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X RAY KUB 1
1. X-ray KUB
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
2. Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2
3. History
William Roentgen, a German
Physicist, was the first to
discover X-radiation, which
earned him the Nobel Prize in
Physics in 1901.
3
Dept of Urology, GRH and KMC, Chennai.
4. X-Ray Word Origin
• X-ray was an unknown type of radiation when Roentgen first
observed them.
• In order to name the unknown radiation, he called it as X-radiation or
X-ray.
• Even though, later called them Roentgen rays, the name X-ray is the
one widely used.
4
Dept of Urology, GRH and KMC, Chennai.
6. X-ray Spectrum
• X-rays are a type of electromagnetic waves.
• X-rays have wavelengths ranging from 0.01 to 10 nanometers, hence
their wavelengths are shorter than those of Ultraviolet rays and
typically longer than those of gamma rays.
6
Dept of Urology, GRH and KMC, Chennai.
7. X-ray Production
When the fast moving electrons
hit on an anode made of
Tungsten in case of medical use,
X-rays are produced.
7
Dept of Urology, GRH and KMC, Chennai.
8. Standard View
• The standard view is an Antero
posterior supine view.
• Patient lies supine.
• X‐ray tube is positioned overhead.
• X‐rays pass in the AP direction.
• Ideally, the patient is asked to hold
their breath (so that breathing
movement will not make the image
blurry) and the X‐ray is taken.
• Standard plate size 14”-17”
8
Dept of Urology, GRH and KMC, Chennai.
9. Other Views
To get spatial orientation of
opacities
• Oblique view
To look for free air and air fluid
levels
• Erect view
9
Dept of Urology, GRH and KMC, Chennai.
10. Systematic Reading
• Type of Radiograph-Area and View
• Patient identification and investigation timing
• Technical quality of the X-ray
• Ensure the sides with visible anatomy
• Look further into details
10
Dept of Urology, GRH and KMC, Chennai.
11. Assessing Technical Quality of X-ray
• Has everything been included? • The entire anatomy should be
included from level of T10 upto
2 cm below the lower margin of
symphysis pubis.
• Both the hemi‐diaphragms
should be visible, lower margin
of symphysis pubis should be
visible.
11
Dept of Urology, GRH and KMC, Chennai.
12. • Has the exposure been
adequate?
• Exposure is related to the
number of X‐rays that reach the
detector and make the image.
• If the exposure is adequate, the
spine should be clearly
visualized.
• In case of overexposure, soft
tissue shadows will be minimal.
Assessing Technical Quality of X-ray
12
Dept of Urology, GRH and KMC, Chennai.
13. Looking for Details-ABCDE of X ray
A
B
C
D
E
• Air in the Wrong Place
• Bowel
• Calcifications
• Disability of Bones
• Everything else
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Dept of Urology, GRH and KMC, Chennai.
14. Looking for Details-ABCDE of X ray
A
B
C
D
E
• Air in the Wrong Place
• Bowel
• Calcifications
• Disability of Bones
• Everything else
• Pneumoperitoneum
• Pneumoretroperitoneum
• Pneumobilia
• Portal venous gas
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Dept of Urology, GRH and KMC, Chennai.
15. Looking for Details-ABCDE of X ray
A
B
C
D
E
• Air in the Wrong Place
• Bowel
• Calcifications
• Disability of Bones
• Everything else
• Dilated small bowel
• Dilated large bowel
• Volvulus
• Fecal loading
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Dept of Urology, GRH and KMC, Chennai.
16. Looking for Details-ABCDE of X ray
A
B
C
D
E
• Air in the Wrong Place
• Bowel
• Calcifications (Common)
• Disability of Bones
• Everything else
• Urinary tract stones
• Nephrocalcinosis
• Pancreatic calcification
• Calcified lymphnodes
• Phleboliths
16
Dept of Urology, GRH and KMC, Chennai.
17. Looking for Details-ABCDE of X ray
A
B
C
D
E
• Air in the Wrong Place
• Bowel
• Calcifications (Uncommon)
• Disability of Bones
• Everything else
• Calcified costal cartilage
• Adrenal calcification
• Abdominal aortic aneurysm
(AAA) calcification
• Calcified uterine fibroids
• Prostate calcification
• Abdominal aortic calcification
(normal calibre)
• Splenic artery calcification
17
Dept of Urology, GRH and KMC, Chennai.
18. Looking for Details-ABCDE of X ray
A
B
C
D
E
• Air in the Wrong Place
• Bowel
• Calcifications (Uncommon)
• Disability of Bones
• Everything else
• Sclerotic and lucent bone lesions
• Spine pathology
• Solid organ enlargement
• Fractures
18
Dept of Urology, GRH and KMC, Chennai.
19. Looking for Details-ABCDE of X ray
A
B
C
D
E
• Air in the Wrong Place
• Bowel
• Calcifications (Uncommon)
• Disability of Bones
• Everything else
• Medical and surgical objects
• Foreign bodies
• Lung bases
19
Dept of Urology, GRH and KMC, Chennai.
20. X-Ray KUB-Purpose
1. As a preliminary test in acute abdomen
2. To ensure the technical quality of the examination in case of
planned contrast usage.
3. To detect any calcific densities that could be urinary tract calculi.
4. To determine whether a contraindication to abdominal
compression exists.
5. To determine whether bowel preparation is adequate before
contrast study
6. To check the position of stents after urological procedures.
20
Dept of Urology, GRH and KMC, Chennai.
21. Abdominal Compression-Contraindications
• Spine deformity
• Abdominal distension (ileus, bowel obstruction, ascites)
• Acute abdomen findings
• Various types of urinary tract diversions and stomas
• Acute renal colic
• IVC filter (Relative contraindication)
21
Dept of Urology, GRH and KMC, Chennai.
22. Anatomical Landmarks
• Organ Outlines
• Major Muscles
• Properitoneal fat
• Perivesical fat plane
• Stomach and Bowel gas
22
Dept of Urology, GRH and KMC, Chennai.
23. Anatomical Landmarks-Organ Outline
Organ outlines are visible because
of the contrasting radiolucent
mesenteric or retroperitoneal fat
that surrounds the organs.
• Renal Outline- Bean shaped soft
tissue density, smooth outline,
extends from T12 to L2 on Lt
side & L1 to L3 on Rt side ( 3.5
vertebral bodies )
• Small kidney - if < 3 vertebrae
• Enlarged kidney - if > 4 vertebrae
23
Dept of Urology, GRH and KMC, Chennai.
24. Anatomical Landmarks-Major Muscles
• Psoas shadow – If absent
indicates presence of fluid in the
adjacent compartment. (In 20%
cases, normally absent on one
side).
• Quadratus lumborum- 1cm
lateral to Psoas shadow.
24
Dept of Urology, GRH and KMC, Chennai.
25. Anatomical Landmarks-Properitoneal fat
• It is the continuation of the
posterior paranephric space.
• It is sandwiched between
transversalis fascia and the
parietal peritoneum.
• Its medial interface marks the
lateral extent of the peritoneal
cavity
25
Dept of Urology, GRH and KMC, Chennai.
27. Anatomical Landmarks- L4
• L4 vertebrae is the first lumbar
vertebrae with a transverse
process pointing upwards when
examined from above
downwards.
• Further labelling of vertebrae
should be done either above or
below L4.
27
Dept of Urology, GRH and KMC, Chennai.
28. Renal Calcifications-X ray KUB
Most common cause of renal calcifications is
Renal calculus disease
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Dept of Urology, GRH and KMC, Chennai.
30. Technical factors
• Peak kilovoltage (kVp )of xray beam of 60-70 kVp is optimal for
searching faintly opaque or small stones.
• At 80-90 kVp small stones may be invisible.
• For obese patients >70-80 kVp may be needed.
• 50 kVp is ideal for lucent uric acid stones.
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Dept of Urology, GRH and KMC, Chennai.
31. Patient Factors
• Girth and obesity of the patient
• Extraurinary calcifications can obscure or mimic renal calculi.
• Calculi overlapped by bony structures
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Dept of Urology, GRH and KMC, Chennai.
33. Stone Size
• Xray KUB can detect calcium containing calculi as small as 1 to 2 mm.
• Less opaque stones such as cystine are not visible until 3-4 mm in
size.
• Non opaque calculi like uric acid are generally need to be 1 cm or
larger to be faintly visible.
33
Dept of Urology, GRH and KMC, Chennai.
34. Stone Composition
• Two thirds of stones are composed of mixture of different crystals
• Single crystal (or Pure ) stones constitute only one third of all urinary
calculi.
• Pure stones can have characteristic radiographic appearances.
• Crystalline admixtures have varied appearances.
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Dept of Urology, GRH and KMC, Chennai.
35. Stone composition and Shape
• Pure Calcium oxalate monohydrate stone- Homogeneously densely
opaque, smooth edges and may be dentate.
• Calcium oxalate monohydrate stone with >60% - Irregularly
marginated with heterogeneous, variegated radiopacity.
• Predominant Calcium oxalate dehydrate stone-Stippled and
spiculated with radial striations.
• Pure calcium phosphate stones- similar to Pure calcium oxalate stones
in appearance
• Triple phosphate stones- Laminated appearance
• Magnesium ammonium phosphate Hexahydrate(Struvite)-Staghorn
35
Dept of Urology, GRH and KMC, Chennai.
36. Stone composition and shape
• Pure uric acid stones- Non opaque on plain radiographs
• Uric acid stones with calcium coats- variably radiopaque on xray
• Cystine stones-moderately radiopaque, homogeneous ground glass
opacity, may be often large and multiple with staghorn configuration
• Staghorn in children or young adults should rise the suspicion of
Cystine stones.
• Matrix stones-non radiopaque on plain radiographs
• Xanthine stones- Radiolucent stones, but an admixture with calcium
may offer radiopacity
36
Dept of Urology, GRH and KMC, Chennai.
54. Ureteric Calculus
Ureteric calculus can be located near the
transverse process of the lumbar vertebra
and over the sacral vertebrae.
At the level of ischial spine, ureter turns
medially to join the bladder at VUJ which is
the most common site of obstruction in
ureteric calculus.
54
Dept of Urology, GRH and KMC, Chennai.
55. Mimicking Ureteric Calculi
• Phleboliths
• Calcified costal cartilage
• Gall stones
• Enteroliths
• Calcified mesenteric lymph node
• Pancreatic calcifications
• Sacral bone islands
• Aortic or other arterial calcifications
• Fallopian tube occlusion rings
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Dept of Urology, GRH and KMC, Chennai.
56. Phleboliths and Ureteric calculi
• Phleboliths are literally "vein stones"
• Represent calcification within venous
structures.
• They are particularly common in the pelvis
where they may mimic ureteric calculi, and
are also encountered frequently in venous
malformations.
• Differentiating points: Often have
Radiolucent centers, multiple, mostly below
the level of ischial spine, located along the
course of veins.
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Dept of Urology, GRH and KMC, Chennai.
59. Bladder Calculi
• Size ranges from 1-2 mm to large calculi of many cms
• May be solitary or multiple in number
• Range from densely radiopaque stones to faintly radiopaque stones
depending on the composition.
• May have variety of shapes
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Dept of Urology, GRH and KMC, Chennai.
65. Bladder Wall calcification
• Schistosomiasis –Common
• Tuberculosis –Rare
• Alkaline encrysting cystitis – After radiotherapy in the presence of
necrotic or ischemic bladder tissue and alkaline urine produced by
Proteus infection.
• After cyclophosphamide or mitomycin treatment of bladder
• Primary amyloidosis –submucosal amyloid deposition
• Prune Belly Syndrome-Dystrophic calcification of dome
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Dept of Urology, GRH and KMC, Chennai.
68. Prostatic Calcifications
• Primary prostatic
calcification
• Secondary prostatic
calcification
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Dept of Urology, GRH and KMC, Chennai.
69. Prostatic Calcifications
• Primary prostatic
calcification
• Normally present in 30% of
subjects.
• Usually small (1-5mm) and
multiple
• Due to calcium deposition on
corpora amylacea
• Usually calcium phosphate
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Dept of Urology, GRH and KMC, Chennai.
70. Prostatic Calcifications
Secondary prostatic
calcification
• In abnormal prostates with
benign hyperplasia,
obstruction and stasis,
infection or carcinoma or
after radiotherapy.
• Secondary prostatic
calcification due to
obstruction may measure
upto 10 mm or more.
70
Dept of Urology, GRH and KMC, Chennai.
71. Primary prostatic calculi
• Small multiple calcifications
• Due to calcification of corpora
amylacea
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Dept of Urology, GRH and KMC, Chennai.
72. Secondary Prostatic Calcification
• Trilobed secondary prostatic
calcification in voiding
dysfunction due to neurogenic
bladder
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Dept of Urology, GRH and KMC, Chennai.
73. Secondary Prostatic Calcification
• Dystrophic calcification of prostate
in Genitourinary tuberculosis
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Dept of Urology, GRH and KMC, Chennai.
74. Secondary Prostatic Calcification
• Secondary prostatic calcification
due to urethro prostatic urinary
reflux
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Dept of Urology, GRH and KMC, Chennai.
75. Urethral Calculi
• Native calculi – Rare and are formed within the urethra (Dumbell
Shaped)
• Migrant calculi- Arise in the kidney or bladder and then descend into
the urethra (Small stones struck at proximal to narrowing)
75
Dept of Urology, GRH and KMC, Chennai.
76. Native Calculi
• Dumbell shaped with portion of
calculus inside the bladder.
• Associated urethral stricture may
be present.
• May develop in prostate bed after
prostatectomy, particularly Open.
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Dept of Urology, GRH and KMC, Chennai.
77. Migrant Calculi
• After lithotripsy, patient
underwent steinstrasse of urethra
due to urethral stricture in this
case.
77
Dept of Urology, GRH and KMC, Chennai.
78. Other Indicental
Findings
Vas deferens calcification
• May be due to degenerative
changes in diabetes or with
aging
• Or due to chronic infection
• Tramline calcification of ampulla
is typical
78
Dept of Urology, GRH and KMC, Chennai.
79. Other Indicental
Findings
Seminal vesicle calcification
• Due to chronic infection of
tuberculosis or schistosomiasis.
• Patchy, coarse and asymetrical
in TB
• Symmetrical in schistosomiasis
• Rare causes – Old age, urinary
reflux
79
Dept of Urology, GRH and KMC, Chennai.
