Intravenous urography is one of radiography examination which basically inserted water-soluble or contrast fluid into the urinary system to assess the functionality of the urinary system. Patient normally came for this examination has suffered serious or bad pain in their kidneys or blood in their urine (hematuria).By this IVU examination, the anatomical structures of the entire urinary system can be shown and clearly be visualized. It can also evaluate the functionality of that structures especially kidney (renal), urether, urinary bladder and urethra. The main objective of this examination test is to assesss any abnormality, obstruction or pathological problems in the urinary system such as to detect the presence of renal stone in the kidney, cancer (bladder cancer or kidney cyst) before the physicians make the decision for the best type of treatment you require. The other functions or reasons of this examination is to assess the rate of urine excretion, and the absorption rate by these structures including size, shape and the location of smooth muscle around the kidney (renal). For patients with renal stone in their kidney, this examination normally is done to see or assess the effect of the renal stones on their urinary system and also the urine flow. For your information, this intravenous urography is basically used contrast media to done its examination. Non-ionic compound of iodine contrast is normally used for this examination due to its solubility (water soluble), low osmolality and less harmful interaction (less side effect) to the body. Example of non-ionic compound of iodine contrast that can be used for this examination are; iopamidol, ioxehol, ioversol and iopromide. The iodine contrast will be injected about 50-70 ml into the median antecubital vein at the elbow joint. After a few minutes, the contrast can be seen in the both kidney and the radiographic images of the urinary system can be taken.
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The preparations for the patient are quite simple. Besides the patients prepare theirselve with general psychological and physiological preparation, they also need to prepare some additional preparation for their intravenous urography examination. The patients are not allowed to take or eat any food for 5 hours before the examination. The patient must also be ambulant for 2 hours before the examination to reduce the bowel gases. In this case, the normal preparation administered for bowel preparation does not or fail to help to improve the quality of the diagnostic image of the examination. Moreover, its make the examination become worst to the patient by making the administered of the preparation unpleasant and discomfort for the patient to follow. Special instructions, considerations and preparations are given for the patient who has previously had severe contrast media reaction. For this patient, considerations should be given to give methyl prednisolone 32mg orally by 12 hours and 2 hours before the injection of contrast media as to ensure that low osmolality contrast media is used.
The contrast media that being used in this intravenous urography test is either high or low osmolality contrast. Both contrasts are acceptable to be used as contras media in this examination of intravenous urography (IVU) test. But most of the radiologists and radiographers are preferable to used low osmolality contrast media (LOCM) due to its fewer side effects to the body. Low osmolality contrast media (LOCM) are commonly used for the patients who are poorly hydrated, patient with renal or cardiac failure, diabetic patient and patient with strong history of allergic. Patient with previous severe of contrast media, infants, small children, and elderly are also given with low osmolality contrast media (LOCM). The dose for adult is 50ml while for the pediatric patient; the dose is 1mlkg¹.
There are specific techniques or steps to insert the contrast media into the organ structures of the urinary system. Before the contrast media is inserted into the body, the patient will be asked to change their clothes to the hospital gown as well as to remove all the things that can cause artifacts to the film. Then, the contrast media is injected into the median antecubital veins of the hand which located at the elbow joint. As to maximize the density of the nephrogram, the injection is given rapidly as bolus to the patient. Nephrogram is the process when the dye 'light up' or 'glowing up' the kidney. The effect of contrast media administered may cause the upper arm or shoulder to be pain. This pain can be relieved or reduce by moving the arms away from the medial body through abduction movement of the arms.
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In this examination, the preliminary film is required. The patient is positioned in supine position with full-length anterior-posterior projection (AP) of the abdomen in inspiration (inhalation) condition. The lower border of the cassette is at the level of symphysis pubis and the x-ray tube is then centered at the midline of the level of iliac crest. The next examination procedures could not be proceeding further until the preliminary film have been reviewed and satisfied by the radiologist or radiographer.
After the preliminary film is being satisfied by the radiologist or radiographer in charge and the contrast media is injected to the patient, a few numbers of diagnostic images of the urinary system are taken to see the progression on the system. There are few sequences of the radiograph films that must be taken on the patient by the radiologist or radiographer in charge. The first sequence of the film is immediate film. This film must be done in anterior-posterior projection (AP projection) of the renal areas. The film is exposed for about 10 to 15 seconds after the injection of contrast media. The purpose of this film is to see the nephrogram of the renal (kidneys). Second film is 5 minute film. This 5 minute film also does in anterior-posterior projection of the renal areas. This film is taken to assess the need to modify the techniques either to give further injection of contrast media or not. The further injection of contrast media is given when there has been poor initial opacification of contrast media in the renal areas. If 5 minute film does not show any evidence of any obstruction, a compression is applied immediately at the abdomen to form better pelvicalyceal distention. However the compression has contraindication too. The compression is contraindicated after recent abdominal surgery or renal trauma, and it also contraindicated if there is a large abdominal mass on the patient. The film of the compression method must be coned to the renal (kidney) and to the proximal uterus. After the 5 minutes of the compression on the abdomen, the film is then being taken by the radiologist or radiographer in charge.
The third sequence of film is 15 minutes film. This film also requires the radiologist or radiographer in charge to take the images in anterior-posterior projection (AP projection) of the renal areas. The 15 minutes film mentions or show the structure of renal areas after 15 minutes of contrast media injection. During this time, the pelvicalyceal system is expanding with the opaque urine. The compression can be removed when the satisfactory demonstration of pelvicalyceal system has been achieved. After the 15 minutes film is done, the released film will be done to the patient. For this sequence, the image is taken in supine position of anterior-posterior projection (AP projection) of the abdomen. The image on the film will show the whole entire of urinary tract. If the film of this sequence is satisfied by the radiologist or radiographer in charge, then the patient is asked to empty their bladder by urinating (micturition process). The last sequence of the film that must be taken is the image after the micturition process (after micturition film). This film (film after the micturition) is very important to assess the emptying of urine in the bladder. The emptying of urine in the bladder is assess by based on the differences of clinical findings and radiological findings in the earlier films.
For intravenous urography (IVU), the contraindications in this examination test are just about the contrast media. The contraindications are more about the risks in usage of contrast media in the procedure. The patient will feel dehydration after this IVU test. However, the dehydration only can affect the patient with renal failure, patient with myeloma; which is the malfunctioning of plasma cells and the infancy patient. The dehydration can be preventing by ensuring a good hydration to the patients before beginning the procedures. In additional, the patients who are suspected to be hypersensitivity to iodine substance also can induce the contraindication in the procedure. The patients in this situation are not recommended to use substances that contain iodine or iodine based as contrast media.
The intravenous urography (IVU) must be done with full proper and well prepared to reduce or prevents any complications to the patient especially during administered of contrast media and the technique of film sequences. These are important to enhance or get the best quality images of urinary system without repeating the radiographs for few times as well as to prevent or minimize the complications. The examples of the complications that may be able to be occurring are; vascular toxicity of the venous due to the usage of contrast media and the patient will feel pains at the injection's site due to the perivenous injection. The pains from the injected site will extend until to the upper arms. These pains can be reduce by abducting the arms which is by the movement of the arms away from the body. Therefore, if there is any serious complications presence or happen after the administered of contrast media or the procedure of the examination test, the patients are advisable to come to the hospital or contact the physicians to get immediate treatment.
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