell carcinoma
(left, with arrows) and organ metastases (LM – liver
metastasis, SM – splenic metastasis).

Figure 23. UTS (left) and CT scan (right) showing diffuse


malignancies (eg. lymphomas).
Figure 20. Cysts, as shown in IVP (left), UTS (upper right)
and CT scan (lower right). Cysts in IVP are white. URINARY BLADDER

• Normal filled UB: very smooth borders, like a balloon


• Normal post-void UB: not more than 50cc of urine left;
if more than 50cc, then UB is more prone to infection

05 March 2009 | Thursday Page 5 of 9


patty.nina.ad.aoo
OS 214 Renal Module Dr. Fragante
Imaging of the KUB Exams 1 & 2, Lab Exam

Figure 24. Normal filled UB (left and middle) and normal


post-void UB (right).

A. Cystolithiasis (2011 trans) Enlarged prostate


• Stones of the UB; calcific, rounded/ovoid opacity that Figure 27. Enlargement of the prostate, leading to UB
have the same density as bone and may look like obstruction and cystitis.
eggs • Patients have poor stream due to retention
• Capacity of UB is decreased; there may also be reflux • UTZ is used to evaluate prostate
• Patient becomes more prone to cystitis
• Usually lamellated; lamellae represent times of C. Emphysematous Cystitis
deposition, just like in “tree rings” • Characterized by infection of UB and UB wall with
• Mves with changes in position gas-forming organisms (2011 trans); thus, there is air
• Uually smooth borders but can be mulitlobulated outlining the wall of the bladder
• “Mickey Mouse” appearance because of diverticula
Plain Contrast D. Chronic Cystitis
• UB may become fibrotic, and have vesico-ureteral
reflux
• Can lead to chronic renal parenchymal disease

E. Contracted Bladder
• UB capacity approximately only 20cc; “one drink of
iced tea, ihi na agad”
• Treated with bladder augmentation (2011 trans);
“neobladder”, attached to ileal segment

Figure 25. Plain and contrast films showing cystolithiasis. UB Div

UB Div

Figure 28. Emphysematous cystitis. Note the outline of ai


in the UB wall (shown by arrows) and the “Mickey Mouse”
appearance (UB Div – UB diverticula).

VUR
Figure 26. UB calculi with blood clots, as shown in UTS.

B. Prostatic Enlargement with Chronic Bladder


Obstruction/Cystitis

Figure 29. Chronic cystitis: with vesico-ureteral reflux


(VUR), as shown in contrast film (left), and with thickened

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patty.nina.ad.aoo
OS 214 Renal Module Dr. Fragante
Imaging of the KUB Exams 1 & 2, Lab Exam

bladder wall (white lining of the UB located in the center), Figure 32. Bladder extrophy. The ureters are dilated, and
as shown in CT scan (right). the symphysis pubis widened.

G. UB Malignancy
• There is a change from “full moon” to “half/crescent
moon”
• UB wall may be eaten up (2011 trans)
• Risk factor: smoking and alcohol intake
• Most common: transitional cell CA

Figure 30. Normal findings in UTS (top images), compared


to findings of cystitis in UTS (bottom images). The normal
UB has smooth walls, while the cystitic UB has rough
edges.
Figure 33. UB malignancy as shown in CT scan (left) and
contrast film (right), where the “crescent moon” is very
evident.

ADRENAL GLANDS
A. Adrenal Gland Hyperplasia

Figure 31. Contracted bladder.

F. Post-traumatic Bladder Extrophy


• UB not only descends, but goes out (2011 trans) Figure 34. CT scans showing normal adrenal gland (left)
• There is widening of the symphysis pubis; also, there and hyperplastic adrenal gland (right).
is bilateral dilatation of the collecting systems (also
ureters) B. Pheochromocytoma
• Due to pelvic fractures, motorcycle accidents, • Tumors of the adrenal medulla, resulting in increase
horseback riding in catecholamine production
• May involve urethras in males (2011 trans) • Hypertension is one manifestation
• As opposed to adrenal gland hyperplasia,
pheochromocytoma look like round masses; in the
former, the original shape is somewhat retained (2011
trans)

05 March 2009 | Thursday Page 7 of 9


patty.nina.ad.aoo
OS 214 Renal Module Dr. Fragante
Imaging of the KUB Exams 1 & 2, Lab Exam

Before Stenting After Stenting


Figure 37. The left angiogram shows renal artery stenosis,
while the right angiogram shows the effect of stenting (no
more stenosis).

Figure 35. Pheochromocytoma, as seen in UTS (left) and


CT scans (right).

RENAL VASCULAR LESIONS

• Renal angiography – used for visualizing the vascular APPENDIX


tree of the kidneys; aside from locating lesions, this is
also used in screening for organ transplants
o Philippines has one of the highest rates of
kidney transplantation

Figure 36. Normal renal angiogram.

Figure 38. CT scans of the normal kidney.

05 March 2009 | Thursday Page 8 of 9


patty.nina.ad.aoo
OS 214 Renal Module Dr. Fragante
Imaging of the KUB Exams 1 & 2, Lab Exam

3 min

10 mins

Scout

Post-void Full bladder


Figure 39. Series of IVP contrast films: scout film (no contrast yet, left), 3 minutes after injection (top middle), after 10 minutes
(top right), full bladder (bottom right) and post-void bladder (bottom middle).

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