Tuberculosis of kidneys.

Acute pyelonephritis.

Pyonephrosis and paranephritis.

Tuberculosis of kidneys.

Question: what is acute pyelonephritis?

It is a sudden inflammation of both the parenchyma and the pelvis of the kidney (either one kidney or both)

Question: what is the classification of pyelonephritis?

1. Primary and secondary pyelonephritis

In primary pyelonephritis; there is no dysfunction of urine outflow

In secondary pyelonephritis; there is dysfunction of urine outflow due to urolithiasis, tumors, iatrogenic factors (catheterization) etc.

2. Unilateral and bilateral pyelonephritis

3. Acute and chronic

4. Serous and purulent

5. By the mode of bacteria pathway there are differed

i. hematogenous spread

ii. ascending spread

iii. urogenic

iv. Urolithiasis or infected urinary stones

v. tuberculosis of the kidneys;

6. By the course, age, stage of the organism there are differed:

i. pyelonephritis of newborn;

ii. pyelonephritis of the aged (old) patients;

iii. pyelonephritis of the pregnant women;

iv. Pyelonephritis in diabetes mellitus patients.

Question: what is the etiology of pyelonephritis?

Primary pyelonephritis is caused by the following bacteria:

1. E. coli (most common cause)

2. Staphylococcus species (saprophyticus or fecalis)

3. Proteus

4. Klebsiella

5. Pseudomonas

6. Enterococci

Secondary pyelonephritis is due to the following

1. Urolithiasis

2. Tumors of urinary tract

3. Immunocompromised patients (HIV, diabetes, malignancy)

4. Iatrogenic causes (catheterization)

5. Pregnancy due to; Mechanical pressure of pregnant uterus on ureters, neurohumoral changes, asymptomatic bactriuria.

6. Urinary tract infections (cystitis, urethritis etc.)

Question: what is the pathogenesis of pyelonephritis?

1. Bacteria gets to the kidneys through hematogenous or ascending way (through the urethra, bladder, ureter and to renal pelvis and kidney)

2. An inflammatory process begins resulting to the signs and symptoms such as lumbar pain, fever, chills etc.

Question: what is the clinical manifestation (signs and symptoms) of pyelonephritis?

The triad of pyelonephritis is (lumbar/flank pain, fever and chills)

1. Lumbar or flank pain

2. Fever more than 38⁰C

3. Chills/shaking

4. Abdominal pain

5. Nausea and vomiting

6. Sweating (diaphoresis)

7. Fatigue

8. Mental confusion

9. Gross hematuria

10. Dysuria

11. Urine Urgency

12. Nocturia

13. Positive Pasternesky sign during physical examination

Question: what is the diagnostic principle of pyelonephritis?

1. Complete blood count: shows leukocytosis, high ESR

2. Urinalysis: shows cloudy fluid with heavy pyuria, bacteriuria, mild proteinuria, and often microscopic or gross hematuria.

3. CT scan/MRI of abdomen may show:

i. alterations in renal parenchymal perfusion

ii. renal abscesses,

iii. perinephric fluid

iv. inflammatory masses

v. obstruction (renal calculi, tumor)

vi. MRI can evaluate renal vasculature abnormalities

4. abdominal ultrasound

i. renal abscesses,

ii. stones

5. Plain abdominal X-ray may show renal stones

6. Excretory urography may show

i. Enlarged kidneys

ii. Renal stones

iii. Deformation of renal calices

7. Cystoscopy may show hemorrhage from the ureters

8. Chromocystoscopy should be used in pregnant women and those who are allergic to contrast used in IVP

9. Retrograde cystogram can show vesicoureteral reflux, stones tumors etc.

Question: what is the differential diagnosis of pyelonephritis?

1. Pancreatitis (Elevated serum amylase and normal results of urinalysis allow differentiation)

2. Basal pneumonia (pleuritic nature of the pain and the chest x-ray usually allow differentiation)

3. Acute intraabdominal disease (acute appendicitis, cholecystitis, and diverticulitis)

4. Pelvic inflammatory disease (PID)

5. Renal abscess and perinephric abscess (Radiographic studies often are necessary to confirm the specific diagnosis)

6. Tuberculosis of the urinary tract (intravesical signs- Yellow raised nodules surrounded by a halo of hyperemia, "golf-hole" (gaping) ureteral orifice, Mycobacterium tuberculosis in urine or blood culture, contracted bladder)

Question: what is the principle of treatment of pyelonephritis?

1. Hospitalization with complete bed rest

2. Antibiotic therapy: administer an aminoglycoside (amikacin, gentamicin, or tobramycin) plus ampicillin intrave­nously in full dosage

3. Antipyretic and analgesics (ibuprofen, naproxen, piroxicam etc.)

4. Disintoxication therapy (intravenous fluids such as normal saline, ringer’s lactate)

5. Surgery in case of the following: renal carbuncle, perinepheric abscess, large calculi

6. Treatment of purulent pyelonephritis involves decapsulation and nephrostomy

7. Treatment of secondary acute pyelonephritis is aimed at removing the cause

Question: name the possible complications of pyelonephritis

1. Acute kidney failure

2. Infection around the kidney (perinephric abscess)

3. Sepsis

4. pyonephrosis

5. Shock

Question: what is pyonephrosis?

It is a suppurative destruction (pus formation) of the renal parenchyma, with total or almost complete loss of kidney function.

Question: what is the etiology of pyonephrosis?

Spread of infection may be hematogenous or ascending way

1. Infected Hydronephrosis

2. Pyelonephritis

3. Tuberculosis

4. Risk factors for pyonephrosis include

i. immunosuppression due to medications (eg, steroids), disease (eg, diabetes mellitus, acquired immunodeficiency syndrome [AIDS]),

ii. Any anatomic urinary tract obstruction (eg, stones, tumors, ureteropelvic junction obstruction, pelvic kidney, horseshoe kidney).

Question: what are the clinical findings (signs and symptoms) of pyonephrosis?

1. fever,

2. chills,

3. flank pain,

4. Abdominal pains

5. Nausea and vomiting

6. Fatigue/ malaise

7. Intensive pyuria

8. Intravesical signs: Pus discharge from the ureteral openings.

Question: what is the principle of diagnosis of pyonephrosis?

1. CBC: high leukocytosis and ESR

2. Urinalysis: pyuria, heavy bacteriuria

3. Cystoscopy:: Pus discharge from the ureteral openings

4. Retrograde pyelography: Dilatation of hollow system with unequal contours.

1. CT scan/ MRI:

i. thickening of the renal pelvic wall

ii. dilatation and obstruction of the collecting system

iii. enlarged kidney

6. Ultrasound:

i. dilatation of the pelvi-calyceal system

ii. echogenic collecting system debris - considered the most reliable sign

iii. fluid-fluid levels within the collecting system

iv. incomplete (dirty) echoes of collecting system gas can be occasionally seen

Question: what is the differential diagnosis of pyonephrosis?

1. Hydronephrosis (normal urinalysis, apyretic, intoxication signs absent)

2. Pyelonephritis (hematuria,)

3. Tuberculosis of the urinary tract (intravesical signs- Yellow raised nodules surrounded by a halo of hyperemia, "golf-hole" (gaping) ureteral orifice, Mycobacterium tuberculosis in urine or blood culture, contracted bladder)

Question: treatment of pyonephrosis?

a. percutaneous nephrostomy to drain the infected collecting system

b. Nephrectomy if the functioning of the other kidney is normal

c. Intravenous Antibiotics

Question: what is perinephric abscess?

It is a collection of suppurative material in the perinephric space (between the renal capsule and the perirenal (Gerota's) fascia)

Paranephric abscess is a chronic suppurative process outside the renal (Gerota) fascia

Question: what is the etiology of perinephric abscess?

1. Most result from rupture of an intrarenal abscess into the perinephric space; the causative organisms are usually

i. coliform bacteria

ii. Pseudomonas,

iii. less often staphylococci and obligate anaerobes

Question: what is the clinical presentation of perinephric abscess?

A. chills,

B. fever low grade

C. unilateral flank pain,

D. abdominal pain

E. Malaise and prostration

F. Dysuria

G. Tenderness over the affected kidney and costovertebral angle.

H. Large mass may be felt or percussed in the flank.

I. Erythema and edema of the overlying skin may be evident

Question: what is the principle of diagnosis of perinephric abscess?

1. CBC: leukocytosis, high ESR

2. Urinalysis: pyuria and bacteriuria

3. Positive blood cultures may be observed

4. serum creatinine and blood urea nitrogen values generally are normal unless both kidneys are involved

1. plain abdominal X-ray: shows flank mass

6. excretory urography (done on inspiration and expiration ): Limitation or absence of mobility of kidney (classic sign), may show delayed visualization or nonfunction related to obstructive uropathy or parenchymal disease.

In case of paranephric abscess the main sign is Limitation of diaphragm excursions on the side of lesion

Question: what is the principle of perinephric abscess and paranephric abscess treatment?

Perinephric abscess treatment:

1. percutaneous nephrostomy

2. intravenous antibiotics

Operative treatment for paranephric abscess:

1. Lumbotomy, opening of perinephric abscess with its drainage

2. intravenous antibiotics

Question: what is the etiology of tuberculosis of urinary tract?

Bacteria (Mycobacterium tuberculosis)

Question: what is the classification of urinary tract tuberculosis with the help of X-ray, clinical findings?

1. I — nondestructive (infiltrate) tuberculosis of kidney;

2. II — initial destruction (papillitis or small, by diameter about 1 cm, single cavity);

3. III —marked destruction (caverns or policavernosial tuberculosis one of kidney segments);

4. IV — total or subtotal destruction (policavernose tuberculosis of two segments, tubercular pyonephrosis, calcification kidney).

Three forms of tuberculosis:

a. tuberculoinfiltrative,

b. ulcerous and

c. scar

Question: what are the signs and symptoms of tuberculosis of the urinary tract?

1. low-grade but persistent fever,

2. night sweats

3. Symptoms of cystitis (dysuria, hematuria, urine urgency etc.)

4. Hematuria

5. Evidence of extragenital tuberculosis may be found (lungs, bone, lymph nodes, tonsils, intestines)

Question: what is the diagnosis of kidney's tuberculosis?

1. CBC: leukocytosis, high ESR

2. Urinalysis: pyuria, ‘’sterile ‘’ pyuria (no microbes detected in urine)

3. Blood culture positive for mycobacterium tuberculosis

4. Positive tuberculin test (Mantoux test): skin induration more than 5mm

5. Cystoscopy: intravesical signs are;

i. Yellow raised nodules (Tubercles) surrounded by a halo of hyperemia

ii. ulcer,

iii. microcyst,

iv. gaping and pulled in ureteral openings ("golf-hole" (gaping) ureteral orifice)

6. abdominal X-ray:

i. enlargement of one kidney

ii. Obliteration of the renal and psoas shadows due to perinephric abscess.

iii. Punctate calcification in the renal parenchyma

7. Excretory urography

i. distortion of calyx,

ii. ureteral dilation above a UVJ stricture or a rigid fibrotic ureter with multiple strictures

iii. Small and contracted urinary bladder (thimble bladder) or with filling defects.

8. CT scan

i. calyceal abnormalities,

ii. hydronephrosis

iii. urinary tract calcifications, and renal parenchymal cavities

Question: what is the treatment of tuberculosis of the urinary tract?

1. Medical treatment:

i. Antituberculosis agents for 6months:

First 2months: rifampicin 600 mg, isoniazid 300 mg, pyrazinamide 1 g, 1 g of vitamin C daily for 2months

4months: 900 mg of rifampin, 1.5 g of pyrazinamide, and 1 g of vitamin C twice a week for 4 months.

ii. If, after 3 months, cultures are still positive and gross involvement of the affected kidney is radiologically evident, nephrectomy should be considered.

iii. If bacteriologic and radiographic studies demonstrate bilateral disease, only medical treatment can be considered

2. Surgical treatment:

i. Nephrectomy

ii. Operation of Boari: Plastic of the deformed ureter with wall of urinary bladder.

Дата добавления: 2015-10-29