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  • 1. Plain Film of the Abdomen
  • 2. Introduction
    • Plain films of the abdomen are used primarily to assess calcifications and intestinal perforation or obstruction.
    • The plain radiograph is commonly used as a preliminary radiograph before other studies such as CT and barium enema.
  • 3. Techniques
    • X-ray abdomen
    • Ultrasound abdomen
    • CT scan abdomen
  • 4. X ray abdomen
    • The most common plain radiograph of the abdomen is an anteroposterior (AP) view with the patient in the supine position.
    • The AP view of the abdomen is also called a KUB film because it includes the kidneys, ureters, and bladder.
    • When acute abdominal disease is suspected clinically, an erect film of the abdomen and a posteroanterior (PA) view of the chest are also required.
  • 5. Normal Imaging
    • Soft Tissue
    • The abdomen is composed primarily of soft tissue.
    • The liver is a homogeneous structure located in the right upper quadrant.
    • In the left upper quadrant a similar angular structure, the splenic angle, can be identified by the fat shadow around the spleen.
  • 6. A Normal plain film of the abdomen. The lower margins of the posterior portion of the liver, the hepatic angle (H), and the lower part of the spleen (S) are delineated by a fat shadow. Both kidneys (K) and the psoas muscle shadows ( arrowheads ) are outlined by a fat shadow. The properitoneal fat stripe is also shown bilaterally ( arrows ).
  • 7. B Diagram of normal abdominal plain film.
  • 8.
    • Organ enlargement can be recognized by the effect of displacement on nearby bowel loops or by obliteration of the adjacent normal fat or gas pattern.
    • It is poorly differentiated in X rays.
  • 9.
    • Fat Shadow
    • Fat is present in the retroperitoneal space adjacent to the psoas muscle.
  • 10.
    • Gas Pattern
    • It is seen in the stomach and colon, but it is rarely seen in the normal small bowel because the air rapidly traverses the organ.
    • The presence of more than a minimal amount of gas in the small bowel should be considered abnormal and is indicative of a functional ileus or mechanical obstruction.
  • 11.
    • Identification of the differences between the gas shadows of the jejunum, ileum, or colon helps to assess the location of bowel obstruction.
    • A gas pattern in distended intestinal loops is usually limited above the point of mechanical obstruction, but functional ileus has a more diffuse distribution in both the small intestine and the colon.
    • If the gas shadow in the intestine is displaced to an unusual location, a soft-tissue mass, either inflammatory or neoplastic, may be suspected.
  • 12.
    • The presence of air-fluid levels in a distended small intestine on upright films suggests either functional ileus or mechanical obstruction.
    • The presence of solid material with a mottled appearance and small bubbles of gas surrounded by the colonic contour suggests feces in the colon.
  • 13.
    • A large amount of gas seen in the peritoneal cavity indicates postoperative status or bowel perforation.
    • In the right upper quadrant, air that is seen in the biliary tree or around the gallbladder suggests cholecystoenteric fistula or emphysematous cholecystitis.
  • 14.
    • Bony Structure or Calcification
    • Bony structures comprise the ribs superiorly, the lumbar spine, and the pelvis.
    • Calcifications in the abdomen include calculi in the urinary or biliary tract, pancreatic calcifications (which are usually indicative of chronic pancreatitis, with or without carcinoma), or ectopic gallstone in the small bowel associated with mechanical obstruction from gallstone ileus.
    • Suspicion of urinary calculi is a common indication for abdominal radiography.
    • Ultrasonography is the better choice for evaluating gallstones.
  • 15. Technique Selection
    • The routine abdominal films are used to assess pneumoperitoneum and air-fluid levels.
    • The PA view of the chest is usually obtained as part of an acute abdominal series because an abnormality in the chest may have symptoms referred to the abdomen.
    • Plain abdominal radiography is less sensitive in evaluating solid organs or metastases.
  • 16.
    • Ultrasonography and CT, has shown to be more sensitive in assessing disorders of the abdominal solid organs and metastatic diseases.
    • Acute cholecystitis is better assessed by ultrasonography or nuclear medicine studies.
  • 17. Radiology of the Urinary Tract
  • 18. Techniques
    • Abdominal X-rays
    • Intravenous Urography
    • Retrograde Pyelography
    • Ultrasonography
    • CT scan
    • MRI
    • Nuclear medicine
    • Angiography
  • 19. Abdominal X-rays
    • Radiographs of the abdomen when used to evaluate the urinary tract are often referred to as KUBs (kidney, ureter, and bladder).
    • KUBs may serve a role as preliminary films prior to an examination such as an intravenous urography, or they may be used as a general evaluation of the abdomen or the urinary tract.
  • 20. Normal KUB. Note that portions of the normal renal contours ( arrows ) are visible and should be evaluated. No abnormal calcifications, soft tissue densities, or bony lesions are evident.
  • 21.
    • In the setting of trauma, fractures of the lumbar transverse processes suggest possible renal injuries and pelvic fractures raise concern for coexistent bladder or urethral trauma.
    • Air and calcifications should be specifically sought over the urinary tract.
    • Radiographs are also useful for detecting and evaluating urinary tract calculi.
  • 22.
    • Emphysematous pyelonephritis, a urologic emergency with high mortality, is the result of a renal infection by gas-producing organisms and may be diagnosed on plain films by mottled or linear collections of air within the renal parenchyma.
    • If emphysematous pyelonephritis is suspected, emergency computed tomography (CT) should be performed to delineate the extent of involvement and immediate urologic consultation obtained.
  • 23. Intravenous Urography
    • Intravenous urography (IVU), also known as intravenous pyelography (or more commonly, the IVP)
    • The study should always begin with a scout KUB.
    • This has several purposes including detection of calcifications (which may be obscured after contrast material is injected), exclusion of contraindications to the study (retained barium, etc.).
  • 24.
    • Intravenously injected iodinated contrast is excreted primarily by glomerular filtration in the kidney, opacifying the urinary tract as it progresses from the kidney through the ureter and to the bladder.
    • Capturing this sequential "opacification" on radiographs is the fundamental basis of the IVU.
  • 25.
    • Optimal visualization of the kidney is accomplished very early in the examination.
    • Within 1 to 3 minutes after injection, the contrast bolus is filtered by the glomeruli and fills the nephron, resulting in intense opacification of the renal parenchyma; this phase of contrast opacification is called the nephrogram .
    • Evaluation of the kidneys during the nephrographic phase is often enhanced with tomograms (nephrotomograms).
    • The kidneys should be evaluated for their position, orientation, size, contour, and radiographic density.
  • 26. Normal nephrotomogram. Note the position of the kidneys within the abdomen, with the right kidney slightly lower than the left; the size of the kidneys, the symmetry of the nephrograms; and the renal contour, which is smooth.
  • 27.
    • Soon after the nephrographic phase, contrast begins filling the intrarenal collecting system including the calyces and renal pelvis. This portion of the study is termed the pyelographic phase .
    • Several films are used to evaluate the collecting system (intrarenal collecting system and ureter)
    • The intrarenal collecting system consists of calyces, infundibula, and the renal pelvis.
  • 28.
    • The individual renal calyx is a delicate appearing cup-shaped structure.
    • The normal delicate, cup-like appearance can be distorted or irregular in conditions such as papillary necrosis, tuberculosis, or transitional cell carcinoma.
    • Subtle rounding or ballooning of the calyces is one of the earliest signs of urinary tract obstruction.
    • The renal pelvis should be evaluated for filling defects and mass effect.
  • 29. Normal pyelogram. Note the delicate cup-shaped appearance of the calyces and the relative symmetry of the renal pelvis with no evidence of dilation or mass effect.
  • 30.
    • The ureter extends from the ureteral pelvic junction to the ureteral vesicle junction.
    • The ureter is an actively peristalsing structure that is not normally seen in total on the IVU.
    • In fact, complete visualization of the ureter may suggest distal obstruction.
    • The ureter should be inspected for filling defects, which can be caused by stones or tumor, and should be symmetric in size.
  • 31. Normal KUB showing contrast opacified ureters. Due to peristalsis, the ureter may not be visible in its entirety.
  • 32.
    • Finally, the bladder is opacified last on the study beginning around 5 minutes after injection.
    • Early filling films, later distended films, and postvoiding images complete the evaluation of the bladder.
    • Bladder wall thickness can sometimes be visualized and assessed, especially if thickened.
    • Additionally, the bladder mucosa should be scrutinized for irregularity or filling defects that may suggest a mass.
  • 33. Normal bladder. Note the location of the bladder just above the pubic symphysis, as well as its smooth contour. No filling defects should be seen.
  • 34. Retrograde Pyelography/Cystography/ Urethrography
    • Direct injection of water-soluble iodinated contrast material is a useful method of examining various regions of the urinary tract.
    • The advantage of this method of evaluation is the direct control over the contrast injection rather than reliance on secondary excretion from the kidney.
    • Retrograde pyelography, often carried out in conjunction with cystoscopy, is performed by placing a small catheter into the distal ureter.
    • Contrast material is then injected through this catheter into one or both ureters.
    • Fluoroscopy and conventional radiographs should then be obtained.
  • 35.
    • This study usually results in excellent evaluation of the ureter and intrarenal collecting system.
    • The ureter is typically seen in its entirety, which rarely occurs with other imaging studies.
    • Interpretation is similar to that of the IVU.
  • 36.
    • Imaging of the bladder is performed with a cystogram, for which a catheter is placed into the bladder and contrast material is then injected.
    • One advantage to cystography is that vesicoureteral reflux can be evaluated during the conventional cystogram unlike during IVU.
    • CT cystography, in which after contrast instillation CT imaging is utilized instead of conventional films, has been used in the setting of trauma to evaluate for bladder injury.
  • 37.
    • The urethra may be evaluated with contrast material via two methods.
    • In one, the urethra is evaluated during voiding, often following a cystogram (voiding cystourethrogram or VCUG).
    • Alternatively, a retrograde study may be performed (retrograde urethrogram).
    • The urethra in males is generally evaluated for injuries but may also be examined for filling defects, masses, strictures, and fistula.
    • The female urethra is most commonly examined for diverticula.
  • 38. Normal antegrade urethrogram . The mild areas of narrowing and dilation are normal. On an antegrade study, unlike a retrograde examination, the proximal urethral is distended and readily assessed. No evidence of stricture or extravasation is seen.
  • 39.  
  • 40. Normal female VCUG. Note the smooth contour of the urinary bladder and the short, conical appearing urethra.
  • 41. Ultrasonography
    • kidneys should be assessed for echogenecity,size, location, and symmetry.
    • Unlike the IVU, where masses are often nonspecific, ultrasonography allows a more detailed evaluation including the ability to confidently diagnose the most common renal mass—the simple cyst.
  • 42.
    • Calcifications are characteristic on ultrasound.
    • Renal stones or calcifications may be detected within the renal parenchyma or in the intrarenal collecting system.
    • Ultrasonography is also excellent for detecting hydronephrosis with the distended collecting system being easily recognized.
  • 43.
    • The ureters are not normally seen on ultrasound due to obscuring overlying tissue and their small size.
    • The bladder may demonstrate mass lesions, such as transitional cell carcinoma, or stones.
    • The urethra is not typically seen on an ultrasound image although urethral diverticula may occasionally be demonstrated.
  • 44. Computed Tomography
    • CT is now the dominant radiologic imaging modality for evaluation of the urinary tract.
    • CT scans of the urinary tract may be performed with and/or without intravenous iodinated contrast material depending on the indications.
  • 45.
    • Noncontrast studies may be performed to evaluate stone disease and other calcifications.
    • Additionally, noncontrast views of the kidneys serve as a baseline to evaluate for lesion enhancement after contrast administration, a critical factor in mass evaluation.
  • 46.
    • With rapid scanning and contrast bolus timing, several sequential phases of opacification within the kidney can be delineated by CT including corticomedullary, nephrographic, and excretory phases.
    • The corticomedullary phase can be seen if scanning is performed during the first 20 to 90 seconds after contrast administration and represents the early preferential blood flow to the renal cortex
  • 47.
    • Subsequently, contrast begins to pass into the distal collecting tubules within the renal medulla, resulting in a more homogeneous opacification of the renal parenchyma, termed the CT nephrographic phase . This generally occurs around 2 to 4 minutes after contrast medium injection.
    • Finally, the excretory phase is seen when contrast opacifies the collecting system .
    • Each different phase of opacification may better demonstrate different disease processes.
  • 48.
    • CT has the ability to noninvasively evaluate the vascular system, and thin-section early CT images accurately demonstrate the main arterial and venous structures of the kidney .
    • Just as with IVU or any modality, the kidneys should be evaluated for position, orientation, size, and radiographic density.
    • Unlike IVU, however, CT provides much greater specificity regarding renal disease, including mass lesions.
    • CT is sensitive in detecting renal masses.
  • 49. Normal CT angiogram of the renal arteries, 3-D reconstruction. Note that this image clearly demonstrates that there are two right renal arteries. This is a normal variant. In this case, the renal arteries are patent without evidence of significant stenosis.
  • 50.
    • CT is also useful in staging renal neoplasms.
    • Non-neoplastic renal disease, such as trauma and complicated infections, is accurately demonstrated on CT images.
    • Spiral CT has become the study of choice for evaluating suspected ureteral stones.
    • The bladder wall should be evaluated for thickening and irregularity, which may suggest hypertrophy, inflammation, or carcinoma.
    • Stones may be detected within the bladder.
    • The urethra is not normally seen on CT.
  • 51. Magnetic Resonance Imaging
    • Just like CT, technical advances in magnetic resonance (MR) imaging have led to increasing use in urinary imaging.
    • MR imaging of the kidney is performed with gadolinium as the contrast agent, not iodinated contrast material.
    • Like CT, contrast-enhanced phases of imaging (arterial, corticomedullary, nephrographic, and excretory) are all visible.
  • 52. Normal MRI of the kidneys. The appearance of the kidneys is variable on MR imaging depending on imaging factors. The top left image is a T 1 -weighted sequence and the top right is T 2 weighted. The bottom images were obtained after gadolinium injection and demonstrate the corticomedullary and nephrographic phases.
  • 53. Normal MR imaging of the kidneys. This image was obtained in the coronal plane and after gadolinium injection.
  • 54. Nuclear Medicine
    • Renal evaluation is typically performed by intravenous bolus injection of renal-specific agents such as technetium-labeled mercaptoacetyltriglycine ( 99m Tc-MAG 3 ).
    • Images are acquired every few seconds that demonstrate renal blood flow, with additional images obtained over several minutes that show renal uptake and excretion.
  • 55.
    • Information about renal perfusion, morphology, relative function of each kidney, and excretion can be extremely useful in evaluation of conditions such as renovascular hypertension, obstruction, and renal transplant examination.
    • In general, nuclear medicine renal studies suffer from fairly low spatial resolution and, therefore, are often used in conjunction with other imaging studies.
    • Radionuclide cystography is another useful test used to diagnose and monitor vesicoureteral reflux.
    • Radioactive iodine labeled metaiodobenzylguanidine (MIBG) examination. MIBG collects in adrenal medullary tissue and is useful in diagnosis and evaluation of pheochromocytoma.
  • 56. Angiography
    • The renal arteriogram is performed after puncture of a more peripheral vessel such as the common femoral artery, with advancement of a catheter into the renal artery origin.
    • Contrast material is injected via the catheter and rapid, typically digital, conventional radiographic images are obtained.
    • The main role for angiography today is aiding and guiding interventional techniques.
  • 57. Normal renal arteriogram. The renal arterial system is visualized in detail with spatial resolution superior to that of other techniques. Delayed images can be obtained to show the venous phase and/or the collecting system filling with contrast material.
  • 58. Technique selection
  • 59. Plain X ray
    • Limited use for evaluating Genito urinary tract.
    • Can be used in finding abnormal stones, bones, gases and masses.
    • Utility is limited by its lack of sensitivity and specificity.
    • Can be used effectively to follow radiographically visible stone disease.
    • Also used for assessing stone burden or urethral stone passage.
  • 60. IVU/IVP
    • Assesses both morphology and function .
    • Lack of sensitivity and specificity.
    • Used to evaluate for mucosal lesions—transitional cell carcinoma of upper urinary tracts, urinary tract for congenital anomalies and to assess obstruction.
    • Replaced by modern modalities in many indications such as renal masses, Urinary tract infections, trauma, ureteric colic and vascular diseases eg.renovasular hypertension.
  • 61.
    • Voiding cysto urethrography is used in evaluating urethral reflux.
    • Retrograde Urography is used for suspected urethral injuries.
  • 62. Nuclear medicine
    • Renal scintigraphy is used for the assessment of Renal function i.e obstruction, renovascular hypertension, Renal transplants.
    • MIBG is used to diagnose pheochromocytoma.
    • MIBG is also used for detecting metastatic or recurrent disease or extra-adrenal lesions.
  • 63.