solitary kidney with a stone, Ivu cas study


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solitary kidney with a stone, Ivu cas study

  1. 1. IVU Case Study<br />IVU room at KKUH<br />Case place: at King Khalid Universal Hospital (KKUH).<br />Presentation was done by: Shatha Jamal Al-Mushayt<br />UN: 427200465<br />
  2. 2. Patient information<br />Gender: Female<br />Age: 53 years old<br />Weight: 70 Kg<br />Transport: walking<br />Allergic to dust, egg, and fish.<br />Date of exam: 26-12-2009<br />patient history<br />Solitary(only one) left kidney with stone. <br />A history of mild allergy to contras media <br />
  3. 3. Symptoms and signs<br />The patient had a history of solitary LT kidney with stone and this exam was requested to check up her stone condition and if there is any effect caused by it. <br />Since she had only one kidney, this increases the risk of developing kidney stones.<br />Patient did not complain from pain.<br />
  4. 4. Patient preparation <br />Patient Creatinine level was within the normal range according to KKUH( 62–115 µmol/L).<br />Consent form was signed.<br />Patient was asked If she has asthma or allergy to some food or medications. As this requires having some medications before the exam.<br />Cont.<br />
  5. 5. Patient preparation <br />Patient was asked to come on time.<br />Patient was informed that:<br /><ul><li>Other patients may have the same appointment. So, the priority will be to the one who come first.
  6. 6. The exam may take longer time according to the condition of the kidneys & their secretion of CM.</li></ul> Cont.<br />
  7. 7. Patient preparation <br />The day before the exam:<br />No drugs by mouth (except for diabetic patients)<br />Light dinner or only fluids (no dairy products or soft drinks like Pepsi)at 7:30 pm- preferable.<br />At 8:30 pm, 60 gm of caster oil (can be taken with a spoon of honey or jam).<br />Then, plenty amount of fluids (no dairy products or soft drinks like Pepsi) until 11 pm.<br />Then, Nothing by mouth until the exam is done. Except for diabetic or renal failure patients, they can have some water.<br />Cont.<br />
  8. 8. Patient preparation <br />The day of exam: <br />Patient was not pregnant for sure.<br />Patient voided immediately before the exam.<br />Patient put on a hospital gown without any object in the area of interest that may superimpose an essential anatomy.<br />Injection set & crash cart were ready by side. <br />
  9. 9. Allergic preparation<br />Prednisone tablets were prescribed to the patient as follows,<br />The day before the exam + the day of the exam: 50mg twice a day.<br />Two days after the exam: 10 mg twice a day.<br />The third day after the exam: 5 mg twice a day.<br />
  10. 10. Technique FILMS WERE TAKEN IN SEQUENCE <br />Control (full KUB) film was first taken. <br /><ul><li>Patient position: </li></ul>supine, no trunk rotation, midsagital plane to the center of the table, arms extended by sides away from body, and pillow under pt head.<br /><ul><li>Center point: </li></ul>2 cm above the midway between the highest points of iliac crest.<br /><ul><li>Central Ray:</li></ul>perpendicular to image receptor(IR), vertical beam.<br /><ul><li>Collimationmust include the xiphoid process and symphsispupis.
  11. 11. Marker on the right side of patient.
  12. 12. Patient was asked to hold her breath during exposure. </li></li></ul><li>Control (KUB) film<br />Radiograph 1:<br />
  13. 13. CM injection<br />Omnipaque300 mgI/ml: <br />Low osmolar, non-ionic contrast media <br />Injected intravenously after the control film.<br />CM Dose: 70 ml. (remember, adult dose= 1 ml per Kg)<br />The patient was informed that she may feel fever after injection (normally);but she did not feel so. <br />
  14. 14. Technique<br />Nephrogramfilm-Immediately after injection<br /><ul><li>Patient position: </li></ul>As for the full KUB control film.<br /><ul><li>CP: midway between xiphoid process & iliac crest (kidney area).
  15. 15. CR: perpendicular to IR, vertical beam
  16. 16. Collimation less than full KUB film. prevent cutoff kidney.
  17. 17. Marker: RT of the patient
  18. 18. Patient was asked to hold her breath during exposure. </li></li></ul><li>Nephrogram<br />Radiograph 2: <br />
  19. 19. Technique<br />Full KUB film-5 minuets since injection.<br /><ul><li>Technique as for the full KUB control film.</li></li></ul><li>KUB- 5 MIN SINCE INJECTION<br />Radiograph 3: <br />
  20. 20. Technique<br />Full KUB film-15 min since injection<br /><ul><li>Technique as for the full KUB control film.</li></li></ul><li>KUB- 15 MIN<br />Radiograph 4:<br />Major calyx<br />Renal pelvis<br />Minor calyx <br />Pelvi-uretric<br />junction<br />Kidney <br />Proximal ureter<br />Middle ureter<br />Distal ureter<br />Vesico-uretric<br />junction<br />Urinary bladder<br />
  21. 21. technique<br />LPO: left posterior oblique-19 min since injection. <br /><ul><li>This was an additional film ordered by the radiologist. </li></ul>Why? To demonstrate the LT ureter clearly.<br /><ul><li>Patient position:</li></ul> supine and partially(~30-45 degrees) rotated to the left side, arm of RT side was raised across upper chest, RT side knee was flexed for support of lower body, pillow under head. <br /><ul><li>CP:</li></ul>2 cm above the midway between the spine & the highest point of iliac crest.<br /><ul><li>CR:</li></ul>perpendicular to IR, vertical beam.<br /><ul><li>Collimation must include kidneys without cut and symphsispupis.
  22. 22. LTmarker
  23. 23. patient was asked to hold her breath during exposure</li></li></ul><li>LPO-19 min<br />Radiograph 5: <br />
  24. 24. technique<br />Full bladder-34 min<br /><ul><li>Patient position:</li></ul>supine, no trunk or pelvis rotation, midsagital plane to the center of the table, arms extended by sides away from body or rested on chest, and pillow under pt head.<br /><ul><li>CP: 5 cm above symphasispupis.
  25. 25. CR: perpendicular to IR
  26. 26. Collimate coned view of bladder.
  27. 27. RT marker
  28. 28. patient was asked to hold her breath during exposure.</li></li></ul><li>Full bladder-34 min (coned view)<br />Radiograph 6:<br />
  29. 29. technique<br />The radiologist was satisfied with the full bladder film. So he asked for a Post void film.<br />Post Void film is a full length KUB film after emptying the bladder from CM.<br /><ul><li>Technique as for the full KUB control film.</li></li></ul><li>Post void -KUB <br />Radiograph 7:<br />
  30. 30. Finally! <br />Images were sent to PACS<br />IVU room at KKUH<br />
  31. 31. After care<br />The patient was asked if she had hard breathing or any discomfort; but she was fine . <br />The injection needle was removed.<br />
  32. 32. My comments<br /><ul><li>During exposure, it is better to be done on expiration; but in KKUH they just instruct the patient to take a deep breath then hold it.</li></ul>Around 3 Syringes each of 25 ml were used to equal 70 ml for CM injection<br />Source Image receptor distance (SID) in all images was = 100 cm<br />KV= 75 <br />Uretric compression was not used as the case did not need it & the radiologist did not instruct to apply it.<br />Minuets marker as annotation were used; but not shown in these images.<br />
  33. 33. Findings 2 radioopaquecalcular shadow density <br />Control film showing two radio-opaque calcular shadow density projecting over the lower pole of the left kidney opposite to the level of L2.<br />
  34. 34. Findings<br />Solitary LT kidney showing normal enhancement of the kidney after IV contrast administration with spontaneous normal excretion of CM.<br />Nephrogram<br />
  35. 35. Finding<br />Normal configuration of the pelvicalyceal system with filling defect of the lower collecting system(yellow circles) due to the previously noted stones with no back pressure effect. <br />15 min KUB film<br />5 min KUB film<br />
  36. 36. finding<br />No residual contrast seen in the UB after voiding. (arrow: urinary bladder area)<br />PV-KUB film<br />
  37. 37. Conclusion<br />Two small left renal stones with no back pressure effect.<br />
  38. 38. Renal stones<br />They are small, solid masses may form when acid salts or minerals, normally found in urine, become solid crystals inside the kidney.<br />Most kidney stones contain Calcium.<br />They typically leave the body by passage in the urine stream. <br /><ul><li>However, they can build up inside your kidney & form larger stones.
  39. 39. If stones grow to sufficient size</li></ul> before passage (at least 2-3 mm),<br /> they can cause obstruction of the<br />ureter.<br />
  40. 40. Symptoms <br />many are formed & passed without causing symptoms; but if a kidney stone causes a blockage, or moves into the ureter, some symptoms are:<br />Severe pain on 1 or both sides of back. <br />Feeling frequent urge to urinate, or a burning sensation during urination <br />Bloody or cloudy urine <br />Sudden spasms of excruciating pain.<br />Feeling sick or vomit.<br />
  41. 41. Causes of kidney stones<br />Gender: Men are 4 times more likely to get kidney stones than women<br />History: if someone has a history of kidney stone 50 % chance of developing another one within 5 years.<br />High risk factors of developing kidney stones:<br />Family history of kidney stones.<br />Age: 20 - 50 yr.<br />Taking certain medicines e.g. indinavir(in the treatment of HIV infection) &taking too many or too often laxatives.<br />Solitary kidney, or an abnormally shaped kidney <br />High protein diet.<br />Not drinking enough fluids.<br />
  42. 42. diagnosis of a kidney stone<br />can be confirmed by:<br /> Radiological studies <br />Ultrasound examination;<br />Urine tests & blood tests.<br />When a stone causes no symptoms, watchful waiting is a valid option.<br />In which time is allowed to pass before medical intervention or therapy is used.<br />A 9 mm kidney stones<br />
  43. 43. Treatment<br />Non Surgical:<br />For stones smaller than about 5mm, being physically active + drinking a lot of water is often enough.<br />Extracorporeal shock wave lithotripsy (ESWL)<br />Common method uses x-ray or US imaging and a lithotripter which send shock waves to kidney stone, break it up into small crystals that passed in urine.<br />Surgical:<br />Ureteroscopic stone removal<br />Using a acystoscope<br />Percutaneousnephrolithotomy (PCNL)<br /> Telescopic instrument (nephroscope) is used to break the stone using a laser beam or shock waves<br />
  44. 44. references of pathology<br /><ul><li>
  45. 45.</li></li></ul><li>Thank you <br />Shatha Al-Mushayt, L-7<br />Presented at 2010<br />