Babeh Edi

Intravenous Urogram Basic (Full notes in Tutorials section)

Basic Anatomy Meschan, I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London Indications for imaging Suspected urinary tract pathology. Repeated infections ? focus, damage, (when linked with other symptoms.) Heamaturia. Investigation of hypertension not controlled by medication in young adults. Renal colic. Trauma. Contra Indications: General contra indications to water soluble contrast agents. Hepato renal syndrome, Thyrotoxicosis, Pregnancy, (Allow 28 days from childbirth) Blood urea raised above 12 mmol./L. urography unlikely to be successful. See the Useful Articles section for notes on patients taking metformin Patients Preparation: Basic abdominal preparation, aperients taken for 24 hours previous, to clear faecal residue. Nil by mouth for 4-6 hours before the examination. Patient to remain ambulant as long as possible to reduce air swallowing. Adaptations to patient preparation will be required for certain groups of patients e.g. children, diabetics and patients with other predisposing medical conditions, in line with current department practice. Basic Patient Position The patient lies supine on the table midline aligned to the midline of the table.  IVU Patient Positions a) AP   &       b) Bladder                           Meschan, I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London Central Ray Control Film of abdomen The vertical central ray is centered in the midline at the level of L3 at the lower costal margin, It may be necessary to alter the centering position to ensure the upper margin of the renal outlines are visible and the symphysis pubis. Exposure is made on suspended expiration. Renal area films The vertical central ray is centered in the midline at the level of the midpoint of the upper and lower borders of the renal outlines. Exposure is made on suspended expiration. Bladder Films The central ray is angles 15 degrees caudally and centered in the midline to a point at a level midway between the symphysis pubis and the ASIS. Exposure is made on suspended expiration. Radiation protection Direct lead rubber gonad protection using a "half apron" or Kings Lyn shields when possible. Film Sequence Preliminary film (Control), (35 x 43cm) supine full A.P. abdomen to include lower border of symphysis pubis and diaphragm, to check, abdominal preparation, exposure values and for any calcifications overlying the renal tract areas. Supplementary films to determine position of any opacities. Inspiration film of renal areas for suspected calculi. 35° posterior oblique of the renal areas. Tomogram of the renal areas at 8-11cm.   Preliminary film (Control), (24 x 30 cm) Inspiration Contrast Media Injection The median cubital vein is punctured with a 19 gauge needle and the warmed (40*C) contrast agent is injected rapidly. Films are then taken at intervals to demonstrate the whole of the renal tract. Product Main constituent Iodine mg./ml Dose Route Niopam 300 Iopamidol 300 50ml. I.V. Omnipaque 350 Iohexhol 350 50ml. I.V. Urograffin 370 Diatrozates 370 50ml. I.V. End of Injection, (24 x 30cm) A.P. of the renal areas to show the nephrogram, i.e. the renal parenchyma opacified by the contrast medium in the renal tubules. . 5 Minute film, (24 x 30cm) A.P. of the renal areas to determine if excretion is symmetrical or if uptake is poor and a further dose of contrast agent is required. . Compression may be applied in some centers at this point to distend the pelvicalyceal systems to demonstrate any filling defects and a film taken at 10 minutes of the renal areas. Compression should not be used in cases of suspected renal colic, renal trauma or after recent abdominal surgery. 15 Minute film (35 x 43cm) (On release if compression has been applied) to demonstrate the pelvicalyceal systems and the ureters. 25 Minute film (24 x 30cm) 15° caudal angulation centered 5 cm above the upper border of the symphysis pubis to demonstrate the distended bladder. Post Micturition film (24 x 30cm) 15° caudal angulation centered 5 cm above the upper border of the symphysis pubis to demonstrate the bladder emptying success, and the return of the previously distended lower ends of ureters to normal. Patient Aftercare General psychological reassurance. Needle wound site dressed and checked for extravasation. Check patient understands how to receive the results. Ensure patient understands any preparation instructions are finished Escort to changing rooms and bid good-bye. Exposure Factors Kv mAS FFD (cm) Grid Focus AEC Cassette 65 - 70 50 - 100 100  Yes Broad Yes 35 x 43 cm 24 x 30 cm Evaluation of the Image ID and markers must be present and correct in the appropriate area of the film Evidence of collimation on four sides equally around the centering point Optimal exposure should just penetrate all the contrast media filled structures and contrast should be optimised  to visualise fully the renal and soft tissue structures. Related Projections Inspiratory, expiratory and oblique projections may be required to demonstrate the relationship of opacities and filling defects to the renal tract. Tomography, may be required to accurately demonstrate the renal outlines and overcome shadowing from the gastro intestinal tract. Prone films may be required to investigate pelvi ureteric and ureteric obstruction as the heavy contrast laden urine will more readily gravitate to the site of the obstruction. Rapid sequence films may be taken in cases of suspected renal hypertension to evaluate differential rates of contrast excretion. Delayed films may be taken for up to 24 hours in order to demonstrate the actual site of ureteric obstruction. Additional modalities Radio nuclide imaging for renal function evaluation. Radio nuclide imaging for renal transplant rejection assessment. Ultrasound for bladder investigation as a first line of imaging. Ultrasound for renal cyst imaging and drainage if required. C.T. for investigation of trauma and renal masses. Renal Angiography. Retrograde pyelography, Urethrography. Magnetic resonance imaging.