RENAL US

8/18/2019 RENAL US

1/76

Diana Pancu, MD

RENAL ULTRASOUND

8/18/2019 RENAL US

2/76

Right: with biopsy needleLeft: prostate showing a hypoechoic

Lesion suspicious for cancer

8/18/2019 RENAL US

3/76

8/18/2019 RENAL US

4/76

Objectives

• Clinical indications for performing ED renal !

• "pproach to performing the ! study• #ormal anatomy

• "bnormal findings

• Clinical $mpact

8/18/2019 RENAL US

5/76

Clinical Indications for ED

Renal Ultrasound

• Suspected renal colic

% Colic&y flan& pain radiating to groin % 'ematuria

• Clinical question

% Presence of hydronephrosis % "bsence of other pathology (""")

8/18/2019 RENAL US

6/76

!erfor"in# t$e Stud%

• Patient preparation:

% none

• *ransducer: +-M'. or +/ M'.

% /- M'. for thin patient

• Patient positioning

% !upine

% Posterior obli0ue, lateral decubitus, prone

8/18/2019 RENAL US

7/76

Anato"%

• 1idneys are retroperitoneal, *23 4 L5

• Right &idney is lower than the left &idney

• Right &idney is posterio4inferior to li6er 7

gallbladder

• Left &idney is inferior4medial to the spleen

• "drenal glands are superior, anterior,

medial to each &idney

8/18/2019 RENAL US

8/76

$ 8 C

" 9

R * "

Celiac

ais

!M"

Renal artery

Renal 6ein

&epatic

'eins

Right&idney

Left

&idney

Liver

!pleen

8/18/2019 RENAL US

9/76

Renal Scannin# Approac$es

8/18/2019 RENAL US

10/76

Approac$ to Scannin#

• Right &idney scanningapproach: anterior, lateral, posterior

• Li6er is the acoustic

window

• Left &idney: re0uires a posterior

approach, through the spleen

• "ir4filled bowel impedes

anterior scanning

$

LI'ER STO(AC&

S ! L E E N

I'C

AORTA) )

S

8/18/2019 RENAL US

11/76

Anato"%

• ;423 cm long, 54/ cm wide, +45 cm thic& •

8/18/2019 RENAL US

12/76

R enal arter%

Renal vein

Ureter

Renal capsule Corte*

(edullar% p%ra"ids

(inor

Cal%*

)idne% Anato"%

(edulla

Sinus

(ajor

Cal%*

8/18/2019 RENAL US

13/76

Sono#rap$ic Appearance

• reters are normally not seen

• Renal pel6is is blac& when 6isible

• Renal sinus is echogenic due to fat

• Medullary pyramids are hypoechoic

• Corte is mid4gray, less echogenic thanli6er or spleen

• Capsule is smooth and echogenic

8/18/2019 RENAL US

14/76

Ri#$t )idne% Lon# A*is

8/18/2019 RENAL US

15/76

Li6er

Diaphragm

!inus

Corte

Anterior

!osterior

Superior Inferior

Ri#$t )idne% Lon# A*is

8/18/2019 RENAL US

16/76

Ri#$t )idne% S$ort A*is

8/18/2019 RENAL US

17/76

Ri#$t )idne% S$ort A*is

8ertebral

?ody

R 1idney

"ortaRenal a

8/18/2019 RENAL US

18/76

Left )idne% Lon# A*is

8/18/2019 RENAL US

19/76

Left )idne% Lon# A*is

Anterior

!osterior

Superior Inferior

!pleen

1idney

Rib

S$ado+

8/18/2019 RENAL US

20/76

Left )idne% S$ort A*is

8/18/2019 RENAL US

21/76

Left )idne% S$ort A*is

Anterior

!osterior

Ri#$t LeftLi6er

!pleen

L 1idney

8/18/2019 RENAL US

22/76

Co""on !itfalls in

Renal Scannin#

• @ailure to scan both &idneys

• Mista&ing prominent renal pyramids forhydronephrosis

• Mista&ing prominent pyramids for cysts

• Confusing normal renal arteries for the

ureter

8/18/2019 RENAL US

23/76

Co""on !itfalls in

Renal Scannin#

• @ailure to scan through the bladder to search

for stone at the uretero46esicular >unction

• $nability to 6isuali.e left &idney due to

anterior probe placement• @ailure to scan the aorta in suspected renal

colic

8/18/2019 RENAL US

24/76

Nor"al 'ariants

• Dro"edar% $u"ps

% Lateral &idney bulge, same echogenicity as the corte

• &%pertrop$ied colu"n of ,ertin

% Cortical tissue indents the renal sinus

• Double collectin# s%ste"

% !inus di6ided by a hypertrophied column of ?ertin

• &orses$oe -idne%

% 1idneys are connected, usually at the lower pole

• Renal ectopia

% 9ne or both &idneys outside the normal renal fossa

8/18/2019 RENAL US

25/76

Clinical Indications

./ Obstructive Uropat$%

8/18/2019 RENAL US

26/76

Nep$rolit$iasis

• 23A of the ! population

• $ncidence of renal colic is +A with /-Arecurrence within 2- years

– Manthey DE. Emerg Med Clin North Am.2001;19(3): 633-54

8/18/2019 RENAL US

27/76

Radio#rap$ic (odalities

Radio#rap$%

• B3A !ensiti6ity, BA !pecificity

% !harma R#, !hah $,

8/18/2019 RENAL US

28/76


I'! vs/ US

• Prospecti6e study, / patients

% !inclair D, Filson !, *oi ", et al "nn Emerg

Med 2://B4//;, 2;;

ULTRASOUND

Sensitivity=85%Specifcity=92%

IVPSensitivity=90%Specifcity=94%

8/18/2019 RENAL US

29/76


ED Ultrasound 0 )U, vs/ I'!

• Prospecti6e study, 2- patients

Sensitivity = 97%Specifcity = 59%

'enderson, !, et al: Acad Emerg Med 2;;G/:BBB4B2

Sensitivity = 97%Specifcity = 59%

PPV = 81% NPV = 92%

8/18/2019 RENAL US

30/76


&elical CT1 2old Standard

• "ccurate, fast, no contrast• $dentifies presence and si3e of stone

• Location of stone• Le6el of obstruction

• 9ther sources of pain

8/18/2019 RENAL US

31/76

Stone on CT

• sually 6isuali.ed

• #ot 6isuali.ed

% !tone is etremely small H 2 mm

% !tone is of relati6ely low C* attenuation:

$ndina6ir stones

% !tone ecluded from imaging due to respiratory6ariation

8/18/2019 RENAL US

32/76

&elical CT

Secondar% 4indin#sSensitivit%• reteral dilatation ;-A

• Perinephric stranding 3A• Collecting system

dilatation +A

• Renal enlargement 2A

Specificit%• reral dilatation ;+A

• Perinephric stranding ;+A• Collecting system

dilatation ;5A

• Renal enlargement ;A

!mith "R "m Roentgenol 2B:22-;4222+, 2;;B

8/18/2019 RENAL US

33/76

Location of Stone

• + patients

• Rate of spontaneous stone passage• 33A for proimal ureteral stones

• 5BA for midureteral stones

• 2A for distal ureteral stones

% Morse R J Urol 2;;2G 25/:3B+43B/

8/18/2019 RENAL US

34/76

5idt$ of Stone

• /3- patients

• Rate of spontaneous stone passage % 2--A for stones that were 2 mm or smaller in width

% ;-A for stones 3 to + mm

% -A for stones that were 5 mm

% //A for stones that were / mm

% +/A for stones that were B mm % 3/A for stones that were mm

% 23A for stones that were mm• eno " rology 2;G 2-:/554/5B

8/18/2019 RENAL US

35/76


Ultrasound•

@ast• Can identify other causes of pain

• !afe in pregnant patients, children

8/18/2019 RENAL US

36/76

&%dronep$rosis

Dilatation of the urinary tract at any le6el

secondary to intrinsic and or etrinsic

obstruction to urine flow

8/18/2019 RENAL US

37/76

&%dronep$rosis

• Intrinsic6 acquired % Renal lit$iasis

% #eoplasm (renal, ureteral, bladder)

% Papillary necrosis

% reterocele

% ?lood clot

% #eurogenic bladder

% "nticholinergics

% Pregnancy, P$D, uterine prolapse)

% Diuretics

% 8esico4ureteral reflu

% Diabetes insipidus

• Intrinsic6 con#enital

% !tenosis (ureteral,

urethral, meatal)

% "dynamic ureter

% !pinal cord defects

% Duplication of the

ureter

% reterocele

8/18/2019 RENAL US

38/76

&%dronep$rosis in Renal Colic

!mith "R "m Roentgenol 2;;BG 2B:22-;4222+

Sensitivity = 90%

Specifcity = 93%

PPV = 92%

NPV = 90%

Dalrymple rol 2;;G 2/;:+/45-

Sensitivity = 87%

Specifcity = 90%

PPV = 90%

NPV = 89%

8/18/2019 RENAL US

39/76

Obstructive Uropat$%

2radin# S%ste" 1 Subjective• Mild

% Minimal separation of calyces

• Moderate % Dilation of ma>or and minor calyceal system

• Severe % Mar&ed dilation of the renal pel6is and thinningof the renal parenchyma

8/18/2019 RENAL US

40/76

Ran#e of &%dronep$rosis

Nor"al (ild (oderate Severe

8/18/2019 RENAL US

41/76

(ild &%dronep$rosis

)idne% Liver

2,

8/18/2019 RENAL US

42/76

(oderate 1 Severe

&%dronep$rosis

Liver

)idne%

Dilated pelvis

2,

8/18/2019 RENAL US

43/76

Renal !at$olo#%

./ Renal C%sts

8/18/2019 RENAL US

44/76

Renal C%sts

• "rise in the renal corte, commonly single rather

than multiple

• Cysts do not communicateG hydronephrosis does

• !hape is round or o6al

• Echo free

• !harp interface between the mass and renal tissue

• Large renal cysts may be mista&en for aortic

aneurysms

8/18/2019 RENAL US

45/76

Renal C%sts

Li6er

1idney

Cyst

!catter 3-

?owel

8/18/2019 RENAL US

46/76

!roble"s 7 !itfalls

• Mista&ing cysts for hydronephrosis

• Mista&ing cysts for aortic aneurysm

8/18/2019 RENAL US

47/76

Case !resentation

• 5- yo male presents with complaints of

recent se6ere headaches, diaphoresis,

and palpitations

• PE anious male

% ?P 32-I23- 'R 25/ RR 2 * ;; % Physical eam otherwise normal

8/18/2019 RENAL US

48/76

Ultrasound of )idne%s

Li6er

Diaphragm

1idney

(ass

Rib

S$ado+

8/18/2019 RENAL US

49/76

Case Develop"ent

• *he patient was managed with alpha and

beta4adrenergic bloc&ing agents

• rine studies re6ealed ele6atedmetanepherine and catecholamine le6els

• *he patient was diagnosed with

pheochromocytoma

8/18/2019 RENAL US

50/76

8/ Renal (asses

Renal !at$olo#%

8/18/2019 RENAL US

51/76

Renal (asses

• ltrasound 6isuali.es most solid and cystic renal masses

• ?eyond scope of EM ultrasound

• "ppearance

% $rregular borders % Poorly defined interfaces between mass and &idney

• Comple masses

% Comple ultrasonic appearance

% Cysts or solid masses may represent infection or hemorrhage

% May ha6e fluid le6els

8/18/2019 RENAL US

52/76

Case !resentation

• +/ year old male with history of Crohn=s presents

with sudden onset of right flan& pain 'e is

nauseated and has 6omited a few times 'ereports hematuria and denies fe6er, dysuria,

abdominal pain

8/18/2019 RENAL US

53/76

!$%sical E*a"

Joung man in moderate distress from pain

• ?P 23/IB 'R 22- * ;

• Lungs: clear to ascultation• 'eart: *achycardia without murmur

• "bdomen: soft, non4tender, normal bowel

sounds• ?ac&: right costo46ertebral angle tenderness

on percussion

8/18/2019 RENAL US

54/76

Renal Ultrasound

Ri#$t )idne% Left )idne%

8/18/2019 RENAL US

55/76

Ultrasound

T$in !arenc$%"a

Dilated Cal%cesDistinct S$ado+

Ec$o#enic

Structure

8/18/2019 RENAL US

56/76

CT Results

• ?ilateral !taghorn Calculi

• ?ilateral moderate hydronephrosis

• Right sided + mm stone at the 8

8/18/2019 RENAL US

57/76

Su""ar% 7 Ta-e1&o"e !oints

• ! is an ad>unct in the e6aluation of

patients with suspected renal colic % E6aluate &idneys

% E6aluate aorta

• !can both &idneys

8/18/2019 RENAL US

58/76

Renal

ltrasound

!te6e

8/18/2019 RENAL US

59/76

RE#"L "#"*9MJ

RENAL

CORTE9

(EDULLA

(A:OR

CAL;CES

RENAL

!EL'IS

RENAL

(EDULLAR;

!;RA(ID

RENAL

CA!SULEURETER

(INOR

CAL;9

RENAL

COLU(N

8/18/2019 RENAL US

60/76

RENAL SONO2RA!&;

• !aired retroperitoneal or#ans• Renal sinus1 dense central ec$oes due to

renal fat

% Contains• Collectin# s%ste" cal%ces6 infundibula6 7 part of

renal pelvis

% bifid s%ste" seen as t+o separate lobulations

• Renal vessels renal $iliu"• L%"p$atics

• 4at

• 4ibrous tissues

8/18/2019 RENAL US

61/76

RE#"L !$#!• Central area of the &idney

from the medial border

• ?ounded by fat

% anteriorly and posteriorly byfibrous sheath &nown as

8/18/2019 RENAL US

62/76

RENAL SONO2RA!&;

• Renal parenc$%"a 1 8 parts corte* 7 "edulla % t$ic-est at t$e renal poles

• Corte* located bet+een capsule 7 "edulla % lo+ level unifor" ec$oes % less ec$o#enic t$an liver 7 spleen % Colu"ns of ,ertin < colu"ns of cortical

tissue located bet+een p%ra"ids

Kcan enlar#e 7 "i"ic a "ass

K nor"al variant• "edulla

% variable in si3e but avera#e adult -idne% "easures =1.8 c" in len#t$> ?1@ c" in +idt$> 8/A1?/B c" in

t$ic-ness

% renal volu"e is esti"ated b% +ater displace"ent

• ' < B/?= * len#t$ * +idt$ * anterior posteriordi"ension

8/18/2019 RENAL US

63/76

RENAL SONO2RA!&;

•Renal parenc$%"a 1 8 parts corte* 7

"edulla

% (edulla• !%ra"ids 1 trian#ular or rounded

$%poec$oic areas

• Rounded 3ones of decreasedec$o#enicit% bet+een corte* 7renal sinus

• Specular ec$oes interspersed att$e junction of t$e corte* 7

"edulla represents arcuate

arteries 7 veins C-no+n as

cortico"edullar% junctionD

8/18/2019 RENAL US

64/76

RENAL SONO2RA!&;

• 8ascular echange

% renal arteries

• come off of aorta 4 can be multiple• right renal artery (RR") 4 seen posterior to I'C in

sa#ittal plane

% renal 6eins

• come off of $8C

• left renal 6ein (LR8) 4 seen between !M" 7 aorta

in the trans6erse plane

RE#"L "R*ERJ

8/18/2019 RENAL US

65/76

8/18/2019 RENAL US

66/76

RENAL SONO2RA!&;

• Renal anatomy

% &idney is co6ered by a true capsule

% &idney is surrounded by perinephric fat % fat is bounded anteriorly 7 posteriorly by

fibrous sheath 4

8/18/2019 RENAL US

67/76

LE@* RE#"L "R*ERJ and 8ein

LRA

LR'

RENAL SONO2RA!&;

8/18/2019 RENAL US

68/76

RENAL SONO2RA!&;

• Congenital 6ariations

% fetal lobulations

% dromedary hump

% agenesis

% ectopic

• cross4fused ectopic 4 both located on same side and

usually connected

% horseshoe 4 isthmus of tissue that connects both&idneys

% pel6ic &idney 4 fails to migrate from pel6ic area

during embryology

8/18/2019 RENAL US

69/76

RENAL SONO2RA!&;

• Physiology 4 + functions

% filtration

% reabsorbtion % tubular secretions

• Essential lab 6alues

% ?# 4 ?lood rea #itrogen

% Creatinine

RENAL SONO2RA!&;

8/18/2019 RENAL US

70/76

RENAL SONO2RA!&;

• $ndications for sonography eam % hydronephrosis

% non 6isuali.ation on I'! eam

% e6aluation of flan& masses

% a6oidance of contrast agent ("llergy to $8Pcontrast)

% decreased or poor renal function

% e6aluation of abscess

% e6aluation of renal transplant

% e6aluation of urinary bladder

% hematuria 7 or flan& pain

RENAL SONO2RA!&;

8/18/2019 RENAL US

71/76

• $maging techni0ue 4 no prep necessary

% patient position 4 obli0ue 7 decubitus positions

wor& the best

% LP9 I use li6er for acoustic window for

imaging the right % Rt Lateral ducubitus best position for left

&idney 4 use spleen

% techni0ue setting• highest fre0uency possible that allows for proper

penetration

% gain settings are 6itally important

RENAL SONO2RA!&;

8/18/2019 RENAL US

72/76

RENAL SONO2RA!&;

• $maging techni0ue 4 Complete study

% must be bilateral 7 include the bladder

% multiple planes including sagittal 7 trans6erse % scan superior to inferior and medial to lateral to

be assured you scan the entire &idney

% compare cortical density to that of the li6er % if hydronephrosis 4 try to demonstrate the ureter

8/18/2019 RENAL US

73/76

RENAL SONO2RA!&;

• $maging techni0ue 4 if malignancy is suggested

you must scan 7 sur6ey for in6ol6ement of:

% $8C % Renal 6eins

% Li6er

% Retroperitonium

RENAL SONO2RA!&;

8/18/2019 RENAL US

74/76

RENAL SONO2RA!&;

• reters

% arise as budli&e outgrowths from the mesonephric

or Folffian ducts

% a6erage si.e +- cm long / mm in diameter

% courses retroperitoneal to the bladder

?ladder thin walled, smooth 7 uniform /mm in diameter

loo& for abnormal densities or interruptions of the

wall

6olume trans6erse "P length

8/18/2019 RENAL US

75/76

"DRE#"L

8/18/2019 RENAL US

76/76

"DRE#"L

Documents

RENAL US