OS 206: Abdomen and Pelvis

KUB Radiologic Anatomy

Dr. K. Baldivio

3
November 27, 2012

TOPIC OUTLINE
I. II. Introduction X-ray A. Plain Film B. Excretory Urography/ Intravenous Pyelography C. Renal Angiography CT Scan Normal physiological variations Pathology Some Questions

Continues medially to ensheath the renal vessels Pararenal Fat ! External to the renal fascia; the extraperitoneal fat of the lumbar region that is most obvious posterior to the kidney !

III. IV. V. VI.

Legends: From the Powerpoint presentation From the lecturer From other sources (textbook, Internet, etc.)!

Renal hilum o Medial indentation, which opens into the renal sinus o Versus renal pelvis: expansion of superior end of ureter o Exit and entry of the renal vein, renal artery, nerves, and tubules that drain urine from the kidney. Renal Pelvis o Its apex continuous with the ureter o Receives 2 or 3 major calyces, each of which divides into 2 or 3 minor calyces o Each minor calyx indented by renal papilla, the apex of renal pyramid.

I. INTRODUCTION RADIOLOGY Radiology involves minimal or non-invasive anatomic evaluation Modalities o X-ray o Ultrasound (not in the lecture) o CT Scan o MRI THE EXCRETORY SYSTEM Excretory organs Kidneys Products eliminated Primary Secondary Water, nitrogenous Heat, CO2 wastes, inorganic salts CO2 Heat, H2O Heat CO2, H2O, Salts, Urea Solid wastes, CO2, H2O, Salts, secretions Urea

Ureters Muscular ducts that run inferiorly from the apex of renal pelvis (Moore). Not usually seen in plain film since collapsed Urinary Bladder When empty, lies partially superior to the pubic bones. (Moore) Not usually seen in plain film unless with contrast or if entirely filled with urine. X-RAY A. PLAIN FILM o o o o o o o o o o No contrast or dye injected/ swallowed because it will obscure organs. The general location, size and other pathologic findings are identified first before contrast is added. Usually done in supine position, in deep inspiration. Recall: The patients right side is on your left (Treat as if you are looking at the mirror). Soft tissue mass/ fat: grey Air or fluid: black Other structures that may be observed Bowel gas patterns Track foreign bodies Calcifications ! Phleboliths: Calcified pelvic veins, with lucent center and calcified walls. They appear as round structures in plain film. It is considered normal.

Lungs Skin GI tract

The Urinary System Helps keep the body in homeostasis Controls composition and volume of blood

Kidneys Visualized due to perirenal fat Fat wasting occurs in disease hence they become less visible. To appreciate the kidneys, bowel preparation must be done. Otherwise, fecal material may obstruct the view. Renal position o From level of T11-L3 (or T12-L4) o Axis of the kidneys lie parallel and lateral to the psoas muscle (psoas shadow) o Right kidney is 2 cm lower than the left because of the position of the liver. o The lower pole is more anterior relative to the superior pole o Kidneys are oriented down and out, its lateral borders has many humps. ! Embryologic indentations, called Dromedary humps. o In upright position, kidneys descend 2-3 cm and move moderately with respiration. Coverings of the kidney: o Renal capsule ! Adherent to the kidney ! Protection from blunt trauma ! Continuous with the hilum o Perirenal fat ! Not seen normal unless fibrotic or inflamed ! Surrounds the kidneys and their vessels as it extends into their hollow centers, called the renal sinuses. ! Keeps kidneys in position ! In plain film, grey region around psoas major and kidney o Renal fascia ! Membranous layer that encloses the kidneys, perirenal fat and suprarenal glands

Left kidney

Right kidney

Psoas line

Iliacus

Iliacus

Urinary bladder

Figure 1. Normal Plain Film of abdomen showing kidneys and urinary bladder

Arielle, Nikki, Roger

Page 1 / 4

KUB Radiologic Anatomy

OS 206

1 3 2 4 5 6 7

A.
8

9 10

B. Figure 2. Close-up view of plain film showing natural contrast between kidney and the low-density retroperitoneal fat that surrounds it. B. EXCRETORY UROGRAPHY/ INTRAVENOUS PYELOGRAPHY (IVP) Serial films are obtained 15- 25 minutes as contrast is excreted by the kidneys visualize the renal collecting system, ureters and bladder. o Ureters cannot generally be seen, except upon its entry into the posterior trigone of the bladder. Phases 1. Nephrographic phase: Renal tubules process the contrast o A problem with a medulla will be manifested by a delay in the visualization of the contrast (eg. stab wound). o Structures visualized: 1. Renal tubules, seen as striations in the pyramids (Note: Pyramids + cortex= parenchyma) 2. Renal columns of Bertin 3. Apex 4. Renal papilla 2. Pyelographic phase: o Additional structures visualized, when the contrast material reaches this phase: ! Minor calyx (6-14/ kidney according to Maam.) - Dense peripheral and lucent center - Fornix and body connect to the major calyx. ! Major calyx (3-4/ kidney) ! Renal pelvis: Triangular beginning of the ureter - Discharge of urine from the renal pelvis is accompanied by ureteral peristalsis ! Ureter - Not seen completely - Narrow at certain areas, where stones are likely to lodge: 1. Uretero-pelvic junction 2. Uretero-vesical junction 3. At the bifurcation of the common iliac vessels ! Bladder - Full: Egg shaped and smooth - Partially distended: irregular shape, and with air - Problem: Thick and irregular wall - Higher in females due to uterus

13

12

Figure 3. Intravenous Pyelography Figure 2: 1 - Superior pole of kidney 2 - Twelfth rib 3 - Superior calyces 4 - Middle calyces 5 - Renal calyces 6 - Inferior calyces 7 - Left kidney

8 - Right Kidney 9 - Inferior pole of kidney 10 - Ureter 11 - Margin of psoas 12 - Distal ureter 13 - Urinary bladder

RENAL ANGIOGRAPHY o o Maam didnt elaborate much on this. A vascular catheter is inserted into the femoral artery (percutaneous), to visualize blood vessels, malformations or adnormal enhancements. Iodine-based. CT SCAN

Figure 4. CT scan (Axial cut) showing the kidneys. FIGURE 4: This is a contrast CT scan; intravenous contrast was administered while the images were being obtained. Notice that the kidneys are slightly lighter grey than the adjacent muscle tissue near the vertebral body. This results from the kidney concentrating and excreting iodinated contrast. The renal parenchyma is relatively homogeneous. CT scans are fairly sensitive indicators of kidney function. If a kidney were not functioning (from lack of perfusion,

Arielle, Nikki, Roger

Page 2 / 4

!
severe tubular dysfunction, etc.) then the kidneys wouldn't 'enhance' (appear lighter grey). The renal pelvis is white because iodinated contrast has filled the collecting system.

KUB Radiologic Anatomy

OS 206

Figure 8. Horseshoe kidney 4. DUPLICATION OF THE RENAL PELVIS AND URETER - If ureter is redundant, chronic UTI and ureteric spasm may occur.

Figure 5. CT slice through the mid-abdomen showing multiple normal-appearing organs, which are labeled. NORMAL PHYSIOLOGICAL VARIATIONS 1. HYPOLASTIC KIDNEY - Hypoplasia: Underdeveloped" small

Figure 9. Duplication of renal pelvis & ureter 5. POLYCYSTIC KIDNEY - May be congenital - Normal, but may be prone to infection

Figure 6. Hypoplastic kidney 2. MOBILE / PTOTIC KIDNEY - Kidney may exceed L3

Liver

Figure 10. Polycystic kidney 6. RENAL CYST - Smooth wall, grey and fluid- filled - Becomes problematic when compressed if too big or becomes infected.

Figure 7. Ptotic kidney 3. HORSESHOE KIDNEY - Lower poles are fused - Common anatomic variant, but prone to obstruction due to twisting due to twisting at the isthmus.

Figure 11. Renal cyst

Arielle, Nikki, Roger

Page 3 / 4

!
PATHOLOGY 1. ABSCESSES AROUND THE KIDNEY: Collection of pus (debris)" soft tissue density More dense than normal left hemi abdomen Splinting: lumbar vertebrae displaced laterally Extrinsic compression by a psoas abcess

KUB Radiologic Anatomy

2. 3.

OS 206

2. OVARIAN MASS Ureter deviated medially Pelvis is dilated" hydronephrosis 3. URETERO- NEPHROLITHIASIS Appearing as dense structures due to calcium 4. FILLING DEFECT OF PELVIS 5. PELViCACTASIA SECONDARY TO AN OBSTRUCTED URETER Obstructive uropathy" non functioning kidney Swelling of pelvis and calyces" pressure pushes it outward

My brahs and brohs. I shall win Monopoly Deal in the future. Med life crises- mates. Ith, you will find your glenoid fossa. OR NOT! Am kidding, Joson loves you. GJ Empire will go down. OR UP! HAPPY BIRTHDAY! Johnny baby he is just there :> 4. My roommies, aka the internet less people. 5. My forever transmates, Ari Ni Roger. 6. Chorchor zebras. 7. MSSR lovabies. 8. Variable seatmates. GOOD MORNING APPENDIX! 9. POST IT! If theres a Will, theres a Kei. And then theres Aaron and Ith HAHA. 10. FUTURE 2018. I hope you enjoyed the Freshman Orientation Program ;) Hello Pugad Sayk babies! MWAH MWAH. 11. TRP CHORALalaloopsies! 12. Psych Republiquans Meggie, Vince, Bernette, Pia, Chiong and Kevin Kevins! Also hello to my library-mates! Ano bang meron kang di ko mabitiwan. Di ako tinitigilan. Arielle joke for the trans: What do you call a hipster med student? (ILIAC- CRESTer HIHI) Nikki: Ihi ka ba? I like U-RINE kasi! Hello! Good luck sa ating lahat sa TRP and sa exams.

6. RENAL CELL CARCINOMA Soft tissue mass extending" lost normal architecture Pelvo- calyceal system may be distended" beginning of hydronephrosis 7. BLASTIC BONES Abnormal deposition of bone, usually seen in prostate cancer. Versus lytic bones: abnormal resorption 8. BLADDER CYSOCOELE Outpouching of the bladder/ Merry Christmas Weak pelvic floor, may be due to multiple births 9. LINEAR CALFICIFATION OF BOTH URETERS 10. URETHRAL STENOSIS/ NARROWING May be due to enlarged prostate The narrowing may result in low bladder capacity

SOME QUESTIONS

!
RENAL TRANSPLANT Q: How do you visualize transplanted kidneys? Are they visible in plain film? (not verbatim) o Some perirenal fat is retained around the transplanted kidney. o The best modality would be CT scan, paired with good history taking. o Management is tailored based on what the patient has had. o Transplanted kidney should be shielded from radiation therapy, if needed.

PA vs. AP VIEW o Kidneys appear larger in PA view. This is because the kidneys are located posteriorly. Be careful on this in the clinics. Larger appearance in PA view doesnt mean that the kidneys are actually enlarged. PA film only magnifies the kidney. When writing reports, indicate: The kidneys are magnified, but not enlarged. End of Transcription GREETINGS, GREETINGS! Remo: Good Morning. Gusto ko po sanang batiin si Maam Mantaring, ehem ehem Good Morning! At sa lahat ng mga KulayNaBumubudoodoomBumubuhaySaMundoodoom # Hello nga pala kay Geoff haha mula kay Arielle. Arielle: And if am flying solo, at least am flying free # Good morning Roger! BOW! A million hugs and kisses to: 1. WAKA- bles. More gimmicks, movie nights and dine outs for my med life! Mah girlies Patring and Kei baybeh.

Arielle, Nikki, Roger

Page 4 / 4