1. Done & Presented by: Fathiya Mohammed Al-Harthy College of Health Sciences Medical Diagnostic Imaging Department Medical Imaging CP2 Case study presentation

2. Content: Introduction Anatomy of the urinary system& jugular vien. Diseases & Treatment of the urinary system symptoms Diagnosis and examination Clinical Assessment& investigation requested Medical Diagnostic Imaging a)- Brief description of MDI procedure b)-Results of MDI c)-Description of physician's diagnosis d)-A comparison of MDI & Physicians diagnosis Patient outcome a)-Patient prognosis b)-Discussion of effectiveness of MDI investigation Conclusion References

3. Introduction: A 61years old expatriate lady was admitted in female ward in Rashid hospital as a known case of (CKD) chronic kidney disease/failure & with a past history of polycystic disease. She was brought to the angio room for Permanent Hemodialysis access for the first time. The nurse in angio room checked the patient ID & conform the procedure with her and wither a consent form is signed. The nurse started preparing the patient(after making sure that the neck site right side at the jugular vein is shaved) by cleaning with betadine & keep the sterile drape on the patient's body while the puncture site is exposed. The Radiologist done U/S of the puncture site to localize the jugular vien.Then he inserted the permanent catheter under fluoroscopy. Finally, the radiologist sutured the insertion site & in the fixation part of the catheter. The doctor sent the patient back to the word & reported that the patient is ready for dialysis & she can proceed with her routine life.

4. Cont; Catheter placement: The right internal jugular vein is the preferable insertion site for permanent dialysis catheter. Catheter placed via this route have a direct path to the distal S.V.C & right atrium & can be tuned with gently slopping course towards either a lateral chest wall (as in this case) or parasternal exit site. Catheter insertion via the left jugular vein is less desirable because of the high number of curves & the need to transverse the innominate vein.

5. Anatomy& physiology of the urinary system: The urinary system is the main excretory system &consists of the following : 2 kidneys 2 ureters 1 urinary bladder 1 urethra. Right kidney Left Renal pelvis Left ureter Urinary bladder Right Renal cortex left Renal calyces

6. The kidneys remove urea from the blood through tiny filtering units called nephrons The ureters are the tubes that convay urine from kidneys to the urenary bladder The urenary bladder is a pear shaped structure.It opens into the urethra at its lowest point, the neck. The urethra is a canal exdending from bladder neck to the exterior,at the urethral orifice The hilum is the concave medial border of the kidney where blood &lymph vessels,the ureter & nerves enter.The renal pelvis is a funnel – shaped structure that acts as a receptacle for the urine formed. It has number of distal branches called calyces. The body takes nutrients from food and uses them to maintain all bodily functions including energy and self- repair. Urinary system function

7. Anatomy& physiology of the jugular vein: The internal jugular veins begin at the jugular foramina in the middle cranial fossa and each is continuation of a sigmoid sinus.They run down words in the neck behind the sternocleidomastoid muscles. Behind the clavicle they unite with the subclavian veins,carrying the blood from the upper limb to form the brachiocephalic veins.

8. Pathology related to the urinary system: 1.Benign prostate hyperplasia (BPH) 2.Painful bladder syndrome/Interstitial cystitis (PBS/IC) 3.Kidney stones or calculi 4.Prostatitis 5. Renal (kidney) failure 6.Urinary tract infections (UTI) Urinary incontinence 7. Hydronephrosis 8.Urinary system carcinoma 9.Renal cyst 10.Polycystic disease 11.Chronic kidney disease (CKD) is the gradual reduction of kidney function that may lead to permanent kidney failure, or end-stage renal disease (ESRD). Treatment, There is no cure for chronic kidney disease. Strategies for slowing progression: Control of blood glucose, Control of high blood pressure, treat complications of disease; and replace lost kidney function

9. Symptoms of urinary system: Flank pain, Abdominal mass, Nausea and vomiting, Urinary tract infection, Fever, Painful urination (dysuria), increased urinary frequency, increased urinary urgency Sometimes unilateral hydronephrosis does not have symptoms Related to the case: Patient was a known case of C.K.D Examination to confirm diagnosis: Lab test: Urinalysis is a test that studies the content of urine for abnormal substances such as protein or signs of infection, Urodynamic tests, Urine culture lab test Plain KUB x-ray Special X-ray examination: Cysto urethrogram, Intravenous Pylogram, Retrograde Pylogram. Abdominal MRI CT scan of the KUB or Abdomen Isotope renography Ultra sound KUB or abdomen Related to the case: Angiogram for permanent Hemodialysis acess. U/S of neck to locate the jugular site.

10. Clinician's assessment symptoms /presentation for current investigation: A 61years old expatriate lady was admitted in female ward in Rashid hospital as a known case of (CKD) chronic kidney disease/failure. She was brought to the angio room for Permanent Hemodialysis access for the first time. Clinical assessment &diagnosis by physician for current investigation: Patient is a known case of C.K.D she was a case of poly cystic disease. Investigation requested: Angiogram for Hemodialysis access

11. Medical diagnostic imaging Brief description of MDI examination: Prior to the exam : No medication. Anticoagulant therapy is discontinued because the risk of hemorrhage is considerably increased. Patient can be discharged next day after making sure no heamatoma or bleeding on the puncture site. Patient should be on bed rest. Patient should be fasting 12hours before the angio. Blood investigation should be done prior to the procedure(urea, ceriateneen, PT, PTT, Hepatitis, and HIV) The procedure: The Radiologist done U/S of the puncture site to localize the jugular vein & then he introduced the sheath. Next,through it & under fluoroscopy (Ap position) he introduced the guide wire and placed it at the beginning of the right internal jugular vein area by injecting 10ml of heparinated saline for placement checking. After making sure that the catheter is in situ, he placed the permanent Hemodialysis catheter. He insured that his is in the correct place again by the flashed blood which came out from the big vein. Finally, the radiologist sutured the insertion site & in the fixation part of the catheter. The doctor sent the patient back to the word & commented that the patient is ready for dialysis & she can proceeds with her routine life.

12. Cont; Results of MDI – radiologist opinion: The placement of the catheter was successful as the flashed blood from the catheter was strong &can be used for dialysis purpose. Description of physicians' diagnosis: Patient was a known case of C.K.D as she was a past case of poly cystic disease. Comparison of MDI & physicians diagnosis: After the angiogram was done & the catheter was placed successfully the radiologist commented that the patient can proceed with her routine life even she is ready for the dialysis. Therefore the access is of a benefit to simplify the dialysis for the patient with only one interventional MDI procedure so she need not redo the examination again unless her referring doctor suggested.

13. Patient outcome Patient prognosis: Patient can proceed with her life. She can be discharged immediately after angiogram.She can go for renal dialysis normally at the opinion of the urologist. Discussion of the effective of the MDI investigation used: With angiogram the permanent was placed successfully with out the need to go for surgery. Therefore the patient can be discharged immediately or can start the dialysis. The access is of a benefit to simplify the dialysis for the patient with only one interventional MDI procedure so she need not redo the examination again unless her referring doctor suggested or has anther treatment plan.

14. Conclusion: A 61years old expatriate lady was admitted female ward in Rashid hospital as a known case of (CKD) chronic kidney disease/failure. She was brought to the angio room for renal dialysis catheter placement. Patient was prepared by the nurse before doctor starts the procedure. The doctor done the case & the placement of the catheter done successfully & patient was shifted back to the ward for her referring doctor's opinion as she is welling to go home as the radiologist commented/ reported on her file or to go for dialysis immediately.

15. References: lndianetzone.com http://kidney.niddk.nih.gov/kudiseases/pubs/yoururinary/ fmhs.auckland.ac.nz http://www.mayoclinic.org/diseases-treatments/alphalist-i.html / ispub.comispub.co www.theacpa.org www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/ imagingpathways.health.wa.gov.au www.emedicinehealth.com/chronic_kidney_disease/article_em.htm kidney.niddk.nih.gov/kudiseases/.../choosingtreatment www.UrologyHealth.org www.healthline.com/channel/kidney-cancer.html manju- imagingxpert.blogspot.com. med-ed.virginia.edu (ROSS &WILSON Anatomy and physiology in Health and Illness,10th edition,2006) unckidneycenter.org frca.co.uk renalinfo.com