INTRAVENOUS PYELOGRAPHY(IVP) - PowerPoint Presentation

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INTRAVENOUS PYELOGRAPHY(IVP)

OR

INTRAVENOUS UROGRAPHY(IVU)

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An 

intravenous pyelogram

 or 

IVP

is a special radiological procedure used to visualize abnormalities of the urinary system, including the kidneys, 

ureters

, and bladder.

It is done to study renal function detects pathology and study the anatomical variation or to see the anatomy and physiology of the renal system.

X-rays are the oldest and most frequently used form of medical imaging.

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When a contrast material is injected into a vein in the patient's arm, it travels through the blood stream and, concentrates in the kidneys, and is passed out into the

ureters

with urine, turning these areas bright white on the x-ray images. An IVP allows the radiologist to view and assess the anatomy and function of the kidneys,

ureters

and the bladder.

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An IVP can show the size, shape, and position of the urinary tract, and it can evaluate the collecting system inside the kidneys. During IVP, a dye called contrast material (sodium

diatrizoate

)is injected into a vein(20-40 ml) in your arm. A series of X-ray pictures is then taken at timed intervals.IVP is commonly done to identify diseases of the urinary tract, such as kidney stones, tumours, or infection. It is also used to look for problems with the structure of the urinary tract that were present from birth (congenital).

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A preliminary X-ray picture (KUB) will be taken before the IVP. This picture is reviewed by the radiologist before the next part of the test begins. An IVP test may not be done if these pictures show a problem.

Other tests that may be used instead of an intravenous pyelogram (IVP) include computerized tomography(CT scan), ultrasound, angiography, and, occasionally, MRI.

Abdominal Ultrasound, Angiogram

CT Scan of the Body, MRI of the Abdomen

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An IVP can be performed in either emergency or routine circumstances.

Emergency IVP

This procedure is carried out on patients who present to an Emergency department, usually with severe renal colic and a positive 

hematuria

 test. In this circumstance the attending physician requires to know whether a patient has a kidney stone and if it is causing any obstruction in the urinary system.

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Patients with a positive

finding

for kidney stones but with no obstruction are usually discharged with a follow-up appointment with a urologist

Patients with a kidney stone 

and

 obstruction are usually required to stay in hospital for monitoring or further treatment.

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An Emergency IVP is carried out roughly as follows:

plain KUB or abdominal X-ray;

an injection of contrast media, typically 50 ml;

delayed abdominal X-ray, taken at roughly 15 minutes post injection.

If no obstruction is evident on this film a post-

micturition

film is taken and the patient is sent back to the Emergency department. If an obstruction 

is

 visible, a post-

micturition

film is still taken, but is followed up with a series of radiographs taken at a "double time" interval. For example, at 30 minutes post-injection, 1 hour, 2 hours, 4 hours, and so forth, until the obstruction is seen to resolve. This time delay can give important information to the urologist on where and how severe the obstruction is.

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Routine IVP

This procedure is most common for patients who have unexplained microscopic or macroscopic

hematuria

. It is used to ascertain the presence of a tumour or similar anatomy-altering disorders. The sequence of images is roughly as follows:

plain or Control KUB image;

immediate X-ray of just the renal area;

5 minute X-ray of just the renal area.

15 minute X-ray of just the renal area.

A post-

micturition

X-ray is taken afterwards. This is usually a coned bladder view.

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Biochemical tests before IVP

Blood Urea

Serum

Creatinine

If BU or SC is ↑dose of dye also ↑to delineate the kidney.

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Before having an intravenous pyelogram (IVP), tell your doctor if:

You are or might be pregnant.

You are breast-feeding. The contrast material used in this test can get into your breast milk. Do not breast-feed your baby for 2 days after this test. During this time, you can give your baby breast milk you stored before the test, or formula. Discard the breast milk you pump for 2 days after the test.

You have an intrauterine device in place.

You are allergic to the iodine dye used as the contrast material for X-ray tests or to anything else that contains iodine.

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You have ever had a serious allergic reaction, such as after being stung by a bee or from eating shellfish.

Within the past 4 days, you have had an X-ray test using barium contrast material (such as a barium enema).

You have had kidney problems in the past or have diabetes, especially if you take 

metformin

 (

Glucophage

) to control your diabetes. The contrast material used during an IVP can cause kidney damage in people who have poor kidney function.

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If you have had kidney problems in the past, blood tests (SC,BUN) may be done before the test to make sure that your kidneys are working properly.

You may need to stop eating and drinking for 8 to 12 hours before the IVP.

You also may need to take a laxative the evening before the test. The aim of this is to clear the intestines, which will make the X-ray pictures clearer and possibly have an enema the morning of the test) to make sure that your bowels are empty(tab charcoal &

gasex

to reduce gas formation, and

tb

herbolax

to clean the bowel as laxative)

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You may be asked to remove some or all of your clothes and to wear a gown during the exam. You may also be asked to remove

jewelry

, removable dental appliances, eye glasses and any metal objects or clothing that might interfere with the x-ray images.

Dye should be given very slowly and should not be

extravasate

.

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INDICATIONS

An intravenous pyelogram examination helps the radiologist assess abnormalities in the urinary system, as well as how quickly and efficiently the patient's system is able to handle fluid waste.

The exam is used to help diagnose symptoms such as blood in the urine or pain in the side or lower back.

The IVP exam can enable the radiologist to detect problems within the urinary tract resulting from:

Kidney stones

Enlarged prostate

Tumors

in the kidney,

ureters

or urinary bladder

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Surgery on the urinary tract

Congenital anomalies of the urinary tract

An abdominal injury,

Bladder and kidney infections,

Blood in the urine(

Haematuria

),

Flank pain (possibly due to kidney stones).

Obstruction or damage to any part of the urinary tract can often be seen on an IVU.

Look for problems with the structure of the urinary tract.

Look for damage to the urinary tract after an injury.

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Contraindication

Allergy to iodine dye

Renal failure

Multiple myeloma

Hyperuricaemia

Sickle cell anaemia

Diabetes mellitus with dehydration

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Procedure of IVU

Normal Appearances

Immediately after the contrast is administered, it appears on an X-ray as a 'renal blush'. This is the contrast being filtered through the cortex. At an interval of 3 minutes, the renal blush is still evident (to a lesser extent) but the calyces and renal pelvis are now visible. At 9 to 13 minutes the contrast begins to empty into the 

ureters

 and travel to the bladder which has now begun to fill. To visualize the bladder correctly, a post

micturition

X-ray is taken, so that the bulk of the contrast (which can mask a pathology) is emptied.

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An intravenous pyelogram (IVP) is usually done by a radiology technologist.

You will be asked to wear a gown and to lie on a couch. Contrast dye is then injected into a vein in your hand or arm. This may sting a little. The dye then starts to filter through the kidneys into the

ureters

which go from each kidney to the bladder. A series of X-ray pictures is then taken over your abdomen, usually every 5-10 minutes. You stay on the couch between each X-ray picture, but you may be asked to get up to empty your bladder before the final X-ray picture is taken. The procedure usually takes about 30-60 minutes. However, some pictures may be taken hours later in certain circumstances. You should be able to go home as soon as the procedure is finished. You can eat normally straight afterwards.

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During the Procedure:-

You will go to the X-ray department for the IVP test. While you are lying face up on the X-ray table, dye is injected through an IV placed in a vein.

The X-rays are taken at several intervals, such as at 0, 5, 10, and 20 minutes. Zero time is the time of injection of the dye. The test is completed when the kidneys,

ureters

, and bladder show up on the X-ray. Although the dye is

colorless

, it makes the kidneys and

ureters

appear white on the X-ray so that they contrast with the background of the rest of the abdomen.

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If,

for

e.g

,

the kidneys,

ureters

, and bladder can be seen after the

5-min

film is taken, then one last film will be taken immediately after you have urinated. If only one kidney and its

ureter

are seen after the

5,10, & 20min

pictures are taken, then the doctor will decide when further films should be taken. As a general rule, the interval for further films is determined by doubling the time from the last film. The time will be doubled until both kidneys and

ureters

can be seen.

For

e.g

,

if only one kidney and its

ureter

are seen after the

20-min

picture is taken, then the next film will be done 40

min

later. If the X-ray technician is still unable to see the kidneys after the

40-min

film, then the next test will be taken 80

min

later.

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While you are waiting for the X-rays to be taken, the nurses will check frequently to ensure that you are not experiencing any pain, nausea, or vomiting and, at the same time, will check your blood pressure, pulse, and breathing to make sure that these vital signs remain normal. If you have pain, nausea, or vomiting, the nurse can give appropriate medicines through the IV to help these symptoms.

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Image Assessment

The kidneys are assessed and compared for:

Regular appearance, smooth outlines, size, position, equal filtration and flow.

The

ureters

are assessed and compared for:

Size, a smooth regular and symmetrical appearance. A 'standing column' is suggestive of a partial obstruction.

The bladder is assessed for:

Regular smooth appearance and complete voiding.

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Congenital anomaly like

polycystic kidney, horse shoe kidney, single kidney, duplication of kidney or

ureter

.

Hydronephrosis

Hydroureter

Hydroureteronephrosis

Vesico

ureteric

reflux

Ureterocele

PUJ obstruction

Renal stones

Ureteric

stones

Bladder stones

Renal tuberculosis

Renal

tumor

 

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Benefits

Imaging of the urinary tract with IVP is a minimally invasive procedure.

IVP images provide valuable, detailed information to assist physicians in diagnosing and treating urinary tract conditions from kidney stones to cancer.

An IVP can often provide enough information about kidney stones and urinary tract obstructions to direct treatment with medication and avoid more invasive surgical procedures.

No radiation remains in a patient's body after an x-ray examination.

X-rays usually have no side effects.

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Risks

There is always a slight chance of damage to cells or tissue from radiation, including the low levels of radiation used for this test.

There is slight risk of having an allergic

rxn

 to the contrast material. The reaction can be mild (itching, rash, flushing or warm feeling, and a metallic taste in the mouth.) or severe (for

e.g

, trouble breathing or breathing difficulties & sudden shock/collapse due to low BP). Death resulting from an allergic

rxn

is very rare. Most reactions can be controlled with medicine. Be sure to tell your doctor if you have asthma or allergies of any kind, such as hay fever, iodine allergy, bee stings, or food allergies.

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People with certain conditions (such as diabetes, multiple myeloma, chronic kidney disease, sickle cell disease, or 

pheochromocytoma

) have increased chances of having sudden kidney failure from IVP. Older adults and people taking medicines that affect the kidney may also have increased chances for problems after an IVP.

Acute kidney failure is a rare complication.

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What are the limitations of IVP exams?

An IVP shows details of the inside of the urinary tract including the kidneys,

ureters

and bladder. Computed tomography (CT) 

ormagnetic

resonance imaging (MRI) may add valuable information about the functioning tissue of the kidneys and surrounding structures nearby the kidneys,

ureters

and bladder. Small urinary tract

tumors

and stones are more easily identified on these examinations. IVP exams are not usually indicated for pregnant women.

The uses for IVP in infants and children are limited. Other tests, including ultrasound, can be used in most cases to evaluate the kidneys and bladder. In general, IVPs are rarely done in

pediatric

patients