Transcript 05. GUT techniques and normal anatomy dr sharkaygu dec 12 2010

GUT 365 COURSE
Exam. techniques and
normal anatomy
DR M.S. ELSHARKAWY
ASSOCIATE PROF.
AND
CONSULTANT RADIOLOGIST
Outline of the lecture
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Dividing GU SYSTEMS
Anatomy and modalities
Basic radiological terminology.
Techniques of examination.
What u can see in each modality.
BASIC ANATOMY
• GENITO-URINARY SYSTEM
KIDNEYS
URETERS
URINARY BLADDER
• SUPRARENAL GLANDS
• MALE GENITAL SYSTEM
Testicles
• FEMALE GENITAL SYSTEM
Uterus, fallopian tubes and ovaries.
Genito-urinary system
• Intravenous urography
• Cysto-urethography
• Retrograde pyelography
• Hysterosalpingography
• Antegrade pyelography
GU INVESTIGATION
• IONIZING RADIATION
PLAIN FILM (KUB)
IVU(IVP)
CT SCAN
ISOTOPIC SCAN
ANGIOGRAPHY
• NONIONIZING RADIATION
ULTRASOUND
MRI
GU INVESTIGATION
WHAT WE REALY USE NOW
• IONIZING RADIATION
PLAIN FILM (KUB)
IVU(IVP)
CT SCAN
ISOTOPIC SCAN
ANGIOGRAPHY
• NONIONIZING RADIATION
ULTRASOUND
MRI
KUB
• Conventional plain
film of the abdomen
called a KUB
(Kidneys, Ureters,
Bladder)
Plain film (KUB)
Plain film
(KUB)
IVU
• Also called IVP (intravenous pyelogram)
• Demonstrates both function and structure of
the renal system
• Function
– filtration
• Structure
– Contrast filled filtration system
Indications for Intravenous
urography
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Evaluation of abdominal masses
Urolithiasis / calculus
Pyelonephritis
Polycystic kidney
Hydronephrosis
Trauma
Tumour
Vesicoureteral reflux
Preoperative evaluation
Renal hypertension
Renal obstruction
Renal colic
Congenital abnormality
– Horseshoe kidney
– Pelvic kidney
– Duplicate collecting system
Contraindications for
Intravenous urography
• Kidneys inability to filter contrast media
• Allergic history
• Lack of kidneys
• Patient History
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Asthma
High creatinine
Circulatory or cardiovascular disease
Sickle cell disease
Diabetes mellitus (metformin)
Multiple myeloma
Equipment required
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X-ray table with tomographic capabilities
Medical trolley
Compression band (belt)
40-60mls of intravenous contrast
Saline, alcohol swabs
22 gauge needle (or bigger) butterfly
Extension tube (if using cannula)
60ml syringe
Access to sharps container
Arm board
Kidney dish
Emesis bag
Micropore tape
Radiographic
– Cassettes 35 x 43, 24 x 30 (30 x 40)
– Time marker
– Anatomical marker
IV cannula
Butterfly with extension tube
Cannula
60ml syringe with cannula
Compression band
Trolley
Kidney dish
Emesis bag
Patient preparation
• Patient preparation:
– Take two laxative 2 days before
– Take two more laxative the night before.
• Once in your department
• Explain procedure to patient
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Contrast
Needle
Bladder control
compression
Patient preparation
• Patient to empty bladder
• Change into gown (removing all
artefacts)
• obtain patient history
Have you had one of these before?
– Allergies
– Asthma
– Diabetes
– Creatinine level (blood test required)
IVP
Patient position
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Patient in supine position
Head on pillow
Arm relaxed by sides
One arm out to side for injection of contrast
Support under patients knees
Attach footboard to foot end of table.
Attach shoulder support (where available)
Ureteric compression ready for action
IVU
• Basic views for IVU studies
• These are local protocol variable
• Include:
– Control (preliminary) AP abdomen
– Control Kidneys (AP kidneys)
– Immediate ( 1 minute) collimated around kidneys.
(nephrogram)
– 5 minute (plain)
• 3 levels of tomography
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10 minute
Release image (post compression)
Bladder
Oblique bladder X 2
Post micturition (post void)
IVU
• Preliminary x-ray
(control)
• Time = zero
• Projection
– Anteroposterior supine
Abdomen
• Position of patient
– in supine position
– Anteroposterior
– Arms relaxed by patients
side
– Suspended respiration
on expiration.
– Shield gonads
– Compression at level of
sacrum
cont.
• Central ray
– Perpendicular to image receptor
– Midsagittal plane
– At level of iliac crests
• Include
– From pubic symphysis to diaphragm
– Lateral borders of kidneys/ureters/bladder
– Time markers
• Use a 35 X 43 regular cassette lengthwise.
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Preliminary x-ray (control)
Time = zero
Projection
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Position of patient
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Perpendicular to image receptor
Midsagittal plane
At level of lumbar vertebra 1
(midpoint between xiphoid process
and iliac crests)
Include
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in supine position
Anteroposterior
Arms relaxed by patients side
Suspended respiration on
expiration.
Shield gonads
Compression at level of sacrum
Central ray
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Control Kidneys
Anteroposterior supine Kidneys
Upper and lower poles of both
kidneys
Lateral borders of both kidneys
Height in cms
Use a 24 X 30 (30 X 40 for bigger
patients) regular cassette.
Nephrogram
• After intravenous injection
has taken place a
nephrogram is a common
starting point for IVU’s
• Patient care (contrast
administration will give
warm flush sensation,
strange taste in mouth, and
may feel as though wetting
self)
• Nephrogram is a designed to
look at the kidneys
parenchyma.
• This image is taken at 1
minute post injection.
• Tomography is utilised here
Nephrotomogram
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Time
– Immediate (1 minute)
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Anatomy position
– Midsagittal plane in the midline of image receptor
– With no rotation
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Central beam
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Perpendicular to image receptor
Centred at L1
In midsagittal plane
At predetermined height (6-11cms)
In tomographic mode
Include:
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Upper and lower poles of both kidneys
Include lateral margins of kidneys
Kidneys should be well demonstrated
Surrounding anatomy should be blurred
Time marker should be well visualised
Anatomical marker should be well visualised
Height markers should be well visualised
Nephrogram
Nephrotomogram
5 minute nephrogram
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Time
– 3-5 minutes
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Anatomy position
– Midsagittal plane in the midline of image receptor
– With no rotation
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Central beam
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Perpendicular to image receptor
Centred at L1
In midsagittal plane
Plain film (no tomography)
Include:
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Upper and lower poles of both kidneys
Include lateral margins of kidneys
Kidneys should be well demonstrated
Time marker should be well visualised
Anatomical marker should be well visualised
3-5 minutes post inj.
3-5 minute nephrogram
5 minute nephrotomograms
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Time
– 3-5 minutes
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Anatomy position
– Midsagittal plane in the midline of image receptor
– With no rotation
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Central beam
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Perpendicular to image receptor
Centred at L1
In midsagittal plane
At predetermined height (6-11cms)
Tomography
Include:
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3 x-rays at specified height then one above and one below
Upper and lower poles of both kidneys
Include lateral margins of kidneys
Kidneys should be well demonstrated
All surrounding anatomy should be blurred
Time marker should be well visualised
Anatomical marker should be well visualised
Height markers should be well visualised
Nephrotomogram
10 minute with compression
Time
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10 minutes –
Anatomy position
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Midsagittal plane in the midline of image receptor –
With no rotation –
Central beam
Perpendicular to image receptor
Centred at L1
In midsagittal plane
At predetermined height (6-11cms)
Tomography
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Include:
3 x-rays at specified height then one above and one below
Upper and lower poles of both kidneys
Include lateral margins of kidneys
Kidneys should be well demonstrated
Time marker should be well visualised
Anatomical marker should be well visualised
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10-15 minute full length
Release
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Time 10-15minutes
Remove compression band
Projection
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Anatomy position
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Perpendicular to image receptor
Midsagittal plane
At level of iliac crests
Include
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in supine position
Anteroposterior
Arms relaxed by patients side
Suspended respiration on expiration.
Compression at level of sacrum
Central ray
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Midsagittal plane in the midline of image
receptor
With no rotation
Position of patient
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Anteroposterior supine Abdomen
From pubic symphysis to diaphragm
Lateral borders of kidneys/ureters/bladder
Time markers
Kidneys ureters and bladder should be
well demonstrated
Use a 35 X 43 regular cassette.
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Time 45-60 minutes
Remove compression band
Projection
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Anatomy position
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Caudal angulation 15 degrees
Midsagittal plane
At level of Anterior superior iliac spine
Collimated to include bladder
Include
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in supine position
Anteroposterior
Arms relaxed by patients side
Suspended respiration on expiration.
Central ray
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Midsagittal plane in the midline of
image receptor
With no rotation
Position of patient
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Anteroposterior axial bladder
Bladder
Apex to base of bladder
Lateral borders bladder including VUJ
(where possible)
Pubic bones should be projected
below bladder.
bladder and distal ureters should be
well demonstrated filled with contrast
Use a 18 X 24 regular cassette.
Urinary bladder
Bladder
The end
Post micturition / post void
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Time 45-60 minutes
Remove compression band
Projection
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Anatomy position
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Caudal angulation 15 degrees
Midsagittal plane
At level of Anterior superior iliac spine
Collimated to include bladder
Include
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in supine position
Anteroposterior
Arms relaxed by patients side
Suspended respiration on expiration.
Central ray
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Midsagittal plane in the midline of image
receptor
With no rotation
Position of patient
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Anteroposterior axial bladder
Apex to base of bladder
Lateral borders bladder including VUJ
(where possible)
Time markers
bladder should be well demonstrated filled
with contrast
Use a 18 X 24 regular cassette.
bladder
Basics of GU Anatomy
• The
kidneys
are
retroperitoneal
organs
emptying medially into the
ureters,
which
course
inferiorly into the pelvis and
enter the urinary bladder,
where
the
urine
is
temporarily stored until it is
cleared to the exterior
through the urethra.
• The adrenal, or suprarenal
glands are related to the
kidneys more by proximity
than function, producing
steroids
(cortex)
and
catecholamines (medulla).
IVU
• Normal excretory phase
of an IVU (intravenous
urogram). This film was
taken approximately 10
minutes following IV
injection of iodinated
contrast material. The
kidneys are excreting
contrast into non
dilated calyces
(arrows), renal pelvis
(p), ureters (*) and
bladder (B).
KIDNEYS
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The renal hilum opens up into the renal sinus, a space in which the renal
pelvis, calices, vessels, and nerves lie surrounded by fat. The renal pelvis is
the superior end of the ureter, formed from two to three major calices.
Each major calyx is formed from two or three minor calices, into which
protrude a renal papilla, the apex of pyramid-shaped clusters of collecting
ducts that form the renal medulla. Surrounding the medulla is the renal cortex,
the excretory system of the kidney that contains the Bowman’s capsule, the
proximal and distal convoluted tubules, the loop of Henle, and supporting
parenchymal tissue and vasculature.
Each minor calyx with its associated pyramid and cortex comprises one lobule
of the kidney, these lobules having formed from distinct embryologic
structures (mesonephros) that coalesce during renal development .
NORMAL
IVU
Anatomy
KIDNEY
• Retroperitoneal against
posterior abdominal wall
at level of T12-L3
vertebrae, the right
kidney slightly lower
than the left due to
displacement by the right
lobe of liver. The right
kidney is posterior to the
liver, duodenum and
ascending colon; the left
kidney is related to the
spleen, stomach,
pancreas, jejunum, and
descending colon.
RT
KIDNEY
• There are many variations of the renal vasculature—
the following is the most common configuration. The
renal arteries branch from the abdominal aorta
between L1 and L2, the right renal artery passing
posterior to the IVC. There may be more than one
renal artery (on one or both sides) in 20-30% of the
time. The renal veins lie anterior to the arteries; the
longer left renal vein passes anterior to the aorta
before draining into the inferior vena cava. This
anatomy makes the left kidney more desireable for
transplant giving the surgeon some extra vessel to
work with for creating the vascular anastomoses in the
recipient. Common variants include retroaortic and
circumaortic left renal veins.
KIDNEYS
• Superior and inferior poles, anterior
and posterior surfaces, medial and
lateral margins. The renal hilum,
located at the medial margin, is a cleft
that provides access for the
vasculature and an exit for the ureters.
A tough, fibrous capsule surrounds the
kidney .
• The ureters exit medially from the kidney at the
renal hilum posterior to the renal vessels , then
course inferomedially along the psoas major
muscle and transverse processes of the lumbar
vertebrae.
• They cross the external iliac artery just distal to
the bifurcation of the common iliac, then course
along the lateral wall of the pelvis to empty into
the posterior aspect of the urinary bladder at the
bladder trigone
• .Blood is supplied by the ureteral branches of
renal and testicular or ovarian arteries, and
abdominal aorta. Renal and testicular or ovarian
veins supply venous drainage.
Bladder &
Urethra
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When empty, the bladder lies on the
pelvic floor surrounded by
extraperiotoneal fatty tissue, posterior to
the pubic bones. As it fills, it ascends in
the extraperitoneal fatty tissue and enters
the greater pelvis, reaching as high as the
level of the umbilicus when full. In males,
it is situated anterior to the rectum and
superior to the prostate gland. In females,
it is anterior to the vagina and
anteroinferior to the uterus.
The anterior portion of the bladder, the
apex, is connected to the medial umbilical
ligament (vestigal urachus). The superior
surface is covered with peritoneum. There
are two inferolateral surfaces, a base, and
a neck.
The body of the bladder extends from the
apex to the posterior end, the fundus. The
ureters enter the bladder through the
internal ureteric orifices at the
posterolateral angles of the trigone, which
is located at the posterior base of the
bladder and extends inferiorly to its
anteroinferior angle at the neck of the
bladder and the internal urethral orifice.
RADIOOPAQUE
CT
CROSS SECTIONAL
Kidney
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Renal fascia
Hilum
Renal sinus
Renal cortex
– Renal columns
• Renal medulla
– Renal pyramids
• Calyces
– Minor calyces
– Major calyces
– Renal pelvis
Transverse CT urographic images obtained with non–log-rolling procedure in 41-year-old
woman.
Kim S et al. Radiology 2008;247:747-753
©2008 by Radiological Society of North America
Selected transverse CT urographic images obtained with a multi-detector row CT scanner
and supplemental infusion of normal saline show normal anatomy.
McTavish J D et al. Radiology 2002;225:783-790
©2002 by Radiological Society of North America
Transverse CT urographic images obtained with non–log-rolling procedure in 41-year-old
woman.
Kim S et al. Radiology 2008;247:747-753
©2008 by Radiological Society of North America
CT urogram in 41-year-old man with microhematuria
Chow, L. C. et al. Am. J. Roentgenol. 2007;189:314-322
Copyright © 2007 by the American Roentgen Ray Society
CT urogram in 41-year-old man with microhematuria
Chow, L. C. et al. Am. J. Roentgenol. 2007;189:314-322
Copyright © 2007 by the American Roentgen Ray Society
. Selected coronal CT urographic images obtained with a multi-detector row CT scanner and
supplemental infusion of normal saline show normal anatomy.
McTavish J D et al. Radiology 2002;225:783-790
©2002 by Radiological Society of North America
CT urographic MIP image obtained with a multi-detector row CT scanner and supplemental
infusion of normal saline shows normal anatomy and has been edited to remove some of the
osseous structures.
McTavish J D et al. Radiology 2002;225:783-790
©2002 by Radiological Society of North America
CT
• 3D reconstructed image
from CT scan of the
abdomen and pelvis
known as CT IVP. This
exam is quickly
replacing the
conventional IV
Urogram. This 3D
reconstruction is
performed through the
right kidney (K) and
follows the normal
ureter (arrows) all the
way to the ureter's
insertion into the
bladder .
Duplicated collecting system with an ectopic ureterocele in a 34-year-old woman.
Silverman S G et al. Radiology 2009;250:309-323
©2009 by Radiological Society of North America
CTA
3D-4D
Normal three-dimensional volume-rendered color-coded excretory phase image of a threephase CT urogram supplemented with 10 mg of intravenous furosemide in a 55-year-old man
demonstrates completely distended and opacified collecting systems, ureters, and bladder.
Silverman S G et al. Radiology 2009;250:309-323
©2009 by Radiological Society of North America
Renal Ultrasound.
• Sagittal view of
normal left kidney
showing normal
cortex (C) and
echogenic (bright)
renal sinus fat (F)
Color Doppler Renal Ultrasound
. View of normal right
renal artery (red)
and vein (blue) with
spectral
analysis
(bottom of image)
showing normal low
resisitence
wave
form in the artery .
MRI
• T2 weighted images
through the kidneys
(K) in the coronal
plane .
.MRU
Leyendecker J R et al. Radiographics 2008;28:23-46
©2008 by Radiological Society of North America
58-year-old man with right benign fibrovascular polyp and left incomplete ureteral duplication
Blandino, A. et al. Am. J. Roentgenol. 2002;179:1307-1314
Copyright © 2007 by the American Roentgen Ray Society
Obstructive uropathy in an 80-year-old woman with urothelial carcinoma of the bladder.
Silverman S G et al. Radiology 2009;250:309-323
©2009 by Radiological Society of North America
Importance of cine MR urography in demonstrating the entire ureters with static-fluid
techniques.
Leyendecker J R et al. Radiographics 2008;28:23-46
©2008 by Radiological Society of North America
Normal MR urogram in a 57-year-old man.
Silverman S G et al. Radiology 2009;250:309-323
©2009 by Radiological Society of North America
MRA Accessory artery in a 35-year-old patient with severe hypertension.
Soulez G et al. Radiographics 2000;20:1355-1368
©2000 by Radiological Society of North America
Adrenal glands
Adrenal gland
• Stylized drawing of normal
adrenal cortex and medulla.
• The cortex produces steroid
hormones and the medulla
produces epinephrine and
norepinephrine
• .From Duxter et al.
Treatment of the
Postmenopausal Woman:
Basic and Clinical Aspects.
3rd edition. Lippincott,
Williams and Williams, 1999 .
Adrenal
Glands
• The major products of the
adrenal cortex include
cortisol, aldosterone, and
dehydroepiandosterone
(DHEA) from the zona
glomerulosa, zona
fasciculata, and zona
reticularis, respectively. The
major products of the
adrenal medulla are the
catecholamines epinephrine
and norepinephrine. You
cannot differentiate cortex
from medulla on imaging
(this is a microscopic
finding).
Adrenal
Glands
• The right adrenal gland is located 1-2 cm cephalad to the
upper pole of the right kidney, and lies posterior to the
inferior vena cava and medial to the right lobe of the
liver. The left adrenal gland is at the same level or
caudal to the right adrenal gland, anteromedial to the
upper pole of the left kidney, lateral to the aorta and
posterior to the pancreas and splenic vessels .
CT ADRENAL GLAND
• Unenhanced CT scan
through the level of the
adrenal glands shows
normal appearing
bilateral adrenal glands
in the suprarenal
fossa. The glands take
on the appearance
of an upside down "V"
or "Y" often (arrows) .
Testicles
Male
Pelvis
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The testis measures 3.5-4 cm in
length and 2-3 cm in width and is
covered by the fibrinous tunica
albuginea. The spermatic cord enters
the testis along the posterosuperior
margin, known as the mediastinum
testes. The testis is divided into
lobules arrayed radially around the
mediastinum testes; each lobule
being composed of branching
seminiferous tubules.
The epididymis is 6-7 cm in lenth, 7-8
mm diameter at the globus major
(head of epididymis at mediastinum
testis) and 1-2 mm at the tail where it
continues as the vas deferens. The
vas deferens courses through the
spermatic cord and exits via the deep
inguinal ring. At the base of the
prostate, it joins the seminal vesicle to
form the ejaculatory duct.
20-30 ducts form the prostate gland,
draining into the prostatic urethra at
the verumontanum, located between
the internal and external urethral
sphincters. 3 zones of ductular
drainage subdivide the prostate: the
peripheral zone, the central zone, and
the transitional zone.
NORMAL TESTIS
Tunica
Albuginea
Intact
HOMOGENOUS MEDIUM SIZE ECHOS
Power Doppler -Normal Testis
Normal
Vasculature
of Testis
Very important
Absent flow = torsion •
Flow present doesn't= no torsion •
Duplex ultrasound of testis
. In this patient with
suspected torsion,
normal color flow
(red and blue
represents flow) and
spectral analysis
(arrows) show both
venous and arterial
flow thereby
excluding torsion .
Female pelvis
MRI pelvis
Hysterosalpingography
Uterine
cavity
Fallopian
tube