mass ivp.pptx

UROLOGY

1. INTRAVENOUS PYELOGRAM

2. INTRODUCTION It is most frequently performed to evaluate the calyces and pelvis of the kidneys. Urters and urenary bladder when abnormalities of these organs are suspected. An abdominal flat plate ( kub ) film is taken , an iodinated contrast medium such as diatrisoate sodium or diatrizoate megulumate is injected,and then serial film is performed.

3. INDICATIONS IN ADULTS: Screening of the entire urinary tract especialy in cases of haematuria or pyuria . Diseases of renal collecting system and renal pelvis. Differentiation of function of both kidneys. Abnormalities of the ureter . TB of the urinary tract. Calculus disease. Potential renal donors. Prior to endo urological procedures and surgery of urinary tract. Suspected renal injury. Renal colic or blank pain.

4. IN CHILDREN VATER ANOMALIES: These patients have vertibral , anal, tracheo -oesophageal, and renal anamoloes are seen in about 90% of patients. Malformation of urinary tract,e.g.,polycystic disease,PUJ obstraction etc. Neutrological disorders affecting urinary tract. Enuresis in the presence bacteriuria , abnormal urinary sediment,adolecents,diurnal / nocturinal incontinence and history of recurrent urinary tract infection. Anorectal anomalies.

5. CONTRAINDICATIONS(RELATIVE) Severe history of anaphylaxis previously carries 30% risk of similar reaction on a subsequent occation . The risk is lower with low osmolar contrast media. Iodine sensitivity. Pregnancy

6. RISK FACTOR Cardiac failure: For patients in cardiac decompensation , hyperosmolar contrast should not be used as the media intensify the congestive cardiac failure. Low osmolar contrast media like lohexol should be used.

7. Dehydration: Renal shut down may be precipitated especialy in infants,diabetics and in multiple myeloma patients as it causes protein precipitation in renal tubules and result in anuria . Dehydration can cause thrombosis of renal vein and renal failure in children.

8. Diabetes with Azotimia: These patient are prone to nephrotoxic contrast media effects. 1in 2000 patients can develop renal shutdown. Previous allergic reaction: In this cases, non-ionic agents should be used and injectable steroids should be given 12 and 4 hours before procedure. History of pheochromacytoma: contrast media can presipitate hypertensive crisis.

9. CONTRAST MEDIA Doses: In adults In children Non ionic contrast media: Iohexol-omnipaque 300 mg I/ml-40-80 ml or 350 mg I/ml 40-80 ml 240 mg I/ml Below 7 kg 4 ml/kg Above 7 kg 3 ml/kg 300mg I/ml 3 ml/kg Ionic media: 300 to 600 mg Iodine equivalent / kg body weight. Maximum of 40 gm of Iodine. Meglumine iothalamate or diatrizoate 60% containing equivalent of 280 mg I/ml of iodine. Dose is 1-2 ml /kg body weight. Below 6 months :10ml 6 months-2 yrs :20ml 2-10yrs :

10. MODE OF INJECTION Contrast media is usualy given as a I.V. Bolus injection within 30-60 seconds. The density of the nephrogram is directly proportional to the plasma concervation of contrast media. Mor iodine increases the density of the of the nephrogram . Large doses contrast media increase diuresis which distends the collecting system these increasing the diagnostic information from the urogram .

11. PATIENT PREPARATION For adults: Ask for any history of diabates mellitus, pheochromocytoma renal disease, or allergy to drugs and any specufic foods. Fasting for four hours. Do not dehydrate the patient.

12. BOWEL PREPARATION Low residue diet like dal-chapati /non-vegetation food and flenty of oral fluids. Bowel wash given till bowelis clear of faecal matter on the previous night. Laxatives is recommended to eliminate faecal matter from the colon and to reduce ammount of gas in the bowel. Dulcolax ( biscodyl ) is given 2-4 tablets at bedtime for 2 days prior to the I.V.U If the dose not cause aduquate bowel cleanising then give castor oil. Caster oil is an oil is an effective catharis when administrated in the dose of 30-60ml. Castor oil is contraindicated in case of abdominal pain of unknown cause,old and debilitated patients. In older patients it is adviseable to use a suppository in the morning in addition to oral laxatives.

13. For children: No paediatric patient should ever be purposely dehydrated as it ia hazardousto do so. Colon should be empty for I.V.U. For this laxative to given Cleaning enemas are used in choldren older than 2years. A preliminary is taken. If this shows unduegas are faces in this colonthe nurse can administer a cleanising enema using saop suds. The child posted for urographymust not have a full stomach to avoid vomitting . So the child should not be given anything by mouth forb3-4 hours prior to the procedure.

14. PROCEDURE . Patient is placed in supine position with pelvis at cathode sidevof the tube. A support is placed under patient’s knees to reduce lordotic curvature of lumbosacral spine and provide comfort. A scout film is taken including the kidneys, bladder and urethral regions on a large size film

15. CONTRAST MEDIA Contrast media is injected intravenously into a prominent vein in the arm. Test injection of 1ml of contrast is given and patient is abserved for 1 min to look for any contrast reactions. Then the rest of the contrast is rapidly injected within 30-60 seconds.

16. The appearance of pyelogram (contrast in calyces) is seen to mintes after contrast injection. During is transit, it may be concentrated as much as 50 times producing a dence pyelogram .

17. EQUIPMENT Equipment should be capable of short exposure to avoid motion blurring. Usually a moving grid is used. Source to image distance-40 inches or 1 metre. Contrast-non-ionic best. Dose 1-2 ml/kg. Filming : The concentrating ability of the kidney is not fully developed in neonates, so delay is given for initial films. First film is taken 15 mints after. Adequate colimation should be used so as to reduce total absorbed dose and effect of scattered radiation on film quality. Fast film-screen combinations and minimum number of films should be taken.

18. Gonadal protective shields should be used. If bowl gas obscures the renal region, either paddle compression technique should be used or place the child in prone positionas it displaces bowel away from the kidneys or use post compression release technique.

19. FILMING TECHNIQUE Low kv (65-75)high mA (600-1000) and shortvexposure should be used to get optimum image contrast

20. STANDARD FILM TAKEN Plain X-ray KUB/scout film-14”×17” 1 minute film-10”×12” 5 minute film-10”×12”

21. INTRAVENOUS PYELOGRAM -FILM TAKEN 15 minute film----15”×12” 10 minute film----15”×12” 35 minute film----14”×17” Post void film-----10”×8”

22. Plain x-ray KUB /scout film diagnosis Calculus Intestinal abnormalities Intestinal gas pattern Calcification Abdominal mass Foreign body

23. 1 minute film 1 minute shows nephrogram . This radiograph is often omittedas tge renal outline are usually adequately visualised on 5 minute film.

24. 5 minute film 5 minute shows nephrogram , renal pelvis upper part of ureter . Compression band is now applied on patient’s abdomen and the balloon is positioned on anteroir superior iliac spine where ureters cross pelvis brim. This is to produce better pelvicalyceal distension.

25. COMPRESSION CONTRAINDICATED IN: Renal trauma Large abdominal mass Abdominal aneurysm After abdominal surgery If 5 minute film shows dilated calyces or if calyces and pelvis are not adequately opecified,obstruction exists and compression band should not be applied.

26. 15 MINUTE FILM Visualisation of ureter better in prone position as they fill better. This position reverses the curve of the inferior course of the ureters making it anti-dependent to gravity. Another method to see ureter is modified trendelenberg technique with 15-20 degrees head low tilt with the patient supine.

27. 30 MINUTE FILM It gives complete over view of the urinary tract; kidney, ureter , bladder, bladder distension can be evaluated

28. POST VOID FILM Taken imediately after voiding. It is used to assess for: Residual urine; Bladder mucosal lession ; Diverticula ; Bladder tumour; Outlet obstraction ; VUR.

29. ABNORMAL BLADDER

30. SPECIAL FILM IN IVU Oblique view Erect view Prone film Delayed films in IVU

31. OBLIQUE VIEW To project the ureter away from spine and to separate overlying radio opaque shadow mimicking calculi. Oblique views are also used for visualisation of posterolateral aspects of bladder; Differentiation of extrinsic or intrinsic renal,ureteral or bladder masses and for doubtful urethral masses.

32. ERECT FILM Provoke of emptying in urinary tract; Demobtrate layering of calculi in cysts and abscesses; Detect urinary tract gas not seen and other films; Have optimum demonstration of renal ptosis,bladder hernia,cystocele and areas of obstraction ureter.

33. PA PRONE POSITION

34. PRONE FILM Viewing of ureteral areas not seen in supine films. Demonstration of renal ptosis and bladder hernia.

35. AP SUPINE DELAYED POSITION

36. DELAYED FILMS In IVU TAKEN 1-24 hours after injection. Cases of obstraction where early nephrogram is seen but collecting system is not seen. Long standing hydronephrosis in which renal paranchyma is seen but collecting system is not visualised until many houts later. Congenital lesions like non-visualised upper calyceal system with ectopic or obstracted ureter.