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MAG₃-F₀ Scintigraphy in Decision Making for Emergency Intervention in Renal Colic After Helical CT Positive for a Urolith

Departments of Radiology, Urology, Emergency/Urgent Care Medicine, and Medicine, University of Miami/Jackson Memorial Medical Center, Miami, Florida

View larger version (83K): [in this window] [in a new window]   FIGURE 1. No obstruction, selected images, posterior views. Numbers indicate minutes after injection when 2-min images were obtained and also time points on renogram. E = intensity-enhanced image; FL = first-pass flow (3-s image).

View larger version (115K): [in this window] [in a new window]   FIGURE 2. (A) Partial obstruction, proximal (ureteropelvic junction), moderate. Hydronephrosis (2 min), late filling, and then retention (stasis) are seen within pelvis of right kidney (6–22). Ureter is seen intermittently without stasis. Cortical retention is mild. Left kidney is small and hypofunctioning (atrophic) but drains normally despite some activity that is more prominent than usual activity in pelvis. Because of size discrepancy, abnormalities in relative flow and function of kidneys cannot easily be seen. (B) Partial obstruction, distal (ureterovesical junction), severe. Decreased flow and function of right kidney and cortical retention of activity are evident. Delayed (20 min) and persistent high-intensity activity (stasis) is seen in pelvis and ureter. E = intensity-enhanced image; FL = first-pass flow (3-s image).

View larger version (87K): [in this window] [in a new window]   FIGURE 3. Acute, total obstruction. Severe impairment of flow and function in right kidney, persistent cortical nephrogram, no visualization of drainage system even after enhancement (22E), and rising renogram are seen. Nonvisualization of right ureter even after enhancement (22E) is critical in differentiating total obstruction from stunned kidney (Fig. 4). E = intensity-enhanced image; FL = first-pass flow (3-s image).

View larger version (93K): [in this window] [in a new window]   FIGURE 4. Dysfunctioning kidney after decompression, or stunned kidney, is seen on left, a few hours after passage of calculus. Flow and function are decreased (2 min). Cortical nephrogram is persistent, and drainage system is visualized (10 min) and empties normally (without retention, 30 min). Ureter is visible after enhancement. Renogram is plateauing. In more recent decompression (after minutes), flow and function may be more severely reduced and renogram may even be rising, but still, ureter is visible after enhancement, thus separating stunned kidney from total obstruction (Fig. 3). E = intensity-enhanced image; FL = first-pass flow (3-s image).

View larger version (97K): [in this window] [in a new window]   FIGURE 5. Recovery of stunned kidney in same patient as in Figure 4. First row shows recent decompression (few hours). Second row was obtained at 48 h. Third row was obtained at 6 d. Left cortex retains activity (30 min), drainage system appears normal, and gradual return to normal is seen with recovery of flow and function (2 min) and normalization of renogram. E = intensity-enhanced image; FL = first-pass flow (3-s image).

View larger version (96K): [in this window] [in a new window]   FIGURE 6. Chronic effects of obstruction on renal function and anatomy shown by 3 studies from same patient. On 9/14/95, right kidney was totally obstructed for several days, resulting in hydronephrosis and decreased flow and function. Left kidney had good function and drainage. Patient did not accept decompression. On 3/29/96, right kidney was still totally obstructed and barely functioning, whereas left kidney was acutely and completely obstructed. Patient was anuric. Bilateral decompression followed this study. On 10/7/96, patient had new left colic from stone, which induced left partial distal obstruction; left kidney had recovered much of its function since 3/29/96 because of decompression soon after obstruction. Right kidney had undergone atrophy because of persistent obstruction from 9/14/95 until 3/29/96, but drainage was normal. Studies were obtained after administration of 10 mCi MAG3 and 40 mg furosemide. Selected pictures, from left to right, show flow study; images at 2 min, 10 min, and 30 min; and renograms. FL = first-pass flow (3-s image).