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Surgery > UITM Notes > Flashcards

UITM Notes Flashcards

1
Q

Define hydronephrosis

A

Aseptic dilatation of the kidney caused by obstruction to the outflow of the urine

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2
Q

What are the causes of hydronephrosis?
1. Unilateral ureteric obstruction
2. Bilateral ureteric obstruction

A

Unilateral ureteric obstruction
1. Extramural obstruction
- Tumors from adjacent structures

  1. Intramural obstruction
    - Congenital stenosis, ureterocele
    - Inflammatory strictures
    - Neoplasm of ureter/bladder CA
  2. Intraluminal obstruction
    - Calculus
    - Sloughed papilla in papilla necrosis

Bilateral ureteric obstruction
1. Congenital
- Posterior Urethral Valves
- Urethral atresia

  1. Acquired
    - BPH/Prostate CA
    - Post-op bladder neck scarring
    - Urethral strictures
    - Phimosis
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3
Q

What investigations can be done to diagnose hydronephrosis?

A

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)

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4
Q

What is the indication for operation in hydronephrosis?

A
  • Bouts of renal pain
  • Increasing hydronephrosis
  • Evidence of parenchymal damage
  • Infection
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5
Q

What surgical options are available for hydronephrosis (Based on severity)?

A

Mild cases:
- Pyeloplasty -> To correct uteropelvic junction obstruction
- Endoscopic pyelolysis

Severe cases:
- Nephrectomy -> Surgical removal of kidney

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6
Q

What is the pathological complication of hydronephrosis if left untreated?

A

Calyceal dilatation -> Pressure atrophy -> Damaged of renal parenchyma -> Thin, lobulated, and fluid-filled sac

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7
Q

Define acute pyelonephritis

A

Infection of the upper urinary tract (Kidney and upper ureter), usually ascending in nature

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8
Q

State the etiology of acute pyelonephritis
1. Ascending infection
2. Hematogenous infection

A

Ascending infection (Most common route)
- Urinary stasis
- Causative agents - E.coli, Proteus, Klebsiella

Hematogenous infection
- Infection at tonsil, dental caries, renal TB

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9
Q

How will a patient with acute pyelonephritis present to you?

A
  • 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

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10
Q

State the investigations and the relevant positive findings for acute pyelonephritis

A

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

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11
Q

What is the possible treatment for acute pyelonephritis?

A

Medical:
- Empirical IV broad-spectrum antibiotics (AMOXICILLIN or GENTAMICIN)

Surgery:
- Done if already have complication (abscess) or stone causing obstruction

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12
Q

What are the complications of acute pyelonephritis if left untreated?

A
  • Pyonephrosis
  • Perinephric abscess
  • Renal insufficiency
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13
Q

Explain on the pathology of chronic pyelonephritis

A

Chronic, recurrent reflux of infected urine -> Interstitial inflammation and scarring of renal parenchyma (Patchy distribution) -> Atrophy and dilated renal tubules

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14
Q

State the classical triad of pyonephrosis

A
  • Anemia
  • Fever (High fever with rigors)
  • Swelling in the groin

+ Symptoms of cystitis

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15
Q

Describe the management plan of pyonephrosis

A
  • 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
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16
Q

Classify the type of stones based on opacity

A

Radio-opaque
- Calcium oxalate (75%)
- Phosphate calculus (15%)
- Cysteine
- Xanthine (Rare)

Radio-lucent
- Uric acid

17
Q

State (5) secondary stones
(Medical conditions that could cause urinary stones)

A
  • 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

18
Q

How will a patient will kidney stones present to the clinic?

A
  • Present with uremia
  • Pain
  • Ureteric colic
  • Hematuria
  • Pyuria (infection) -> septicemia especially when kidney is obstructed
19
Q

State the (5) impaction site of ureteric stone

A
  • Utero-pelvic junction
  • Crossing iliac artery
  • Juxtaposition of vas deferens/broad ligament
  • Enter bladder wall
  • Ureteric orifice
20
Q

What are the symptoms if one has ureteric stone?

A
  • Ureteric colic
  • Strangury (painful passage of few drops of urine)
21
Q

What are the common symptoms if one has bladder stone?

A
  • 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)
22
Q

What could be done to temporarily relieve urolithiasis?

A
  1. Double J stent
  2. Nephrostomy
23
Q

What diagnostic imaging can be done to diagnose a case of kidney stone or ureteric stone?

A
  1. X-ray KUB (90%) -> diagnosed opacities: calcified lymph node, phleboliths, ossified tip 12th rib
  2. IVU -> Established presence and position of calculus and the function of the other kidney
  3. Abdominal US -> to locate for treatment (ESWL)
  4. 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)

24
Q

How would you diagnose a case of bladder stone in clinic?

A

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)

25
Q

What is the acute management for urolithiasis patient?

A
  1. Hydration
  2. Pain management (NSAIDS)
  3. Antispasmodic (CCB -> DOXAZOSIN, alpha blocker -> NIFEDIPINE)
  4. Antibiotics if infection
26
Q

What’s the size of the stone (urolithiasis) eligible for medical expulsive therapy?

A

<5mm
40-50% chance of pass within 6 weeks

27
Q

What is the indication of surgery for kidney stones?
What surgical option you would offer?

A

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

28
Q

State 3 complications of kidney stones.

A
  • Hydrocalyx
  • Hydronephrosis
  • Impaired renal function -> renal failure
29
Q

How would you manage a case of ureteric stone?

A

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

30
Q

State 3 complication of ureteric stone if left untreated.

A
  • Lodges to bladder
  • Ureter colic
  • Hydroureter
31
Q

How would you manage a case of bladder stone?

A

Transurethral litholopaxy (1st LINE)
- Cystoscopy used to visualize stone
- Fragments removed by OPTICAL LITHOTRITE

Percutaneous suprapubic litholopaxy/Open vesicolithotomy

32
Q

State (3) complication if a bladder stone is left untreated

A
  • Chronic bladder dysfunction
  • UTI
  • Urinary retention
33
Q

What should be done in order to prevent recurrence?

A

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)

34
Q
A

Surgery (13 decks)

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