All about the IVP

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All about the IVP

• April 1 2004
• Andrea Wilson

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Case from U of Hawaii website

• 16 year old female
• Severe right flank pain with vomiting.
• No fever, urgency, or dysuria.
• PMH unremarkable
• VS T 36.8 P53, RR 24, BP 120/80.
• Abdomen Diffuse tenderness, guarding and rebound
  on the right. Severe R CVA tenderness.
• UA gt100 RBCs, 20-50 WBCs, positive nitrite.
• N CBC and Cr

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5 minutes after contrast
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20 minute film
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• 5 min film L shows normal excretion, R ureter
  not well visualized and calyceal blunting
  (suggesting obstruction)
• 20 min film R- more blunted calyces,
  hydronephrosis, delayed retention of contrast.
• There is a narrowing of the ureter on the right
  in the area of the suspected stone.

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Procedure

• Flat plate X-rays are taken immediately before
  contrast administration and at 5, 10 and 20
  minutes etc.
• Times usually doubled until contrast material
  fills both ureters

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Advantages

• Clear outline of the entire urinary system so can
  see even mild hydronephrosis.
• Easier to pick out obstructing stone when there
  are multiple pelvic calcifications.
• Can show non-opaque stones as filling defects.
• Demonstrate renal function and allow for
  verification that the opposite kidney is
  functioning normally.

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Disadvantages

• need for IV contrast material
• may provoke an allergic response
• multiple delayed films (Can take hours bc
  contrast passes quite slowly into the blocked
  renal unit and ureter.)
• May not have sufficient opacification to define
  the anatomy and point of obstruction.
• Requires a significant amount of radiation
  exposure and may not be ideal for young children
  or pregnant women

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Intravenous contrast

• Usually 1.0 cc/kg
• Contrast allergy and nephrotoxicity (esp if renal
  insufficiency /or D.M.)
• Get a creatinine first
• Greater incidence of adverse reactions with less
  expensive ionic dye than with the nonionic.
• If on metformin, then discontinue med for 2 days
  post-IVP

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What to look for

• Scout film look at kidney and bladder contours,
  kidney stones, ureteric stone
• Contrast films compare sides,
• nephrogram absent/delayed/hyperdense (absent no
  kidney/non-functioning)
• Collecting system and ureter dilatation,
  non-calcified stone or tumor (black filling
  defect)
• Extravasation
• ?Is the calcification in the ureter or not?

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Ureteral stone

• Delayed nephrogram effect
• Columnization ureter is peristaltic so shouldnt
  see entire ureter unless theres a stone.
• Radiopaque calcium oxalate, cystine, calcium
  phosphate, magnesium-ammonium-phosphate
• Radiolucent uric acid, blood clots, sloughed
  papillae

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From Rosens

• 90 of stones lt5 mm will pass.
• 15 of stones 5-8 mm
• gt8 mm usually lithotripsy or surgical removal

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15 min film
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Radiology Cases in Pediatric Emergency Medicine
Loren G. Yamamoto, MD, MPH University of Hawaii
John A. Burns School of Medicine
Another case

• 14 yo female
• Severe stabbing pain in her lower back x 2h
• No fever/chills, urgency, no dysuria
• Also some abd pain menstrual cramps for x 2
  days. nausea and emesis x2
• Pain slightly improved with tylenol.
• LMP 4 wks ago. States not pregnant

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• T36.7 , P89, R 20, BP 90/60, 99.
• Abd soft and non-tender. Normal bowel sounds.
  No rebound
• RgtL side lumbar tenderness.
• Urine dip positive for blood. Preg test -

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Case continued

• Normal CBC, lytes, BUN, Cr
• U/S done but non-diagnositic except for mild
  hydronephrosis of R kidney.
• IVP ordered.
• 20 minute and delayed films shown

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20 min film
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Delayed IVP
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Case continued

• IVP demonstrates an obstruction in the right
  ureter, along with a clinical presentation
  consistent with ureteral colic.
• Ureteral stone likelybut very large density and
  location of the calcified density is not exactly
  in the expected path of the ureter.
• Now complaining of moderate abd pain with
  fluctuating nausea

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Case continued

• Urologist and surgeon consulted.
• CT ordered but radiologist reluctant re second
  dose of contrast.
• Eventually passes tiny stone.
• Appendectomy- has appendicolith.
• Initial CT would have worked better in this case.
  

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References

• Ames CD, Older RA. Imaging in Urinary Tract
  Obstruction. Departments of Urology and
  Radiology, University of Virginia Health System,
  Charlottesville, Virginia, USA
  www.brazjurol.com.br/julho_2001/ Ames_316_325.htm
  
• http//137.222.110.150/calnet/renal1/image
• Leslie SW. The Diagnostic Evaluation of Renal
  Colic in the Emergency Department
  http//www.emedhome.com/features_archive-detail.cf
  m?SFID040300SFTIDnews
• Ouellette H, Tetreault P. Clinical Radiology
  made ridiculously simple. 2000. Pp37-41
• Rosen, Barkin. Emergency Medicine Concepts and
  Clinical Practice. 4th Ed. Vol 3. pp 2252-2256
• Yamamoto LG Kidani DCH. Urolithiasis
  Radiology Cases in Pediatric Emergency Medicine
  Volume 7, Case 5 Kapiolani Medical Center For
  Women And Children. University of Hawaii John A.
  Burns School of Medicine www.hawaii.edu/.../pediat
  rics/ pemxray/v7c05.html
• www.stmichaelshospital.com/.../ image2d.jpg
• www.urologyassociates.com/ urolith.jpg
• www.emedicine.com - Intravenous pyelogram