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RENAL ULTRASOUND

Diana Pancu, MD

Left: prostate showing a hypoechoic
Lesion suspicious for cancer

Right: with biopsy needle

Objectives • • • • • Clinical indications for performing ED renal US Approach to performing the US study Normal anatomy Abnormal findings Clinical Impact .

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) .

prone .Performing the Study • Patient preparation: – none • Transducer: 3.0 MHz for thin patient • Patient positioning – Supine – Posterior oblique. lateral decubitus.0MHz or 3.5 MHz – 5.

medial to each kidney .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.

Hepatic Veins Spleen Celiac axis Liver Renal artery AORTA Renal vein IVC Right kidney SMA Left kidney .

Renal Scanning Approaches .

through the spleen • Air-filled bowel impedes anterior scanning . lateral.Approach to Scanning STOMACH I K AORTA K SPLEEN LIVER IVC S • Right kidney scanning approach: anterior. posterior • Liver is the acoustic window • Left kidney: requires a posterior approach.

capsule. 4-5 cm wide. Columns of Bertin separate pyramids . lymphatics. contains nephrons – Medulla: contains pyramids that pass urine to minor calyces. perinephric fat • Sinus – Hilum: vessels. ureter – Pelvis: major and minor calyces • Parenchyma surrounds the sinus – Cortex: site of urine formation.Anatomy • 9-12 cm long. nerves. 3-4 cm thick • Gerota’s fascia encloses kidney.

Medullary pyramids Kidney Anatomy Minor Calyx Renal artery Major Calyx Renal vein Sinus Medulla Renal capsule Cortex Ureter .

less echogenic than liver or spleen.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. • Capsule is smooth and echogenic .

Right Kidney Long Axis .

Right Kidney Long Axis Anterior Superior Liver Inferior Sinus Cortex Diaphragm Posterior .

Right Kidney Short Axis .

.Right Kidney Short Axis Anterior Right GB Liver Left IVC R Kidney Vertebral Body Posterior Aorta Renal a.

Left Kidney Long Axis .

Left Kidney Long Axis Anterior Superior Inferior Rib Shadow Kidney Posterior Spleen .

Left Kidney Short Axis .

Left Kidney Short Axis Anterior Right Liver Left Spleen L Kidney Posterior .

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 .

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 .

Normal Variants • Dromedary humps: – Lateral kidney bulge. usually at the lower pole • Renal ectopia: – One or both kidneys outside the normal renal fossa . 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.

Obstructive Uropathy .Clinical Indications 1.

2001. Emerg Med Clin North Am. 19(3): 633-54 .Nephrolithiasis • 12% of the US population • Incidence of renal colic is 3% with 50% recurrence within 10 years – Manthey DE.

67% Specificity – Sharma RN. Shah I. Gupta S. 1989 . et al: Thermogravimetric analysis of urinary stones. Br J Urol 64:564-566.Radiographic Modalities Radiography • 62% Sensitivity.

Toi A.Radiographic Modalities IVP vs. Ann Emerg Med 18:556-559. 1989 . US • Prospective study. 85 patients ULTRASOUND Sensitivity=85% Specificity=92% IVP Sensitivity=90% Specificity=94% – Sinclair D. et al. Wilson S.

IVP • Prospective study.Radiographic Modalities ED Ultrasound + KUB vs.1998. et al: Acad Emerg Med.5:666-671. 108 patients Sensitivity = 97% Specificity = 59% Sensitivity = 97% Specificity = 59% PPV = 81% NPV = 92% Henderson. S. .

fast. no contrast • Identifies presence and size of stone • Location of stone • Level of obstruction • Other sources of pain .Radiographic Modalities Helical CT.Gold Standard • Accurate.

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 .

1996 . AJR Am J Roentgenol 167:1109-1113.Helical CT Secondary Findings Sensitivity Specificity • Ureteral dilatation 90% • Perinephric stranding 82% • Collecting system dilatation 83% • Renal enlargement 71% • Ureral dilatation 93% • Perinephric stranding 93% • Collecting system dilatation 94% • Renal enlargement 89% Smith.

145:263-265 . J Urol. 1991.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.

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. 10:544-546 . 1977. Urology.

children .Radiographic Modalities Ultrasound • Fast • Can identify other causes of pain • Safe in pregnant patients.

Hydronephrosis Dilatation of the urinary tract at any level secondary to intrinsic and or extrinsic obstruction to urine flow .

Hydronephrosis
• Intrinsic, acquired










• Intrinsic, congenital

Renal lithiasis
Neoplasm (renal, ureteral, bladder)
Papillary necrosis
Ureterocele
Blood clot
Neurogenic bladder
Anticholinergics
Pregnancy, PID, uterine prolapse)
Diuretics
Vesico-ureteral reflux
Diabetes insipidus

– Stenosis (ureteral,
urethral, meatal)
– Adynamic ureter
– Spinal cord defects
– Duplication of the
ureter
– Ureterocele

Hydronephrosis in Renal Colic
Sensitivity = 90%
Specificity = 93%

PPV = 92%
NPV = 90%

Smith. AJR Am J Roentgenol. 1996; 167:1109-1113
Sensitivity = 87%
Specificity = 90%

Dalrymple. J Urol. 1997; 159:735-740

PPV = 90%
NPV = 89%

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

Range of Hydronephrosis Normal Mild Moderate Severe .

Mild Hydronephrosis GB Kidney Liver .

Moderate .Severe Hydronephrosis GB Liver Kidney Dilated pelvis .

Renal Cysts .Renal Pathology 1.

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 .Renal Cysts • Arise in the renal cortex. commonly single rather than multiple • Cysts do not communicate.

Renal Cysts Liver Cyst Kidney Scatter 20 Bowel .

Problems & Pitfalls • Mistaking cysts for hydronephrosis • Mistaking cysts for aortic aneurysm .

and palpitations • PE anxious male – BP 210/120 HR 145 RR 18 T 99 – Physical exam otherwise normal . diaphoresis.Case Presentation • 40 yo male presents with complaints of recent severe headaches.

Ultrasound of Kidneys Kidney Liver Diaphragm Rib Shadow Mass .

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 .

Renal Masses .Renal Pathology 2.

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 .

He is nauseated and has vomited a few times. abdominal pain.Case Presentation • 35 year old male with history of Crohn’s presents with sudden onset of right flank pain. dysuria. He reports hematuria and denies fever. .

non-tender. normal bowel sounds • Back: right costo-vertebral angle tenderness on percussion .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.

Renal Ultrasound Right Kidney Left Kidney .

Ultrasound Echogenic Structure Distinct Shadow Thin Parenchyma Dilated Calyces .

CT Results • Bilateral Staghorn Calculi • Bilateral moderate hydronephrosis • Right sided 3 mm stone at the UVJ .

Summary & Take-Home Points • US is an adjunct in the evaluation of patients with suspected renal colic – Evaluate kidneys – Evaluate aorta • Scan both kidneys .

RT(R).Renal Ultrasound Steve Geiersbach. MS. RDMS .

RENAL ANATOMY MEDULLA RENAL CORTEX MAJOR CALYCES RENAL PELVIS URETER RENAL MEDULLARY PYRAMID RENAL COLUMN RENAL CAPSULE MINOR CALYX .

dense central echoes due to renal fat – Contains: • Collecting system: calyces. infundibula. & part of renal pelvis – bifid system seen as two separate lobulations • • • • Renal vessels: renal hilium Lymphatics Fat Fibrous tissues .RENAL SONOGRAPHY • Paired retroperitoneal organs • Renal sinus.

RENAL SINUS • Central area of the kidney from the medial border • Bounded by fat – anteriorly and posteriorly by fibrous sheath known as Gerota’s fascia – laterally by the laterocoronal fascia which becomes continuous with peritoneum & abdominal wall .

2.2 parts cortex & medulla – thickest at the renal poles • Cortex located between capsule & medulla – low level uniform echoes – less echogenic than liver & spleen – Columns of Bertin = columns of cortical tissue located between pyramids • » can enlarge & mimic a mass » normal variant medulla – variable in size but average adult kidney measures 912 cm in length.RENAL SONOGRAPHY • Renal parenchyma .49 x length x width x anterior posterior dimension .0 cm in thickness – renal volume is estimated by water displacement • V = 0.5-4. 4-6 cm in width.

triangular or rounded hypoechoic areas • Rounded zones of decreased echogenicity between cortex & renal sinus • Specular echoes interspersed at the junction of the cortex & medulla represents arcuate arteries & veins (known as corticomedullary junction) .RENAL SONOGRAPHY • Renal parenchyma .2 parts cortex & medulla – Medulla • Pyramids .

seen posterior to IVC in sagittal plane – renal veins • come off of IVC • left renal vein (LRV) .can be multiple • right renal artery (RRA) .RENAL SONOGRAPHY • Vascular exchange – renal arteries • come off of aorta .seen between SMA & aorta in the transverse plane .

RENAL ARTERY .

RENAL SONOGRAPHY • Renal anatomy – kidney is covered by a true capsule – kidney is surrounded by perinephric fat – fat is bounded anteriorly & posteriorly by fibrous sheath .Gerota’s facia .

LEFT RENAL ARTERY and Vein LRA LRV .

isthmus of tissue that connects both kidneys – pelvic kidney .RENAL SONOGRAPHY • Congenital variations – – – – fetal lobulations dromedary hump agenesis ectopic • cross-fused ectopic .fails to migrate from pelvic area during embryology .both located on same side and usually connected – horseshoe .

Blood Urea Nitrogen – Creatinine .3 functions – filtration – reabsorbtion – tubular secretions • Essential lab values – BUN .RENAL SONOGRAPHY • Physiology .

RENAL SONOGRAPHY • Indications for sonography exam – – – – – – – – – hydronephrosis non visualization on IVP exam evaluation of flank masses avoidance of contrast agent (Allergy to IVP contrast) decreased or poor renal function evaluation of abscess evaluation of renal transplant evaluation of urinary bladder hematuria & or flank pain .

– technique setting • highest frequency possible that allows for proper penetration – gain settings are vitally important .RENAL SONOGRAPHY • Imaging technique .use spleen.oblique & decubitus positions work the best – LPO / use liver for acoustic window for imaging the right – Rt. Lateral ducubitus best position for left kidney .no prep necessary – patient position .

try to demonstrate the ureter .RENAL SONOGRAPHY • Imaging technique .Complete study – must be bilateral & include the bladder – multiple planes including sagittal & transverse – scan superior to inferior and medial to lateral to be assured you scan the entire kidney – compare cortical density to that of the liver – if hydronephrosis .

if malignancy is suggested you must scan & survey for involvement of: – – – – IVC Renal veins Liver Retroperitonium .RENAL SONOGRAPHY • Imaging technique .

RENAL SONOGRAPHY • Ureters – arise as budlike outgrowths from the mesonephric or Wolffian ducts – average size 30 cm long 5 mm in diameter – courses retroperitoneal to the bladder Bladder thin walled. smooth & uniform 5mm in diameter look for abnormal densities or interruptions of the wall volume = transverse x AP x length .

muscle and bone weakness . malaise.ADRENAL GLANDS • Physiology: two endocrine glands – cortex .oversecretion of adrenal cortex » increased plasma volume. anorexia. bronzing of the skin – Cushing’s disease .secretes steroids • Mineralocorticoids • Glucocorticoids • Sex hormones – Addison’s disease .hypofunction of adrenal » hypotension. mild alkalosis.

vasoconstrictor – together they breakdown glycogen to glucose .accelerator of the heart • norepinephrine .produces epinephrine & norepinephrine • epinephrine .ADRENAL GLANDS • Physiology: two endocrine glands – Medulla .