solitary kidney with a stone, ivu cas study
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IVU CASE STUDY
Case place: at King Khalid Universal Hospital (KKUH).Presentation was done by: Shatha Jamal Al-MushaytUN: 427200465
IVU room at KKUH
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PATIENT INFORMATION Gender: Female Age: 53 years old Weight: 70 Kg Transport: walking Allergic to dust, egg, and fish.
Date of exam: 26-12-2009
PATIENT HISTORY Solitary(only one) left kidney with stone. A history of mild allergy to contras media
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SYMPTOMS AND SIGNS The patient had a history of solitary LT
kidney with stone and this exam was requested to check up her stone condition and if there is any effect caused by it.
Since she had only one kidney, this increases the risk of developing kidney stones.
Patient did not complain from pain.
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PATIENT PREPARATION Patient Creatinine level was within
the normal range according to KKUH( 62–115 µmol/L).
Consent form was signed.
Patient was asked If she has asthma or allergy to some food or medications. As this requires having some medications before the exam.
Cont.
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PATIENT PREPARATION Patient was asked to come on time. Patient was informed that:
Other patients may have the same appointment. So, the priority will be to the one who come first.
The exam may take longer time according to the condition of the kidneys & their secretion of CM.
Cont.
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PATIENT PREPARATION The day before the exam:
1. No drugs by mouth (except for diabetic patients)
2. Light dinner or only fluids (no dairy products
or soft drinks like Pepsi) at 7:30 pm- preferable.
3. At 8:30 pm, 60 gm of caster oil (can be taken with a spoon of honey or jam).
4. Then, plenty amount of fluids (no dairy
products or soft drinks like Pepsi) until 11 pm.
5. Then, Nothing by mouth until the exam is done. Except for diabetic or renal failure patients, they can have some water.
Cont.
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PATIENT PREPARATION The day of exam:
1. Patient was not pregnant for sure.2. Patient voided immediately before
the exam.3. Patient put on a hospital gown
without any object in the area of interest that may superimpose an essential anatomy.
4. Injection set & crash cart were ready by side.
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ALLERGIC PREPARATIONPrednisone tablets were prescribed to
the patient as follows,
1. The day before the exam + the day of the exam: 50 mg twice a day.
2. Two days after the exam: 10 mg twice a day.
3. The third day after the exam: 5 mg twice a day.
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TECHNIQUE FILMS WERE TAKEN IN SEQUENCE
1. Control (full KUB) film was first taken.
Patient position: supine, no trunk rotation, midsagital plane to the center of
the table, arms extended by sides away from body, and pillow under pt head.
Center point: 2 cm above the midway between the highest points of iliac
crest. Central Ray: perpendicular to image receptor(IR), vertical beam.
Collimation must include the xiphoid process and symphsis pupis.
Marker on the right side of patient.
Patient was asked to hold her breath during exposure.
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CONTROL (KUB) FILM
Radiograph 1:
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CM INJECTION Omnipaque 300 mgI/ml: Low osmolar, non-ionic contrast
media Injected intravenously after the
control film. CM Dose: 70 ml. (remember, adult dose= 1 ml
per Kg)
The patient was informed that she may feel fever after injection (normally);but she did not feel so.
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TECHNIQUE2. Nephrogram film-Immediately after injection
Patient position: As for the full KUB control film.
CP: midway between xiphoid process & iliac crest (kidney area).
CR: perpendicular to IR, vertical beam
Collimation less than full KUB film. prevent cutoff kidney.
Marker: RT of the patient
Patient was asked to hold her breath during exposure.
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NEPHROGRAMRadiograph 2:
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TECHNIQUE3. Full KUB film-5 minuets since
injection.
Technique as for the full KUB control film.
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KUB- 5 MIN SINCE INJECTIONRadiograph 3:
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TECHNIQUE4. Full KUB film-15 min since injection
Technique as for the full KUB control film.
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KUB- 15 MINRadiograph 4:
Distal ureter
Urinary bladder
Middle ureter
Proximal ureter
Renal pelvis
Kidney
Minor calyx
Major calyx
Vesico-uretric junction
Pelvi-uretric junction
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TECHNIQUE5. LPO: left posterior oblique-19 min since injection.
This was an additional film ordered by the radiologist.
Why? To demonstrate the LT ureter clearly. Patient position: supine and partially(~30-45 degrees) rotated to the left side,
arm of RT side was raised across upper chest, RT side knee was flexed for support of lower body, pillow under head.
CP: 2 cm above the midway between the spine & the highest
point of iliac crest. CR: perpendicular to IR, vertical beam. Collimation must include kidneys without cut and
symphsis pupis. LT marker patient was asked to hold her breath during exposure
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LPO-19 MINRadiograph 5:
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TECHNIQUE6. Full bladder-34 min
Patient position: supine, no trunk or pelvis rotation, midsagital
plane to the center of the table, arms extended by sides away from body or rested on chest, and pillow under pt head.
CP: 5 cm above symphasis pupis. CR: perpendicular to IR Collimate coned view of bladder. RT marker patient was asked to hold her breath during
exposure.
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FULL BLADDER-34 MIN (CONED VIEW)Radiograph 6:
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TECHNIQUEThe radiologist was satisfied with the full
bladder film. So he asked for a Post void film.
7. Post Void film is a full length KUB film after emptying the bladder from CM.
Technique as for the full KUB control film.
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POST VOID -KUB Radiograph 7:
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FINALLY!
Images were sent to PACS
IVU room at KKUH
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AFTER CARE
The patient was asked if she had hard breathing or any discomfort; but she was fine .
The injection needle was removed.
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MY COMMENTS During exposure, it is better to be done on
expiration; but in KKUH they just instruct the patient to take a deep breath then hold it.
Around 3 Syringes each of 25 ml were used to equal 70 ml for CM injection
Source Image receptor distance (SID) in all images was = 100 cm
KV= 75 Uretric compression was not used as the
case did not need it & the radiologist did not instruct to apply it.
Minuets marker as annotation were used; but not shown in these images.
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FINDINGS 2 radioopaque calcular
shadow density
Control film showing two radio-opaque calcular shadow density projecting over the lower pole of the left kidney opposite to the level of L2.
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FINDINGS Solitary LT
kidney showing normal enhancement of the kidney after IV contrast administration with spontaneous normal excretion of CM.
Nephrogram
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FINDING Normal
configuration of the pelvicalyceal system with filling defect of the lower collecting system(yellow
circles) due to the previously noted stones with no back pressure effect.
5 min KUB film
15 min KUB film
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FINDING No residual
contrast seen in the UB after voiding. (arrow: urinary bladder area)
PV-KUB film
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CONCLUSIONTwo small left renal stones with no
back pressure effect.
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RENAL STONES They are small, solid masses may form
when acid salts or minerals, normally found in urine, become solid crystals inside the kidney.
Most kidney stones contain Calcium. They typically leave the body by passage in
the urine stream. However, they can build up inside your
kidney & form larger stones. If stones grow to sufficient size before passage (at least 2-3 mm), they can cause obstruction of the ureter.
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SYMPTOMS many are formed & passed without causing
symptoms; but if a kidney stone causes a blockage, or moves into the ureter, some symptoms are:
Severe pain on 1 or both sides of back. Feeling frequent urge to urinate, or a burning
sensation during urination Bloody or cloudy urine Sudden spasms of excruciating pain. Feeling sick or vomit.
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CAUSES OF KIDNEY STONES Gender: Men are 4 times more likely to get kidney
stones than women History: if someone has a history of kidney stone
50 % chance of developing another one within 5 years.
High risk factors of developing kidney stones: Family history of kidney stones. Age: 20 - 50 yr. Taking certain medicines e.g. indinavir (in the
treatment of HIV infection) &taking too many or too often laxatives.
Solitary kidney, or an abnormally shaped kidney
High protein diet. Not drinking enough fluids.
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DIAGNOSIS OF A KIDNEY STONEcan be confirmed by: Radiological studies Ultrasound examination; Urine tests & blood tests.
When a stone causes no symptoms, watchful waiting is a valid option. In which time is allowed to pass before medical
intervention or therapy is used.
A 9 mm kidney stones
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TREATMENTNon Surgical:1. For stones smaller than about 5mm, being
physically active + drinking a lot of water is often enough.
2. Extracorporeal shock wave lithotripsy (ESWL)
Common method uses x-ray or US imaging and a lithotripter which send shock waves to kidney stone, break it up into small crystals that passed in urine.
Surgical:3. Ureteroscopic stone removal Using a a cystoscope4. Percutaneous nephrolithotomy (PCNL) Telescopic instrument (nephroscope) is used to
break the stone using a laser beam or shock waves
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REFERENCES OF PATHOLOGY
http://en.wikipedia.org/wiki/Kidney_stone
http://hcd2.bupa.co.uk/fact_sheets/html/Kidney_stones.html
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THANK YOU Shatha Al-Mushayt, L-7
Presented at 2010