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  • Hip fracture
  • Pelvic fractures
  • Pelvic fractures
  • Open book
  • Lytic mets
  • Sclerotic mets
  • Lytic mets
  • Obliteration of PSOAS shadow
  • Splenomegally
  • Bezoar
  • AAA
  • RCC with calcification
  • Right RCC
  • Ureteral injury
  • stab
  • Left flank trauma
  • KUB and IVP

    1. 1. KUB’s and IVP’s Kristopher R. Carlson 2009
    2. 2. KUB <ul><li>Kubota Corporation </li></ul><ul><li>Knoxville Utilities Board </li></ul><ul><li>Kidneys, Ureters, Bladder </li></ul><ul><li>Katholieke Universiteit Brabant </li></ul>KIDNEYS, URETERS, BLADDER
    3. 3. A little physics <ul><li>Closer to film = smaller </li></ul><ul><li>Closer to beam = larger </li></ul><ul><li>Radiation vs background: </li></ul><ul><li>CXR= 0.01 - 1.30 mSv. = 5-15d </li></ul><ul><li>AXR - 0.12 - 9.90 mSv. = 2-3m </li></ul><ul><li>IVP = 3 mSv = 0.5-1.5 years </li></ul><ul><li>CT abdomen = 10 mSv + = 3-5 years </li></ul><ul><li>Coast to Coast Airplane Ride = 0.01mSv </li></ul>www.Radiologyinfo.org, www.hps.org
    4. 4. KUB = Kidneys, Ureters, Bladder <ul><li>Adequacy </li></ul><ul><ul><li>Adrenals to 2cm below pubic symphysis </li></ul></ul><ul><li>Bones, Stones, Masses, Gasses </li></ul><ul><li>Abnormal Calcifications </li></ul><ul><ul><li>Renal, ureteral, gallstones, tumors, etc. </li></ul></ul><ul><li>Foreign Objects </li></ul><ul><ul><li>It’s amazing what people can do with things and their orifices. </li></ul></ul>
    5. 5. KUB, how to look at em. <ul><li>Get a System. </li></ul><ul><li>#1 = Name and Date!!! </li></ul><ul><li>Quality, penetration, pt position </li></ul><ul><li>Outside  In, vs. Inside  Out </li></ul><ul><li>Look at everything. </li></ul>
    6. 6. Anatomy, the basics
    7. 7. Anatomy
    8. 8. PSOAS <ul><li>Position </li></ul><ul><li>Size </li></ul><ul><li>Orientation </li></ul><ul><li>Axis </li></ul><ul><li>Symmetry </li></ul>
    9. 9. Position <ul><li>Normally T12-L3 </li></ul><ul><li>R lower than L </li></ul><ul><ul><li>R = L1 – L3 </li></ul></ul><ul><ul><li>L = T12 – L2/3 </li></ul></ul>
    10. 10. Size <ul><li>Normal adult </li></ul><ul><ul><li>10-13cm </li></ul></ul><ul><li>Children </li></ul><ul><ul><li>Use normogram </li></ul></ul>
    11. 11. Orientation and Axis
    12. 12. Bones <ul><li>Fractures </li></ul><ul><ul><li>Vertebral Bodies pelvis, etc.. </li></ul></ul><ul><li>Metastases </li></ul><ul><ul><li>Lytic or blastic lesions </li></ul></ul><ul><li>Absence of bones </li></ul><ul><ul><li>Sacral agenesis </li></ul></ul><ul><li>Diastasis </li></ul><ul><ul><li>Symphysis, SI joints </li></ul></ul>
    13. 13. Vertebrae
    14. 15. Pelvic Fractures
    15. 19. Mets
    16. 22. Not METS
    17. 23. Missing bones
    18. 24. Extra Bones
    19. 25. Stones <ul><li>Overlying kidney/ureter/bladder </li></ul><ul><li>Kidneys </li></ul><ul><ul><li>PSOAS mnemonic </li></ul></ul><ul><ul><ul><li>Position, Size, Orientation, Axis, Symmetry </li></ul></ul></ul><ul><li>Course of ureters </li></ul><ul><ul><li>Lateral transverse processes </li></ul></ul><ul><li>Other Stones / Calcifications </li></ul>
    20. 40. Masses <ul><li>Renal contour </li></ul><ul><li>Soft tissue densities </li></ul><ul><li>Psoas shadows </li></ul><ul><li>Displacement of normal structures </li></ul>
    21. 47. Colonic hydatid cyst
    22. 48. Gases <ul><li>Bowel gas </li></ul><ul><ul><li>Distribution / location </li></ul></ul><ul><li>Gas filled fluid collections </li></ul><ul><li>Gas in the wrong place </li></ul><ul><li>Free air </li></ul><ul><ul><li>Hemi diaphragms. </li></ul></ul><ul><ul><li>Better with upright CXR </li></ul></ul>
    23. 58. Abnormal Calcifications / Objects <ul><li>Multiple? </li></ul><ul><li>Foreign bodies </li></ul><ul><ul><li>Iatrogenic </li></ul></ul><ul><ul><ul><li>surgical clips, IUDs, IVC filters </li></ul></ul></ul><ul><ul><li>Accidental </li></ul></ul><ul><ul><ul><li>Bullets, swallowed items! </li></ul></ul></ul><ul><ul><li>Projectional </li></ul></ul><ul><ul><ul><li>Clothing, body piercings </li></ul></ul></ul>
    24. 64. Whew…..Had enough? IVP’s?
    25. 65. IVP = IntraVenous Pyelogram <ul><li>Timed series of images of the abdomen after administration of 50-100mL IV contrast. </li></ul><ul><ul><li>Scout Film </li></ul></ul><ul><ul><li>Early Nephrogram Films </li></ul></ul><ul><ul><li>Tomograms </li></ul></ul><ul><ul><li>Excretion Films </li></ul></ul>
    26. 66. Pre-Exam Considerations <ul><li>Bowel prep? </li></ul><ul><ul><li>Useful in the chronically constipated </li></ul></ul><ul><ul><li>No randomized study to prove effective </li></ul></ul><ul><li>Hydration </li></ul><ul><ul><li>Increased contrast if dehydrated </li></ul></ul><ul><ul><li>Increased risk of injury </li></ul></ul>
    27. 67. Contrast Media <ul><li>Ionic (high osmolar) Contrast Media </li></ul><ul><ul><li>Hypaque, Conray, Renograffin </li></ul></ul><ul><ul><li>Hypertonic to serum by 5 to 7 fold </li></ul></ul><ul><li>Low Osmolar Contrast Media </li></ul><ul><ul><li>Omnipaque, Visipaque </li></ul></ul><ul><ul><li>50% reduction in osmolality </li></ul></ul>
    28. 68. Contrast Media <ul><li>Indications for Low Osmolar Contrast </li></ul><ul><ul><li>Previous reaction to contrast </li></ul></ul><ul><ul><li>History of Asthma or Allergy </li></ul></ul><ul><ul><li>History of Cardiac Disease or Dysfunction </li></ul></ul><ul><ul><li>Generalized Debilitation </li></ul></ul><ul><ul><li>Blood Dyscrasias </li></ul></ul><ul><ul><li>Risk of Aspiration </li></ul></ul><ul><ul><li>Age < 1 year </li></ul></ul>
    29. 69. Adverse effects of contrast <ul><li>Chemotoxic </li></ul><ul><ul><li>Nephrotoxicity </li></ul></ul><ul><ul><ul><li>Nonoliguric </li></ul></ul></ul><ul><ul><ul><li>Creatinine peaks in 3-5 days </li></ul></ul></ul><ul><ul><ul><li>Risk 1 in 1000-5000 if no risk factors </li></ul></ul></ul><ul><ul><ul><li>Risk factors: renal insufficiency, DM, CHF, hyperuricemia, proteinuria, multiple doses of contrast </li></ul></ul></ul><ul><ul><ul><li>Metformin (Glucophage) overdose causes lactic acidosis  withhold for 48 hours after contrast </li></ul></ul></ul><ul><li>Anaphylactoid / Idiosyncratic </li></ul>
    30. 70. Adverse effects of contrast <ul><li>Anaphylactoid / Idiosyncratic </li></ul><ul><ul><li>Mild : metallic taste, warmth, sneezing, coughing, mild hives  no treatment </li></ul></ul><ul><ul><li>Moderate : vomiting, severe hives, HA, palpitations, facial edema </li></ul></ul><ul><ul><li>Severe : hypotension, bronchospasm, laryngeal edema, pulmonary edema, LOC </li></ul></ul><ul><ul><li>Idiosyncratic rxns for ionic contrast = as high as 12%, most mild. </li></ul></ul><ul><ul><li>Tx with Antihistamine = mild, Epi or beta agonist = severe. </li></ul></ul><ul><ul><li>Non-ionic = 3% </li></ul></ul>
    31. 71. Contrast “Allergic”? <ul><li>Consider non-allergenic imaging </li></ul><ul><li>Prophylaxis: </li></ul><ul><ul><li>Prednisone = 50mg PO x 3 doses </li></ul></ul><ul><ul><ul><li>13hrs, 7hrs, 1hr before dose. AND….. </li></ul></ul></ul><ul><ul><li>Benadryl 50mg PO 30 min prior to dose </li></ul></ul><ul><ul><li>Other regiments exist. </li></ul></ul>Maddox, T. Adverse Reactions to Contrast Material: Recognition, Prevention, and Treatment AFP. Oct 2002.http://www.aafp.org/afp/20021001/1229.html
    32. 72. Scout Film <ul><li>KUB as discussed </li></ul>
    33. 73. Early Nephrogram Films <ul><li>Most dense at 30 seconds to 1 minute </li></ul><ul><li>Evaluates renal parenchyma </li></ul><ul><li>PSOAS </li></ul><ul><li>Masses </li></ul><ul><li>Dromedary Hump </li></ul><ul><li>Fetal Lobulations </li></ul>
    34. 74. Tomograms <ul><li>Increase sensitivity for space occupying lesions </li></ul><ul><li>Midplane in view of L2 vertebral bodies in focus </li></ul><ul><li>Immediate detects parenchyma </li></ul><ul><li>Delayed detects collecting system </li></ul>
    35. 75. Excretion Films <ul><li>2 or 3 between 5 and 15 minutes </li></ul><ul><li>Need to see collecting system, ureters and bladder </li></ul><ul><li>Oblique views may help to evaluate filling defects or calcifications </li></ul><ul><li>Prone views distend the distal ureter </li></ul><ul><li>Upright films may help to evaluate for renal ptosis, cystoceles, layering stones </li></ul><ul><li>Post void films help assess bladder outlet obstruction </li></ul>
    36. 79. <ul><li>Kidney </li></ul><ul><ul><li>7-9 papillae, each cupped by a minor calyx </li></ul></ul><ul><ul><li>Each minor calyx narrows to form an infundibulum </li></ul></ul><ul><ul><li>Minor calyces coalesce to form 2-3 major calyces </li></ul></ul><ul><ul><li>Major calyces coalesce to form the renal pelvis </li></ul></ul>
    37. 84. Stones
    38. 87. Tumors
    39. 96. Other stuff
    40. 98. Trauma
    41. 101. Trauma IVP <ul><li>Useful in emergent situations on the table: </li></ul><ul><ul><li>2 mL / kg IV given intraoperatively </li></ul></ul><ul><ul><li>Image x 1 at 10 minutes </li></ul></ul>
    42. 103. Summary <ul><li>KUB’s and IVP’s provide rapid, low risk, low radiation way to assess a variety of complaints and pathologies. </li></ul><ul><li>Be systematic </li></ul><ul><li>Bones, Stones, Masses, Gases </li></ul><ul><li>PSOAS </li></ul><ul><li>Be aware of contrast and radiation </li></ul>
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