이학종분당서울대학교병원. Ultrasound in Urinary Colic

Transcription

1 이학종분당서울대학교병원 Ultrasound in Urinary Colic

2 U l t r a s o u n d i n U r i n a US: Normal Kidney r y C o l i c

3 Contents Definition and clinical consideration Pathophysiology US in in obstructive uropathy Doppler US US in in urolithiasis US in in renal infection

4 Definition:Obstruction Urine removal < Urine production Upsets dynamic balance Anatomical Obst. Fixed point of narrowing

5 Definition:Obstruction Anatomical Obst. Functional Obst. Primary obstructive megaureter Some cases of UPJ obstruction Detrusor-bladder neck and detrusorexternal sphincter dyssynergia

6 Definition:Hydronephrosis Dilatation of Collecting sys. Nonobstructive hydronephrosis Congenital megacalyces Postobstructive dilatation Vesicoureteral reflux High flow states

7 Renal colic Most intense form of pain Requires prompt treatment Lifetime risk of acute flank pain attack 1-10% Etiology ureteral calculi >> pyelonephritis UPJ obstruction Extrinsic ureteral obstruction intestinal, gynecologic, retroperitoneal, vascular

8 Pathophysiology of pain increase in intraluminal pressure stretches nerve endings in mucosa produced colicky pain contraction of smooth m. in ureter wall spasm of muscles increased production of lactic acid afferent impulses to spinal cord (T11-L1 level)

9 Treatment of renal colic Two concepts effective pain control maximal preservation of renal function by release of ureteric obstruction Pain control Standard: parenteral administration of narcotic analgesics Side effects: GI Sx or excessive sedation NSAID Decreased eicosanoid mediated pain pathway Decrease in ureteral contractility, RBF may detrimental to renal function

10 Obstruction: Experimental studies Murphy GP et al. J Urol Murphy GP et al. The renal hemodynamic response to acute and chronic ureteral occulsions. J Urol Yarger WE et al. Intrarenal hemodynamics following chronic unilateral ureteral obstruction in the dog. Am J Physiol Moody TE et al. Relationship between renal blood flow and ureteral pressure during 18 hours of total unilateral ureteral occlusion. Invest. Urol. 1975

11 Pathophysiology Early Late RBF GFR RVR Urine output Renal lymphatics

12 US in obstruction Noninvasive, safe, easily performed No radiation Sensitivity: 98% Specificity: 75%

13 USG:False (+) 2-26% Extrarenal pelvis Renal cystic disease VUR Vessel in renal sinus

14 Parapelvic cyst

15 Vessel in renal sinus

16 USG: False(-) 2-3% of obstruction Small intrarenal pelvis Recent onset obstruction Tumor infiltration Dehydration Decompression d/t backflow or tear

17 Doppler Effect The pitch of perceived sound varies when its source moves in relation to observer by Christian J. Doppler, 1841

18 Doppler Equation f = 2fv cos 0 / c f : incident transmitting frequency (usually 2-10 MHz) v : blood flow ( cm/s) c : sound velocity ( 1540 m/s) 0 : Doppler angle (30-60º)

19 Doppler US Renal sinus vessels vs pyelocaliectasis Ureter jet: high grade, acute obstruction Resistive Index

20 Ureter jet

21 Normal Ureter jet visible in 89% (57/64) mean frequency of jets: 4.1 jets/min Hydronephrosis ureteral calculus: 11% (1/9) UPJ obstruction: 28.6% (2/7) Nonobstructive hydronephrosis: 72.7% (8/11) Absence or asymmetry of jet hydronephrosis is likely to be obstructive Kuzmic AC, et al. Eur J Radiol 2001;39:

22 Doppler Indexes Pulsatility index Resistive index Diastolic/ Systolic ratio Peak systolic velocity

23 Resistive Index(RI) RI = (syst. peak v.- diast. peak v.) Normal RI Usually below 0.65 syst. peak v.

24 Resistive Index(RI) Interlobar or arcuate a. Affecting factors location age BP HR medication

25 RI : Mechanism Obstruction Pressure gradient Local humoral response (TXA2, renin-angiotensin system) Vascular resistance RI

26 Obstruction: RI>0.7! RI dri 1989 Platt (n=38) / Rodgers(n=14) /-0/ / Kessler (n=20) 0.77+/ / Brkljacic(n=21) / /-0.034

27 Obstruction: RI>0.7? RI dri 1996 Lee (n=31) / / Akata (n=28) 0.66+/ Vada (n=43) 0.75+/ (Control: 0.71+/- 0.06)

28 Obstruction: RI>0.7? RI Gr. A Acute, severe 0.73+/ Gr. B Acute, mild 0.62+/ Gr. C Chronic, severe 0.63+/ Gr. D Chronic, mild 0.61+/- 0.06

29 Distal Ureter Stone RI = 0.81

30 Bladder Tumor RI = 0.67

31 Obstructive Uropathy Doppler US does not have a value in differentiating obstructive and nonobstructive hydronephrosis. RI changes only in acute and severe obstruction.

32 Partial obstruction: Effect of Furosemide Lee HJ, et al. Acad Radiol 2001;8:

33 Partial obstruction: Effect of Furosemide RI RK, F(+) RK, F(-) LK, F(+) LK, F(-) Pre 1Hr 6Hr 1D 3D 1Wk 2Wk 4W

34 0.1 5 Partial obstruction: Effect of Furosemide dri RK, F(+) RK, F(-) LK, F(+) LK, F(-) Pre 1Hr 6Hr 1D 3D 1Wk 2Wk 4W

35 RI and Effect of Furosemide RI before and after furosemide is valuable in evaluating dilated collecting system. Furosemide accentuates dri, especially early after obstruction.

36 US in urolithiasis

37 General consideration Common cause of obst. M:F=2-3:1 Bilateral: 15% Age: 20-40

38 Clinical Manifestation Acute intermittent flank pain c/s Nausea or Vomiting Chronic dull flank pain Persistent hematuria Recurrent infection

39 Stone composition Calcium Calcium phosphate 5-10 Calcium oxalate-phosphate Calcium oxalate Struvite Cystine 1-3 Uric acid 5-10 Opacity

40 Distal ureter stone

41 Twinkling artifacts from urinary stones Color and Power twinkling artifacts 30/36 of stones (83%) reflections of rough interface formed by a crystalline aggregates Lee JY et al. AJR 2001;176:1441-5

42 Emphysematous Pyelonephritis Life-threatening Gas formation in renal parenchyma E. coli, Klebsiella pneumoniae, Aerobacter aerogenes, Proteus mirabilis DM, female.

43 Emphysematous Pyelonephritis Gassed-out kidney Kim SH, et al. Radiology Illustrated: Uroradiology pp

44 Pyonephrosis formation of pus in kidney and collecting system Sx of APN + hydronephrosis Findings fluid-debris level acoustic shadowing of air in the collecting system weak echoes from dilated collecting system

45 Pyonephrosis

46 Xanthogranulomatous Pyelonephritis (XGPN) Destruction, replacement by lipid-laden Macrophage Gross pathology Massive renal enlargement Lithiasis Peripelvic fibrosis Hydronephrosis Yellow mass replacing renal parenchyma

47 Xanthogranulomatous Pyelonephritis 3yrs/ M

48 Malacoplakia Rare granulomatous inflammation Michaelis-Gutmann body Urinary bladder: Common site F: M= 4: 1 Radiologic Findings Solitary or multiple ill-defined mass Diffuse enlargement

49 Malacoplakia

50 Summary

51 Thank You!