eMedicine Specialties > Radiology > Genitourinary
Obstructive Uropathy, Acute: Imaging
Updated: Mar 10, 2008
Radiography
Findings
The plain abdominal radiograph or KUB film has long been the initial imaging study of choice in patients presenting with symptoms of acute flank pain. Calculi may have a variable appearance on radiographs depending on their chemical composition, especially the percentage and distribution of calcium within them. They may appear homogeneously dense and smooth to laminated and jagged.
While 90% of stones contain calcium, the sensitivity of plain films has been reported at only 50-60%, with a specificity of 70%. Therefore, in many centers, plain radiographs are deferred in favor of CT in the acute setting. In some instances, renal and ureteral calculi are detected on plain abdominal radiographs obtained for another reason.
Most noncalcified stones, blood clots, and most other intraluminal obstructive causes are radiolucent; therefore, they are not seen on abdominal radiographs. In trauma, the presence of pelvic fractures and soft-tissue mass in the abdomen or pelvis may alert the radiologist to the possibility of ureteral injury, a rare complication, or obstruction from a large hematoma.
IVU, also termed excretory urography, came into clinical existence in the 1920s as a method of evaluating the structure and function of the kidney and urinary tract. It served as both a screening study and diagnostic imaging study in patients with acute renal or ureteral colic, demonstrating calculi and the presence of obstruction fairly accurately.
Since 1995, noncontrast helical CT has superseded IVU in this setting, at least as a screening study. Obstructive uropathy demonstrated on unenhanced helical CT often requires no further imaging studies. An estimated 15% of helical CT studies require radiopaque contrast media to confirm or exclude pelvic calcifications as stones or phleboliths.21 However, IVU may be performed if findings are equivocal or a noncalculus etiology is suggested.
IVU begins with a scout or preliminary radiograph. Additionally, oblique scout radiographs may be obtained. Preinjection linear tomograms are helpful when the bowel pattern obscures the areas of interest. Following the administration of the contrast agent, coned films and tomograms are then obtained, with the intervals and total number of films being quite variable. In a normal kidney, opacification of the renal parenchyma is observed within 1 minute. Within the next 2 minutes, the pelvocalyceal system may be seen, followed by the ureters approximately 5-10 minutes postinjection.
In an obstructed kidney, delayed accumulation of contrast is seen, resulting in a nephrogram that is initially of lower density. Progressive concentration of contrast within the renal cortex and medulla occurs, producing the classically described "obstructive nephrogram" that may persist for some duration. Striations may occasionally be seen in the parenchyma, representing contrast material within dilated tubules.
The pelvocalyceal system may not opacify for hours or at all, depending on the severity of obstruction. Dilatation proximal to the obstructing process may be seen as hydronephrosis and hydroureter, which may be minimal in the acute situation. A standing column of contrast may be observed proximal to the obstruction. Pyelosinus extravasation of contrast and mild clubbing of the calyces also may be seen.
Degree of Confidence
Degree of confidence in interpreting plain film in acute obstructive uropathy depends on the etiology. Determining the presence of calculi depends on multiple factors, including the size of the stone, chemical composition, location, and multiplicity. Equally important are the technical factors involved in obtaining an optimal radiograph. Further imaging is required when calculi are observed, to confirm their presence and determine if signs of obstruction exist.
On an IVU, the findings of a persistent nephrogram and delayed passage of contrast through the urinary system indicate with a high degree of confidence that an obstruction is present. IVU is best performed following a screening study that produces either negative or equivocal results.
False Positives/Negatives
Both false positives and false negatives are quite common, as the sensitivity and specificity of plain radiographs are poor. Small calcified stones, radiolucent stones, clots, and mucosal edema are not visualized. In addition, a large patient body habitus and overlying bowel may obscure even densely calcified stones, resulting in a false-negative interpretation.
Most false positives occur because of the presence of other calcific densities within the perceived or expected areas of the kidney and ureter. While gallstones usually are multiple and have a faceted appearance, they may be seen overlying the right kidney and, even on oblique films, may be indistinguishable from renal calculi. In the pelvis, phleboliths often are misinterpreted as ureteral calculi. The radiolucent center of a phlebolith may not always be present to help differentiate the two.
As reported in the literature, IVU sensitivity in the evaluation of acute flank pain varies from 52-87%. The detection of calculi as a cause of obstructive uropathy depends on multiple factors, including stone size and location, as well as the degree of obstruction. As a result, false-negative studies are not uncommon in the urographic evaluation of calculi.
The presence of a standing column of contrast does not always indicate the site of obstruction, as it may be seen in normal individuals.
Computed Tomography
Findings
On unenhanced helical CT, calcified calculi appear as opaque densities within the genitourinary tract, as in radiographs. Interestingly, calculi that are radiolucent on plain film also are of high attenuation on CT. Researchers have reported that Hounsfield values may be used to differentiate the types of calculi, as this can provide the clinician information concerning an underlying metabolic disorder as well as influence treatment decisions. However, the overlap in Hounsfield values among the different stones makes this of limited use.
These values become important in determining the presence of an intraluminal blood clot, which appears dense on CT but has a lower attenuation value than calculi. An exception to the normal high attenuation of calculi has been described in a small percentage of HIV -positive patients being treated with indinavir, a protease inhibitor.22 As the stones are of soft-tissue attenuation, they are not detected on non–contrast-enhanced CT.
As mentioned previously, unenhanced helical CT is not a physiologic imaging study, and the sole finding of a stone is inadequate to make the diagnosis of obstruction. Therefore, secondary signs of obstruction, as detected on CT, are necessary to confirm the diagnosis and obtain an idea concerning the severity of obstruction. In the presence of ureteral calculi, proximal ureterectasis is the most commonly seen indirect sign. This also may be observed with other causes of intraluminal obstruction.
Dilatation of the pelvocalyceal system is seen on CT as anterior and medial bulging of the renal pelvis, which is of low attenuation compared to the surrounding renal parenchyma. Renal enlargement also may be observed in some patients. Perinephric fat stranding, representing engorged lymphatics and/or edema, is seen as linear wispy densities in the normally low-attenuation fat. Moderate-to-severe perinephric stranding generally corresponds to the degree of obstruction present.
Periureteral stranding densities often are seen, again representing edema in the surrounding fat. Other signs of obstruction include the rim sign, which refers to the soft-tissue attenuation halo around an intraureteral calculus, ureteral wall edema, and blurring of the renal sinus fat. One or more of these secondary signs usually is present, and the predictive values of the individual signs have been reported in the literature. Ureterectasis, hydronephrosis, and periureteral and perinephric stranding each have a positive predictive value of approximately 90%.
Hydronephrosis and perinephric stranding may be the only signs of obstruction in patients with inadvertent ligation of the ureters, while the presence of an intra-abdominal hematoma in a posttraumatic setting or an inflammatory mass in a patient with abdominal pain indicates a possible etiology.
The administration of IV contrast material in the above situations may help delineate the ureter and determine whether the obstruction is indeed secondary to extrinsic compression. In many patients, IVU or direct visualization of the urinary tract is needed to establish the diagnosis.
Contrast-enhanced CT in obstruction produces findings similar to that first described with IVU, revealing a prolonged parenchymal phase. The persistent nephrogram, in which the kidney appears with either a homogeneous or mottled density, results from delayed passage of contrast into the collecting system. Pyelosinus extravasation is well demonstrated on CT as areas of contrast material within the renal sinus fat.
Degree of Confidence
Degree of confidence in interpreting an unenhanced helical CT in a patient with a ureteral stone depends on the presence of secondary signs of obstruction. Ureterectasis and perinephric stranding, when present together, have a positive predictive value of 99%. With other causes, secondary signs of obstruction increase the confidence in making the diagnosis, although a clear-cut cause may not be evident.
False Positives/Negatives
The largest source of false-positive errors in unenhanced helical CT results from phleboliths in the pelvis. On CT, the radiolucent center is not present to help differentiate them from stones, and some stones have a lucent center. The false-positive rate in most studies is approximately 4%. Administration of IV contrast may help by outlining the ureter and separating it from extraluminal densities.
The absence of secondary signs of obstruction, as may occur in early obstruction, can result in a false-negative study, especially when no intraluminal or extraluminal cause may be seen. The incidence of false negatives is reported to be 0-6%.
Ultrasonography
Findings
The hallmark of obstruction on US is the presence of hydronephrosis. Prominent anechoic structures within the renal sinus represent a dilated pelvocalyceal system. Renal calculi also may be demonstrated as echogenic foci with or without shadowing. This finding depends on the size of the calculi, with smaller stones blending into the echogenic renal sinus. Ureteral calculi and ureterectasis are detected less often. While UPJ and UVJ stones may be observed, mid ureteral stones are extremely difficult to detect.
The reported sensitivity of US in the detection of a ureteral stone and associated obstruction is 60-70%. As a result, US is not routinely used in the evaluation of acute renal or ureteral colic. However, it is an important screening examination in pregnant patients with acute flank pain and in acute renal failure.23,24 The gravid uterus causes ureteric obstruction, and a ureteric stone may be missed
Doppler sonography is an additional tool that may be employed when radiation exposure is undesirable, such as in pregnant patients. The RI, which is a measure of impedance to renal blood flow, may be raised when obstruction to urine outflow exists. In most centers, obstruction is indicated by an RI greater than 0.70 or a difference of greater than 0.10 between the kidneys. However, any process causing decreased perfusion will result in an elevated RI. Ureteral jets also may be evaluated; these may be absent or decreased in frequency in acute obstruction.
Degree of Confidence
US has inherent limitations that restrict its use in patients with symptoms of acute renal or ureteral colic. Even in those patients in whom it is used, further imaging often is required for confirmation and characterization of the obstruction.
False Positives/Negatives
The presence of obstruction is inferred by visualizing a dilated collecting system. This may be minimal or even absent in acute obstruction. In addition, ureteral calculi are not well demonstrated. The false-negative rate is as high as 35% in patients with uropathy secondary to a calculus lodged in the ureter. Technical limitations to the study, such as patient obesity, bowel gas, and operator skill, also may result in a false-negative study.
The false-positive rate is approximately 10% in patients with urolithiasis. The source of such errors includes vascular calcifications that may simulate a calculus. Peripelvic cysts, an extrarenal pelvis, or even a normal collecting system may be misinterpreted as representing hydronephrosis. Doppler sonography can help by readily distinguishing renal hilar vessels from a slightly dilated collecting system.
Nuclear Imaging
Findings
Scintiscans and time-activity curves before and after administration of a diuretic (furosemide) are obtained over a period of approximately 35 minutes. In a normal renogram, initial increased activity is seen as tracer accumulates within the kidney. As tracer moves into the collecting system and ureter, the activity in the kidney starts to drop. In kidneys with dilated collecting systems, an up-slope in the time-activity curve occurs as tracer is retained within the kidney.
Administration of furosemide in a nondilated kidney results in a washout of tracer activity from the collecting system, reflected as a down-slope on the time-activity curve. T½ is defined as the time taken for reduction of activity by 50%; a normal T½ is less than 10 minutes withTc 99m-MAG3.
In a kidney with collecting system dilatation, a decrease in activity with furosemide indicates a nonobstructive cause of dilatation. In an obstructed kidney, no response is observed following the injection of furosemide. A prolonged T ½ greater than 20 minutes is highly indicative of obstruction. In addition, the scintiscans, while providing the data for the time-activity curve, also may indicate the site of obstruction, past which little or no activity is seen.
Degree of Confidence
Diuresis renography is accepted as a useful examination in distinguishing obstructive from nonobstructive urinary tract dilatation, especially when collecting system dilatation has been detected on another imaging study. In general, it correlates with findings at surgery and ureteral perfusion studies.
To make this study definitive, renal function must be at least partially preserved. The glomerular filtration rate (GFR) must be greater than 15 mL/min for an obstructive time-activity curve to be judged accurate. In patients where the GFR is less than 15 mL/min, no response to the administration of furosemide is observed. No washout of activity occurs regardless of the presence or absence of obstruction. Thus, the study is deemed indeterminate and further workup or intervention is required to make the diagnosis.
False Positives/Negatives
False-positive results are encountered predominantly as a result of impaired renal function and overly compliant collecting systems. Both result in a delayed washout phase, leading to the erroneous diagnosis of obstruction. In addition, use of an inadequate dose of diuretic may lead to a similar conclusion.
The incidence of false-negative findings is lower and may result from a noncompliant collecting system. In a partially obstructed urinary tract, the high-flow state following diuretic administration may overcome the obstruction, resulting in a normal-appearing time-activity curve.
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References
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Further Reading
Keywords
acute hydronephrosis, acute obstructive nephropathy, renal calculi, nephrolithiasis/urolithiasis, urinary obstruction
