Urinary pathology Flashcards
1
Q
The difference between urological and nephrological problem
A
- Surgicla vs medical intevrention
- Pain, welling, haematuria = urological
- Microsocpuc haematuria with tubular casts in urine and quicker deterioration of renal function = neprhological problem
2
Q
Urolithiasis
A
- Crystalline precipitation due to absoloute or relative increase in solute conc (dehydration), change in pH and stasis
- 4 sites of stone impaction due to physiological narrowing.
- Pelvitureteric junction - PUJ
- Vesicoureteric junction - VUJ
- Ureter entering pelvic brim
- Ureter crossed by iliac vessels
3
Q
Structursal abnormalities in ureters
A
- Often unmasked during protocol investiagtiosn after childhood UTI
- horse-shoe kdiney - lowe rpoles bridged by renal tissue causing ureters to kink
- Bifid ureter, retrocaval ureter (behind VC)
- Duplex ureter - Weigert-Meyer law - upper moiety ectopic (opens mor einfero-medially), lower moiety orthotopic
- Incomplete upper tract duplication - asymptomatic or rarely symptomatic if reflux is into othe rlimb instead towards the bladder (saddle reflux/yo-yo reflux)
4
Q
What is a retrocaecal/circumcaval ureter
A
- 50% type I- fish hook sign at L3
- Also called LOW LOOP
- Obstructive uropathy +/- stones
5
Q
Common ureteric stone types
A
- Oxalate - red spiky surface (rosary bead/coronaviridae like) causes mucosal injury and haematuria, often associated with acquired cystic disease (even seen in cancer in this group_
- Urate - high uric acid- gout
- Phosphate - struvite - stag horn calculus - cast of calyceal system - usually in infection, hydronephrosis
- Apatite-struvite-brushite (calcium phosphate) - all infection related stones (other metabolic)
- Cystine
Struvite = triple phosphate/infection stone (magnesium ammonium phosphate)
6
Q
What is the presentation of an UTI
A
- Shooting pain from loin to groin (fixed loin pain in acute pyelonephritis)
- Fever with chill and rigor
- Burnign sensation on passing urine (micturition)
- SMoky urine due to haematuria
7
Q
What are the commonest abcteria for UTI
A
- Gram negative coliforms- E coli, Klebsiella, Proteus (particularly involved in a condition called malakoplakia due to macrophage phagocytic defect)
- Staph saprophyticus ( gram positive in young sexually active females)
8
Q
Management of a UTI
A
- Dipstix- leucocytes (response) and nitrates (bacterial metabolism) high
- Culture- in male, recurrent, high in dipstix as above, discordance with clinical findings
- Lower tract UTI- Nitrofurantoin, Trimethoprim antibiotics
- Upper tract UTI- Cephalexin
- Non-responding cases- culture sensitivity and consult microbiologist
9
Q
Recurrent UTI vs Reinfection
A
- Recurrent- different bacteria- precipitating clinical factors remain same
- Reinfection- same bacteria- may need culture sensitivity and more treatment
10
Q
Management of urolithiasis (ureteric stones)
A
- <5 mm- manage UTI, plenty of fluids- will pass – graveluria
- Medical expulsive therapy- assisted graveluria- alpha adrenergic blockers- tamsulosin, terazosin, doxazosin
- > 15 mm, symptomatic, infective, obstructive- active management
- For acute presentation may need double J stent to facilitate drainage
11
Q
Invetsiagtions for ureteric stones
A
- Ultrasound
- X ray KUB (kidney-ureter-bladder)
- CT KUB (If X ray contraindicated- pregnancy)
12
Q
Active management of ureteric stones
A
- ESWL- Extra corporeal shock wave lithotripsy
- Dormia basketing (retrograde approach)
- PCNL- Percutaneous nephrolithotomy (antegrade approach)
- May combine with ISWL (intra corporeal) for large stone during PCNL
- Open surgery- rare, historical
- Nephrectomy- rare, historical unless seriously non function with calculus pyonephrosis, xanthogranulomatous pyelonephritis and malakoplakia (both can masquerade as cancer)
13
Q
Complications of ureteric stones - untreated
A
- Infection/UTI (acute pyelonephritis in upper tract)
- Obstruction
- Chronic pyelonephritis
- Non-functioning kidney
14
Q
Complications of treater ureteric stones
A
- Recurrent metabolic stones
- Stainstrasse- stone street- ureteric obstruction if large stone subjected to ESWL
15
Q
A
16
Q
Ureteric stones
A
- A- Oxalate (commonest)- envelope like
- B- Urate
- C- Cysteine
- D- Struvite/phosphate- coffin lid like
17
Q
Metabolic states -> ureteric stones
A
- Hypercalciuria- hyperparathyroidism
- Hyperoxaluria- usually due to diet ( may be dietary fads) (ethylene glycol poisoning/anti freeze causes oxaluria- fatal- not relevant)
- Hyperuricosuria- typically gout
- Cystinuria- genetic
- Renal tubular acidosis
- Nephrocalcinosis- deposition of calcium in kidney- dystrophic- in damaged tissue, metastatic in healthy tissue
18
Q
Dietary modification for ureteric stones
A
- Hydration, restricted sodium and animal protein ( so called stone clinic effect)
- Do not restrict calcium- may cause stones due to oxaluria
- Reduce high oxalate (high oxide veg) and high purine food (mostly animal protein)
- Stone leaflet
19
Q
High oxalate food (can lead to stones)
A
- Beans (green and dried), Beer (draft, stout, lager, pilsner) , Beets, Berries (blackberries, blueberries, raspberries, strawberries, juice made from berries) Black tea, Black pepper
- Celery, Chocolate, cocoa, Eggplant , Figs
- Greens (collard greens, dandelion greens, endive, escarole, kale, leeks, mustard greens, parsley, sorrel, spinach, Swiss chard, watercress) , Green peppers
- Lemon, lime, and orange peel
- Nuts, Pecans, peanuts, peanut butter
- Okra, Rhubarb, Sweet potato , Tofu
20
Q
High purine food (need to restrict for ureteric stone reduced likelihood)
A
- Organ meats: brain, heart, kidney, liver, sweetbreads
- Meat extracts: bouillon, consommé, stock, gravy
- Meat: beef, chicken, goose, lamb, pork
- Shellfish: clams, mussels, scallops, shrimp, oysters
- Fish: anchovies, fish roe, herring, mackerel, sardines, and others
- Certain vegetables: asparagus, cauliflower, kidney beans, lentils, lima beans, mushrooms, peas, spinach
21
Q
Obstructive Uropathy
A
- Flow problem
- Luminal- stone, tumour, acute papillary necrosis (diabetes, historically phenacetin)
- Mural (wall)- tumour, stricture, PUJO (pelvi-ureteric junctional obstruction)
- Extrinsic- compression by tumour
- Unilateral- cause is at or above vesicoureteric junction
- Bilatral- lower obstruction at or below bladder neck- BPH, hypertrophic bladder neck
22
Q
PUJO- PELVI-URETERIC JUNCTIONAL OBSTRUCTION
A
- Usually, no demonstrable underlying cause- transit defect
- Sometimes, an accessory artery in wrong position
- Needs dismembering (Anderson-Heinz) or non dismembering pyeloplasty- depending on whether to keep or reposition the PUJ
23
Q
BPH - Benign prostatic hypeprlasia
A
- Hyperplasia- increase in the number of cells- glands, muscle, may be stroma predominant which may be histologically worrying for soft tissue tumour
- Involves the transitional zone
- Cancer involves the peripheral zone
24
Q
Effects of obstructive uropathy
A
- Water hammer effect- reflux/back pressure
- Hydroureter- megaureter - dilated
- Hydropelvis- swelling and dilation of pelvis (which may be intra or extra renal)
- Hydrocalycosis- blunting of calyx (normally cup shaped) and then convexity
- Hydronephrosis
- Chronic pyelonephritis
25
Q
Ix and Mx of suspected UT obstruction
A
26
Q
ACUTE AND CHRONIC PYELONEPHRITIS (CPN)
A
- Acute- as discussed in stones
- Chronic pyelonephritis- chronic complication due to obstruction
- Results in non-functioning kidney
- Removed as it may be a source o sepsis
- End stage kidney and interstitial nephritis- term reserved for end point of systemic renal disease- not to be used in histological description of CPN
27
Q
Chronic pyelonephritis - patho
A
Fibrosis
Inflammation
Atrophy
28
Q
Non-functioning kidney– possible causes
A
- Cortical atrophy
- Dilated pelvicalyceal/pyelocaliceal system (PCS)
- Antler horn like calculus (staghorm struvite)
- Cystic
29
Q
What is the histology of chronic pyelonephriotis: histology
A
- Tubular cystic atrophy, dilation with pink colloid like material (thyroidisation)
- Chronic inflammatory infiltrate (not to be referred to as interstitial nephritis)
- Variable globally sclerosed glomeruli ( but no glomerulonephritides)
- Age related vascular fibroelastosis
30
Q
Clinical triads and urinary pathology (stones)
A
- Pain, swelling, haematuria- stones/obstruction
- Painless frank haematuria or late pain in the triad- exclude malignancy
