990812_eus教學(4)重點式急診泌尿系統超音波之應用

Emergency Ultrasound (EUS)教學(4)

重點式急診泌尿系統超音波之應用

新光醫院急診醫學科

陳國智醫師

中華民國醫用超音波學會指導醫師

臨床情境

• 65歲男性，突發性左側腰痛30分鐘，Severity 9/10，從左腰痛到左側睪丸處

• 請問你該怎麼辦 ?

• 急診超音波在此能提供什麼幫忙?

臨床情境

• 49歲女性，糖尿病患者，發燒及左側腰痛二週，診所診斷為泌尿道感染，但患者對於口服抗生素反應不佳

• 請問你該怎麼辦 ?

• 超音波在泌尿道感染能提供什麼幫忙?

正常的腎臟解剖及超音波影像認識

[重要]

泌尿道系統包含雙側腎臟 + 膀胱

任何重點掃描都應包含兩個互補介面

Compartments of the retroperitoneum

Anatomic relationship of the kidneys

Overview of kidney anatomy

正常的腎臟解剖位置

• 腎臟位在後腹腔，T12 - L4

• 右腎低於左腎

• 右腎在肝和膽的後/下方

• 左腎在脾的內/下方

• 腎上腺在腎臟的上/前/內側

Overview of kidney anatomy

• 長: 9-13 cm; 寬: 4-6 cm; 厚: 2.5-3.5 cm

• Gerota’s fascia: – 包覆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

Longitudinal ultrasound view of the

normal right kidney

Transverse ultrasound view of the

normal right kidney

Normal left kidney

Normal filled urinary bladder

Male Pelvis

Prostate Enlargement

Longitudinal images of normal right kidney

Transverse image of normal right kidney

Transverse view of renal blood supply of the

right kidney

腎臟之超音波影像

• 正常情況下看不到輸尿管 (Ureters)

• Pelvis: 看的到的時候呈現黑色影像

• Sinus: 因為脂肪所以呈現白色 (echogenic)

• Medullary pyramids: hypoechoic

• Cortex:

– mid-gray, less echogenic than liver or spleen.

• Capsule: smooth and echogenic

重點式急診泌尿系統超音波掃描注意事項

• 病患準備:

– 無

• 探頭: 3.0 ~ 3.5 MHz

– 瘦的人: 5.0 MHz

• 病患姿勢

– 平躺 (Supine)

– Posterior oblique,

lateral decubitus,

prone

I

LIVER STOMACH

IVC

AORTAK K

S

重點式急診泌尿系統超音波之應用

?

Clinical indications for EUS

• Acute flank pain/suspected renal colic

• Acute urinary retension

• Bladder size estimation

• Acute renal failure

• Complicated UTI (APN & renal abscess)

• Trauma

Acute flank pain/

suspected renal colic

EUS重點:

懷疑有obstruction時

排除AAA時

Acute flank pain/suspected renal colic

• 急性腹/腰痛和血尿的評估– 懷疑腎絞痛 (renal colic)

– s/s: 腰陣痛合併鼠蹊部轉移– 診斷工具: IVP v.s. US v.s Helical CT

• EUS的重點: – 有無阻塞，如hydronephrosis (2K1B都要掃)

– 要會辨識stone在超音波下的影像– > 50y/o, 需同時排除AAA

• 進階掃描:– 阻塞物之定位及合併症

Overview of degrees of hydronephrosis

Mild Hydronephrosis

Moderate Hydronephrosis

Severe Hydronephrosis

Hydronephrosis with

acute calyceal rupture

Dilated ureter below bladder

(transverse view)

Algorithm

for renal colic

Renal stone

EUS重點:

Hyperdense lesion with acoustic shadow

Renal stone

Renal pelvis stone &

Hydronephrosis

Ureteropelvic junction stone

Ureterovescicular junction stone

Renal cyst

EUS重點

1. smooth, round, or oval

2. no internal echo

3. well-defined margin

4. posterior enhancement

Renal cyst

Polycystic kidney

Renal abscess

為什麼這不是simple renal cyst ?

Bladder

• 解尿解不出來，要不要立刻導尿呢?

– Acute urine retension

• 小朋友要導尿留U/C，會不會failure ?

– Bladder size evaluation

膀胱容積 (ml) =

長 * 寛 * 高 * 0.75 (error: 15-35%)

Bladder index volume (AP * Transverse) 2.4cm2 = 2ml

Fungating bladder mass(拜託, 有obstructive uropathy一定要看UB)

Acute renal failure

重點:

找有無post-renal obstruction

Acute renal failure

• Pre-renal

– Kidney & IVC evaluation

• Intrinsic

– Difficult

• Post-renal

– Search obstruction

Complicated UTI

(APN & renal abscess)

EUS應用重點時機

1. Risk factors

2. Treatment failure

3. Severe sepsis/septic shock

Risk factors for complicated APN

• Elderly

• Male

• History of preexisting renal diseases

• Current use of catheters

• Previous renal calculi

• Diabetes mellitus

Chen KC, et al. AJEM (in press), doi:10.1016/j.ajem.2010.01.047

50F, Septic shock

50F, Peri-renal abscess

Emphysematous Pyelonephritis

Trauma

EUS重點

Highly operator dependent

若gross hematuria, 血行動力不穩or 危險機轉，仍應考慮CECT

Renal trauma

Subcapsular renal hematoma

(Trauma)

57M, Post-ESWL

Catheters

Ureteral stent in the proximal dilated ureter

Foley in the bladder with the

balloon deflated

Foley in the bladder with the

balloon inflated

Pitfalls

1. Bedside US is limited in scope

2. Hydronephrosis may be mimicked

3. Presence of hydronephrosis may be masked by dehydration

4. The absence of hydronephrosis does not rule out a ureteral stone

5. Patients with an acute AAA often present with flank pain

6. A bladder mass may be a hematoma

精選個案影片

1. Left obstructive uropathy with ureteral stone

2. Right obstructive uropathy with ureteral stone

3. Right UPJ stone with obstructive uropathy + urine extravasation + nephritis

4. AUR with bilateral hydronephrosis

5. Right obstructive uropathy caused by UB tumor

6. Ketamine-induced interstitial cystitis

7. Left renal gas-forming abscess

8. Post-ESWL subcapsular hematoma

9. AAA presenting as hematuria and flank pain

Take-Home Points

• 重點式急診泌尿系統超音波應用時機– Suspect obstructive uropathy

– Acute renal failure

– Acute urine retension

– Complicated pyelonephritis

– Trauma

• 掃描雙側腎臟及膀胱 (長軸和短軸)

• 對於大於50歲患者，小心AAA

• Treat the patient, Not the scan

重點式泌尿系統超音波實作練習

990812_eus教學(4)重點式急診泌尿系統超音波之應用

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