KUB full version

• filter blood

• Create urine as a waste by-product

Urinary sytem’s function

• Renal or ureteric pain

• Suspected Renal mass (large kidney)

• Nonfunctioning kidney on urography

• Hematuria

• Recurrent urinary infection

• Trauma

• Suspected polycystic disease

Cinical indication for KUB imaging

4-5 glasses of water

How many glasses of water should the pt drink if they undergo a KUB ultrasound, since the bladder has to be full?

3.5-5 Mhz curvilinear probe

Probe for the KUB ultrasound

3.5 MHz

Transducer for normal or obese patiens

5 MHz

Transducer for slim patients

Kidneys

bean-shaped organs situated on the back of the

abdominal wall, behind the peritoneum at the level of T12-L3.

to accomodate the liver

Why is the right kidney, slightly lower than the left kidney?

Renal Capsule/Rind

Outer covering of the

kidney that appear as bright, smooth,

echogenic line around the kidney.

Renal Cortex

homogeneous echoes that

are less than (hypoechoic) or equal

(Isoechoic)to the density/echogenicity of

the liver or spleen.

Renal Sinus

Innermost part of the kidney and

has the greatest echogenicity. It is hyperechoic and is composed of calyces, the renal pelvis, fat, and the major intrarenal vessels

Medullary Pyramids/Renal Pyramids

show up as rounded triangular structure and is regularly spaced hypoechoic

to anechoic areas within the kidney. It may appear in scanning when urine-filled, or

otherwise not visible.

smooth; ovoid reniform

On longitudinal view (long axis), The renal contours should be ____ and of an ___ shape

Oval

If the transducer is held in the sagittal plane, the kidney appears more ___

appears bean shaped

with the medial side

rather flat.

If the transducer is held in a coronal plane, the kidney appears?

round/circular; C-shaped

On Transverse view (short axis), the kidney appears _____ to _____ shaped

size of a

kidney

The _____ may point to

its condition or

pathological state

Cortical thickness

normally 10 mm in length and is measured from renal capsule to the

base of the triangular medullary pyramids

Parenchymal thickness

measured from the renal

capsule to the edge of the renal sinus.

Under 1 cm

What measurement of the parenchymal thickness is considered abnormal?

14-18 mm

Normal parenchymal thickness

Dromedary humps

A bulge on the lateral border of the mid-pole of the left kidney, which can be confused with a renal mass

Crossed fused ectopic kidney

The left kidneyy is fused to the lower pole of the right kidney.

Renal ectopia

The kidney lies in an abnormal position

Compensatory Hypertrophy

A single functioning kidney will hypertrophy to compensate. This effect is most marked in children and young adults.

Horshoe kidney

This condition involves fusion of the lower poles of two kidneys (rarely the upper poles)

Deep suspended inspiration

What breathing instructions should be done in a KUB ultrasound?

the kidneys will move in the caudal direction, which may

facilitate evaluation of the kidneys.

What will happen to the kidney if the pt inhales deeply?

For the right kidney, right liver lobe.

For the left kidney, the spleen.

For the left and right kidney, which anatomical structures should be used as an acoustic windows for both kidneys?

Supine, L & R lateral decubitus position

Preferred patient position for KUB ultrasound

prone position

If kidneys have not been imaged adequately turn the patient into what position?

Anterior, lateral, superior

Right kidney approach

Requires a posterior approach, through the spleen.

Left kidney approach

Supine position: right kidney longitudinal/sagittal scanning

• Point the probe indicator towards the patient’s head.

• place your probe at the Right Midaxillary Line around the 10th to 11th intercostal space.

• Center the kidney on the ultrasound screen.

• Consider angling the probe slightly oblique (10-20 degrees counterclockwise) to avoid rib

shadow artifact and optimize your view.

• Slowly tilt/fan the probe anteriorly and posteriorly to assess the entire kidney.

Supine position: Right kidney transverse scanning

• Maintaining the longitudinal view of the right kidney, center the kidney on your screen, and

then rotate your probe 90 degrees counterclockwise.

• The probe indicator should be pointing Posteriorly.

Supine position: left kidney longitudinal and transverse scanning

• Point the probe indicator towards the patient’s head.

• Place your probe at the Left Posterior Axillary Line around the 8th to 10th intercostal space.

• To reach the posterior axillary line, your knuckles should touch the bed.

• Sometimes you may need to rely on the patient’s breathing pattern to bring the left kidney into

view.

Lateral Decubitus position L & R: Intercostal view

Use fingers to find the most caudad intercostal space at the anterior axillary line and put the probe

so the non-indicator edge is at the costal margin.

Prone position: posterior view

Find the medial rib margin with your fingers and apply gel medial to this rib. The curvilinear

probe, indicator obliquely cephalad, is placed as in the following image on a patient’s right side.

Move around medial to the rib in this region to find the kidney and optimize the long axis view.

FLUID FILLED MASS

One of the most common abnormalities in the kidneys are cysts (fluid-filled sacs). Cysts are

generally asymptomatic.

FLUID FILLED MASS

The cyst is round with no internal echoes, slight posterior acoustic

enhancement, and a lateral wall shadow

Pararenal

Simple cysts can bulge-off of a kidney

Cortical

Simple cysts can bulge-off of a cortex

Parapelvic

Simple cysts can bulge-off of a medullary area

Malignant

Most solid kidney masses or tumors are ____

Solid Mass

They maybe well circumscribed or irregular and may alter the shape of the kidney wit echogenicity may be

increased or decreases depending on the degree of necrosis.

Renal Cell Carcinoma

The most common

type of kidney cancer is

Complex Mass

have a thicker wall, or solid material inside instead of just fluid. Once discovered, additional imaging tests may be

performed to monitor them and distinguish benign from cancer.

Angiomyolipoma

It is a benign neoplasm of the kidney.

Angiomyolipoma

This tumor is made of various amounts of fat, smooth muscle, and vascular elements.

Angiomyolipoma

is almost always markedly hyperechoic to renal parenchyma, often as hyperechoic as renal sinus fat

RENAL STONE/ NEPHROLITHIASIS/ RENAL CALCULI

are hard collections of salt and minerals often made up of calcium or uric acid.

NEPHROCALCINOSIS

is a condition in which calcium levels in the kidneys are increased.

HYDRONEPHROSIS

is defined as distention of the renal calyces and pelvis with urine as a result of obstruction of the outflow of urine distal to the renal pelvis.

HYDRONEPHROSIS

This happens

because urine does not fully empty from the body

HYDRONEPHROSIS

Accumulation of urine in the renal collecting system (pelvis and/or calyces) shows up as an anechoic structure, typically in the middle of the hilum.

HYDRONEPHROSIS

Radiologists frequently describe this as splitting of the central sinus

RENAL PARENCHYMAL DISEASE /CKD

describes medical conditions which damage the renal cortex and renal medulla parts of the kidney. These diseases may be congenital, hereditary or acquired

(chronic).

RENAL PARENCHYMAL DISEASE /CKD

Increased cortical or cortical and medullary echodensity indicates ____

Small end-stage kidneys

less than 7 cm in length, will not recover any significant function, and the patient should be put on a dialysis or a transplantation programme.

dialysis or a transplantation programme

Small end-stage kidneys, less than 7 cm in length, will not recover any significant function, and the patient should be put on a

URETERS

are narrow muscular tubes 4–6 mm in diameter, with a lumen of 2–8 mm, depending on peristalsis.

ureteral jets

the effect of urine entering the urinary bladder ureteral orifices, can be observed on real time examination.

Because of their position behind the bowel

Why is it not easy to examine normal ureters by ultrasound?

kidney or bladder

If dilated(for some pathological reasons), the ureters are easier to see particularly near the ___.

Lower end of the ureters

can be observed by scanning through a full bladder, which provides a useful acoustic window

Ureteral calculi

almost always originate in the kidneys, although they may continue to grow once, they lodge in the ureter

Urinary Bladder

a hollow elastic organ that functions as the body’s urine storage tank.

Urinary Bladder

It is located in the pelvic cavity anterior to the rectum and superior to the reproductive organs of the pelvis

Filler Bladder

creates a perfect acoustic window for evaluation of the distal ureteral orifices in the bladder posterior wall.

500ml

The normal bladder is a fluid-filled structure with a volume when full of

about ___

Filled

A bladder must be ___ for adequate evaluation

Filled urinary bladder

will normally appear to have thin walls without wall irregularities and with homogenous large echo-

free/anechogenic content.

Degree of Distention

Quantity if Urine stored

The size, shape and thickness of the wall of bladder vary with the ____ or depending on the ____

Transverse Plane

Sagittal Plane

The bladder may be thought of as a roughly ovoid structure, although the shape varies with distension and with pressure from adjacent organs, becoming more of a rectangle in the ___, particularly in women, and pyramidal in the ___.

>3 mm

>5 mm

The normal bladder wall is thickened when ___ when distended ___ when nondistended

anterior approach

pubic symphysis (suprapubic)

The bladder is scanned from an ___, with the transducer just above the ____.

Supine

Longitudinal and Transverse Scan

Patient position and Scanning technique used in urinary bladder

posterior to the pubic bone/symphysis

too superiorly

One of the most important things to remember when performing bladder ultrasound is that the bladder is directly ___. If you are unable to get proper images, most likely your ultrasound probe is placed ____.

SUPINE POSITION: (1)LONGITUDINAL VIEW OF THE URINARY BLADDER

• Place the transducer with the indicator pointing towards the patient’s head in the patient’s

midline, right above the pubic symphysis.

• Rock the probe so that it points down towards the pelvic cavity.

• Observe the lateral borders of the bladder by tilting/fanning the probe left and right.

SUPINE POSITION: (2)TRANSVERSE VIEW OF THE URINARY BLADDER

• center the bladder and then rotate the transducer 90 degrees counterclockwise. The

indicator should now point to the patient’s Right side.

• Make sure to tilt the ultrasound probe so it scans into the pelvic cavity.

• • Tilt/Fan the probe to examine the entire bladder from superior to inferior.

Transverse View

The Width and Depth of the bladder are measured in the ____

Longitudinal View

The superior-inferior dimension (Height) is measured in the ___

300-400 mL

50-100mL

Most ultrasound machines will automatically calculate the entire bladder volume which should be less than ___ in healthy adults and Post Void Residual (PVR) should be less than ___

URINARY BLADDER CALCULI/VESICAL CALCULUS /CYSTOLITH

They develop when the minerals in concentrated urine crystallize and form stones. This often happens when you have trouble completely emptying your bladder.

URINARY BLADDER CALCULI/VESICAL CALCULUS /CYSTOLITH

are hard masses of minerals in your bladder.

Chronic cystitis

results in focal or diffuse thickening of the urinary bladder wall

URINARY BLADDER DIVERTICULUM

is an outpouching from the bladder wall, whereby mucosa herniates through the bladder wall. It may be solitary or multiple in nature and can vary considerably in size.

URINARY BLADDER MASS

are generally echogenic, irregularly shaped, and are found either mounted on the bladder wall or in areas of irregularly increased bladder wall thickness.

URINARY BLADDER CLOTS

In the event of trauma, blood clots may add mobile echogenic content to the bladder