RENAL ULTRASOUND

Diana Pancu, MD

Left: prostate showing a hypoechoic

Lesion suspicious for cancer

Right: with biopsy needle

Objectives

Clinical indications for performing ED renal US

Approach to performing the US study
Normal anatomy
Abnormal findings
Clinical Impact

Clinical Indications for ED

Renal Ultrasound
Suspected renal colic
Colicky flank pain radiating to groin
Hematuria

Clinical question:
Presence of hydronephrosis
Absence of other pathology (AAA)

Performing the Study

Patient preparation:
none

Transducer: 3.0MHz or 3.5 MHz

5.0 MHz for thin patient

Patient positioning
Supine
Posterior oblique, lateral decubitus, prone

Anatomy
Kidneys are retroperitoneal, T12 - L4
Right kidney is lower than the left kidney
Right kidney is posterio-inferior to liver &
gallbladder
Left kidney is inferior-medial to the spleen
Adrenal glands are superior, anterior,
medial to each kidney

Hepatic
Veins

Spleen
Celiac
axis

Liver
Renal artery

AORTA

Renal vein

IVC

Right
kidney

SMA

Left
kidney

Renal Scanning Approaches

Approach to Scanning

STOMACH

AORTA

SPLEEN

LIVER

IVC

Right kidney scanning

approach: anterior, lateral,
posterior
Liver is the acoustic
window

Left kidney: requires a posterior

approach, through the spleen
Air-filled bowel impedes
anterior scanning

Anatomy
9-12 cm long, 4-5 cm wide, 3-4 cm thick
Gerotas fascia encloses kidney, capsule,
perinephric fat
Sinus
Hilum: vessels, nerves, lymphatics, ureter
Pelvis: major and minor calyces

Parenchyma surrounds the sinus

Cortex: site of urine formation, contains nephrons
Medulla: contains pyramids that pass urine to minor
calyces. Columns of Bertin separate pyramids

Medullary pyramids

Kidney Anatomy

Minor
Calyx
Renal artery

Major
Calyx

Renal vein

Sinus

Medulla
Renal capsule

Cortex

Ureter

Sonographic Appearance

Ureters are normally not seen

Renal pelvis is black when visible
Renal sinus is echogenic due to fat
Medullary pyramids are hypoechoic
Cortex is mid-gray, less echogenic than
liver or spleen.
Capsule is smooth and echogenic

Right Kidney Long Axis

Right Kidney Long Axis

Anterior
Superior

Liver

Inferior
Sinus
Cortex

Diaphragm
Posterior

Right Kidney Short Axis

Right Kidney Short Axis

Anterior

Right

GB Liver

Left

IVC

R Kidney
Vertebral
Body

Posterior

Aorta
Renal a.

Left Kidney Long Axis

Left Kidney Long Axis

Anterior
Superior

Inferior
Rib
Shadow

Kidney
Posterior
Spleen

Left Kidney Short Axis

Left Kidney Short Axis

Anterior
Right Liver

Left

Spleen
L Kidney
Posterior

Common Pitfalls in
Renal Scanning
Failure to scan both kidneys
Mistaking prominent renal pyramids for
hydronephrosis
Mistaking prominent pyramids for cysts
Confusing normal renal arteries for the
ureter

Common Pitfalls in
Renal Scanning
Failure to scan through the bladder to search
for stone at the uretero-vesicular junction
Inability to visualize left kidney due to
anterior probe placement
Failure to scan the aorta in suspected renal
colic

Normal Variants
Dromedary humps:
Lateral kidney bulge, same echogenicity as the cortex
Hypertrophied column of Bertin:
Cortical tissue indents the renal sinus
Double collecting system:
Sinus divided by a hypertrophied column of Bertin
Horseshoe kidney:
Kidneys are connected, usually at the lower pole
Renal ectopia:
One or both kidneys outside the normal renal fossa

Clinical Indications
1. Obstructive Uropathy

Nephrolithiasis
12% of the US population
Incidence of renal colic is 3% with 50%
recurrence within 10 years

Manthey DE. Emerg Med Clin North Am.2001;

19(3): 633-54

Radiographic Modalities
Radiography
62% Sensitivity, 67% Specificity
Sharma RN, Shah I, Gupta S, et al:
Thermogravimetric analysis of urinary stones.
Br J Urol 64:564-566, 1989

Radiographic Modalities
IVP vs. US
Prospective study, 85 patients
ULTRASOUND
Sensitivity=85%
Specificity=92%

IVP
Sensitivity=90%
Specificity=94%

Sinclair D, Wilson S, Toi A, et al. Ann Emerg

Med 18:556-559, 1989

Radiographic Modalities
ED Ultrasound + KUB vs. IVP
Prospective study, 108 patients
Sensitivity = 97%
Specificity = 59%
Sensitivity = 97%
Specificity = 59%

PPV = 81%
NPV = 92%

Henderson, S, et al: Acad Emerg Med.1998;5:666-671.

Radiographic Modalities
Helical CT- Gold Standard
Accurate, fast, no contrast
Identifies presence and size of stone

Location of stone
Level of obstruction
Other sources of pain

Stone on CT
Usually visualized
Not visualized
Stone is extremely small < 1 mm
Stone is of relatively low CT attenuation:
Indinavir stones
Stone excluded from imaging due to respiratory
variation

Helical CT
Secondary Findings
Sensitivity

Specificity

Ureteral dilatation 90%

Perinephric stranding 82%
Collecting system
dilatation 83%
Renal enlargement 71%

Ureral dilatation 93%

Perinephric stranding 93%
Collecting system
dilatation 94%
Renal enlargement 89%

Smith. AJR Am J Roentgenol 167:1109-1113, 1996

Location of Stone
378 patients
Rate of spontaneous stone passage
22% for proximal ureteral stones
46% for midureteral stones
71% for distal ureteral stones

Morse R. J Urol. 1991; 145:263-265

Width of Stone
520 patients
Rate of spontaneous stone passage

100% for stones that were 1 mm or smaller in width

90% for stones 2 to 3 mm
80% for stones that were 4 mm
55% for stones that were 5 mm
35% for stones that were 6 mm
25% for stones that were 7 mm
12% for stones that were 8 mm
Ueno A. Urology. 1977; 10:544-546

Radiographic Modalities
Ultrasound
Fast
Can identify other causes of pain
Safe in pregnant patients, children

Hydronephrosis
Dilatation of the urinary tract at any level
secondary to intrinsic and or extrinsic
obstruction to urine flow

Hydronephrosis
Intrinsic, acquired

Intrinsic, congenital

Renal lithiasis
Neoplasm (renal, ureteral, bladder)
Papillary necrosis
Ureterocele
Blood clot
Neurogenic bladder
Anticholinergics
Pregnancy, PID, uterine prolapse)
Diuretics
Vesico-ureteral reflux
Diabetes insipidus

Stenosis (ureteral,
urethral, meatal)
Adynamic ureter
Spinal cord defects
Duplication of the
ureter
Ureterocele

Hydronephrosis in Renal Colic

Sensitivity = 90%
Specificity = 93%

PPV = 92%
NPV = 90%

Smith. AJR Am J Roentgenol. 1996; 167:1109-1113

Sensitivity = 87%
Specificity = 90%

Dalrymple. J Urol. 1997; 159:735-740

PPV = 90%
NPV = 89%

Obstructive Uropathy
Grading System - Subjective
Mild
Minimal separation of calyces

Moderate
Dilation of major and minor calyceal system

Severe
Marked dilation of the renal pelvis and thinning
of the renal parenchyma

Range of Hydronephrosis

Normal

Mild

Moderate

Severe

Mild Hydronephrosis

GB
Kidney

Liver

Moderate - Severe
Hydronephrosis

GB

Liver

Kidney
Dilated pelvis

Renal Pathology
1. Renal Cysts

Renal Cysts
Arise in the renal cortex, commonly single rather
than multiple
Cysts do not communicate; hydronephrosis does
Shape is round or oval
Echo free
Sharp interface between the mass and renal tissue
Large renal cysts may be mistaken for aortic
aneurysms

Renal Cysts

Liver
Cyst
Kidney

Scatter 20
Bowel

Problems & Pitfalls

Mistaking cysts for hydronephrosis
Mistaking cysts for aortic aneurysm

Case Presentation
40 yo male presents with complaints of
recent severe headaches, diaphoresis,
and palpitations
PE anxious male
BP 210/120 HR 145 RR 18 T 99
Physical exam otherwise normal

Ultrasound of Kidneys
Kidney

Liver
Diaphragm

Rib
Shadow

Mass

Case Development
The patient was managed with alpha and
beta-adrenergic blocking agents
Urine studies revealed elevated
metanepherine and catecholamine levels
The patient was diagnosed with
pheochromocytoma

Renal Pathology

2. Renal Masses

Renal Masses
Ultrasound visualizes most solid and cystic renal masses
Beyond scope of EM ultrasound
Appearance
Irregular borders
Poorly defined interfaces between mass and kidney

Complex masses
Complex ultrasonic appearance
Cysts or solid masses may represent infection or hemorrhage
May have fluid levels

Case Presentation
35 year old male with history of Crohns presents
with sudden onset of right flank pain. He is
nauseated and has vomited a few times. He
reports hematuria and denies fever, dysuria,
abdominal pain.

Physical Exam
Young man in moderate distress from pain
BP 125/67
HR 110 T 98
Lungs: clear to ascultation
Heart: Tachycardia without murmur
Abdomen: soft, non-tender, normal bowel
sounds
Back: right costo-vertebral angle tenderness
on percussion

Renal Ultrasound
Right Kidney

Left Kidney

Ultrasound

Echogenic
Structure

Distinct Shadow

Thin Parenchyma
Dilated Calyces

CT Results
Bilateral Staghorn Calculi
Bilateral moderate hydronephrosis
Right sided 3 mm stone at the UVJ

Summary & Take-Home Points

US is an adjunct in the evaluation of
patients with suspected renal colic
Evaluate kidneys
Evaluate aorta

Scan both kidneys

Renal
Ultrasound

Steve Geiersbach, MS, RT(R), RDMS

RENAL ANATOMY
MEDULLA
RENAL
CORTEX
MAJOR
CALYCES
RENAL
PELVIS
URETER

RENAL
MEDULLARY
PYRAMID

RENAL
COLUMN

RENAL
CAPSULE
MINOR
CALYX

RENAL SONOGRAPHY
Paired retroperitoneal organs
Renal sinus- dense central echoes due to
renal fat
Contains:
Collecting system: calyces, infundibula, & part of
renal pelvis
bifid system seen as two separate lobulations

Renal vessels: renal hilium

Lymphatics
Fat
Fibrous tissues

RENAL SINUS

Central area of the kidney

from the medial border
Bounded by fat

anteriorly and posteriorly by

fibrous sheath known as
Gerotas fascia
laterally by the laterocoronal
fascia which becomes
continuous with peritoneum &
abdominal wall

RENAL SONOGRAPHY

Renal parenchyma - 2 parts cortex & medulla

thickest at the renal poles

Cortex located between capsule & medulla

low level uniform echoes

less echogenic than liver & spleen
Columns of Bertin = columns of cortical
tissue located between pyramids

can enlarge & mimic a mass

normal variant
medulla

variable in size but average adult kidney measures 912 cm in length; 4-6 cm in width; 2.5-4.0 cm in
thickness

renal volume is estimated by water displacement

V = 0.49 x length x width x anterior posterior

dimension

RENAL SONOGRAPHY

Renal parenchyma - 2 parts cortex &

medulla

Medulla

Pyramids - triangular or rounded

hypoechoic areas

Rounded zones of

decreased
echogenicity between cortex &
renal sinus

Specular echoes interspersed at

the junction of the cortex &
medulla represents arcuate
arteries & veins (known as
corticomedullary junction)

RENAL SONOGRAPHY
Vascular exchange
renal arteries
come off of aorta - can be multiple
right renal artery (RRA) - seen posterior to IVC in
sagittal plane

renal veins
come off of IVC
left renal vein (LRV) - seen between SMA & aorta
in the transverse plane

RENAL ARTERY

RENAL SONOGRAPHY
Renal anatomy
kidney is covered by a true capsule
kidney is surrounded by perinephric fat
fat is bounded anteriorly & posteriorly by
fibrous sheath - Gerotas facia

LEFT RENAL ARTERY and Vein

LRA

LRV

RENAL SONOGRAPHY
Congenital variations

fetal lobulations
dromedary hump
agenesis
ectopic
cross-fused ectopic - both located on same side and
usually connected

horseshoe - isthmus of tissue that connects both

kidneys
pelvic kidney - fails to migrate from pelvic area
during embryology

RENAL SONOGRAPHY
Physiology - 3 functions
filtration
reabsorbtion
tubular secretions
Essential lab values
BUN - Blood Urea Nitrogen
Creatinine

RENAL SONOGRAPHY
Indications for sonography exam

hydronephrosis
non visualization on IVP exam
evaluation of flank masses
avoidance of contrast agent (Allergy to IVP
contrast)
decreased or poor renal function
evaluation of abscess
evaluation of renal transplant
evaluation of urinary bladder
hematuria & or flank pain

RENAL SONOGRAPHY
Imaging technique - no prep necessary
patient position - oblique & decubitus positions
work the best
LPO / use liver for acoustic window for
imaging the right
Rt. Lateral ducubitus best position for left
kidney - use spleen.
technique setting
highest frequency possible that allows for proper
penetration
gain settings are vitally important

RENAL SONOGRAPHY
Imaging technique - Complete study
must be bilateral & include the bladder
multiple planes including sagittal & transverse
scan superior to inferior and medial to lateral to
be assured you scan the entire kidney
compare cortical density to that of the liver
if hydronephrosis - try to demonstrate the ureter

RENAL SONOGRAPHY
Imaging technique - if malignancy is suggested
you must scan & survey for involvement of:

IVC
Renal veins
Liver
Retroperitonium

RENAL SONOGRAPHY
Ureters
arise as budlike outgrowths from the mesonephric
or Wolffian ducts
average size 30 cm long 5 mm in diameter
courses retroperitoneal to the bladder

Bladder
thin walled, smooth & uniform 5mm in diameter
look for abnormal densities or interruptions of the
wall
volume = transverse x AP x length

ADRENAL GLANDS
Physiology: two endocrine glands
cortex - secretes steroids
Mineralocorticoids
Glucocorticoids
Sex hormones
Addisons disease - hypofunction of adrenal
hypotension, malaise, anorexia, bronzing of the skin
Cushings disease - oversecretion of adrenal cortex
increased plasma volume; mild alkalosis, muscle and
bone weakness

ADRENAL GLANDS
Physiology: two endocrine glands
Medulla - produces epinephrine & norepinephrine
epinephrine - accelerator of the heart
norepinephrine - vasoconstrictor
together they breakdown glycogen to glucose