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U17 + 18 > Urinary pathology > Flashcards

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
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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
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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)
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4
Q

What is a retrocaecal/circumcaval ureter

A
  • 50% type I- fish hook sign at L3
  • Also called LOW LOOP
  • Obstructive uropathy +/- stones
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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)

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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
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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)
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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
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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
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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
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11
Q

Invetsiagtions for ureteric stones

A
  • Ultrasound
  • X ray KUB (kidney-ureter-bladder)
  • CT KUB (If X ray contraindicated- pregnancy)
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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)
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13
Q

Complications of ureteric stones - untreated

A
  • Infection/UTI (acute pyelonephritis in upper tract)
  • Obstruction
  • Chronic pyelonephritis
  • Non-functioning kidney
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14
Q

Complications of treater ureteric stones

A
  • Recurrent metabolic stones
  • Stainstrasse- stone street- ureteric obstruction if large stone subjected to ESWL
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15
Q
A
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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

U17 + 18 (22 decks)

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