UITM Notes Flashcards
Define hydronephrosis
Aseptic dilatation of the kidney caused by obstruction to the outflow of the urine
What are the causes of hydronephrosis?
1. Unilateral ureteric obstruction
2. Bilateral ureteric obstruction
Unilateral ureteric obstruction
1. Extramural obstruction
- Tumors from adjacent structures
- Intramural obstruction
- Congenital stenosis, ureterocele
- Inflammatory strictures
- Neoplasm of ureter/bladder CA - Intraluminal obstruction
- Calculus
- Sloughed papilla in papilla necrosis
Bilateral ureteric obstruction
1. Congenital
- Posterior Urethral Valves
- Urethral atresia
- Acquired
- BPH/Prostate CA
- Post-op bladder neck scarring
- Urethral strictures
- Phimosis
What investigations can be done to diagnose hydronephrosis?
Urine and blood test
1. Urinalysis -> TRO UTI, hematuria
2. FBC -> WCC count
3. Renal profile -> Urea, Creatinine, Sodium and Potassium
Imaging
1. US and KUB X-ray - 1st line to rule out obstructive causes
2. CT scan (more sensitive than US)
Other test (If no evidence of obstruction)
- Isotope renography
- IV pyelogram
- Perfusion pressure flow
- Voiding cystourethrography (TRO Vesicoureteral reflux in children)
What is the indication for operation in hydronephrosis?
- Bouts of renal pain
- Increasing hydronephrosis
- Evidence of parenchymal damage
- Infection
What surgical options are available for hydronephrosis (Based on severity)?
Mild cases:
- Pyeloplasty -> To correct uteropelvic junction obstruction
- Endoscopic pyelolysis
Severe cases:
- Nephrectomy -> Surgical removal of kidney
What is the pathological complication of hydronephrosis if left untreated?
Calyceal dilatation -> Pressure atrophy -> Damaged of renal parenchyma -> Thin, lobulated, and fluid-filled sac
Define acute pyelonephritis
Infection of the upper urinary tract (Kidney and upper ureter), usually ascending in nature
State the etiology of acute pyelonephritis
1. Ascending infection
2. Hematogenous infection
Ascending infection (Most common route)
- Urinary stasis
- Causative agents - E.coli, Proteus, Klebsiella
Hematogenous infection
- Infection at tonsil, dental caries, renal TB
How will a patient with acute pyelonephritis present to you?
- Fever +/- chills/rigors
- Nausea & Vomiting
- Back pain/Flank pain
- Symptoms of lower UTI/cystitis (Urgency, Frequency, Dysuria, Hematuria)
In elderly:
- Fever
- Altered mental status
- Organ decompensation/failure
In child (<2 Y):
- Fever
- Failure to thrive
- Feeding difficulty
- Vomiting
Physical examination
- SEPTIC LOOKING
- TACHYCARDIA
- Positive RENAL PUNCH
State the investigations and the relevant positive findings for acute pyelonephritis
Blood test:
1. FBC -> Leukocytosis
2. Renal profile -> Kidney damage
3. Blood culture and sensitivity
Urine test: (Midstream urine using clean catch, CBD, or suprapubic needle aspiration)
1. UFEME -> UTI, hematuria
2. Urine culture and sensitivity
Imaging:
1. Kidney US -> Detect any underlying cause
2. CT scan contrast -> alteration in renal perfusion, perinephric fluid accumulation, underlying cause
What is the possible treatment for acute pyelonephritis?
Medical:
- Empirical IV broad-spectrum antibiotics (AMOXICILLIN or GENTAMICIN)
Surgery:
- Done if already have complication (abscess) or stone causing obstruction
What are the complications of acute pyelonephritis if left untreated?
- Pyonephrosis
- Perinephric abscess
- Renal insufficiency
Explain on the pathology of chronic pyelonephritis
Chronic, recurrent reflux of infected urine -> Interstitial inflammation and scarring of renal parenchyma (Patchy distribution) -> Atrophy and dilated renal tubules
State the classical triad of pyonephrosis
- Anemia
- Fever (High fever with rigors)
- Swelling in the groin
+ Symptoms of cystitis
Describe the management plan of pyonephrosis
- IV antibiotic
- Drainage of the kidney (Percutaneous nephrostomy -> If too large, then open nephrostomy)
- If stone present, remove it
- Consider NEPHRECTOMY of kidney if it is already damaged and other kidney is still good
Classify the type of stones based on opacity
Radio-opaque
- Calcium oxalate (75%)
- Phosphate calculus (15%)
- Cysteine
- Xanthine (Rare)
Radio-lucent
- Uric acid
State (5) secondary stones
(Medical conditions that could cause urinary stones)
- Primary hyperparathyroidism
- Prolonged thiazide usage
- Milk-alkali syndrome
- Sarcoidosis
- Renal tubular acidosis
Milk alkali syndrome -> Triad of elevated calcium levels, metabolic alkalosis and AKI
Sarcoidosis -> Causes hypercalcemia
How will a patient will kidney stones present to the clinic?
- Present with uremia
- Pain
- Ureteric colic
- Hematuria
- Pyuria (infection) -> septicemia especially when kidney is obstructed
State the (5) impaction site of ureteric stone
- Utero-pelvic junction
- Crossing iliac artery
- Juxtaposition of vas deferens/broad ligament
- Enter bladder wall
- Ureteric orifice
What are the symptoms if one has ureteric stone?
- Ureteric colic
- Strangury (painful passage of few drops of urine)
What are the common symptoms if one has bladder stone?
- Suprapubic pain, dysuria, intermittent, frequency, hesitancy, nocturia, retention
- Hematuria + sudden termination voiding + dull/sharp pain (referred to tip of penis, scrotum, perineum, back, hip)
- UTI (common)
What could be done to temporarily relieve urolithiasis?
- Double J stent
- Nephrostomy
What diagnostic imaging can be done to diagnose a case of kidney stone or ureteric stone?
- X-ray KUB (90%) -> diagnosed opacities: calcified lymph node, phleboliths, ossified tip 12th rib
- IVU -> Established presence and position of calculus and the function of the other kidney
- Abdominal US -> to locate for treatment (ESWL)
- Non-contrast CT scan KUB (GOLD STANDARD)
Other tests
- Dipstick, culture, and sensitivity: microhematuria, urine pH, crystals (stone composition)
- Renal profile: Urea, Creatinine, Electrolytes
- Metabolic (recurrent)
How would you diagnose a case of bladder stone in clinic?
Diagnostic imaging:
1. Radiography (KUB)
2. Abdominal US -> Acoustic shadow
3. Cystoscopy -> Visualize the stone and assess the number, size, and position
Others:
- Dipstick, urine C&S
- Renal profile
- Metabolic (recurrent)
What is the acute management for urolithiasis patient?
- Hydration
- Pain management (NSAIDS)
- Antispasmodic (CCB -> DOXAZOSIN, alpha blocker -> NIFEDIPINE)
- Antibiotics if infection
What’s the size of the stone (urolithiasis) eligible for medical expulsive therapy?
<5mm
40-50% chance of pass within 6 weeks
What is the indication of surgery for kidney stones?
What surgical option you would offer?
Indication for surgery:
- Symptomatic (persistent pain)
- Obstruction
- Infection
- Staghorn
A. Extracorporeal shock wave lithotripsy (ESWL) Size 0.5 - 1.5cm
- Bombard shockwave break stone to fragments
- Few sessions needed for completion of fragmentation
- Post ESWL: decompression by ureteric stent or percutaneous nephrostomy
- Complication: INFECTION
- Contraindication:
1. Distal urinary tract obstruction
2. Obese
3. Pregnant
4. Patient taking oral anti-coagulants
B. Percutaneous nephrolithotomy (PCNL) Size > 1.5cm
- Needle into urinary tract -> Nephroscope to visualize the stone -> If small stone, just grasp it / If larger stone, fragmented by US, laser or electrohydraulic probe -> Nephrostomy drain is left to decompress the kidney and allow repeated access
- Complication:
1. Hemorrhage from renal parenchyma
2. Perforation collecting system
State 3 complications of kidney stones.
- Hydrocalyx
- Hydronephrosis
- Impaired renal function -> renal failure
How would you manage a case of ureteric stone?
Conservative
- If small stone
- Radiograph every 6-8 weeks
Minimal access surgery:
Indication
1. Failure to pass
2. Large stone
3. Bladder outlet obstruction
4. Infection
- Endoscopic stone removal (DORMIA BASKET) -> Lower/Middle part of the ureter
- If can’t be caught by endoscopy/basket -> UTEROSCOPIC STONE REMOVAL
State 3 complication of ureteric stone if left untreated.
- Lodges to bladder
- Ureter colic
- Hydroureter
How would you manage a case of bladder stone?
Transurethral litholopaxy (1st LINE)
- Cystoscopy used to visualize stone
- Fragments removed by OPTICAL LITHOTRITE
Percutaneous suprapubic litholopaxy/Open vesicolithotomy
State (3) complication if a bladder stone is left untreated
- Chronic bladder dysfunction
- UTI
- Urinary retention
What should be done in order to prevent recurrence?
Check for:
- Serum calcium to exclude HYPERPARATHYROIDISM, SERUM UA
- Analysis of stone passed
- Keep hydrated (High fluid intake) -> best prophylactic measures
- HYPERURICEMIA (Avoid foods rich in purine)
- Urinary alkalization (mainly for cystine and urate stone)
