IVU CASE STUDY

Case place: at King Khalid Universal Hospital (KKUH).Presentation was done by: Shatha Jamal Al-MushaytUN: 427200465

IVU room at KKUH

PATIENT INFORMATION Gender: Female Age: 53 years old Weight: 70 Kg Transport: walking Allergic to dust, egg, and fish.

Date of exam: 26-12-2009

PATIENT HISTORY Solitary(only one) left kidney with stone. A history of mild allergy to contras media

SYMPTOMS AND SIGNS 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.

Since she had only one kidney, this increases the risk of developing kidney stones.

Patient did not complain from pain.

PATIENT PREPARATION Patient Creatinine level was within

the normal range according to KKUH( 62–115 µmol/L).

Consent form was signed.

Patient was asked If she has asthma or allergy to some food or medications. As this requires having some medications before the exam.

Cont.

PATIENT PREPARATION Patient was asked to come on time. Patient was informed that:

Other patients may have the same appointment. So, the priority will be to the one who come first.

The exam may take longer time according to the condition of the kidneys & their secretion of CM.

Cont.

PATIENT PREPARATION The day before the exam:

1. No drugs by mouth (except for diabetic patients)

2. Light dinner or only fluids (no dairy products

or soft drinks like Pepsi) at 7:30 pm- preferable.

3. At 8:30 pm, 60 gm of caster oil (can be taken with a spoon of honey or jam).

4. Then, plenty amount of fluids (no dairy

products or soft drinks like Pepsi) until 11 pm.

5. Then, Nothing by mouth until the exam is done. Except for diabetic or renal failure patients, they can have some water.

Cont.

PATIENT PREPARATION The day of exam:

1. Patient was not pregnant for sure.2. Patient voided immediately before

the exam.3. Patient put on a hospital gown

without any object in the area of interest that may superimpose an essential anatomy.

4. Injection set & crash cart were ready by side.

ALLERGIC PREPARATIONPrednisone tablets were prescribed to

the patient as follows,

1. The day before the exam + the day of the exam: 50 mg twice a day.

2. Two days after the exam: 10 mg twice a day.

3. The third day after the exam: 5 mg twice a day.

TECHNIQUE FILMS WERE TAKEN IN SEQUENCE

1. Control (full KUB) film was first taken.

Patient position: supine, no trunk rotation, midsagital plane to the center of

the table, arms extended by sides away from body, and pillow under pt head.

Center point: 2 cm above the midway between the highest points of iliac

crest. Central Ray: perpendicular to image receptor(IR), vertical beam.

Collimation must include the xiphoid process and symphsis pupis.

Marker on the right side of patient.

Patient was asked to hold her breath during exposure.

CONTROL (KUB) FILM

Radiograph 1:

CM INJECTION Omnipaque 300 mgI/ml: Low osmolar, non-ionic contrast

media Injected intravenously after the

control film. CM Dose: 70 ml. (remember, adult dose= 1 ml

per Kg)

The patient was informed that she may feel fever after injection (normally);but she did not feel so.

TECHNIQUE2. Nephrogram film-Immediately after injection

Patient position: As for the full KUB control film.

CP: midway between xiphoid process & iliac crest (kidney area).

CR: perpendicular to IR, vertical beam

Collimation less than full KUB film. prevent cutoff kidney.

Marker: RT of the patient

Patient was asked to hold her breath during exposure.

NEPHROGRAMRadiograph 2:

TECHNIQUE3. Full KUB film-5 minuets since

injection.

Technique as for the full KUB control film.

KUB- 5 MIN SINCE INJECTIONRadiograph 3:

TECHNIQUE4. Full KUB film-15 min since injection

Technique as for the full KUB control film.

KUB- 15 MINRadiograph 4:

Distal ureter

Urinary bladder

Middle ureter

Proximal ureter

Renal pelvis

Kidney

Minor calyx

Major calyx

Vesico-uretric junction

Pelvi-uretric junction

TECHNIQUE5. LPO: left posterior oblique-19 min since injection.

This was an additional film ordered by the radiologist.

Why? To demonstrate the LT ureter clearly. Patient position: 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.

CP: 2 cm above the midway between the spine & the highest

point of iliac crest. CR: perpendicular to IR, vertical beam. Collimation must include kidneys without cut and

symphsis pupis. LT marker patient was asked to hold her breath during exposure

LPO-19 MINRadiograph 5:

TECHNIQUE6. Full bladder-34 min

Patient position: 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.

CP: 5 cm above symphasis pupis. CR: perpendicular to IR Collimate coned view of bladder. RT marker patient was asked to hold her breath during

exposure.

FULL BLADDER-34 MIN (CONED VIEW)Radiograph 6:

TECHNIQUEThe radiologist was satisfied with the full

bladder film. So he asked for a Post void film.

7. Post Void film is a full length KUB film after emptying the bladder from CM.

Technique as for the full KUB control film.

POST VOID -KUB Radiograph 7:

FINALLY!

Images were sent to PACS

IVU room at KKUH

AFTER CARE

The patient was asked if she had hard breathing or any discomfort; but she was fine .

The injection needle was removed.

MY COMMENTS 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.

Around 3 Syringes each of 25 ml were used to equal 70 ml for CM injection

Source Image receptor distance (SID) in all images was = 100 cm

KV= 75 Uretric compression was not used as the

case did not need it & the radiologist did not instruct to apply it.

Minuets marker as annotation were used; but not shown in these images.

FINDINGS 2 radioopaque calcular

shadow density

Control film showing two radio-opaque calcular shadow density projecting over the lower pole of the left kidney opposite to the level of L2.

FINDINGS Solitary LT

kidney showing normal enhancement of the kidney after IV contrast administration with spontaneous normal excretion of CM.

Nephrogram

FINDING 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.

5 min KUB film

15 min KUB film

FINDING No residual

contrast seen in the UB after voiding. (arrow: urinary bladder area)

PV-KUB film

CONCLUSIONTwo small left renal stones with no

back pressure effect.

RENAL STONES They are small, solid masses may form

when acid salts or minerals, normally found in urine, become solid crystals inside the kidney.

Most kidney stones contain Calcium. They typically leave the body by passage in

the urine stream. However, they can build up inside your

kidney & form larger stones. If stones grow to sufficient size before passage (at least 2-3 mm), they can cause obstruction of the ureter.

SYMPTOMS many are formed & passed without causing

symptoms; but if a kidney stone causes a blockage, or moves into the ureter, some symptoms are:

Severe pain on 1 or both sides of back. Feeling frequent urge to urinate, or a burning

sensation during urination Bloody or cloudy urine Sudden spasms of excruciating pain. Feeling sick or vomit.

CAUSES OF KIDNEY STONES Gender: Men are 4 times more likely to get kidney

stones than women History: if someone has a history of kidney stone

50 % chance of developing another one within 5 years.

High risk factors of developing kidney stones: Family history of kidney stones. Age: 20 - 50 yr. Taking certain medicines e.g. indinavir (in the

treatment of HIV infection) &taking too many or too often laxatives.

Solitary kidney, or an abnormally shaped kidney

High protein diet. Not drinking enough fluids.

DIAGNOSIS OF A KIDNEY STONEcan be confirmed by: Radiological studies Ultrasound examination; Urine tests & blood tests.

When a stone causes no symptoms, watchful waiting is a valid option. In which time is allowed to pass before medical

intervention or therapy is used.

A 9 mm kidney stones

TREATMENTNon Surgical:1. For stones smaller than about 5mm, being

physically active + drinking a lot of water is often enough.

2. Extracorporeal shock wave lithotripsy (ESWL)

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.

Surgical:3. Ureteroscopic stone removal Using a a cystoscope4. Percutaneous nephrolithotomy (PCNL) Telescopic instrument (nephroscope) is used to

break the stone using a laser beam or shock waves

REFERENCES OF PATHOLOGY

http://en.wikipedia.org/wiki/Kidney_stone

http://hcd2.bupa.co.uk/fact_sheets/html/Kidney_stones.html

THANK YOU Shatha Al-Mushayt, L-7

Presented at 2010