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INTRAVENOUS PYELOGRAPHY

Danielle Aquino Kevin Baciles Justin Claro Luisa Manalo Dona Sison
Urography – is a general term for the radiographic investigation of the renal drainage or collecting system. The plain abdominal radiographic image provides very little information about the urinary system. The gross outline of the kidneys may be faintly demonstrated because of the fatty capsule surrounding the kidneys. However, in general, the urinary system

. The term pyelography refers to the radiographic demonstration of the renal pelves and calyces. and despite their increasing use. Instrumental Method (Ascending Method/Non-functional Method) – contrast is introduced directly into the canal by means of catheterization or instrumentation or against the natural flow of blood stream. Cystoscopy.blends in with the other soft tissue structures of the abdominal cavity. The excretory techinque of urography is used in examinations of the upper Urinary tracts in infants and children and is generally considered to be the preferred technique in adults unless use of the retrograde technique is definitely indicated. Since the contrast medium is administered intravenously and all parts of the urinary system are normally demonstrated. However. Excretion urography has long been the cornerstone of the imaging evaluation of urinary tract disease. urography may still be important in the diagnosis of some urinary tract disease processes. Hypertensive IVP. other imaging modalities such as. Examples: Ureteral Catheterization. Examples: Intravenous Pyelography.CT. fluid filled portion of the urinary system. Percutaneous Antegrade Urography/Retrograde Anatomy  Kidneys – a pair of gland like organ that function to remove waste materials from the blood and eliminate waste in the urine that they excrete to the extent of about 1-2 liters per day. General radiographic examination of the urinary system is termed urography. thus requiring contrast media to radiographically visualize the internal. The declining use of urography in clinical practice presents a challenge for instruction in urographic technique and interpretation. Two methods: 1. Urethral Catheterization. and MRI are being used with increasing frequency. This radiographic procedure in which contrast media is injected intravenously is termed as an INTRAVENOUS UROGRAM. the ideal ―global‖ urinary tract examination remains controversial. In addition. Excretory Urography (Intravenous Urography/ Functional Method/ Descending Urography) – most frequently employed in which contrast is routinely administered intravenously or to the normal flow of blood stream. Nevertheless. Drip Infusion IVP) 2. the excretory technique is correctly referred to as intravenous urography. alternative modalities also have their limitations. For years the examination has been erroneously called an intravenous pyelogram (IVP).

Renal Pelvis – expanded portion of the ureter at the union of major calyces.5 cm) in length. The calyces are cup-shaped stems aris. and the medial border is concave. passes inferiorly and posteriorly in front of the sacral wing. so that there are usually fewer ca. The major calyces unite to form the expanded.25 inches (3 cm) in thickness. The left kidney usually is slightly longer and narrower than the right kidney. The kidneys are bean-shaped bodies.pering lower part passes through the hilum to become continuous with the ureter *note: The essential microscopic components of the parenchyma of the kidney are called nephrons.6 cm) in width. Calyces – beginning stem of variable number. 3 Constricted Points: 1.ing at the sides of the papilla of each renal pyramid. Right kidney is lower than the left because of the large space occupies by the liver. these are known as the Pelvicalyceal System. Each kidney contains approximately 1 million of these tubular structures. The kidneys measure approximately 4.  Excretory ducts – transport urine to the exterior through: a.5 inches (11.  Ureters – pair of long tubes one extending from the pelvis of each kidney. The wide. The ureters convey the urine from the renal pelves to the bladder by slow. Together. Ureteropelvic Junction (UPJ) – where the renal pelvis funnels down into the small ureter.(Kidneys are somewhat higher in individual with hypersthenic habitus and somewhat lower for asthenic habitus. Brim of the Pelvis – where the iliac blood vessels cross over the ureters. and they unite to form two or three larger tubes called the major calyces. It descends behind the peritoneum and in front of the psoas muscle and the transverse processes of the lumbar vertebrae. which is 10-12 inches in length. upper portion of the re. . and its ta. and they are arbitrarily divided into upper and lower poles. Each calyx encloses one or more papillae. 2. They have slightly convex anterior and posterior surfaces. and then curves anteriorly and medially to enter the posterolateral surface of the urinary bladder at approximately the level of the ischial spine. and about 1. rhythmic peristaltic contractions. The lateral border of each organ is convex. Kidneys have a respiratory excursion of approximately 1‖ and normally drop no more than 2‖ in the change of supine to erect.nal pelvis lies within the hilum. The beginning branches are called the minor calyces (numbering from 4 to 13). The kidneys are approximately located between the level of T12-L3.lyces than pyramids. funnel-shaped renal pelvis. b. 2 to 3 inches (5 to 7.

The bladder varies in size.  Urinary Bladder – musculo-membranous sac which receives the distal portion of the ureter and serves as reservoir for urine. Bladder – carcinoma located in the bladder 2. Pathologic Conditions:    Benign Prostatic Hyperplasia (BPH) . Horseshoe Kidney – Fusion of the kidneys.  . Renal Cell – Carcinoma located in the kidney Congenital Anomaly – abnormality present at birth: 1. Duplicate Collecting System –two renal pelvi and/or ureters from the same kidney. When empty. The urethra arises at the internal urethral orifice in the urinary bladder and extends about I Y'2 inches (3. a base anteriorly and a superior and two inferolateral surfaces. It is freely movable and is held in position by folds of the peritoneum.der can hold approximately 500 ml of fluid when completely full. Most kidney stones that pass down the ureter tend to hang up at the third site. When empty. b. As the blad. a narrow musculomembraneous canal with sphincter type of muscle at the base of the bladder.turition (urination) occurs when about 250 ml of urine is in the bladder. Ureterovesical Junction (UVJ) – (bladder inlet) where the ureter joins the bladder. The adult blad.der fills.8 cm) in the female and 7 to 8 inches (17. The bladder is situated immediately posterior and superior to the pubic symphysis and is directly anterior to the rectum in the male and anterior to the vaginal canal in the female. a. usually at the lower poles. it is pyramidal in shape and presents an apex behind the symphysis pubis. and position according to its content.8 to 20 cm) in the male. and once the stone passes this point and moves into the bladder. it generally has little trouble passing from the bladder and through the urethra to the exterior. Male Urethra – extends from the bladder to the end of the penis. the bladder is located in the pelvic cavity. The most fixed part of the bladder is the neck.Enlargement of the prostate. The desire for mic. Calculus – Abnormal concentration of mineral salts. often called a stone Carcinoma – malignant new growth of epithelial cells. 2. shape.  Urethra – serves to convey urine to the exterior. 1. Female Urethra – passes along the thick anterior wall of the vagina to the external urethral orifice. it gradually assumes an oval shape while expanding superiorly and anteriorly into the abdominal cavity. which rests on the prostate in the male and on the pelvic diaphragm in the female.3.

3. Renal Obstruction – Condition preventing the normal flow of urine through the urinary system. Renal/Uteral Calculi – very common insoluble stones formed from crystal salts found in urine due to excessive intake of mineral salts and insufficient intake of water. Cystitis – inflammation of the bladder. Ptotic Kidney – abnormal depression of the kidney. Pyelonephritis – inflammation of the kidney and the renal pelvis. Falling down of the Kidney. 7. To remove the obstruction. Tumor – new tissue growth where cell proliferation is uncontrolled. Stenosis – narrowing of contraction of passage. Pelvic Kidney – kidney that fails to ascend and remains in the pelvis. 5. Urinary Tract Infection – caused by bacteria that entered the body in retrograde fashion. Abdominal/Pelvic Tumor – any abnormal mass resulting from excessive multiplication of cells swelling. Vesicoureteral Reflux – backward flow of urine from the bladder into the ureters. 2. Glomerulonephritis – Inflammation of the capillary loops in the glomeruli of the kidney. 4. Polycystic Kidney – massive enlargement of the kidney with the formation of many cysts. Internal defects of the Renal system: a. Indications of Urography: 1. a surgery or invasive procedure may be done. Fistula – abnormal connection between two internal organs or between an organ and the body surface. Ureterocele – ballooning of the lower end of the ureter into the bladder. . Hematuria – presence of blood in the urine. Hypertension – persistently high arterial blood pressure. Renal Hypertension – increased blood pressure to the kidneys. It is caused by an obstruction of urine flow in the genitor-urinary tract. Wilms’ – most common childhood abdominal neoplasm affecting the kidney. 6. Hydronephrosis – distention of the renal pelvis and calyces with urine. a. Hydronephrosis – abnormal dilation of the renal pelvis and the calyces of one or both kidneys.            3. Achalasia – abnormal constriction of the urinary system which leads to renal failure.

Multiple Myeloma – malignant condition of plasma cells of bone marrow. 2. thus requiring contrast media to radiographically visualize the internal. failure causing build up of nitrogenous wastes in the blood. Renal Failure 7. fluid filled portion of the urinary system. Extravasation – leakage of contrast media out of the vein into the surrounding tissue. Contraindications: 1. Non-ionic Ionic Contrast It contains Iodine as the opacifying element and other chemical components that create a complex molecule. Hypersensitivity to contrast media.b. Ionic iodinated contrast media contain a positively charged side chain element called CATION. Ionic 2. 4. Vasovagal Response – response to fear. . 5. Diabetes Mellitus 6. Types of Contrast Media: 1. 3. Uremia – complex biochemical abnormality occurring in the kidney. Unprepared Patient Materials Used:  1/3/5 cc syringe  50cc syringe  Catapres (For high BP)  Hydrocort  Micropore  Hypodermic needle for aspiration  Butterfly or IV Cannula Contrast Media The urinary system blends in with the other soft tissue structures of the abdominal cavity. Pregnant Patient 8.

asthma. Most likely to experience adverse contrast reactions to ionic contrast media are those with a history of previous CM reaction. and/or diabetes. creating two separate ions in the blood.The cation is a SALT. (THREE IODINE ATOMS PER TWO ION RELATIONSHIP) Higher Osmolality and Greater chance of Reaction: Once injected. pain at the injection site. Commercial names: 1. Ultravist 3. It has SIX iodine atoms per two particles. It helps to stabilize the contrast media compound. Increase is osmolality can cause vein spasm. hematologic disorders. There might be a disruption in the physiologic balance (homeostasis) which may lead to an adverse reaction. the cation dissociates from the anion. Hexabrix Blood Chemistry: . The cation is combined with a negatively charged component called the anion. This causes fewer adverse contrast reactions than ionic CM. This action creates a hypertonic condition. Approxiamtely half the dose is needed to maintain opacification of the area of interest. and fluid retention. It remains as two particles when introduced into the bloodstream and has twice the iodine concentration as other ionic contrast agents. along with three iodine atoms (Tri-iodinated contrast media). usually consisting of sodium or meglumine. The cation and anion attach to the parent benzoic acid ring. Visipaque 2. or acombination of both. or an increase in the blood plasma OSMOLALITY. kidney/heart/liver disease. These salts increase the solubility of the contrast media. Ionic Contrast agents ay increase the probability that a patient will experience a contrast media reaction. Low Osmolality Organic Iodide It is ionic I nature but holds the nondissociating characteristics of a non-ionic CM.

Epinephrine A common emergency drug. Symptoms: Axiety. nausea. Lactic Acidosis Lactic acidosis occurs when there is too much lactic acid in your body. A lower pH means that your blood is more acidic. Metformin Metformin hydrochloride is a drug that is given for the management of non-insulin dependent diabetes mellitus. 2. May lead to life threatening condition.4. Light headedness. tumor or other conditions of the urinary system. This type of reaction may be based on anxiety and/or fear. Acidosis When your body fluids contain too much acid. Example: Benadryl Contrast Media Reactions: 1. some patients may be premedicated before an iodinated CM procedure is performed. Many things can cause a buildup of lactic acid. Combination of iodinated contrast media and metformin may increase the risk for contrast media induced acute renal failure and lactic acidosis. this is known as acidosis. Elevated creatinine or BUN levels may indicate acute or chronic renal failure. The acidity of your blood is measured by determining its pH. A higher pH means that your blood is more basic. vomiting. Creatinine and BUN are diagnostic indicators of kidney function. To reduce severity of Cm reactions. It often involves drug intervention to counter effects of reaction. . Moderate This reaction is a TRUE ALLERGIC REACTION (Anaphylactic reaction) that results from iodinated CM.The technologist must check the patient’s chart to determine the creatinine and BUN (blood urea nitrogen) levels. The pH of your blood should be around 7. Mild This does not require drug intervention/assistance. Patients whoa re currently taking metformin can be given iodinated CM ONLY if their kidney function levels are within normal limits.

and diabetes must be well hydrated before urography because there is an increased risk of contrast media that can induce renal failure. 3. Fast and prompt response from medical team is required. 6. A light evening meal the night before the examination. Respiratory system – pulmonary edema c. cardiac arryhtmias.  Urograms should have the same contrast and density and the same degree of soft tissue as the abdominal radiographs. Severe Also known as ―vasovagal reaction‖ is a LIFE THREATHENING CONDITION. possible laryngeal swelling. When indicated. Symptoms: Hypotension. cardiac/respiratory arrest *hospitalizatoin for patient is eminent. laryngeal swelling. high uric acid. Vascular system – venous thrombosis d. a. 4. Renal system – temporary failure or complete shutdown f. the patient should not be dehydrated. tachycardia/bradycardia 3. Cardiac system – pulseless electrical activity b. 1-2 days prior to examination to prevent gas formation. Report to x-ray department for examination. loss of conciousness. It must show a sharply defined outline . which may cause the heart rate to drop and the blood pressure to fall dangerously low. 4. 2. 5. Extravasation – leakage of ICM outside of the vessel into surrounding soft tissue Patient Preparation: 1. non-gas forming laxative is given the night before the examination. possible convulsions. Introduction of iodinated contrast agents stimulates the VAGUS NERVE. Nervous system – seizure induction e. hypotesion. However. bradycardia. bronchospasm. Organ Specific Specific organs are affected by the contrast media injection. Low residue diet. No breakfast and no smoking on waking up.Symptoms: urticaria (moderate to severe hives). by costive bowel action. NPO (Nothing per Orem) after midnight. The patients who have multiple myelomas.

BUN levels should range between 8-25mg/100ml. Creatinine and BUN are diagnostic indicators of kidney function. of the kidneys. Technique:   Venous access via the median antecubital vein is the preferred injection site because flow is retarded in the cephalic vein as it pierces the clavipectoral fascia. Consent Form: Venipuncture is an invasive procedure that carries risks for complications. and the guardian should sign the informed consent form. especially when contrast media is injected. lower border of the lvier and the lateral margin of the psoas muscles.5mg/dl. the procedure should be explained to both the child and the guardian. Before beginning the procedure. The technologist must check the patient’s chart to determine the creatinine and BUN (blood urea nitrogen) levels. tumor or other conditions of the urinary system. If a child is undergoing venipuncture. The gauge of the cannula/needle should allow the injection to be given rapidly as bolus to maximize the density of nephrogram. Sensitivity Test: 15-30 minutes The patient is instructed to completely empty the bladder. the technologist must ensure that the patient is fully aware of these potential risks and has signed an informed consent form. 1-2cc of contrast is injected to determine if the patient is sensitive or allergic to contrast or to determine any untoward reaction. Elevated creatinine or BUN levels may indicate acute or chronic renal failure. Normal creatinine levels for the adult are 0. The bladder should be emptied to prevent dilution of the opacified urine when contrast enters the urinary bladder. Procedure . Patients with elevated blood levels have a greater chance of experiencing an adverse contrast media reaction.6-1.

3. MSP of the body center to the midline of the table. Respiration suspended at the end of exhalation. When ureteric compression is to be used. RP – iliac crest. 6. Timing for the entire series is based on the start of the injection. (3) very positioning. The chart should note the amount and type of contrast media given to the patient. (2) determine whether exposure factors are acceptable. Position: KUB 1. Most contrast media reactions will occur within the first 5 minutes following injection. A support should be placed under the patients knees to reduce lordotic curvature of the lumbar spine. This is done to retard the flow of the opacified urine into the bladder and ensures adequate filling of the renal pelves and calyces. 4. and (4) detect any abnormal calcifications. shoulder support must be attached and adjusted to the patient’s height. it should be clamped before injection. 5. Image quality and exposure technique . the patient should be observed carefully for any signs or symptoms indicating a reaction to the contrast media. not the end of it. As the examination proceeds. After the full injection of contrast media. Compression is sometimes applied over the distal ends of the ureters. If the head of the table is to be lowered further to enhance pelvicalyceal system filling. These scout radiograhs should be shown to the radiologist before injection. Each image must be marked with a lead number that indicates the time interval when the radiograph was taken. If the patient has a catheter in place. radiographs are taken at specific time intervals. Patient in supine 2. When the injection is made. the exact start time and the length of injection should be noted. it should be placed so that it is ready for immediate application at specified time.Scout Film (Preliminary film) The scout radiograph is taken to (1) verify patient position. 7. CR perpendicular to RP. Delayed reactions may also occur. The injection usually takes between 30 seconds and 1 minute to complete. Contrast Dosage: Average patient: 3—100 ml (depends on body habitus and physician) Children and Infants: dosage will depend upon the patient’s body weight and age. 8.

The supine position (AP) is the preferred position. Nephrogram or nephrotomogram – is taken immediately after completion of injection (or 1 minute after start of injection) to capture the early stages of entry of the contrast media into the collecting system. 20 minute Obliques – should use LPO and RPO positions to provide a different perspective of the kidneys and project the uereters away from the spine. As a result of improvements in contrast agents. 15-20 minutes: greatest concentration of contrast occurs. and lateral margin of the psoas muscles. it must be placed so that the pressure over the distal ends of the ureters is centered at the level of ASIS. The radiographs must show a sharply defined outline of the kidneys. 2. the supine position (AP) is required most commonly. Once again. The pressure should be released slowly when the compression device is removed to avoid the possibility of visceral rupture. lower border of the liver. a suprapubic catheter. Compression is generally contraindicated if a patient has urinary stones. 10 to 15 minute image – requires a full KUB to include the entire urinary system. Ureteral compression In excretory urography. an abdominal mass or aneurysm. a colostomy. and degree of soft tissue density as do abdominal radiographs. This is done to retard flow of the opacified urine into the bladder and thus ensure adequate filling of the renal pelves and calyces. . Basic Imaging Routine (Sample IVU Protocol) A common basic routine for an IVU is as follows: 1. density. If compression is used. 3. 4. most of the ureteral area is usually demonstrated over a series of radiographs. 5 Minute Image – requires a full KUB to include the entire urinary system. ureteral compression is not routinely used in most health care facilities. The amount of bone detail visible in these studies varies according to the thickness of the abdomen. IV Urography Contrast Opacification after full dose: 1-8 minutes: contrast appears in the pelvicalyceal system. or traumatic injury.Urograms should have the same contrast. As much pressure as the patient can comfortably tolerate is then applied with the immobilization band. compression is sometimes applied over the distal ends of the ureters. With the increased doses of contrast medium now employed.

5. Postvoid radiograph – is taken after the patient has voided. Whether an extra renal mass in the flank is intraperitoneal or extraperitoneal. Presence of residual urine. Erect or Semi Erect – demonstrate opacified bladder and mobility of the kidneys.   Post Voiding or Post Micturation:  Upright – to detect ptotic kidneys. Frequent recommended positions:   AP Urograms – at different time intervals ranging from 3-20 mins. Patient is aked to void or urinate to detect: 1. 2. Prostate enlargement for male. Each kidney lies in an oblique plane and is rotated about 30 degrees anteriorly toward the aorta. *note: Ensure that time markers are placed on the IR prior to exposure to record the tome of exposure. The positions of choice may include a prone (PA) or erect AP. the lower kidney lies perpendicular and the up. 2. The ureters fill well in prone because it reverses the curve of their inferior course. Mobility of the kidneys. which lies on top of the vertebral body. Optional Positions:  Cross Table Lateral – to determine or demonsrate: 1. Such condition as small tumor or masses.per kidney lies parallel to the IR Prone – demonstrate ureteropelvic region and filling of the obstructed ureter in the presence of hydronephrosis. Screen both kidneys and ureters for any abnormal anterior displacement. LPO and RPO – at 5-10 or 5-15 time intervals with 30º body rotation. Kidneys obliquely. 3. When the body is rotated 30 degrees for the AP oblique projection (LPO or RPO position). 4. slanting anteriorly so the urine tends to collect in and distend in the dependent part of the pelvicalyceal system. Oblique and Lateral  . Ureteropelvic junction in presence of hydronephrosis. The bladder should be included on this final radiograph. 3. Posteriorly place upper calyces fill more readily in supine while anterior and inferior parts of calyces and renal pelvis fill more in prone.

check exposure factor. c. e. and location of radiopaque stones or any radiopaque artifacts. 5 Minute Film: * AP of renal mass * To determine if excretion is symmetrical and is invaluable for assessing the need to modify the technique. To localize calcareous shadows and tumor masses. Films:    a. The lower border of cassette is at level of symphysis pubis and the CR in midline at level of iliac crest/umbilicus. Preliminary Film: Supine. d. in expiration. the position of overlying opacities may be further demonstrated by: 1. giving an unobstructed projection of the lower ureters and vesicoureteral orifice areas. To demonstrate bowel preparation. To demonstrate conditions as rotation or pressure displacement of the kidneys. *note: If necessary. 1. full length AP of abdomen in inspiration. b. 15 Minute Film: * Supine full length AP * There is usally adequate distension of the pelvicalyceal systems with opaque urine by this time. the pt. Or 35º posterior oblique views 3. If the film is satisfactory. 2. is asked to void. Supine AP of renal areas. Or Tomography of the kidneys at the level of a third of the AP diameter of th patient (25-40º). 2. The CR is centered in the midline at the level of lower costal margin. AP Trendelenburg 15-20º table elevation – demonstrate lower end of the ureters. Full Bladder * taken to show the bladder. Post Void Film: . Weight of contained fluid stretches the bladder fundus superiorly.

Delayed films up to 24hrs.      . Lateral film of bladder area. In case of Hypertension: Take fast sequences (1min. Bladder Diverticulum Abnormal pouch formed within the bladder. Children – films are taken in 3min. Renal Agenesis Full film KUB from immediate to alst film. film of kidney area with 25º caudal tube angulation). Vesicovaginal Fistula Lateral film of bladder area. 15min and post void after CM injection and further depending upon pathology.       Modification in case of Pathology:  In case of suspicious shadows in renal area: Take lateral film of renal area. Prone Film – to investigate pelviureteric and ureteric obstruction as the heavy contrast laden with urine will more readily gravitate to the side of the obstruction. 3min and 5min film) Ectopic Kidney Full film KUB region from immediate to last film. Delayed Film – may be necessary for up to 24 hrs. Take inspiratory and expiratory film of renal area to demonstrate the relationship of opacities and filling defects of renal tract.* to assess the bladder after emptying. (Patient lies prone after doing 15 min film and after 5 mins of lying prone) Tomography – when there are confusing overlying gas shadows in renal areas. erect oblique film of area of ureter. after injection to demonstrate the actual site of ureteric obstruction. AP with caudal angulation – to separate the over shadows by stomach on the left kidney (AP position. * residual volume of urine Additional Films:  Posterior Obliques of kidneys/ureters/bladder – to determine whether the radiopaque shadow is in the ureter or ourside (Patient is rotated 30-35º in rpo/lpo depending on pathology side). To demonsrate layering of calculi in cysts and abscesses. to displace the overlying bowel gas toward the periphery. Erect Film – to determine whether or not there is small ureteric calculus.

Drip Infusion IVP Preparation: same as IV Urogram Scout Film: same as IV Urogram Sensitivity test: same as IV Urogram Procedure: 2-3 vials or ampoules of contrast is being incorporated with a 200cc of 5% dextrose in water connected to a veno-set or rubber tubing. depending upon the discretion of the radiologist. All exposures are taken in AP position. take time interval exposures. Preparation: same as IV Urograms Scout Film: same as IV Urograms Time intervals: 1.  Note: time interval exposures will depend upon the discretion of the radiologist. 5 minutes – take exposure of the entire urinary system centered to the iliac crest. patient may be allowed to eat. 30. After the amount has been consumed. Take 1. 5.2.  Note: after 2hrs.Hypertensive IVP – Used for hypertensive patient or infant to determine if the kidneys are causing hypertensive condition. 15. . 2. 2. 30 minutes (AP) 5. 45. adjust the height of the dextrose in such a way that the fluid will flow as fast possible. RP – umbilicus or iliac crest.3 mins. 15 minutes (PA) 4. film.  This method provides opacification of the renal parenchyma as well as of the renal drainage canals and thus embraces both nephrography and urography. 3. 2hrs or even up to 2hrs. after completion of injection using (10x12) centered to kidney area. Prepare the IV set and an IV stand. Time intervals: 1. 1hr. 3. Post voiding film.