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Diana Pancu, MD
RENAL ULTRASOUND
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Objectives
• Clinical indications for performing ED renal US
• Approach to performing the US study
• Normal anatomy
• Abnormal findings
• Clinical Impact
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Clinical Indications for ED Renal Ultrasound
• Suspected renal colic– Colicky flank pain radiating to groin – Hematuria
• Clinical question:– Presence of hydronephrosis– Absence of other pathology (AAA)
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Performing the Study
• Patient preparation: – none
• Transducer: 3.0MHz or 3.5 MHz– 5.0 MHz for thin patient
• Patient positioning– Supine– Posterior oblique, lateral decubitus, prone
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Anatomy
• Kidneys are retroperitoneal, T12 - L4
• Right kidney is lower than the left kidney
• Right kidney is posterio-inferior to liver & gallbladder
• Left kidney is inferior-medial to the spleen
• Adrenal glands are superior, anterior, medial to each kidney
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IVC
AO
RT
A
Celiacaxis
SMA
Renal artery
Renal vein
HepaticVeins
Rightkidney
Left kidney
Liver
Spleen
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Renal Scanning Approaches
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Approach to Scanning
• Right kidney scanning approach: anterior, lateral, posterior
• Liver is the acoustic window
• Left kidney: requires a posterior approach, through the spleen
• Air-filled bowel impedes anterior scanning
I
LIVER STOMACH
SP
LE
EN
IVC
AORTAK K
S
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Anatomy• 9-12 cm long, 4-5 cm wide, 3-4 cm thick
• Gerota’s fascia encloses kidney, capsule, perinephric fat
• Sinus– Hilum: vessels, nerves, lymphatics, ureter– Pelvis: major and minor calyces
• Parenchyma surrounds the sinus– Cortex: site of urine formation, contains nephrons– Medulla: contains pyramids that pass urine to minor
calyces. Columns of Bertin separate pyramids
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Renal artery
Renal vein
Ureter
Renal capsule Cortex
Medullary pyramids
Minor Calyx
Kidney Anatomy
Medulla
Sinus
Major Calyx
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Sonographic Appearance
• Ureters are normally not seen
• Renal pelvis is black when visible
• Renal sinus is echogenic due to fat
• Medullary pyramids are hypoechoic
• Cortex is mid-gray, less echogenic than liver or spleen.
• Capsule is smooth and echogenic
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Right Kidney Long Axis
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Liver
Diaphragm
Sinus
Cortex
Anterior
Posterior
Superior Inferior
Right Kidney Long Axis
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Right Kidney Short Axis
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Right Kidney Short Axis
VertebralBody
R KidneyAortaRenal a.
GB
IVC
Liver
Anterior
Posterior
Right Left
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Left Kidney Long Axis
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Left Kidney Long Axis
Anterior
Posterior
Superior Inferior
Spleen
Kidney
Rib Shadow
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Left Kidney Short Axis
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Left Kidney Short Axis
Anterior
Posterior
Right LeftLiver
Spleen
L Kidney
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Common Pitfalls in Renal Scanning
• Failure to scan both kidneys
• Mistaking prominent renal pyramids for hydronephrosis
• Mistaking prominent pyramids for cysts
• Confusing normal renal arteries for the ureter
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Common Pitfalls in Renal Scanning
• Failure to scan through the bladder to search for stone at the uretero-vesicular junction
• Inability to visualize left kidney due to anterior probe placement
• Failure to scan the aorta in suspected renal colic
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Normal Variants
• Dromedary humps:– Lateral kidney bulge, same echogenicity as the cortex
• Hypertrophied column of Bertin: – Cortical tissue indents the renal sinus
• Double collecting system: – Sinus divided by a hypertrophied column of Bertin
• Horseshoe kidney: – Kidneys are connected, usually at the lower pole
• Renal ectopia: – One or both kidneys outside the normal renal fossa
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Clinical Indications
1. Obstructive Uropathy
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Nephrolithiasis
• 12% of the US population • Incidence of renal colic is 3% with
50% recurrence within 10 years
– Manthey DE. Emerg Med Clin North Am.2001; 19(3): 633-54
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Radiographic Modalities
Radiography• 62% Sensitivity, 67% Specificity
– Sharma RN, Shah I, Gupta S, et al: Thermogravimetric analysis of urinary stones. Br J Urol 64:564-566, 1989
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Radiographic Modalities
IVP vs. US• Prospective study, 85 patients
– Sinclair D, Wilson S, Toi A, et al. Ann Emerg Med 18:556-559, 1989
ULTRASOUND Sensitivity=85%Specificity=92%
IVPSensitivity=90%Specificity=94%
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Radiographic Modalities
ED Ultrasound + KUB vs. IVP• Prospective study, 108 patients
Sensitivity = 97%Specificity = 59%
Henderson, S, et al: Acad Emerg Med.1998;5:666-671.
Sensitivity = 97%Specificity = 59%
PPV = 81% NPV = 92%
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Radiographic Modalities
Helical CT- Gold Standard• Accurate, fast, no contrast
• Identifies presence and size of stone
• Location of stone
• Level of obstruction• Other sources of pain
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Stone on CT
• Usually visualized
• Not visualized– Stone is extremely small < 1 mm– Stone is of relatively low CT attenuation:
Indinavir stones– Stone excluded from imaging due to respiratory
variation
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Helical CTSecondary Findings
Sensitivity• Ureteral dilatation 90%• Perinephric stranding 82%• Collecting system
dilatation 83%• Renal enlargement 71%
Specificity• Ureral dilatation 93%• Perinephric stranding 93%• Collecting system
dilatation 94%• Renal enlargement 89%
Smith. AJR Am J Roentgenol 167:1109-1113, 1996
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Location of Stone
• 378 patients
• Rate of spontaneous stone passage • 22% for proximal ureteral stones
• 46% for midureteral stones
• 71% for distal ureteral stones
– Morse R. J Urol. 1991; 145:263-265
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Width of Stone
• 520 patients• Rate of spontaneous stone passage
– 100% for stones that were 1 mm or smaller in width– 90% for stones 2 to 3 mm– 80% for stones that were 4 mm– 55% for stones that were 5 mm– 35% for stones that were 6 mm– 25% for stones that were 7 mm– 12% for stones that were 8 mm
• Ueno A. Urology. 1977; 10:544-546
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Radiographic Modalities
Ultrasound• Fast
• Can identify other causes of pain
• Safe in pregnant patients, children
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Hydronephrosis
Dilatation of the urinary tract at any level secondary to intrinsic and or extrinsic
obstruction to urine flow
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Hydronephrosis
• Intrinsic, acquired– Renal lithiasis– Neoplasm (renal, ureteral, bladder)– Papillary necrosis – Ureterocele– Blood clot– Neurogenic bladder– Anticholinergics– Pregnancy, PID, uterine prolapse)– Diuretics– Vesico-ureteral reflux– Diabetes insipidus
• Intrinsic, congenital– Stenosis (ureteral,
urethral, meatal)
– Adynamic ureter
– Spinal cord defects
– Duplication of the ureter
– Ureterocele
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Hydronephrosis in Renal Colic
Smith. AJR Am J Roentgenol. 1996; 167:1109-1113
Sensitivity = 90%Specificity = 93%
PPV = 92%NPV = 90%
Dalrymple. J Urol. 1997; 159:735-740
Sensitivity = 87%Specificity = 90%
PPV = 90%NPV = 89%
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Obstructive Uropathy Grading System - Subjective
• Mild– Minimal separation of calyces
• Moderate– Dilation of major and minor calyceal system
• Severe– Marked dilation of the renal pelvis and thinning
of the renal parenchyma
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Range of Hydronephrosis
Normal Mild Moderate Severe
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Mild Hydronephrosis
Kidney Liver
GB
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Moderate - Severe Hydronephrosis
LiverKidneyDilated pelvis
GB
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Renal Pathology
1. Renal Cysts
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Renal Cysts
• Arise in the renal cortex, commonly single rather than multiple
• Cysts do not communicate; hydronephrosis does
• Shape is round or oval
• Echo free
• Sharp interface between the mass and renal tissue
• Large renal cysts may be mistaken for aortic aneurysms
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Renal Cysts
Liver
Kidney
Cyst
Scatter 20 Bowel
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Problems & Pitfalls
• Mistaking cysts for hydronephrosis
• Mistaking cysts for aortic aneurysm
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Case Presentation
• 40 yo male presents with complaints of recent severe headaches, diaphoresis, and palpitations
• PE anxious male– BP 210/120 HR 145 RR 18 T
99
– Physical exam otherwise normal
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Ultrasound of Kidneys
Liver
Diaphragm
Kidney
Mass
RibShadow
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Case Development
• The patient was managed with alpha and beta-adrenergic blocking agents
• Urine studies revealed elevated metanepherine and catecholamine levels
• The patient was diagnosed with pheochromocytoma
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2. Renal Masses
Renal Pathology
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Renal Masses
• Ultrasound visualizes most solid and cystic renal masses• Beyond scope of EM ultrasound • Appearance
– Irregular borders
– Poorly defined interfaces between mass and kidney
• Complex masses– Complex ultrasonic appearance
– Cysts or solid masses may represent infection or hemorrhage
– May have fluid levels
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Case Presentation
• 35 year old male with history of Crohn’s presents with sudden onset of right flank pain. He is nauseated and has vomited a few times. He reports hematuria and denies fever, dysuria, abdominal pain.
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Physical Exam
Young man in moderate distress from pain• BP 125/67 HR 110 T 98• Lungs: clear to ascultation• Heart: Tachycardia without murmur• Abdomen: soft, non-tender, normal bowel
sounds• Back: right costo-vertebral angle tenderness
on percussion
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Renal Ultrasound
Right Kidney Left Kidney
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Ultrasound
Thin ParenchymaDilated Calyces
Distinct Shadow
Echogenic Structure
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CT Results
• Bilateral Staghorn Calculi
• Bilateral moderate hydronephrosis
• Right sided 3 mm stone at the UVJ
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Summary & Take-Home Points
• US is an adjunct in the evaluation of patients with suspected renal colic– Evaluate kidneys– Evaluate aorta
• Scan both kidneys