L11 - Kidneys & Urinary Tract Imaging - (part 2).pdf

FRD40721 - Radiography & Medical Imaging Science ( Ultrasound Imaging ) Lecture 10 Kidneys & Urinary Tract Imaging (Part 2) Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Readings • Moore, KL & Dalley, AF 2006, Clinically Oriented...

FRD40721 - Radiography & Medical Imaging Science ( Ultrasound Imaging ) Lecture 10 Kidneys & Urinary Tract Imaging (Part 2) Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Readings • Moore, KL & Dalley, AF 2006, Clinically Oriented Anatomy, 5th Ed. Lippincott, Williams & Wilkins Company, Canada. • Rumack, CM Wilson, SR & Charboneau, JW 2011, Diagnostic Ultrasound Vol.1, 4th Ed. Mosby, St. Louis • Bates, JA 2011, Abdominal Ultrasound: How, Why and When, 3rd Ed. Churchill Livingstone, Edinburgh • Moore, KL & Persaud, TVN 2003, The Developing Human: Clinically Oriented Embryology, 7th Ed. Saunders, USA. • An optional reading for this topic is: Strauss, S et al 2000, “Sonographic Features of Horseshoe Kidney: Review of 34 Patients”, Journal of Ultrasound in Medicine, Vol. 19, pp.27-31. Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Congenital Abnormalities Horseshoe Kidney Failure of kidneys to rotate during development Results in fusion of the lower poles Kidneys can’t migrate past IMA Isthmus located anterior to abdominal aorta Usually functioning tissue but sometimes just a fibrous band at approx L4-L5 Kidneys located lower than normal, with lower poles projected medially Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Congenital Anomalies  HORSESHOE KIDNEY – Incidence 0.01 - 0.25% (Rumack) – Complications: • PUJ obstruction • VUJ reflux • Collecting system duplication • Renal dysplasia Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Congenital Anomalies HORSESHOE KIDNEY Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Congenital Anomalies  ECTOPIA (Pelvic Kidney) – One or both kidneys are found outside the renal fossa. – Usually pelvic / lower abdomen (failure to ascend). – Other locations rare. – Often detected incidentally. – Sometimes small, malrotated and can be prone to reflux, UTI and calculi. Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae ECTOPIA (Pelvic Kidney) Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae ECTOPIA (Pelvic Kidney) Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Congenital Anomalies  DUPLEX COLLECTING SYSTEM • Common (0.5-10%) • Complete duplication: - 2 collecting systems, 2 ureters, 2 ureteral orifices • Incomplete duplication: - 2 collecting systems, ureters join, single ureteral orifice • Duplex kidneys tend to be larger Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae DUPLEX COLLECTING SYSTEM Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Congenital Anomolies DUPLEX COLLECTING SYSTEM Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Congenital Anomalies  KIDNEY AGENESIS – Bilateral - incompatible with life – Unilateral - usually incidental with compensatory hypertrophy – May have other associated genito-urinary variants  SUPERNUMERARY KIDNEY – Additional kidney with renal function – Rare, usually small – Any position Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae KIDNEY AGENESIS Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae SUPERNUMERARY KIDNEY Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae SUPERNUMERARY KIDNEY Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae SUPERNUMERARY KIDNEY Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Clinical Indications for Kidney Urinary Bladder Examination: (KUB ultrasound) • • • • • • Flank Pain/Loin Pain Recurrent UTI’s Suspected kidney stones Haematuria Acute Renal Failure Chronic Renal Failure Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Patient Preparation • Fasting not required • 3 – 4 glasses of water an hour prior to examination with no voiding .Why? • Full Bladder should be seen Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Patient Preparation At Examination:  Check pt compliance with prep.  Pt to wear gown, leave on bra, underpants...  Check Hx on request and record information the referring doctor omitted.  Check previous US images if available.  Look for scars, palpate masses for investigation and ‘where it hurts’.  Communicate with your patient, & ask about their condition Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Equipment • - Curvilinear transducer (2-5MHz) • - Linear transducer for paediatrics, superficial or paediatric assessment. Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Scanning Technique • - Each kidney must be examined completely • - Fan through entire organ in multiple planes to avoid missing pathology • - Planes of assessment: • 1. Sagittal (longitudinal) • 2. Transverse • 3. Coronal • - Variable patient positions • - Variable respiration Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Scanning Technique - Obtain longest length of kidney (sagittal or coronal) - Turn transducer 90° to obtain true transverse - Poles of kidney should be equal size, cortical thickness should be uniform (excluding pathology) throughout - Use tilting rocking motions to completely fan through kidney Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Technique CORONAL – Postero-laterally between lower costal margin and iliac crest – Patient in LPO for right kidney and RPO for left kidney – Supine may be used if adequate window – Position will be highly variable from patient to patient Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Technique CORONAL Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Technique CORONAL - Advantages – Length measurement – Assessment of both poles – Best visualisation for hydronephrosis (same plane as collecting system) – Better able to eliminate the effect of bowel gas Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Technique SAGITTAL – Antero-lateral abdominal wall just beneath lower costal margin – May use intercostal approach for upper pole – Most effective for right kidney, upper pole left kidney (lower obscured by bowel) – Vary patient position Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Technique SAGITTAL Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Technique SAGITTAL - Advantages – Length measurement – Assessment of both poles – Direct comparison of cortex to liver/spleen – High quality acoustic window; • Liver for right kidney • Spleen for upper pole of left kidney Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Technique TRANSVERSE – Same window as sagittal or coronal – May use different windows for upper/lower poles – Keep true transaxial - flexible scanning Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Technique TRANSVERSE collecting system Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Technique TRANSVERSE Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Technique TRANSVERSE - Advantages – Alternative plane – Axial view of collecting system – Axial view of cortex – Optimal plane for artery/vein assessment Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Technique SAGITTAL PRONE – Prone position, scan below 12th rib – Predominantly paediatric - thickening of posterior abdominal muscles make penetration difficult in adults – May provide view of lower pole through retroperitoneum - biopsy Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Technique SAGITTAL PRONE – Advantages – Alternative lower pole acoustic window – Close proximity to kidney – No bowel gas obstruction Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Scanning Technique Right Kidney • • • • - Use liver as an acoustic window Sagittal, coronal and transverse Variable respiration instructions LPO / left decubitus /supine Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Scanning Technique – RT Kidney Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Scanning Technique Left Kidney • • • • - May be more challenging than right Spleen may or may not be useful as acoustic window RPO / right decubitus / supine Sagittal view obstructed by splenic flexure Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Scanning Technique – Left Kidney Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Technique PROXIMAL URETER – Identical to assessment of kidneys – Coronal optimum for imaging collecting system and renal pelvis – Graded compression to follow ureter to bladder. – Only seen throughout its length if dilated. – Look for point of obstruction. Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Technique DISTAL URETER – Full bladder for window – Pass obliquely and posterior to bladder to VUJ – Transverse 2 raised bumps at VUJ – Avoid scanning directly through midline as artefact from rectus abdominus will limit view – Use colour Doppler to observe ureteric jets Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Scanning Technique Bladder - Adequate assessment requires distended bladder - Supine, may require rolling LPO / RPO to assess mobility - Transverse and longitudinal planes Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Appearances-Sagittal Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Appearances-Transverse Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Appearances-Transverse Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Appearances-Coronal Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Ultrasound Appearances-Coronal Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Measurement of the kidney size in ultrasound Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Measurement of the kidney size in ultrasound Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Measurement of Bladder size Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Measurement of Bladder size Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Questions???? Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Summary • • • • Understand the anatomy of the kidney Describe normal variants Explain the technique for imaging the kidneys Recognise and describe the normal ultrasound appearances Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Quiz • The renal pyramids are located in the medulla of the kidney. T/F • The ureters insert on the anterior wall of the bladder. T/F • An hypertrophied column of Berthin is also called a dromedary hump. Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy T/F fchs.ac.ae Sample Exam Question: - Explain why the right kidney is more easily imaged with ultrasound than the left kidney. (3 marks) Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae Answer - Sample Exam Question • The right kidney is inferiorly displaced by the liver and therefore less obscured by ribs. The liver acts as a good acoustic window, displacing bowel gas for better imaging compared to the left kidney which sits higher in the abdomen and can be hidden by bowel and/or rib shadowing. Course: FRD3061 Medical Imaging Science and Methods 2Ultrasound 1 Lecture 4: Kidneys Normal Anatomy fchs.ac.ae