KUB. Kidney Ureter Bladder

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1 KUB Kidney Ureter Bladder

2 Diagnostic Technique Plain KUB Intravenous urography : IVP Voiding cystourethrography : VCUG Hysterosalpingography Ultrasonography

3 Plain KUB The projection includes the entire urinary system From the superior aspects of the kidneys To the pubic symphysis Not include the diaphragm

4 Indication Plain films are widely used in the management of stone diseases

5 What are you looking for? Calcifications Abnormal soft tissue Air within urinary tract Bony abnormalities

6

7

8

9 Transverse Process

10 Urinary Tract Stone Most common cause of acute ureteral obstruction Clinical presentation : 1. Flank pain 2. Intermittent hematuria

11 Clinical Perspective Acute flank pain, with dramatic relief upon passage of the stone 1. UPJ stone : flank pain 2. Proximal ureteric stone : flank pain radiating to the genitals 3. UVJ stone : voiding urgency and suprapubic discomfort, and they cause pain that radiates into the groin and genitals

12 Hematuria

13 Radiologic Evaluation of Hematuria The AUA guidelines recommended upper tract imaging for low- and high-risk patients with microscopic hematuria Gross hematuria -> much higher risk of malignancy than microscopic disease

14 Hematuria : Cause Calculi Infection Cancer Obstruction Anticoagulation Artifactual cause: menstrual blood, food such as beets, berries, rhubarb

15 Radiologic Work-up of Hematuria No universal agreement about the optimal imaging work-up of hematuria Traditionally : IVP was the standard Recently : Multidetector CT scans have become routine MRI can be used to detect urinary tract abnormalities, but has limited use because of its expense and the lack of data supporting its use

16 ACR Appropriateness Criteria Scale for Hematuria

17 ACR Appropriateness Criteria Scale for Hematuria

18 ACR Appropriateness Criteria Scale for Hematuria

19

20 Urinary tract stone Increasing overall prevalence in the last decade Significant impact on the healthcare system : Direct costs : approximately $3,500 per person in 2000 Morbidity associated with complications such as infection and chronic renal failure

21 Urinary tract stone 14% of men and 6% of women Recurrence rates : 50% within 5 10 years 75% within 20 years

22 Renal stone Renal stone Ureteric stone Bladder stone Renal stone Ureteric stone Bladder stone

23 Stone : Plain KUB Depend on stone composition Stones : combination of crystals and proteins Calcium-based stones : 70% 80% of upper urinary tract stones Calcium oxalate monohydrate Calcium oxalate dehydrate Calcium phosphate stones

24 Stone Classification Based on Composition

25 Stone Classification Based on Composition

26 Imaging of Urinary Tract Stone

27

28 Renal stone : A 1 cm calcification at left kidney shadow

29 Renal stone : A 1 cm calcification at left kidney shadow

30

31 Renal stone : A 1 cm calcification at lower part of left kidney shadow

32 Renal stone : A 1 cm calcification at lower part of left kidney shadow

33

34 Staghorn stone at both kidney shadows

35 Staghorn stone at both kidney shadows

36

37 A 1 cm oval shape calcification at left lateral aspect of L4 ; representing left ureteric stone

38 A 1 cm oval shape calcification at left lateral aspect of L4, representing left proximal ureteric stone

39

40 A 5-mm oval shape calcification at right pelvic cavity ; representing right distal ureteric stone

41 A 5 mm oval shape calcification at right pelvic cavity ; representing right distal ureteric stone

42

43 A 7 cm oval shape well-defined calcification in pelvic cavity; representing bladder stone

44 Several oval shape well-defined calcification in pelvic cavity; representing bladder stones

45 Limitation Bowel gas or bowel content Phlebolith : Calcification in pelvic veins May be confused with ureteric calculi Radiolucent stone

46 Multiple calcifications with internal radiolucency in pelvic cavity, representing phlebolith

47 IVP Intravenous Pyelogram

48 Intravenous Pyelogram Use decreased significantly in recent years CT, US or MRI is replacing Remains primary modality for visualization of pelvocalyceal system and ureter

49 Indication : Demonstrated the renal collecting system and ureters Investigate the level of ureteral obstruction in renal unit displaying delayed function Demonstrate renal and ureteral anatomy in special circumstances such as congenital abnormality(horseshoe kidney)

50 Contraindication : Renal insufficiency for worsening of their renal function(contrast induced nephrotoxicity) Multiple consecutive contrast studies < 48 Hr Allergic reaction to contrast such as urticarial

51 Standard Procedure

52

53 What is the abnormality?

54 Hydronephrosis

55

56 A 1 cm calcification at left lateral aspect of L4, representing left mid ureteric stone, causing severe hydronephrosis and hydroureter

57 A 1 cm calcification at left lateral aspect of L4, representing left mid ureteric stone, causing severe hydronephrosis and hydroureter

58

59 Well-defined filling defect in the right renal pelvis: Right renal stone

60 Well-defined filling defect in the right renal pelvis. Right renal stone

61 VCUG Voiding Cystourethrography

62 VCUG Functional study The bladder is filled retrograde via a urinary catheter (Foley) After filling the bladder the retention balloon is deflated, and the catheter is removed

63 VCUG Strictures Obstructions Diverticula Reflux into the ureters

64 Normal VCUG : Male Bladder Urethra

65 Vesicoureteric Reflux

66 Vesicoureteric Reflux

67

68 Hysterosalphingography

69 Indication The radiographic evaluation of the uterus and fallopian tubes Predominantly in the evaluation of infertility

70 Two contraindications for HSG: Pregnancy Active pelvic infection The examination should be done during days 7 12 of the menstrual cycle The endometrium is thin during this proliferative phase Ensure that there is no pregnancy Abstain from sexual intercourse from the time menstrual bleeding ends until the day of the study to avoid a potential pregnancy

71 Complication Two most common : bleeding and infection The patient should be made aware that she may experience light spotting after the procedure, usually lasting less than 24 hours

72

73 Normal Hysterosalphingography

74 Hysterosalphingography

75 Ultrasonography

76

77 A 1 cm hyperechoic lesion with posterior acoustic shadow at mid portion of the kidney, likely calyceal stone

78 A 1 cm hyperechoic lesion with posterior acoustic shadow at mid portion of the kidney, likely calyceal stone

79

80 A 2 cm hyperechoic lesion with posterior acoustic shadow at renal pelvis, causing mild hydronephrosis

81 Computer Tomography

82

83 Multiple small hyperdensity lesions at right upper/mid/lower calyces and left lower calyx: calyceal stones

84 Infection Emphysematous Pyelonephritis Emphysematous Cystitis

85

86 Emphysematous pyelonephritis Pneumoretroperitoneum Mottled gas within renal fossa and crescentic gas collection within Gerota's fascia -> Emphysematous pyelonephritis Linear gas along paraspinal region -> Pneumoretroperitoneum

87

88 curvilinear or mottled gas in the bladder wall

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