Kidneys/Urinary Clinical Cases Flashcards
portal hypertension
-scarring and fibrosis from cirrhosis of liver -> obstruct hepatic portal vein -> pressure rises in hepatic portal vein and its tributaries
-at sites of anastomoses between portal and systemic veins -> varicose veins and blood flow from portal to systemic veins
-so dilated -> walls rupture -> hemorrhage
-esophageal varices at end of esophagus can bleed -> severe and fatal
-to reduce portal hypertension -> divert blood from portal venous system to systemic venous -> liver transplants, and sometimes preceded by transjugular intrahepatic portosystemic shunt (TIPS) procedure while donor liver is procured
-they used to create communication between portal vein and IVC or join splenic and left renal vein (not anymore)
perinephric abscess*
-attachment of renal fascia determine path of extension of perinephric abscess
-ex. fascia at renal hilum firmly attaches to renal vessels and ureter -> preventing spread of pus to contralateral side
-pus from abscess (or blood) may force its way into pelvic between loosely attached anterior and posterior layers of pelvic fascia
-perirenal fascia**
-below renal fascia
-can spread to abdomen bc renal fascia is continuous to transversalis
renal transplantation
-treatment of selected cases of chronic renal failure
-placed in iliac fossa of greater pelvis
-firmly supported
-only short lengths of renal vessels and ureters are required for implantation
-renal artery and vein are joined to external iliac artery and vein
-ureter is sutured into nearby urinary bladder
accessory renal vessels
-during ascent to their final site embryonic kidneys receive blood supply and venous drainage from successively more superior vessels
-inferior vessels degenerate as superior ones take over blood supply and venous drainage
-failure of some of these vessels to degenerate result in accessory (or polar) renal arteries and veins
-variations in number and position of these vessels occur in 25% of people
renal and ureteric calculi
-excessive distention of ureter from kidney stone (renal calculus) -> intermittent pain (ureteric colic)
-forced down ureter by peristalsis
-can cause incomplete or complete obstruction of urine flow
-depend on level of obstruction -> pain referred to lumbar (loin) or inguinal regions (groin), proximal anterior part of thigh, external genital and/or testis
-pain referred to cutaneous areas innervated by spinal cord segments and sensory ganglia which supply ureter -> mainly T11-L2
-ureteric calculi observed and removed with nephroscope
-lithotripsy- shock wave through body breaks stones into fragments and pass into urine
intraperitoneal injection
-peritoneum is semipermeable membrane with extensive surface area
-must of it overlies blood and lymphatic capillary beds (subdiaphragmatic portions mostly)
-fluid injected into peritoneal cavity is absorbed quickly
-anesthetic agents such as solutions of barbiturate compounds -> injected into peritoneal cavity by intraperitoneal injection
peritoneal dialysis
-renal failure- waste products like urea accumulate in blood and tissues -> reach fatal levels
-soluble substances and excess water are removed from system by transfer across peritoneum using dilute sterile solution
-solution introduced into peritoneal cavity on one side then drained from other side
-diffusible solutes and water are transferred between blood and peritoneal cavity as result of concentration gradients between 2 fluid compartments
-employed only temporarily usually
-for long term- use direct blood flow through renal dialysis machine
congenital anomalies of kidneys and ureters
-bifid renal pelvis and ureter
-result from division of metanephric diverticulum (ureteric bud) -> primordium of renal pelvis and ureter
-extent of ureteral duplication depends on completeness of embryonic division of metanephric diverticulum
-bifid renal pelvis and/or ureter can be unilateral or bilateral
-separate openings into bladder is uncommon
-incomplete division of metanephric diverticulum result in bifid ureter
-complete division -> supernumerary kidney
-inferior poles of kidneys can fuse to form horseshoe kidney at L3-L5 bc root of inferior mesenteric artery prevented normal relocation kidneys -> usually no problems, sometimes ureter can be obstructed
-embryonic kidney(s) can lie anterior to sacrum -> do not mistake ectopic pelvic kidney for pelvic tumor
psoas abscess
-abscess from tuberculosis in lumbar region -> spreads from vertebrae to psoas sheath -> psoas abscess develops
-psoas fascia thickens to form strong stocking like tube
-pus from psoas abscess passes inferiorly within fascial tube over pelvic brim and deep to inguinal ligament
-pus surfaces in superior part of thigh
-pus can reach psoas sheath by passing from posterior mediastinum when thoracic vertebrae are disease as well
posterior abdominal wall
-iliopsoas -> relations with kidneys, ureters, cecum, appendix, sigmoid colon, pancreas, lumbar lymph nodes, nerves of posterior abdominal wall
-if any of those are diseased -> movement of iliopsoas causes pain
-iliopsoas test- when intraabdominal inflammation is suspected
-person lies on unaffected side and extend thigh on affected side against examiners hand resistance
-pain = + sign
-acutely inflamed appendix -> + sign
collateral routes for abdominopelvic venous blood
-3 collateral routes form by valveless veins of trunk -> available for venous blood to return to heart when IVC si obstructed or ligated
-inferior epigastric veins-> tributaries of external iliac veins -> anastomose in rectus sheath with superior epigastric veins -> drain in sequence through internal thoracic veins and superior caval system
-superficial epigastric or superficial circumflex iliac veins- anastomose in subcutaneous tissues of anterolateral body wall with one of tributaries of axillary vein (lateral thoracic vein)
-when IVC obstructed -> subcutaneous collateral pathway (thoracoepigastric vein) -> becomes conspicuous (well seen)
-epidural venous plexus- inside vertebral column communicates with lumbar veins of inferior caval system and tributaries of azygos system of veins -> part of superior caval system
abdominal aortic aneurysm
-rupture of aneurysm (localized enlargement) of abdominal aorta
-severe pain in abdomen or back
-unrecognized -> mortality 90% due to heavy blood loss
-repair by opening it -> inserting prosthetic graft-> sewing wall of aneurysmal aorta over graft to protect it
-may be treated by endovascular catheterization procedures too
ureteric calculi
-stones
-cause incomplete or complete obstruction or urinary flow
-can lodge anywhere along ureter -> most often where ureters are relatively constricted:
-> junction of ureters and renal pelvic, where they cross external iliac artery and pelvic brim, where they pass through wall of bladder
-intense pain depending on size, location, type, texture
-can be removed by open surgery, endoscopy, lithotripsy
suprapubic cystostomy
bladder extends superiorly in extraperitoneal fatty tissue of anterior abdominal wall as it fills
-bladder adjacent to wall without intervention of peritoneum
-distended bladder can be punctured (suprapubic cystostomy) or approached surgically for introduction of indwelling catheter or instruments without traversing peritoneum and entering peritoneal cavity
rupture of bladder
-superior position of distended bladder -> can be ruptured by injuries to inferior part of anterior abdominal wall or by fractures of pelvic
-rupture of superior part- frequently tears peritoneum -> results in passage of urine into peritoneal cavity
-posterior rupture- results in passage of urine subperitoneally into perineum
