GUT CASE GUT CASE INVESTIGATIONINVESTIGATION
LECTURE 1LECTURE 1
Nephrolithiasis(renal stones)Nephrolithiasis(renal stones)
EpidemiologyEpidemiology Up to 10% by age 70, usu in 3Up to 10% by age 70, usu in 3rdrd to 4 to 4thth decade decade 4:1 M to F ratio4:1 M to F ratio More prevalent in the SouthMore prevalent in the South
Risk FactorsRisk Factors Hypercalcemic states, CrohnHypercalcemic states, Crohn’’s, stents, RTA, infection, s, stents, RTA, infection,
gout, hypercalciuria, hyperuricosuria, cystinuriagout, hypercalciuria, hyperuricosuria, cystinuria SymptomsSymptoms
Asymptomatic, flank pain, hematuriaAsymptomatic, flank pain, hematuria
CompositionCompositionOPAQUE OPAQUE contains calcium +/ phosphatecontains calcium +/ phosphate Calcium calculiCalcium calculi
Ca oxalate, Ca phosphateCa oxalate, Ca phosphate Struvite calculiStruvite calculi
Magnesium ammonium phosphate= triple phosphateMagnesium ammonium phosphate= triple phosphate
SEMI OPAQUE contains sulphurSEMI OPAQUE contains sulphur Cystine calculiCystine calculi
LUCENTLUCENT Uric acid stones;Xanthine Uric acid stones;Xanthine Matrix (coagulated mucoid material)Matrix (coagulated mucoid material)
CT Imaging of StonesCT Imaging of Stones
Essentially all renal and ureteral calculi have high Essentially all renal and ureteral calculi have high
attenuation on non-contrast CTattenuation on non-contrast CT (all but matrix stones (all but matrix stones have atten of > 100HU)have atten of > 100HU)
CT has sensitivity of 97% and specificity of 96%CT has sensitivity of 97% and specificity of 96% Can also see hydronephrosis, hydroureterCan also see hydronephrosis, hydroureter, renal , renal
enlargement, or perirenal strandingenlargement, or perirenal stranding Must differentiate from phlebolithMust differentiate from phlebolith which is a which is a
calcified blood clot in a pelvic vein.calcified blood clot in a pelvic vein.(appearance: (appearance: round/ovoid, smooth, central lucency, in true pelvis)round/ovoid, smooth, central lucency, in true pelvis)
NephrolithiasisNephrolithiasis
Images: BIDMC, Dept of Radiology, 2001.
Radio opaque stone in calyx
HydronephrosisHydronephrosis
Dilated urine filled pelvis
Stent
HydroureterHydroureter
Images: BIDMC, Dept of Radiology, 2001.
Stent
Obstructive Uropathy Obstructive Uropathy Radiologic AssessmentRadiologic Assessment
Anatomy: Urinary TractAnatomy: Urinary Tract
http://www.urostonecenter.com/images/p1.gif
CortexCortex
MedullaMedulla
Superior Superior OperculumOperculum
Inferior Inferior OperculumOperculum
PelvisPelvis
CalyxCalyx
FornixFornix
Renal CapsuleRenal Capsule
PapillaPapilla
Unequivocal Obstructive Unequivocal Obstructive UropathyUropathy
= = Urinary tract obstructionUrinary tract obstruction
Unequivocal: clear etiologyUnequivocal: clear etiology Obstruction may be at any Obstruction may be at any
site within GU tractsite within GU tract Evidence of post-renal Evidence of post-renal
failurefailure Variable presentation Variable presentation
based on etiologybased on etiology
Sign: Hydronephrosis = dilatation of renal pelvis and ureters
Pathophysiology of Obstructive Pathophysiology of Obstructive UropathyUropathy
Initial increase in ureteral peristalsis & pelvic muscle hypertrophy
Mechanical or functional obstruction
Back up of urine flow = increased renal pressure
Initial increase in renal blood flow
Decrease in renal blood flow
Increase in renal lymphatic flow
Muscle stretched & atonic Aperistalsis
Tubular dilatation
Dilatation of ureters and renal collecting duct system
Parenchymal Atrophy
Renal failure
Pathogenesis of unilateral hydronephrosis. Smith’s Urology p.181
Hydronephrosis
How Acute Obstruction leads to How Acute Obstruction leads to Dilatation and Decreased Tubular Dilatation and Decreased Tubular
FunctionFunction
PathologyPathology
http://www.smbs.buffalo.edu/pth600/IMC-Path/images/Year1/Hydronephrosis_Gross-_Robbins.jpg
Dilated pelvis & calyces, renal atrophy, cut surface
http://www.smbs.buffalo.edu/pth600/IMC-Path/y1case/y1ans21.htm#Obstructivelesionsintheurinarytract
Dilated renal pelvis (arrow), external view
Clinical Presentation: Obstructive Clinical Presentation: Obstructive UropathyUropathy
Renal insufficiencyRenal insufficiency Consider UTO in all patients with unexplained renal insufficiencyConsider UTO in all patients with unexplained renal insufficiencyUrine Output ChangesUrine Output Changes
AnuriaAnuria = complete bilateral UTO = complete bilateral UTOPartial obstruction Partial obstruction normal to elevated UO normal to elevated UO
Hyperkalemic renal tubular acidosisHyperkalemic renal tubular acidosisHypertensionHypertensionLab Abnormalities: normal, microscopic/gross hematuria, pyuria, azotemia, uremia, anemia (2/2 Lab Abnormalities: normal, microscopic/gross hematuria, pyuria, azotemia, uremia, anemia (2/2
chronic infection, ACD), leukocytosischronic infection, ACD), leukocytosis
Lower and Mid Tract (Urethra and Bladder)
Hesitancy in starting urinationLessened forceWeak streamTerminal dribblingHematuriaBurning on urinationCloudy urine (infection)Acute urinary retention
Upper Tract(Ureter and Kidney)
Flank pain radiating along ureter course (distension)
Gross hematuriaNausea/VomitingFever/ChillsBurning on urinationCloudy urine with infectionBilateral uremia
N/V/weight loss
Think Anatomically: Think Anatomically: Where is obstructionWhere is obstruction??
Systemic or
Distal etiology
Bilateral hydronephrosis
Proximal etiology
Unilateral hydronephrosis
Series: 53 of 380 patients
52/53 in lower 1/3 of the ureter.
Causes:
Ureteral stones 64%
Ureteral edema or lucent stones 30%
Neoplasms 4%
Inflammatory disease 2%
Chen et al., J Emerg Med, 1997: 15; 3. 339 – 343.
Most Common in Distal Ureter
Acute Obstruction and AnuriaAcute Obstruction and Anuria
Patients may die from acute Patients may die from acute renal failure with renal failure with oliguria/anuriaoliguria/anuria
Requires prompt Requires prompt recognition and possible recognition and possible surgical interventionsurgical intervention
CT examination: Postcontrast axial scan: The retroperitoneal giant tumor mass compresses the right ureter and causes hydronephrosis (arrows).
http://www.szote.u-szeged.hu/radio/panc/alep8c.htm
Acute complete, bilateral obstruction = Medical Emergency
DiagnosisDiagnosis
Early diagnosis and decompression is Early diagnosis and decompression is criticalcritical to to prevent renal failureprevent renal failure
Continue to Radiologic work-up
UltrasonographyUltrasonographyTest of Choice for Suspected Urinary Tract ObstructionTest of Choice for Suspected Urinary Tract Obstruction
Screening testScreening testIndications: Renal failure of unknown origin/Hematuria/Signs of UTO/UrolithiasisIndications: Renal failure of unknown origin/Hematuria/Signs of UTO/UrolithiasisSensitivity for detection of chronic obstruction: 90%Sensitivity for detection of chronic obstruction: 90%Sensitivity for detection of acute obstruction: 60%Sensitivity for detection of acute obstruction: 60%
Advantages: Advantages: No allergic/toxic complications of radiocontrast mediaNo allergic/toxic complications of radiocontrast mediaFast, inexpensiveFast, inexpensiveDiagnose other causes of renal disease in patient with renal insufficiency of unknown originDiagnose other causes of renal disease in patient with renal insufficiency of unknown origin
Polycystic Kidney DiseasePolycystic Kidney Disease
DisadvantagesDisadvantagesNonspecificNonspecificRarely identifies causeRarely identifies causeFalse positive rate: < 25% with minimal criteria (operator dependent)False positive rate: < 25% with minimal criteria (operator dependent)
Any visualization of collecting systemsAny visualization of collecting systemsFalse negative with acute obstruction, dehydration, sepsisFalse negative with acute obstruction, dehydration, sepsisBowel Gas decreases sensitivityBowel Gas decreases sensitivity
Ultrasound Ultrasound –– Normal Kidney Normal Kidney
Normal renal fat, no dilatation of collecting system, hyperechoic
Normal renal parenchyma, hypoechoic, normal function
Ultrasound Ultrasound –– Obstructive Obstructive UropathyUropathy
Compressed renal fat, hyperechoic
Renal parenchyma, hypoechoic
Dilated collecting duct, hypoechoic (fluid)
CT: normal renal parenchyma with CT: normal renal parenchyma with proximal stone, no obstructive proximal stone, no obstructive
uropathyuropathy
Kawashima et al., RadioGraphics 2004;24:S35-S54
Noncontrast CT
Enhancing calculus in interpolar portion of R Kidney
CT: Hydronephrosis due to CT: Hydronephrosis due to retroperitoneal fibrosis (soft tissue)retroperitoneal fibrosis (soft tissue)
CT (postcontrast): Giant retroperitoneal tumor mass compressing the right ureter, causing hydronephrosis with compression of renal parenchyma (arrows).
http://www.szote.u-szeged.hu/radio/panc/alep8c.htm
CT: Obstructive UropathyCT: Obstructive Uropathy
PACS, Courtesy of Dr. D. Brennan
CT (postcontrast):Obstructive left-sided uropathy with proximal ureteric stone
Dilated Renal Pelvis
Proximal Stone
IVU: Intravenous UrogramIVU: Intravenous UrogramIntravenous Pyelogram = Excretory UrogramIntravenous Pyelogram = Excretory Urogram
1.1. Scout film Scout film calculi? calculi?2.2. IV bolus of radiocontrast dye (ionic contrast) IV bolus of radiocontrast dye (ionic contrast) 3.3. Series of plain films demonstrate kidneys, ureters, urinary Series of plain films demonstrate kidneys, ureters, urinary
bladderbladder4. Upright film post-void to evaluate for obstruction4. Upright film post-void to evaluate for obstruction
AdvantagesAdvantagesAnatomyAnatomyPathology LocationPathology LocationRough indicator of function bilaterallyRough indicator of function bilaterallyLow false positive rateLow false positive rateDetects associated conditionsDetects associated conditions
Papillary necrosis Papillary necrosis intralumenal filling defect intralumenal filling defectCaliceal blunting from previous infectionCaliceal blunting from previous infection
DisadvantagesDisadvantagesCumbersome Cumbersome Requires radiocontrastRequires radiocontrastNeed bowel prep with conventional IVUNeed bowel prep with conventional IVURadiation doseRadiation doseNeed cross-sectional imaging follow upNeed cross-sectional imaging follow up
CT UrographyCT Urography
Evaluate urinary tract for flow defectsEvaluate urinary tract for flow defects
Noncontrast Scout first: UrolithiasisNoncontrast Scout first: Urolithiasis
Coronal reconstructions: visualize entire urinary tractCoronal reconstructions: visualize entire urinary tract
Advantages over Conventional IVUSpeedSensitive to renal parenchyma abnormalitiesSimultaneous evaluation of both renal parenchyma and urinary tractCross-sectional imaging
DisadvantagesRadiation doseIonic Contrast reactions/cannot be used in patients in renal failure
Kawashima et al., RadioGraphics 2004;24:S35-S54
Normal CT UrogramNormal CT UrogramCT Urography
Total Body Opacificantion
Nephrogram
Pyelogram
Normal CT UrogramNormal CT UrogramCT Urography
Total Body Opacificantion
Nephrogram
Pyelogram
Normal CT UrogramNormal CT UrogramCT Urography
Total Body Opacificantion
Nephrogram
Pyelogram
Normal CT UrogramNormal CT UrogramCT Urography
Total Body Opacificantion
Nephrogram
Pyelogram
Pt. JL, PACS, Courtesy of Dr. AC Kim
Normal CT UrogramNormal CT UrogramCT Urography
Total Body Opacificantion
Nephrogram
Pyelogram
Normal CT UrogramNormal CT UrogramCT Urography
Total Body Opacificantion
Nephrogram
Pyelogram
Normal CT UrogramNormal CT UrogramCT Urography
Total Body Opacificantion
Nephrogram
Pyelogram
Contraindications for IVU/CTUContraindications for IVU/CTUHistory of allergy to IV contrastHistory of allergy to IV contrast
Bronchospasm, laryngeal edema, anaphylactic shockBronchospasm, laryngeal edema, anaphylactic shockMay use with history of minor allergic reactions with preprocedural steroids, antihistamines May use with history of minor allergic reactions with preprocedural steroids, antihistamines
(diphenhydramine) 12 hours prior to study(diphenhydramine) 12 hours prior to study
Renal insufficiencyRenal insufficiencyPregnancyPregnancy = relative contraindication (radiation exposure) = relative contraindication (radiation exposure)
MR Urogram can be usedMR Urogram can be usedLikewise: children Likewise: children minimize radiation doses minimize radiation doses
Pts taking oral hypoglycemicsPts taking oral hypoglycemics (metformin) should stop taking meds prior to study (metformin) should stop taking meds prior to studyMay resume after renal function is confirmed normalMay resume after renal function is confirmed normalRisk of lactic acidosisRisk of lactic acidosis
Must be Physician-Supervised- Contrast reactions- Minimize no. of images - Minimize radiation- May use Fluoroscopy
MR UrographyMR Urography
A. A. Unenhanced MR urographyUnenhanced MR urography Heavily T2 weighted Heavily T2 weighted
B. B. Gadolinium-enhanced excretory MR urographyGadolinium-enhanced excretory MR urographyC. C. Excretory MR urography + diureticExcretory MR urography + diuretic
10 mg furosemide IV 10 mg furosemide IV Gadopentetate dimeglumineGadopentetate dimeglumine
AdvantagesAdvantages: : Distinguishes adjacent Distinguishes adjacent soft tissuesoft tissue abnormalities abnormalitiesWith Gadolinium: functional informationWith Gadolinium: functional informationNo ionic contrast No ionic contrast OK in renal failure OK in renal failureNo radiation No radiation children, pregnancy women children, pregnancy women
DrawbacksDrawbacksHigh costHigh costLow sensitivity in detecting calcificationsLow sensitivity in detecting calcificationsTime intensiveTime intensiveMetallic implants/Foreign Body = ContraindicationsMetallic implants/Foreign Body = Contraindications
Blandino et al., AJR 2002; 179: 1307 -1314
Sagittal contrast-enhanced excretory MR urography obstructing right
sided papillary TCC
Excretory Urogram/CTU/MRUExcretory Urogram/CTU/MRUAcuteAcute Obstruction Obstruction
Kidney minimally enlargedDense Nephrogram • Preferential absorption of Na and
water from diseased tubules = concentration of contrast
Delayed appearance of contrast in collecting system
= delayed functionPoor concentration of contrast in the
collecting tubulesNo ureteral dilatation acutely
Ureters not tortuous
Mild Moderate Marked
http://asia.elsevierhealth.com/home/sample/pdf/314.pdf
Excretory Urogram/CTU/MRU Excretory Urogram/CTU/MRU ChronicChronic Obstruction Obstruction
Progressive dilation of collecting system and ureters/tortuous
Urectasis = dilated ureterDecrease number of nephrons 6-12 weeks: irreversible loss of renal
function“Shell nephrogram” parenchymal atrophy
Collecting system: blunt calyces/forniceal angles
Partial Complete
Blandino et al., AJR 2002; 179: 1307 -1314
Calyceal Clubbing
Patient JL Patient JL –– Bladder Mass Bladder Mass
Left Bladder mass surrounding UO
Diagnosis:
57 yo M with known Bladder CA with left hydronephrosis secondary to left bladder cancer.
Management
Foley placement for immediate decompression. Pt urinated following catheter removal and was cleared for d/c
Urology consult for possible stent placement
Renal Cystic DiseaseRenal Cystic Disease
Very commonVery common 50% of pts over age of 50 50% of pts over age of 50 Assoc w/ many syndromes, etiology Assoc w/ many syndromes, etiology
unknown, probably arise from obstructed unknown, probably arise from obstructed tubules or ductstubules or ducts
Most commonly asymptomaticMost commonly asymptomatic Rarely, may have hematuria, HTN, cyst Rarely, may have hematuria, HTN, cyst
infection, or mass effectinfection, or mass effect
CT Characteristics of CT Characteristics of Simple CystsSimple Cysts
Smooth, imperceptible cyst wallSmooth, imperceptible cyst wall Sharp demarcation from surrounding renal Sharp demarcation from surrounding renal
parenchymaparenchyma Water attenuation (<15 HU), homogenous Water attenuation (<15 HU), homogenous
throughout lesionthroughout lesion Non-enhancingNon-enhancing Simple cysts are w/o septations or calcificationSimple cysts are w/o septations or calcification May have slight elevation of adjacent renal May have slight elevation of adjacent renal
parenchyma parenchyma Beak sign Beak sign
Type I Simple CystType I Simple Cyst
Bird Beak Sign
Images: BIDMC, Dept of Radiology, 2001.
Simple Cyst
Aortic aneurysm
Inferior vena cava with filters
Type IV Cystic NeoplasmType IV Cystic Neoplasm
Images: BIDMC, Dept of Radiology, 2001.
Complex renal mass infiltrating lvc
Conditions Associated with Conditions Associated with Multiple CystsMultiple Cysts
Autosomal Dominant PCKDAutosomal Dominant PCKD Autosomal Recessive PCKDAutosomal Recessive PCKD Acquired Cystic Disease (hemodialysis Acquired Cystic Disease (hemodialysis
pts)pts) Von-Hippel-Lindau diseaseVon-Hippel-Lindau disease Tuberous SclerosisTuberous Sclerosis Medullary Sponge KidneyMedullary Sponge Kidney
Benign MassesBenign Masses
CystsCysts AngiomyolipomaAngiomyolipoma Oncocytoma (via epithelial cells of prox tubule)Oncocytoma (via epithelial cells of prox tubule) Renal Adenoma Renal Adenoma Mesoblastic Nephroma (hamartomatous tumor, usu Mesoblastic Nephroma (hamartomatous tumor, usu
present at birth)present at birth) HemangiomaHemangioma Various Renal Pelvic Tumors(papilloma, angioma, Various Renal Pelvic Tumors(papilloma, angioma,
fibroma)fibroma) HematomaHematoma
AngiomyolipomaAngiomyolipoma
Hamartomas containing fat, smooth muscle, and Hamartomas containing fat, smooth muscle, and blood vesselsblood vessels
Usually asymptomatic, but may spontaneously Usually asymptomatic, but may spontaneously bleedbleed
Large AMLs resected or embolizedLarge AMLs resected or embolized Multiple AMLS usually Associated w/ tuberous Multiple AMLS usually Associated w/ tuberous
sclerosissclerosis On CTOn CT *fat attenuation in mass*, strong *fat attenuation in mass*, strong
contrast enhancement (RCCs rarely contain fat), contrast enhancement (RCCs rarely contain fat), no Ca2+ no Ca2+
AngiomyolipomaAngiomyolipoma
Images: BIDMC, Dept of Radiology, 2001.
Note fat content
Malignant MassesMalignant Masses
Renal Cell CancerRenal Cell Cancer Transitional Cell CancerTransitional Cell Cancer WilmWilm’’s Tumor s Tumor Nephroblastomatosis (multiple rests of Nephroblastomatosis (multiple rests of
embryologic metanephric blastoma)embryologic metanephric blastoma) LymphomaLymphoma Metastases (lung, breast, colon, melanoma)Metastases (lung, breast, colon, melanoma)
Renal Cell CaRenal Cell Ca
Most common primary renal malignancy (85% of Most common primary renal malignancy (85% of primary renal tumors)primary renal tumors)
Assoc w/ smoking, family hx, age, Von Hippel-Assoc w/ smoking, family hx, age, Von Hippel-Lindau, Acquired Cystic Disease/chronic dialysis, Lindau, Acquired Cystic Disease/chronic dialysis,
phenacetin abusephenacetin abusePresentation: Hematuria, flank pain, wt loss, palp Presentation: Hematuria, flank pain, wt loss, palp
mass, fever, anemia, paraneoplastic syndromesmass, fever, anemia, paraneoplastic syndromes liver enzymes w/o metsliver enzymes w/o mets Stauffer syndrome Stauffer syndrome
CT characteristicsCT characteristics
VariableVariablefrom complex cyst to large, from complex cyst to large, heterogeneous renal massheterogeneous renal mass
Generally enhancingGenerally enhancing May have calcificationsMay have calcifications May have hemorrhage and central necrosisMay have hemorrhage and central necrosis Usually no fatUsually no fat
Renal Cell CaRenal Cell Ca
Images: BIDMC, Dept of Radiology, 2001.
RCCRCC
Images: BIDMC, Dept of Radiology, 2001.
Renal Trauma
Anatomy of the Kidney
Be suspicious of renal injury with broken ribs
Renal blood supply
Renal arteries
Renal veins
IVC
Ureter
2
Anatomy of the Kidney
3
10-20% of trauma pts. have GU involvement
45% of GU trauma is renal
20-30% of renal trauma pts. have associated abdominal injury
•
•
•
Prevalence of Renal Trauma
4
Mechanisms of Renal Trauma
Blunt trauma (80%): MVA, falls, assaults
Penetrating trauma (20%): gunshot, stabbing, impalement
Predisposing factors: preexisting renal conditions (tumors, hydronephrosis), children, associated abdominal injuries
•
•
•
5
Clinical Presentation of Renal Trauma
Gross or microscopic hematuria (absent in 5%)
Flank pain/ecchymosis
Hemodynamic instability
Presence of other abdominal injuries
•
•
•
•
6
Patient 1: An illustration of imaging modalities
• 18 yo male sustained stab wound to R flank
• P=180, BP 130/80, Hct 36
• CXR nl.
• Why image and with which modality?
7
Indications for Imaging
• Gross hematuria
• Microscopic hematuria with hemodynamic instability
• Persistent microscopic hematuria
• Significant MOI
8
Radiologic Imaging of Renal Trauma
CT with IV contrast
• Gold standard, high sensitivity
• Immediate and delayed post-contrast images to view collecting system
• Images abdomen and retroperitoneum
• Allows diagnosis and staging
• Not for hemodynamically unstable pts.9
Patient 1: CT with IV Patient 1: CT with IV contrastcontrast
Peri-renal hemorrhage
Normal attenuating kidney
10
Patient 1: CT with IV contrast
Contrast extravasation
11
Renal laceration with extravasation of contrast
Retroperitoneal hematoma
Patient 1: CT with IV contrast
12
Intravenous pyelography
Extravasation of contrast from R kidney
Image from Trauma.org
• Inadequate for grading renal injury
• Used in unstable pts prior to surgery to identify functioning contralateral kidney
• Unable to evaluate abdomen and retroperitoneum
Radiologic Imaging of Renal Trauma Cont.
13
Renal Angiography
Devascularization of L kidney
Image fromTrauma.org
• Delineates vascular injury (intimal tears, pseudoaneurysm, AV fistula)
• Use when CT equivocal and continued hemorrhage
• Use for endovascular repair (embolization, stenting)
Radiologic Imaging of Renal Trauma Cont.
14
Renal ultrasound
• Bedside US in ED allows evaluation of abd/pelvic injury/fluid accumulation
• High false neg. rate for renal injury
• Used in areas without CT, or for follow up
Radiologic Imaging of Renal Trauma Cont.
kidney
Subcapsular hematoma
15
• 17 yo unrestrained driver MVA c/o RLQ pain
• VSS
• Hct 45.7, BUN 15, Cr 1.2
• CXR, cervical, lumbar, pelvic plain films nl.
• CT demonstrates renal laceration
• How severe? How manage?
Patient 2: An Illustration of Injury Staging
16
Grade I Contusion: Microscopic or gross hematuria, urological studies normal
Hematoma: Subcapsular, nonexpanding without parenchymal laceration
Grade II Hematoma: Nonexpanding perirenal hematoma confined to renal retroperitoneum
Laceration: <1cm parenchymal depth of renal cortex without urinary extravasation
AAST Organ Injury Scale - Renal Injury
Grade I and II injuries managed conservatively (observation, serial Hct)Grade I and II injuries managed conservatively (observation, serial Hct) 17
Grade III Laceration: >1cm depth of renal cortex, without collecting system rupture or urinary extravasation
Grade IV Laceration: Parenchymal laceration extending through the renal cortex, medulla and collecting system
Vascular: Main renal artery or vein injury with contained hemorrhage
AAST Renal Injury Scale Cont.
Grade III and IV injuries are now managed conservatively Grade III and IV injuries are now managed conservatively 18
Grade V Laceration: Completely shattered kidney
Vascular: Avulsion of renal hilum which devascularizes kidney
AAST Renal Injury Scale Cont.
Surgery! Salvage vs. nephrectomy Surgery! Salvage vs. nephrectomy
Image from www.trauma.org
19
Renal Trauma Conclusions
• CT with contrast
• Look for renal trauma in pts with abdominal trauma and significant MOI
• Grade severity of injury
• 80-90% renal injuries treated conservatively with remarkable resolution!•
• Injuries requiring surgery: vascular injury, shattered kidney, expanding hematoma
23
Imaging in the Imaging in the Evaluation of Female Evaluation of Female
InfertilityInfertility
InfertilityInfertility
Inability to conceive after one year of Inability to conceive after one year of intercourse without contraceptionintercourse without contraception
EpidemiologyEpidemiology Affects 1 in 7 American couplesAffects 1 in 7 American couples
Rate has been stable over the past 50 yearsRate has been stable over the past 50 years
Advances in assisted reproductive technologies Advances in assisted reproductive technologies (ART) has increased interest in infertility (ART) has increased interest in infertility treatmenttreatment
Infertility - CausesInfertility - CausesMale Factor Male Factor –– 40% 40%
AzoospermiaAzoospermiaSperm defect or dysfunctionSperm defect or dysfunctionChronic IllnessChronic Illness
Female FactorFemale Factor –– 40%40%Advanced ageAdvanced ageAnovulatory cyclesAnovulatory cyclesCongenital anomaliesCongenital anomaliesAcquired structural defectsAcquired structural defectsEndocrine abnormalitiesEndocrine abnormalities
Combined Factors – 10% Unexplained – 10%
Infertility Infertility –– Radiologic Evaluation Radiologic Evaluation Largely focuses on female factor infertilityLargely focuses on female factor infertility
Several congenital and acquired conditions affect Several congenital and acquired conditions affect female reproductive functionfemale reproductive function
Complete evaluation of the female reproductive tract Complete evaluation of the female reproductive tract must include cervical, uterine, endometrial, tubal, must include cervical, uterine, endometrial, tubal, peritoneal, and ovarian factorsperitoneal, and ovarian factors
Menu of TestsMenu of Tests
Hysterosalpingogram (HSG)Hysterosalpingogram (HSG) Ultrasound (US)Ultrasound (US) Sonohysterogram (SHG)Sonohysterogram (SHG) Magnetic Resonance Imaging (MRI)Magnetic Resonance Imaging (MRI)
HSGHSG
HysterosalpingogramHysterosalpingogram Historically the mainstay in infertility imagingHistorically the mainstay in infertility imaging
Indications: evaluation of uterine cavity and Indications: evaluation of uterine cavity and patency of tubespatency of tubes
Limitations: does not aid in characterization of Limitations: does not aid in characterization of uterine wall or ovarian pathologyuterine wall or ovarian pathology
UltrasoundUltrasound Test of choice for imaging the female pelvisTest of choice for imaging the female pelvis
No radiation exposureNo radiation exposure
Indications: evaluation of ovarian, uterine wall, and Indications: evaluation of ovarian, uterine wall, and adnexal pathologyadnexal pathology
Limitations: additional imaging may be needed for Limitations: additional imaging may be needed for pre-surgical characterization and localization of pre-surgical characterization and localization of pathologypathology
MRIMRI
Excellent soft tissue characterizationExcellent soft tissue characterization
Indications: guides interventional radiology Indications: guides interventional radiology and surgical management of infertility by and surgical management of infertility by
identifying size, number, and location of identifying size, number, and location of pathologypathology
Female Reproductive TractFemale Reproductive Tract
www.ethal.org.my/.../ 181rmgUterus.html
CervixCervixCervical StenosisCervical Stenosis
Narrowing of the cervix due Narrowing of the cervix due to adhesions or scarringto adhesions or scarring
Patients complain of painful Patients complain of painful or absent periodsor absent periods
Complication of cone Complication of cone biopsybiopsy
Blocks entry of spermBlocks entry of sperm
Fallopian Tube
vary
Ovary
Uterus
AdhesionsCervix
Vagina
www.drkline.com/ risks.html
Cervical StenosisCervical StenosisHSG Findings:
•Internal os < 1mm
•Inability to advance catheter •Non-opacified uterine cavity
BIDMC, PACSVaginaCervical Stenosis
Normal HSG
UterusUterus
SynechiaeSynechiae FibroidsFibroids PolypsPolyps Congenital AnomaliesCongenital Anomalies
SynechiaeSynechiae
Asherman SyndromeAsherman Syndrome
Intrauterine adhesions caused by trauma, infection, or Intrauterine adhesions caused by trauma, infection, or instrumentationinstrumentation
Healing granulation tissue forms bridges across the cavityHealing granulation tissue forms bridges across the cavity
Infertility may result from obliteration of the cavity or Infertility may result from obliteration of the cavity or obstruction to implantationobstruction to implantation
SynechiaSynechia
HSG findingsHSG findings::
Filling DefectFilling Defect
LinearLinear
IrregularIrregular
SynechiaBIDMC, PACS
SynechiaSynechia
US Findings:US Findings:
EchoicEchoic
LinearLinear
Extends from Extends from one wall to one wall to opposite wallopposite wall
Synechia
FibroidsFibroids Benign, smooth muscleBenign, smooth muscle
tumors of the uterustumors of the uterus
Found in 20-30% of Found in 20-30% of reproductive aged womenreproductive aged women
Affects fertility by Affects fertility by interfering with interfering with implantationimplantation
FibroidsFibroidsHSG FindingsHSG Findings
Scalloped endometrial lining
FibroidsFibroids
US FindingsUS Findings::HypoechoicHypoechoic mass mass
May be submucosal, May be submucosal, intramural, or subserosalintramural, or subserosal
Uterine enlargement or Uterine enlargement or distortion may be seendistortion may be seen
Fibroid
Ultrasound aids in characterization of fibroids.
FibroidsFibroids
BIDMC, PACS
MRI aids in:
• characterization and localization of uterine wall pathology
•pre-surgical planning
Fibroids
Uterine AnomaliesUterine AnomaliesA defect in the embryologic development of A defect in the embryologic development of
the Mullerian system can cause congenital the Mullerian system can cause congenital uterine anomaliesuterine anomalies
There are 7 classifications of anomaliesThere are 7 classifications of anomalies
All can be identified by imagingAll can be identified by imaging
Uterine AnomaliesUterine Anomalies
Normal Class II - Unicornuate
Class III - Didelphys Class IV - Bicornuate
Class V - Septate Class VII - DESClass VI - Arcuate
http://www.emedicine.com/radio/topic738.htm
Uterine AnomaliesUterine Anomalies
Bicornuate:
• Indented fundus but otherwise normal uterine wall• No affect on fertility• No infertility treatment necessary
Septate:
• Fibrous band projecting from fundus into uterine cavity • Interferes with implantation• Surgical removal increases fertility
http://www.emedicine.com/radio/topic738.htm
Two classes must be differentiated in the infertility work-Two classes must be differentiated in the infertility work-upup::
Uterine AnomaliesUterine Anomalies
Irregularly shaped uterine cavity on HSG MRI
BIDMC, PACS
Uterine AnomaliesUterine Anomalies
The irregularly shaped uterus seen on HSG andThe irregularly shaped uterus seen on HSG and
MRI in the previous slides was determined to beMRI in the previous slides was determined to be
an arcuate (class VI) uterus. It is on the spectruman arcuate (class VI) uterus. It is on the spectrum
of bicornuate and is believed to be a normalof bicornuate and is believed to be a normal
variant with no affects on fertilityvariant with no affects on fertility . .
Fallopian TubesFallopian Tubes
ObstructionObstruction Pelvic Inflammatory DiseasePelvic Inflammatory Disease FibroidsFibroids EndometriosisEndometriosis AdhesionsAdhesions Tubal spasmTubal spasm
Fallopian TubesFallopian Tubes
Fimbria
Ampulla
Isthmus
Infundibula
Fallopian TubesFallopian Tubes
Left Proximal Obstruction Right Proximal Obstruction
Peritoneal CavityPeritoneal Cavity
AdhesionAdhesion EndometriosisEndometriosis Post surgicalPost surgical Post infectionPost infection
Difficult to image directly but an irregular pattern Difficult to image directly but an irregular pattern of dye overflow on HSG may raise suspicionof dye overflow on HSG may raise suspicion..
OvariesOvaries EndometriosisEndometriosis Polycystic Ovary Syndrome (PCOS)Polycystic Ovary Syndrome (PCOS)
Ovarian stroma
Bilateral Endometriomas
EndometriosisEndometriosis
US Findings:
•Round
•Symmetric
•Hypoechoic cysts
•Low-level echoes
•Persistent
PCOSPCOSUS Findings of PCOUS Findings of PCO::
BilateralBilateral
Round, echogenic ovariesRound, echogenic ovaries
10-1210-12 small folliclessmall follicles
PCOS is a clinical diagnosis. US findings of polycystic ovaries is neither necessary nor sufficient, but in the right clinical setting may be indicative of the diagnosis.
EW is 9 weeks pregnant today.
Early OB Ultrasound at 7 weeks 4 days.