Pyelonephritis

Question 1

What is Pyelonephritis?

Answer 1

Inflammation of the kidney parenchyma and the renal pelvis, usually due to bacterial infection

Question 2

What is uncomplicated pyelonephritis?

Answer 2

Structurally or functionally normal urinary tract in a non-immunocompromised host

Question 3

Whats complicated pyelonephritis?

Answer 3

Structurally or functionally abnormal tract in immunocompromised patient

Question 4

What kind of pyelonephritis is present in a man?

Answer 4

Complicated as it will be due to an abnormal urinary tract

Question 5

How does bacteria reach the kidney?

Answer 5

Ascending from the lower urinary tract, directly from the blood stream, lymphatics

Question 6

How does bacteria reach the kidney via the blood stream?

Answer 6

septicaemia or infective endocarditis

Question 7

How does bacteria reach the kidney via the lymphatics?

Answer 7

retroperitoneal abscess

Question 8

What happens at a cellular level in pyelonephritis?

Answer 8

Neutrophils infiltrate the tubules and interstitial and cause suppurative inflammation, this causes small renal cortical abscesses and streaks of pus in the renal medulla

Question 9

What is the most common organism that causes Pyelonephritis?

Answer 9

Escherichia Coli

Question 10

What organisms cause pyelonephritis in catheters?

Answer 10

Entercoccus faecalis
Staphlococcus aureus, staphylococcus saprophyticus
pseudonomas

Question 11

Other than bacteria, what can cause pyelonephritis?

Answer 11

yeasts or fungi in immunocompromised patients (also mycobacterium app)

Question 12

What are the risk factors for Pyelonephritis?

Answer 12

Factors that reduce the antegrade flow of urine, factors that promote retrograde ascent of bacteria, factors predisposing to infection or immunocompromise, Factors promoting bacterial colonisation

Question 13

What factors reduce integrate flow of urine?

Answer 13

Obstruction in the urinary tract e.g. BPH, spinal cord injury resulting in neuropathic bladder

Question 14

What factors promote retrograde ascent of bacteria?

Answer 14

Female as have shorter urethra
Indwelling catheter or ureteric stents/ nephrostomy tubes in situ,
structural renal abnormalities such as vesicle-ureteric reflux

Question 15

What factors predispose to infection or immunocompromised?

Answer 15

Diabetes mellitus, corticosteroid use, HIV infection

Question 16

What factors promote bacterial colonisation?

Answer 16

Renal calculi, sexual intercourse, oestrogen depletion

Question 17

What is the classical triad for pyelonephritis?

Answer 17

Fever, unilateral loin pain (rarely bilateral) and nausea and vomiting developing over 24-48 hours

Question 18

What are the symptoms of a lower urinary tract infection?

Answer 18

Frequency, urgency and dysuria with or without haematuria

Question 19

What would be found on examination of someone with Pyelonephritis?

Answer 19

Look unwell, pyrexia, and sepsis, costovertebral angle tenderness with or without suprapubic tenderness

Question 20

What are the differential diagnosis for pyelonephritis?

Answer 20

if have backspin, tachycardia and or hypotension is at risk of a potential ruptures AAA
Also Renal calculi, acute cholecystitis, ectopic pregnancy or PID, lower lobe pneumonia or diverticulitis

Question 21

What investigations would you do for someone with a suspected Pyelonephritis?

Answer 21

urinalysis looking for nitrites and leucocytes
Urinary beta HCG for women of child bearing age
urine culture, routine bloods to assess inflammation and renal function
Renal US scan to check for obstruction, and then non contrast CT imaging of renal tract (CT KUB)

Question 22

Is infected obstructed of the emergency tract an emergency?

Answer 22

Yes

Question 23

What is the management for pyelonephritis?

Answer 23

Fluid resuscitation, antibiotics, analgesia and anti emetics

Non-responding cases may need catheterisation and HDU as can become rapidly unwell

Question 24

When should someone be admitted to hospital with pyelonephritis?

Answer 24

clinically unstable, significant dehydration, co morbidities such as diabetes, renal transplant or immunocompromised

Question 25

What should be done in the case of a man with pyelonephritis?

Answer 25

further imaging such as US or CT KUB, and a flexible cystoscopy to find cause

Question 26

What are some complications of pyelonephritis?

Answer 26

severe sepsis, renal scaring, chronic kidney disease, pyeonephrosis, preterm labour, chronic pyelonephritis, emphysematous pyelonephritis

Question 27

What is chronic pyelonephritis?

Answer 27

repeated infections, which then causes fibrosis and scarring and then destruction of the kidney, usually occur in obstruction, causing urinary reflux e.g. structures, diagnosis made from imaging as scarred shrunken kidney is seen, more common in children, manage by reversing cause, antibiotics and optimise renal function

Question 28

What is emphysematous pyelonephritis?

Answer 28

Rare and severe form of acute pyelonephritis, caused by a gas forming bacteria, has a high mortality rate, fail to respond to antibiotics, CT will show gas within and around the kidney, more common in diabetic patients, as high glucose allows CO2 production from fermentation by enterobacteria, may be treated with broad spectrum anti-microbial cover, nephrostomy insertion or percutaneous drainage or nephrectomy