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RENAL ULTRASOUND PowerPoint Presentation

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Description : Check out this medical presentation on Pathology, which is titled "RENAL ULTRASOUND", to know about the clinical indications for performing ED renal US.

Tags : Pathology, RENAL ULTRASOUND, clinical indications

Published on : Aug 06, 2021 | Views : 5100 | Downloads : 23

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Slide 1-

Diana Pancu, MD RENAL ULTRASOUND
Slide 2-

Objectives Clinical indications for performing ED renal US Approach to performing the US study Normal anatomy Abnormal findings Clinical Impact
Slide 3-

Clinical Indications for ED Renal Ultrasound Suspected renal colic Colicky flank pain radiating to groin Hematuria Clinical question: Presence of hydronephrosis Absence of other pathology (AAA)
Slide 4-

Performing the Study Patient preparation: none Transducer: 3.0MHz or 3.5 MHz 5.0 MHz for thin patient Patient positioning Supine Posterior oblique, lateral decubitus, prone
Slide 5-

Anatomy Kidneys are retroperitoneal, T12 - L4 Right kidney is lower than the left kidney Right kidney is posterio-inferior to liver & gallbladder Left kidney is inferior-medial to the spleen Adrenal glands are superior, anterior, medial to each kidney
Slide 6-

IVC AORTA Celiac axis SMA Renal artery Renal vein Hepatic Veins Right kidney Left kidney Liver Spleen Anatomy
Slide 7-

Renal Scanning Approaches
Slide 8-

Approach to Scanning Right kidney scanning approach: anterior, lateral, posterior Liver is the acoustic window Left kidney: requires a posterior approach, through the spleen Air-filled bowel impedes anterior scanning K K S
Slide 9-

Anatomy 9-12 cm long, 4-5 cm wide, 3-4 cm thick Gerota’s fascia encloses kidney, capsule, perinephric fat Sinus Hilum: vessels, nerves, lymphatics, ureter Pelvis: major and minor calyces Parenchyma surrounds the sinus Cortex: site of urine formation, contains nephrons Medulla: contains pyramids that pass urine to minor calyces. Columns of Bertin separate pyramids
Slide 10-

Renal artery Renal vein Ureter Renal capsule Cortex Medullary pyramids Minor Calyx Kidney Anatomy Medulla Sinus Major Calyx
Slide 11-

Sonographic Appearance Ureters are normally not seen Renal pelvis is black when visible Renal sinus is echogenic due to fat Medullary pyramids are hypoechoic Cortex is mid-gray, less echogenic than liver or spleen. Capsule is smooth and echogenic
Slide 12-

Right Kidney Long Axis
Slide 13-

Liver Diaphragm Sinus Cortex Anterior Posterior Superior Inferior Right Kidney Long Axis
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Right Kidney Short Axis
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Right Kidney Short Axis Vertebral Body R Kidney Aorta Renal a. GB IVC Liver Anterior Posterior Right Left
Slide 16-

Left Kidney Long Axis
Slide 17-

Left Kidney Long Axis Anterior Posterior Superior Inferior Spleen Kidney Rib Shadow
Slide 18-

Left Kidney Short Axis
Slide 19-

Left Kidney Short Axis Anterior Posterior Right Left Liver Spleen L Kidney
Slide 20-

Common Pitfalls in Renal Scanning Failure to scan both kidneys Mistaking prominent renal pyramids for hydronephrosis Mistaking prominent pyramids for cysts Confusing normal renal arteries for the ureter
Slide 21-

Common Pitfalls in Renal Scanning Failure to scan through the bladder to search for stone at the uretero-vesicular junction Inability to visualize left kidney due to anterior probe placement Failure to scan the aorta in suspected renal colic
Slide 22-

Normal Variants Dromedary humps: Lateral kidney bulge, same echogenicity as the cortex Hypertrophied column of Bertin: Cortical tissue indents the renal sinus Double collecting system: Sinus divided by a hypertrophied column of Bertin Horseshoe kidney: Kidneys are connected, usually at the lower pole Renal ectopia: One or both kidneys outside the normal renal fossa
Slide 23-

Clinical Indications Obstructive Uropathy
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Nephrolithiasis 12% of the US population Incidence of renal colic is 3% with 50% recurrence within 10 years Manthey DE. Emerg Med Clin North Am.2001; 19(3): 633-54
Slide 25-

Radiographic Modalities Radiography 62% Sensitivity, 67% Specificity Sharma RN, Shah I, Gupta S, et al: Thermogravimetric analysis of urinary stones. Br J Urol 64:564-566, 1989
Slide 26-

Radiographic Modalities IVP vs. US Prospective study, 85 patients Sinclair D, Wilson S, Toi A, et al. Ann Emerg Med 18:556-559, 1989 ULTRASOUND Sensitivity=85% Specificity=92% IVP Sensitivity=90% Specificity=94%
Slide 27-

Radiographic Modalities ED Ultrasound + KUB vs. IVP Prospective study, 108 patients Sensitivity = 97% Specificity = 59% Henderson, S, et al: Acad Emerg Med.1998;5:666-671. Sensitivity = 97% Specificity = 59% PPV = 81% NPV = 92%
Slide 28-

Radiographic Modalities Helical CT- Gold Standard Accurate, fast, no contrast Identifies presence and size of stone Location of stone Level of obstruction Other sources of pain
Slide 29-

Stone on CT Usually visualized Not visualized Stone is extremely small < 1 mm Stone is of relatively low CT attenuation: Indinavir stones Stone excluded from imaging due to respiratory variation
Slide 30-

Helical CT Secondary Findings Sensitivity Ureteral dilatation 90% Perinephric stranding 82% Collecting system dilatation 83% Renal enlargement 71% Specificity Ureral dilatation 93% Perinephric stranding 93% Collecting system dilatation 94% Renal enlargement 89% Smith. AJR Am J Roentgenol 167:1109-1113, 1996
Slide 31-

Location of Stone 378 patients Rate of spontaneous stone passage 22% for proximal ureteral stones 46% for midureteral stones 71% for distal ureteral stones Morse R. J Urol. 1991; 145:263-265
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Width of Stone 520 patients Rate of spontaneous stone passage 100% for stones that were 1 mm or smaller in width 90% for stones 2 to 3 mm 80% for stones that were 4 mm 55% for stones that were 5 mm 35% for stones that were 6 mm 25% for stones that were 7 mm 12% for stones that were 8 mm Ueno A. Urology. 1977; 10:544-546
Slide 33-

Radiographic Modalities Ultrasound Fast Can identify other causes of pain Safe in pregnant patients, children
Slide 34-

Hydronephrosis Dilatation of the urinary tract at any level secondary to intrinsic and or extrinsic obstruction to urine flow
Slide 35-

Hydronephrosis Intrinsic, acquired Renal lithiasis Neoplasm (renal, ureteral, bladder) Papillary necrosis Ureterocele Blood clot Neurogenic bladder Anticholinergics Pregnancy, PID, uterine prolapse) Diuretics Vesico-ureteral reflux Diabetes insipidus Intrinsic, congenital Stenosis (ureteral, urethral, meatal) Adynamic ureter Spinal cord defects Duplication of the ureter Ureterocele
Slide 36-

Hydronephrosis in Renal Colic Smith. AJR Am J Roentgenol. 1996; 167:1109-1113 Sensitivity = 90% Specificity = 93% PPV = 92% NPV = 90% Dalrymple. J Urol. 1997; 159:735-740 Sensitivity = 87% Specificity = 90% PPV = 90% NPV = 89%
Slide 37-

Obstructive Uropathy Grading System - Subjective Mild Minimal separation of calyces Moderate Dilation of major and minor calyceal system Severe Marked dilation of the renal pelvis and thinning of the renal parenchyma
Slide 38-

Range of Hydronephrosis Normal Mild Moderate Severe
Slide 39-

Mild Hydronephrosis Kidney Liver GB
Slide 40-

Moderate - Severe Hydronephrosis Liver Kidney Dilated pelvis GB
Slide 41-

Renal Pathology 1. Renal Cysts
Slide 42-

Renal Cysts Arise in the renal cortex, commonly single rather than multiple Cysts do not communicate; hydronephrosis does Shape is round or oval Echo free Sharp interface between the mass and renal tissue Large renal cysts may be mistaken for aortic aneurysms
Slide 43-

Renal Cysts Liver Kidney Cyst Scatter 20 Bowel
Slide 44-

Problems & Pitfalls Mistaking cysts for hydronephrosis Mistaking cysts for aortic aneurysm
Slide 45-

Case Presentation 40 yo male presents with complaints of recent severe headaches, diaphoresis, and palpitations PE anxious male BP 210/120 HR 145 RR 18 T 99 Physical exam otherwise normal
Slide 46-

Ultrasound of Kidneys Liver Diaphragm Kidney Mass Rib Shadow
Slide 47-

Case Development The patient was managed with alpha and beta-adrenergic blocking agents Urine studies revealed elevated metanepherine and catecholamine levels The patient was diagnosed with pheochromocytoma
Slide 48-

2. Renal Masses Renal Pathology
Slide 49-

Renal Masses Ultrasound visualizes most solid and cystic renal masses Beyond scope of EM ultrasound Appearance Irregular borders Poorly defined interfaces between mass and kidney Complex masses Complex ultrasonic appearance Cysts or solid masses may represent infection or hemorrhage May have fluid levels
Slide 50-

Case Presentation 35 year old male with history of Crohn’s presents with sudden onset of right flank pain. He is nauseated and has vomited a few times. He reports hematuria and denies fever, dysuria, abdominal pain.
Slide 51-

Physical Exam Young man in moderate distress from pain BP 125/67 HR 110 T 98 Lungs: clear to ascultation Heart: Tachycardia without murmur Abdomen: soft, non-tender, normal bowel sounds Back: right costo-vertebral angle tenderness on percussion
Slide 52-

Renal Ultrasound Right Kidney Left Kidney
Slide 53-

Ultrasound Thin Parenchyma Dilated Calyces Distinct Shadow Echogenic Structure
Slide 54-

CT Results Bilateral Staghorn Calculi Bilateral moderate hydronephrosis Right sided 3 mm stone at the UVJ
Slide 55-

Summary & Take-Home Points US is an adjunct in the evaluation of patients with suspected renal colic Evaluate kidneys Evaluate aorta Scan both kidneys