X RAY KUB 1

X RAY KUB 1

1. X-ray KUB
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

2. Moderators:
Professors:
•Prof. Dr. G. Sivasankar, M.S., M.Ch.,
•Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
•Dr. J. Sivabalan, M.S., M.Ch.,
•Dr. R. Bhargavi, M.S., M.Ch.,
•Dr. S. Raju, M.S., M.Ch.,
•Dr. K. Muthurathinam, M.S., M.Ch.,
•Dr. D. Tamilselvan, M.S., M.Ch.,
•Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. History
William Roentgen, a German
Physicist, was the first to
discover X-radiation, which
earned him the Nobel Prize in
Physics in 1901.
3Dept of Urology, GRH and KMC, Chennai.

4. X-Ray Word Origin
•X-ray was an unknown type of radiation when Roentgen first
observed them.
•In order to name the unknown radiation, he called it as X-radiation or
X-ray.
•Even though, later called them Roentgen rays, the name X-ray is the
one widely used.
4Dept of Urology, GRH and KMC, Chennai.

5. Hand with Rings-Anna Bertha Ludwig
5Dept of Urology, GRH and KMC, Chennai.

6. X-ray Spectrum
•X-rays are a type of electromagnetic waves.
•X-rays have wavelengths ranging from 0.01 to 10 nanometers, hence
their wavelengths are shorter than those of Ultraviolet rays and
typically longer than those of gamma rays.
6Dept of Urology, GRH and KMC, Chennai.

7. X-ray Production
When the fast moving electrons
hit on an anode made of
Tungstenin case of medical use,
X-rays are produced.
7Dept of Urology, GRH and KMC, Chennai.

8. Standard View
•The standard view is an Antero
posterior supineview.
•Patient lies supine.
•X‐ray tube is positioned overhead.
•X‐rays pass in the AP direction.
•Ideally, the patient is asked to hold
their breath (so that breathing
movement will not make the image
blurry) and the X‐ray is taken.
•Standard plate size 14”-17”
8Dept of Urology, GRH and KMC, Chennai.

9. Other Views
To get spatial orientation of
opacities
•Oblique view
To look for free air and air fluid
levels
•Erect view
9Dept of Urology, GRH and KMC, Chennai.

10. Systematic Reading
•Type of Radiograph-Area and View
•Patient identification and investigation timing
•Technical quality of the X-ray
•Ensure the sides with visible anatomy
•Look further into details
10Dept of Urology, GRH and KMC, Chennai.

11. Assessing Technical Quality of X-ray
•Has everything been included?•The entire anatomy should be
included from level of T10 upto
2 cm below the lower margin of
symphysis pubis.
•Both the hemi‐diaphragms
should be visible, lower margin
of symphysis pubis should be
visible.
11Dept of Urology, GRH and KMC, Chennai.

12. •Has the exposure been
adequate?
•Exposure is related to the
number of X‐rays that reach the
detector and make the image.
•If the exposure is adequate, the
spine should be clearly
visualized.
•In case of overexposure, soft
tissue shadows will be minimal.
Assessing Technical Quality of X-ray
12Dept of Urology, GRH and KMC, Chennai.

13. Looking for Details-ABCDE of X ray
A
B
C
D
E
•Air in the Wrong Place
•Bowel
•Calcifications
•Disability of Bones
•Everything else
13Dept of Urology, GRH and KMC, Chennai.

14. Looking for Details-ABCDE of X ray
A
B
C
D
E
•Air in the Wrong Place
•Bowel
•Calcifications
•Disability of Bones
•Everything else
•Pneumoperitoneum
•Pneumoretroperitoneum
•Pneumobilia
•Portal venous gas
14Dept of Urology, GRH and KMC, Chennai.

15. Looking for Details-ABCDE of X ray
A
B
C
D
E
•Air in the Wrong Place
•Bowel
•Calcifications
•Disability of Bones
•Everything else
•Dilated small bowel
•Dilated large bowel
•Volvulus
•Fecal loading
15Dept of Urology, GRH and KMC, Chennai.

16. Looking for Details-ABCDE of X ray
A
B
C
D
E
•Air in the Wrong Place
•Bowel
•Calcifications (Common)
•Disability of Bones
•Everything else
•Urinary tract stones
•Nephrocalcinosis
•Pancreatic calcification
•Calcified lymphnodes
•Phleboliths
16Dept of Urology, GRH and KMC, Chennai.

17. Looking for Details-ABCDE of X ray
A
B
C
D
E
•Air in the Wrong Place
•Bowel
•Calcifications (Uncommon)
•Disability of Bones
•Everything else
•Calcified costal cartilage
•Adrenal calcification
•Abdominal aortic aneurysm
(AAA) calcification
•Calcified uterine fibroids
•Prostate calcification
•Abdominal aortic calcification
(normal calibre)
•Splenic artery calcification
17Dept of Urology, GRH and KMC, Chennai.

18. Looking for Details-ABCDE of X ray
A
B
C
D
E
•Air in the Wrong Place
•Bowel
•Calcifications (Uncommon)
•Disability of Bones
•Everything else
•Sclerotic and lucent bone lesions
•Spine pathology
•Solid organ enlargement
•Fractures
18Dept of Urology, GRH and KMC, Chennai.

19. Looking for Details-ABCDE of X ray
A
B
C
D
E
•Air in the Wrong Place
•Bowel
•Calcifications (Uncommon)
•Disability of Bones
•Everything else
•Medical and surgical objects
•Foreign bodies
•Lung bases
19Dept of Urology, GRH and KMC, Chennai.

20. X-Ray KUB-Purpose
1.As a preliminary test in acute abdomen
2.To ensure the technical quality of the examination in case of
planned contrast usage.
3.To detect any calcific densities that could be urinary tract calculi.
4.To determine whether a contraindicationto abdominal
compression exists.
5.To determine whether bowel preparation is adequate before
contrast study
6.To check the position of stents after urological procedures.
20Dept of Urology, GRH and KMC, Chennai.

21. Abdominal Compression-Contraindications
•Spine deformity
•Abdominal distension (ileus, bowel obstruction, ascites)
•Acute abdomenfindings
•Various types of urinary tract diversions and stomas
•Acute renal colic
•IVC filter (Relative contraindication)
21Dept of Urology, GRH and KMC, Chennai.

22. Anatomical Landmarks
•Organ Outlines
•Major Muscles
•Properitonealfat
•Perivesicalfat plane
•Stomach and Bowel gas
22Dept of Urology, GRH and KMC, Chennai.

23. Anatomical Landmarks-Organ Outline
Organ outlines are visible because
of the contrasting radiolucent
mesenteric or retroperitoneal fat
that surrounds the organs.
•Renal Outline-Bean shaped soft
tissue density, smooth outline,
extends from T12 to L2 on Lt
side & L1 to L3 on Rtside ( 3.5
vertebral bodies )
•Small kidney -if < 3 vertebrae
•Enlarged kidney -if > 4 vertebrae
23Dept of Urology, GRH and KMC, Chennai.

24. Anatomical Landmarks-Major Muscles
•Psoas shadow–If absent
indicates presence of fluid in the
adjacent compartment. (In 20%
cases, normally absent on one
side).
•Quadratus lumborum-1cm
lateral to Psoas shadow.
24Dept of Urology, GRH and KMC, Chennai.

25. Anatomical Landmarks-Properitonealfat
•It is the continuation of the
posterior paranephricspace.
•It is sandwiched between
transversalis fascia and the
parietal peritoneum.
•Its medial interface marks the
lateral extent of the peritoneal
cavity
25Dept of Urology, GRH and KMC, Chennai.

26. Anatomical Landmarks-PerivesicalFat line
26Dept of Urology, GRH and KMC, Chennai.

27. Anatomical Landmarks-L4
•L4 vertebrae is the first lumbar
vertebrae with a transverse
process pointing upwards when
examined from above
downwards.
•Further labelling of vertebrae
should be done either above or
below L4.
27Dept of Urology, GRH and KMC, Chennai.

28. Renal Calcifications-X ray KUB
Most common cause of renal calcifications is
Renal calculus disease
28Dept of Urology, GRH and KMC, Chennai.

29. Renal calculus disease-
Identification with X ray
•Technical factors
•Patient factors
•Stone factors
29Dept of Urology, GRH and KMC, Chennai.

30. Technical factors
•Peak kilovoltage(kVp)of xraybeam of 60-70 kVpis optimal for
searching faintly opaque or small stones.
•At 80-90 kVpsmall stones may be invisible.
•For obese patients >70-80 kVpmay be needed.
•50 kVpis ideal for lucent uric acid stones.
30Dept of Urology, GRH and KMC, Chennai.

31. Patient Factors
•Girth and obesity of the patient
•Extraurinarycalcifications can obscure or mimic renal calculi.
•Calculi overlapped by bony structures
31Dept of Urology, GRH and KMC, Chennai.

32. Stone Factors
•Size
•Composition
•Location
32Dept of Urology, GRH and KMC, Chennai.

33. Stone Size
•XrayKUB can detect calcium containing calculi as small as 1 to 2 mm.
•Less opaque stones such as cystineare not visible until 3-4 mm in
size.
•Non opaque calculi like uric acid are generally need to be 1 cm or
larger to be faintly visible.
33Dept of Urology, GRH and KMC, Chennai.

34. Stone Composition
•Two thirds of stones are composed of mixture of different crystals
•Single crystal (or Pure ) stones constitute only one third of all urinary
calculi.
•Pure stones can have characteristic radiographic appearances.
•Crystalline admixtures have varied appearances.
34Dept of Urology, GRH and KMC, Chennai.

35. Stone composition and Shape
•Pure Calcium oxalate monohydrate stone-Homogeneously densely
opaque, smooth edges and may be dentate.
•Calcium oxalate monohydrate stone with >60% -Irregularly
marginatedwith heterogeneous, variegated radiopacity.
•Predominant Calcium oxalate dehydrate stone-Stippled and
spiculatedwith radial striations.
•Pure calcium phosphate stones-similar to Pure calcium oxalate stones
in appearance
•Triple phosphate stones-Laminated appearance
•Magnesium ammonium phosphate Hexahydrate(Struvite)-Staghorn
35Dept of Urology, GRH and KMC, Chennai.

36. Stone composition and shape
•Pure uric acid stones-Non opaque on plain radiographs
•Uric acid stones with calcium coats-variably radiopaque on xray
•Cystinestones-moderately radiopaque, homogeneous ground glass
opacity, may be often large and multiple with staghorn configuration
•Staghorn in children or young adults should rise the suspicion of
Cystinestones.
•Matrix stones-non radiopaque on plain radiographs
•Xanthine stones-Radiolucent stones, but an admixture with calcium
may offer radiopacity
36Dept of Urology, GRH and KMC, Chennai.

37. Calcium Oxalate monohydrate
37Dept of Urology, GRH and KMC, Chennai.

38. Calcium Oxalate dihydrate
38Dept of Urology, GRH and KMC, Chennai.

39. Cystine
39Dept of Urology, GRH and KMC, Chennai.

40. Struvite
40Dept of Urology, GRH and KMC, Chennai.

41. Triple phosphate
41Dept of Urology, GRH and KMC, Chennai.

42. Other causes of Renal calcification
•Nephrolithiasis
•Nephrocalcinosis
•Dystrophic calcifications of vascular structures
•Neoplasms with calcifications
•Renal cysts with calcifications
•Calcified necrotic papilla
•Genitourinary tuberculosis
•Renal infarcts
•ESRD
42Dept of Urology, GRH and KMC, Chennai.

43. GUTB with Renal calcifications
43Dept of Urology, GRH and KMC, Chennai.

44. Medullary nephrocalcinosis
44Dept of Urology, GRH and KMC, Chennai.

45. Renal artery calcification
45Dept of Urology, GRH and KMC, Chennai.

46. Medullary sponge kidney
46Dept of Urology, GRH and KMC, Chennai.

47. Mimicking Urinary Calcifications
•Calcified costal cartilage
•Gall stones (10% cases)
•Splenic calcification
•Splenic artery calcification
•Adrenal calcifications
•Pancreatic calcification
•Hepatic calcification
Clarification Method:
Take an Xrayin Deep inspiration
47Dept of Urology, GRH and KMC, Chennai.

48. Mimicking Urinary Calcifications
•Calcified costal cartilage
•Gall stones (10% cases)
•Splenic calcification
•Splenic artery calcification
•Adrenal calcifications
•Pancreatic calcification
•Hepatic calcification
Clarification Method: Number, faceted
shape, right post oblique films
48Dept of Urology, GRH and KMC, Chennai.

49. Mimicking Urinary Calcifications
•Calcified costal cartilage
•Gall stones (10% cases)
•Splenic calcification
•Splenic artery calcification
•Adrenal calcifications
•Pancreatic calcification
•Hepatic calcification
49Dept of Urology, GRH and KMC, Chennai.

50. Mimicking Urinary Calcifications
•Calcified costal cartilage
•Gall stones (10% cases)
•Splenic calcification
•Splenic artery calcification
•Adrenal calcifications
•Pancreatic calcification
•Hepatic calcification
50Dept of Urology, GRH and KMC, Chennai.

51. Mimicking Urinary Calcifications
•Calcified costal cartilage
•Gall stones (10% cases)
•Splenic calcification
•Splenic artery calcification
•Adrenal calcifications
•Pancreatic calcification
•Hepatic calcification
51Dept of Urology, GRH and KMC, Chennai.

52. Mimicking Urinary Calcifications
•Calcified costal cartilage
•Gall stones (10% cases)
•Splenic calcification
•Splenic artery calcification
•Adrenal calcifications
•Pancreatic calcification
•Hepatic calcification
52Dept of Urology, GRH and KMC, Chennai.

53. Mimicking Urinary Calcifications
•Calcified costal cartilage
•Gall stones (10% cases)
•Splenic calcification
•Splenic artery calcification
•Adrenal calcifications
•Pancreatic calcification
•Hepatic calcification
53Dept of Urology, GRH and KMC, Chennai.

54. Ureteric Calculus
Ureteric calculus can be located near the
transverse process of the lumbar vertebra
and over the sacral vertebrae.
At the level of ischial spine, ureter turns
medially to join the bladder at VUJ which is
the most common site of obstruction in
ureteric calculus.
54Dept of Urology, GRH and KMC, Chennai.

55. Mimicking Ureteric Calculi
•Phleboliths
•Calcified costal cartilage
•Gall stones
•Enteroliths
•Calcified mesenteric lymph node
•Pancreatic calcifications
•Sacral bone islands
•Aortic or other arterial calcifications
•Fallopian tube occlusion rings
55Dept of Urology, GRH and KMC, Chennai.

56. Phlebolithsand Ureteric calculi
•Phlebolithsare literally "vein stones"
•Represent calcification within venous
structures.
•They are particularly common in the pelvis
where they may mimicureteric calculi, and
are also encountered frequently invenous
malformations.
•Differentiating points: Often have
Radiolucent centers, multiple, mostly below
the level of ischial spine, located along the
course of veins.
56Dept of Urology, GRH and KMC, Chennai.

57. Appendicolith
57Dept of Urology, GRH and KMC, Chennai.

58. Fallopian tube occlusion rings
58Dept of Urology, GRH and KMC, Chennai.

59. Bladder Calculi
•Size ranges from 1-2 mm to large calculi of many cms
•May be solitary or multiple in number
•Range from densely radiopaque stones to faintly radiopaque stones
depending on the composition.
•May have variety of shapes
59Dept of Urology, GRH and KMC, Chennai.

60. Bladder Calculi
60Dept of Urology, GRH and KMC, Chennai.

61. Mimicking Bladder Calculi
•Feces in rectum (as low density bladder calculi)
•Retained barium in rectum after contrast study
•Opaque rectal suppositories
•Rectal foreign bodies
•Calcification in rectal tumour
•Calcification in bladder tumour
•Foreign bodies in the vagina
•Primary/secondary vaginal calculi (mostly struvite)
•Calcified fibroids or ovarian tumours
•Prostatic calcifications
61Dept of Urology, GRH and KMC, Chennai.

62. Rectal Fecolith
62Dept of Urology, GRH and KMC, Chennai.

63. Bladder and Vaginal Calculi
63Dept of Urology, GRH and KMC, Chennai.

64. Prostatic Calcification
64Dept of Urology, GRH and KMC, Chennai.

65. Bladder Wall calcification
•Schistosomiasis –Common
•Tuberculosis –Rare
•Alkaline encrystingcystitis –After radiotherapy in the presence of
necrotic or ischemic bladder tissue and alkaline urine produced by
Proteus infection.
•After cyclophosphamide or mitomycintreatment of bladder
•Primary amyloidosis –submucosal amyloid deposition
•Prune Belly Syndrome-Dystrophic calcification of dome
65Dept of Urology, GRH and KMC, Chennai.

66. Bladder wall Calcification-Schistosomiasis
66Dept of Urology, GRH and KMC, Chennai.

67. Alkaline Encrusting Cystitis
67Dept of Urology, GRH and KMC, Chennai.

68. Prostatic Calcifications
•Primary prostatic
calcification
•Secondary prostatic
calcification
68Dept of Urology, GRH and KMC, Chennai.

69. Prostatic Calcifications
•Primary prostatic
calcification
•Normally present in 30% of
subjects.
•Usually small (1-5mm) and
multiple
•Due to calcium deposition on
corpora amylacea
•Usually calcium phosphate
69Dept of Urology, GRH and KMC, Chennai.

70. Prostatic Calcifications
Secondary prostatic
calcification
•In abnormal prostates with
benign hyperplasia,
obstruction and stasis,
infection or carcinoma or
after radiotherapy.
•Secondary prostatic
calcification due to
obstruction may measure
upto10 mm or more.
70Dept of Urology, GRH and KMC, Chennai.

71. Primary prostatic calculi
•Small multiple calcifications
•Due to calcification of corpora
amylacea
71Dept of Urology, GRH and KMC, Chennai.

72. Secondary Prostatic Calcification
•Trilobedsecondary prostatic
calcification in voiding
dysfunction due to neurogenic
bladder
72Dept of Urology, GRH and KMC, Chennai.

73. Secondary Prostatic Calcification
•Dystrophic calcification of prostate
in Genitourinary tuberculosis
73Dept of Urology, GRH and KMC, Chennai.

74. Secondary Prostatic Calcification
•Secondary prostatic calcification
due to urethroprostatic urinary
reflux
74Dept of Urology, GRH and KMC, Chennai.

75. Urethral Calculi
•Native calculi –Rare and are formed within the urethra (Dumbell
Shaped)
•Migrant calculi-Arise in the kidney or bladder and then descend into
the urethra (Small stones struck at proximal to narrowing)
75Dept of Urology, GRH and KMC, Chennai.

76. Native Calculi
•Dumbellshaped with portion of
calculus inside the bladder.
•Associated urethral stricture may
be present.
•May develop in prostate bed after
prostatectomy, particularly Open.
76Dept of Urology, GRH and KMC, Chennai.

77. Migrant Calculi
•After lithotripsy, patient
underwent steinstrasseof urethra
due to urethral stricture in this
case.
77Dept of Urology, GRH and KMC, Chennai.

78. Other Indicental
Findings
Vas deferens calcification
•May be due to degenerative
changes in diabetes or with
aging
•Or due to chronic infection
•Tramline calcification of ampulla
is typical
78Dept of Urology, GRH and KMC, Chennai.

79. Other Indicental
Findings
Seminal vesicle calcification
•Due to chronic infection of
tuberculosis or schistosomiasis.
•Patchy, coarse and asymetrical
in TB
•Symmetrical in schistosomiasis
•Rare causes –Old age, urinary
reflux
79Dept of Urology, GRH and KMC, Chennai.

80. Thank you
80Dept of Urology, GRH and KMC, Chennai.