The document discusses excretory urography, which involves administering intravenous contrast and taking timed radiographic images of the urinary system. It describes the indications for excretory urography such as suspected urinary tract pathology or repeated infections. It outlines the procedure, potential findings on images including abnormalities of the kidneys, ureters and bladder, and complications to watch for like contrast reactions. Key phases of kidney imaging and abnormalities that can be identified are also summarized.

1. FATIMA SHAH

2. Structure and function of urinary system.
Ascending Urography
-
Retrograde/Cystoscopic
Descending Urography
-
Excretory/Intravenous

3. Timed series of radiographic
images of urinary system after
administration of IV contrast.

4. Suspected urinary tract pathology.
Repeated infections -focus, damage
Heamaturia
Investigation of hypertension not
controlled by medication in young
adults.
Renal colic.
Trauma.

5.  General contra indications to contrast
agents.
Diabetes,
Thyrotoxicosis,
Pregnancy
Raised urea creat. urography unlikely to
be successful.
Metformin therapy

6. Bowel prep.
Basic psychological preparation with
reassurance & explanation of technique
Bladder emptied immediately before exam.
 Hx of Previous I.V.U.
Previous experience of iodinated
contrast media.
Abdominal surgery, Allergies, drugs Hx.

7. Ionic or HOCM eg urograffin used.
Iodine is main element which imparts
radio-opacity.
300mg I/kg body wt. 15-25 gm of iodine
given. 20ml of 76% urograffin
Greatest single predictor of contrast
reaction is previous reaction to contrast

8.  MILD & TRANSIENT – NO Rx REQUIRED:
-nausea,vomiting,sensation of heat, tingling,
metallic taste,pain in arm,deire to urinate.
 ANTI-HISTAMINE & STEROID Rx:
-Skin rashes;urticaria ,diffuse erythema.
Angioneurotic edema,pruritis,sneezing&rhinorrhea
 ADRENALINE,AMINOPHYLLINE or SALBUTAMOL,O2
& STEROIDS Rx:
-Broncho spasm and layryngeal edema particularly
due to meglumine.

10. Scout film
 Administration of contrast
 Early nephrogram
 Tomograms
 Excretory films

12. Compression banding:
Aim to produce better PC distension
C/I: Recent abd surgery.
Renal trauma.
Large abd mass.
Obstruction.
If 5min film shows adequate
distension.

15. End of Injection, A.P. of the renal areas to show the nephrogram, i.e. the
renal parenchyma opacified by the contrast medium in the renal tubules.

18. Value of fluoroscopy. Fluoroscopic spot images demonstrate the entire
luminal surface of the ureters.

19. On a radiograph obtained during bladder filling, the contrast material is
smoothly defined and the bladder wall has become less evident. A normal
uterine impression on the superior margin is noted

20. Post Micturition film to demonstrate the bladder emptying success, and the
return of the previously distended lower ends of ureters to normal.

22. Area: supra-renal - below symphysis.
Assessment of Bones, stones, masses &
gases.
Oblique view helpful when pt symptomatic
but no cause seen on KUB.

23. Urethral calculus in pt with hx of severe right flank pain.Collimated Radiograph shows
calcification centered behind symphysis . CT helped confirm presence of urethral
calculus.This case shows importance of full coverage of anatomic structures at KUB.

24. (a) Collimated preliminary radiograph of the pelvis shows no obvious stones

25. Rt post oblique radiograph of pelvis shows 6mm ureteral calculus now projected onto
iliac bone.urogram (not shown)helped confirm rt ureteral obstruction 2ndry to the
stone. This case shows how a calculus can be obscured by the complex sacral anatomy.

27. The plain KUB
shows lumbar
spondylosis
with marked
scoliosis and
obvious
asymmetrical
thickness of
the lateral
abdominal wall
musculatures.

28. AP radiograph of pelvis shows parasymphyseal bone fragment along left
pubis ,mild p. symphysis diastasis, &transverse fracture of rt transverse
process .irregularity of rt SI joint space, suggestive of fracture.

29. Preliminary
image from
excretory
urography
demonstrates a
looped
configuration of
the distal
transverse colon
and splenic
flexure
(arrows).

30. 50yrs female,
known diabetic
presented with
lethargy, fever
with chills and
rigors. Urine
examination
shows multiple
pus cells and
ESR is
elevatedabnor
mal gas in the
left renal
region

31. Another patient
aged 45yr with
similar history
and marked
suprapubic
tendernessKUB
radiograph
showing air with
in the bladder

32. KIDNEYS: visualised if peri-renal fat.
GUT GASES: may over lap.
Change in shape & location
displaced by compression.
CALCIFICATION OVER RENAL AREA:
-True lat/ips-ilateral post oblique views.
-Displacement with ins/exp/upright films.

33. EXTRA-RENAL CALCIFICATION:
-Calcified Costal Cartilage, supra-RG.
-Calcification in tail of pancreas, GB,
liver, Splenic artery.
-Phleboliths, chip fracture of TP.

35. On a scout image
obtained before
excretory urography,
a calculus fills nearly
the entirety of a
bifid right renal
collecting system,
giving it a branched
appearance that
resembles the
antlers of a stag.

36. Plain radiograph of
the abdomen
demonstrates
extensive
calcification in the
left kidney, which
was nonfunctional
(the putty kidney),
consistent with
autonephrectomy
from tuberculosis.

37. URETERS: not visualized.
OPACITIES:
-Intra-Luminal: ureteral stones.
-Intra-mural: schistosomiasis.
GAS SHADOWS: conform to shape of ureter.
EXTRA-URETERAL CALCIFICATION:
-mesenteric LN(mobile)
-phleboliths, calcification in arteries.

38. U.BLADDER & URETHRA:
- not visualised.
- visualised if calculi or foreign body.

39. Contrast in glomeruli & tubules.(1-3min)
Four phases:
SPONTANEOUS: Non-opacified, outlined by
RP fat on plain film.
VASCULAR: Opacification of intra-renal
blood vessels.
TOTAL BODY: “ of pre and retro renal soft
tissue + vascular nephrogram
INTRA-TUBULAR:” of intra-renal tubules.

40. U=([P]xGFR)/Uvol
a-extravasation of contrast
b-absent blood flow :
i-shock
ii-no glomerular filteration :
acute obstruction,infarction

41. Non- Visualisation:
- Insufficient dose of contrast.
- Acute, chronic renal disease
- End stage renal disease.
- Acute tubular obstruction
- Ureteral calculus.
- Renal agenesis
- Renal artery thrombosis,avulsion.

42. Size - Normal range-height of three vertebra.
Enlarged kidneys suggest
-polycystic disease
-acute pyelo or glomerulonephritis
Small kidneys imply chronic disease.
Shape –Cysts & tumors may cause distortion.
Orientation - disorientation may be
-intrinsic, e.g. horseshoe kidney, or
-extrinsic, i.e. pressure effect of other organs

44. image of a
tomographic
sequence
demonstrates
symmetric
nephrograms and
pyelograms. Renal
size is normal.

45. On a 10-minute
image, no pyelogram
is evident. The
nephrograms are
persistent, and the
kidneys are smaller.
With this imaging
sequence alteration,
the patient should be
evaluated
immediately for the
development of
hypotension related
to the procedure or
as a reaction to
contrast material
administration.

46. One-minute image
shows slight
asymmetry of the
nephrographic
opacity, with less
opacity in the right
kidney than in the
left

47. Image obtained
at 80 minutes
shows a
persistent, very
dense right
nephrogram, a
typical finding
in acute high-
grade
obstruction. A
2-mm stone
was discovered
at the right
ureterovesical
junction.

48. Enlarged kidneys in a
young patient with
early, asymmetric
findings of autosomal
dominant polycystic
kidney disease.
Nephrotomogram
shows enlarged
kidneys, the left
more so than the
right. Note the
multiple parenchymal
defects (“Swiss
cheese”
nephrogram).

49. Right renal
artery
stenosis for
evaluation of
renovascular
hypertension
shows a small
right kidney
with
decreased
nephrographic
density and
temporal
asymmetry of
filling of the
right
collecting
system
compared
with the left

50. Fifteen-minute
urographic
image helps
confirm the
asymmetric
renal size. Note
the
hyperconcentra
tion of contrast
material in the
right collecting
system
compared with
the left.

51. Opacification of pelvicalceal system &bladder
Filling defects include:
stone,tcc,blood clots,papillary necrosis
with sloughing of infarcted papilla.
Strictures due to :
-Post inflammation,previous stone impaction
-Post infection,TB, Shistosomiasis
-Cancer, intrinsic-tcc
extrinsic-cevical ca

52. Tomogram
from excretory
urography
demonstrates
absence of the
left kidney
and deviation
of the
descending
colon into the
renal fossa.

53. Common findings in bladder:
-Filling defects , tumors
-Trabeculated , thick walled bladder.

57. different patterns of excavation that can be seen with papillary necrosis:
normal (A), central excavation with ball-on-tee appearance (B), forniceal
excavation (C), lobster claw appearance (D), signet ring appearance (E), and
sloughed papilla with clubbed calix (F).

58. Papillary
necrosis. On an
excretory
urogram,
contrast material
fills central
excavations
(arrows) in the
papilla of the
interpolar region,
Note the
abnormal calices
in the upper and
lower poles as
well.

59. Papillary
necrosis.
Excavation
extending from
the caliceal
fornices (arrows)
produces the
lobster claw
deformity in
another patient.

61. Delayed tomographic
image from excretory
urography shows
caliceal crescents
(arrowheads)
surrounding the
dilated collecting
system. Contrast
material pools
dependently