IVP Best presnetation

IVP best presentation, case approach

1. A case presentation on IVP Speaker - Dr.Sachin Guide- Dr.Kirti Rana Chaturvedi

2. A patient Bheraram 10 year male child presented to pediatric emergency with c/o Abdominal pain since 9 days which increases day by day. No h/o fever and vomiting. No significant past history and family history.

3. Patient is referred to Radiology department for USG Abdomen. USG FINDINGS Right pyonephrosis with ureteritis Right ureteric calculus (~ 19mm in mid part of ureter) Left renal calculi (~10 mm ) Left hydro nephrosis Other findings are - Mild hepatomegaly and multiple enlarged mesenteric lymph nodes.

4. For confirmation of USG abdomen report IVP has been done. IVP REPORT Normally excreting both kidney. Right ureteric calculus B/l renal calculi Left ureter holds contrast in 30 min film with abrupt cut off and in 2 hr film contrast wash away s/o ?left ureteric stricture ? Aberrant vascular structure -Left mild hydroureteronephrosis .

5. Intra venous pyelography (IVP)

6. An intravenous pyelogram (IVP) is a special x-ray examination of the kidneys, bladder, and ureters. It is also called Intravenous Urogram.   An Intravenous Pyelogram can show the size, shape, and position of the urinary tract, and it can evaluate the collecting system inside the kidneys.   Intravenous Pyelogram can be done as a emergency Procedure without any preparation.

7. Indications of IVP An abdominal injury. ureteric fistulas and strictures Bladder and kidney infections. Blood in the urine. Flank pain (possibly due to kidney stones). Tumors .

8. Advantages of IVP -Detailed anatomy of the collecting systems -Demonstration of major calcification -Sensitive for acute obstruction -Low cost

9. Limitations of IVP -It depends on kidney function -Do not differentiate solid or cystic lesion -Requires contrast medium and radiation. -Missing small stones. -Quality of study may be limited by inadequate bowel preparation, bowel ileus, swallowed air and technician variability. -Inconvenience of a long filming sequence.

10. Contraindications -Contrast allergy - Hepato -renal syndrome -Thyrotoxicosis -Pregnancy -Raised serum creatinine

11. how is it performed ? During Intravenous Pyelogram, a dye called contrast material is injected into a vein into the patients arm. A series of X-ray pictures is then taken at timed intervals. The test should be done in a X Ray Department where a doctor is available as on occasions the contrast can cause severe reactions which may lead to medical emergencies.

12. What is the Preparation Required for the Procedure ? The patient may need to be fasting for 8 to 12 hours before the Intravenous Pyelogram. The Patient also may need to take a laxative the evening before the test and possibly have an enema the morning of the test to make sure that the bowels are empty.

13. The standard plain radiographic imaging of the urinary tract is the KUB (kidneys, ureters and bladder), which consists of a full length abdominal film and an upper abdominal (cross-kidney) film taken with the patient supine using a low voltage technique (60-65 kV) to maximise soft-tissue contrast.

14. The full length film in inspiration a 35 x 43 cm cassette positioned with the lower border at the symphysis pubis to ensure the urethra (particularly the prostatic urethra) The cross-kidney film in expiration a 24 x 30 cm cassette with the lower border 2.5 cm below the iliac crests “The study typically includes that portion of the anatomy from the level of the diaphragm to the inferior pubic symphysis

15. (A) Full length and (B) cross kidney films

16. The outline of several anatomical structures can be seen on the KUB renal, psoas and bladder outlines, the KUB is a relatively unreliable diagnostic tool principal use is in the assessment of urinary tract calculi. It is, however, extremely unreliable in the diagnosis of ureteric calculi, with an accuracy of only around 50%.

17. Calcification on IVP--- Urinary tract Renal: calculi, renal cell carcinoma, tuberculosis, Ureter: calculi, tuberculosis, schistosomiasis Bladder: calculi, schistosomiasis, transitional cell carcinoma Outside the urinary tract Musculoskeletal: costal cartilage calcification Hepatobiliary: gallstones, hepatic granuloma Pancreas: chronic pancreatitis Adrenal: tuberculosis, Addison's disease Spleen: granuloma Aorta: atheroma, aneurysm Venous: phlebolith Uterine: fibroid Lymphatic: calcified lymph nodes (presumed postinfective )

18. Contrast LOCM 370 (LOCM = Low osmolar contrast material) Adult dose = 50 – 100 ml Pediatric dose = 1ml for each kg

19. Post contrast IVP films (A) Immediate (Nephrogram phase) (B) 5 min (Secretory phase) (C) 15 min film with compression producing calyceal distension; ( D)30 min film (Ureterogram phase) (E) 45 min film ( Cystogram phase ) (F) Post voiding film

20. Preliminary film (control film)

21. Immediate film ( Nephrogram phase) A.P. view of the renal areas to show the nephrogram , i.e. the renal parenchyma opacified by the contrast medium in the renal tubules. (taking it after injection equals about 10 to 14 seconds which is the approximate arm-to-kidney time).

22. Immediate film (Nephrogram phase)

23. 5-15 minutes film (Secretory phase) -Both Kidney contour -Contrast is filling both the Pyelum or not, -is there any delayed filling?

24. 5-15 minutes film (Secretory phase )

25. 30 minutes film ( Ureterogram phase) : Is there any collecting systems and ureters dilatation or filling defect? (normal ureter filling is rarely demonstrate the whole ureter from proximal to distal as there is a peristaltic wave )

26. 30 minutes film- Ureterogram phase

27. 45 minutes film ( Cystogram phase) : -Bladder size and shape -Contrast is filling the bladder or not -Bladder surface is smooth or rough -Is there any diverticlula , filling defect or prostate indentation?

28. Post voiding film : -Residual urine -Contrast left on upper tract? (normally there is no contrast left on upper urinary tract on post voiding film)

29. Post voiding film

30. IVP REPORTING FORMAT Indication Technique : an IVP was performed following the intravenous administration of contrast. Comparison The scout films demonstrates — Bony shadowing Bowel gas pattern- adequates or inadequates bowel preparation. Renal shadowing Psoas shadowing Any evidences of masses or organomegaly .

31. Conti…. Any radiopaque calculi visible in the kidney or along the ureteral tracts. Following the uneventful administration of ……. cc”s of omnipaque 300 intravenously, the nephrograms and pyelograms are prompt and bilateral. Kidneys are normal in size, shape and axis. There are no masses evident. There is no dilatation or filling defects of the renal calyces or pelvis bilaterally. The ureter are normal in course or calibre, without any filling defects. The bladder is normal in size, shape and contour. No filling defects are evident. There is no significant post void residual. Impression- normal IVP.

32. Pyelo -ureteric Junction Obstruction Shows as Dilation of Right Renal Pelvis and Calyces.

33. Dilation of Left Renal Pelvis and Calyces Above the Obstructing Calculus

34. Renal collecting system and ureters Crossed Renal Ectopia on the Left Kidney and Absent Right Kidney.

35. Renal collecting system and ureters Stab wound of right ureter shows extravasation (at arrow) on intravenous pyelogram.

36. IVP demonstrating a horseshoe kidney. “Flower vase appearance “

37. IVP demonstrating the characteristic stretching of calyces by cysts in polycystic kidneys. Spider leg appearance

38. a Non- opacified partly obstructing ureterocele surrounded by opacified urine in the bladder A later full length film shows opacification of the distended upper moiety ureter running down to the opacified ureterocele

39. Duplex ureters on IVP: complete bilateral

40. Left megaureter on IVP showing dilatation of the entire length of the ureter with secondary pelvi calyectasis

41. Benign prostatic hyperplasia. White = bladder. Dark = benign enlargement of prostate, pushing down on inferior bladder

42. Intravenous pyelogram showed no obstructive uropathy , but symmetric diverticula could be seen near both ureteral orifices (arrows). These lesions, known as Hutch diverticula, are usually congenital rather than occurring as a result of a neurogenic bladder or an infection or obstruction

43. Nodular squamous cell carcinoma of the urinary bladder. Dilated left lower ureter probably secondary to obstruction by tumor . Nonvisualization of the right ureter caused by complete occlusion