Transcript 20111011 X ray conference

報告者：fellow 1 陳筱惠
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Name: 游O琴
Sex: female
Age: 56-year-old
Occupation: 餐飲業
Chart number: 8970369
Date of admission: 2011/09/25
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Right flank pain and black urine for 1 week
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Small kidney with kidney stones was told at
亞東hospital 2~3 years ago. She received
URS + SM then.
Right flank/low abdominal pain and black
urine for 1 week; associated symptoms:
dysuria, frequency, and urgency; no fever or
hematuria
LMD visit twice, but no improvement under
analgesic + oral antibiotic
At ER, foley was inserted for urine retention
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Small kidney with kidney stones was told
at 亞東hospital 2~3 years ago. She
received URS + SM then.
Urinary tract infection or chronic kidney
diseases: denied
No hypertension, diabetes mellutis, heart,
liver, or other significant systemic diseases
Current medicine: nil
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Allergy: no known allergy
Alcohol: denied; betel-nut: denied; cigarette:
denied
Over-the-counter medication or chinese herb:
nil
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No family history of diabetes mellutis,
malignancy, bleeding diathesis, heart, liver,
kidney, or hereditary diseases
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Vital signs: blood pressure: 142/81mmHg; temperature: 36‘C;
pulse rate: 90/min; respiratory rate: 17/min
General apperance: acute ill looking
Eye: conjunctiva: not pale, sclera: no icteric
Neck: supple, no lymphadenopathy or jugular vein engorgement
Chest: symmetric expansion
breathing sound: bilateral clear
heart sound: regular heart beats, no S3 or S4, no
murmurs
Abdomen: soft, flat, diffuse tenderness, no muscle guarding or
rebounding
liver/spleen: impalpable
bowel sound: normoactive
Back: right flank knocking pain
Extremities: no lower limb pitting edema
Skin: intact, no rash
WBC
8.7x1000/ul
Urea N
17.6 mg/dl
Hgb
13.2 g/dl
Creatinine
0.75 mg/dl
Hct
38.2 %
GPT
53 IU/L
MCV
89.3 fl
NA
138 mEq/L
PLT
442 x1000/uL
K
3.8 mEq/L
Sugar
127 mg/dl
Segment
43 %
Band
21 %
Color
Red
Blood
3+
Turbidity
Turbid
bacteria
+
SP. Gravity
1.016
RBC
78/uL
PH
6.5
WBC
129/uL
Leukocyte
1+
Epithelial cell
0/uL
Nitrite
-
Protein
1+
Glucose
-
Ketone
1+
Urobilinogen
0.1
Bilirulin
-
9/24 urine culture:
Viridans streptococcus (>
100,000)
 9/25 blood culture:
negative
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Left kidney Length: 11.2 cm
 Mild dilatation of the pelvocalcyeal systems
 A peri-pelvic echo-free lesion (2.0cm) in the lower pole
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Right kidney Length: 14.4 cm
 Irregular in contour, increased cortical echogenicity and
decreased thickness
 Severe dilatation of the pelvocalcyeal systems and ureter;
multiple tiny hyperechoic lesions without acoustic shadow
kidney and soft tissue-like density
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Bladder: distended
 foley within it.
 A protruding mass (4.9x2.7cm) with connection of a
peri-bladder lumen near right vesicle-ureter junction, a
iso-echoic lesion (1.2cm)
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Right hydronpehrosis and hydroureter, due to
ureterocele; complicated with infection and
probably pyonephrosis and pyoyreter
 Multiple tiny stones inside
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Left minimal hydronephrosis
Urinary bladder mucosal thickening and
enhancement, suggesting chronic cystitis
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Infected purulent urine in an obstructed
collecting system
S/S: typically associated with fever, chills, and
flank pain, although may be asymptomatic,
too
Etiologies:
 Ascending infection of the urinary tract
 Hematogenous spread of a bacterial pathogen
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Incidence: relatively uncommon
 The risk of pyonephrosis is increased in patients
with upper urinary tract obstruction secondary to
various causes (eg, stones, tumors, ureteropelvic
junction [UPJ] obstruction
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Pathogen:
 Escherichia coli, Enterococcus species, Candida
species, Enterobacter species, Acteroides species,
Staphylococcus species, Salmonella species,
Tuberculosis
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Complications:
 Sepsis and septic shock
 Irreversible damage to the kidneys
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Treatment: surgical emergency for
decompression
 Disadvantages of retrograde decompression:
▪ General anesthesia, contraindicated in unstable patients
▪ Smaller-caliber urinary drainage catheter than with
percutaneous access
▪ Increased irritative urinary symptoms
▪ Lack of antegrade access for radiologic studies or
inability to administer medications such as antibiotics
via nephrostomy tube
▪ Bypassing the obstruction may not be possible
in some patients.
▪ Pyelovenous, pyelolymphatic, and pyelosinus backflow
of infected urine into the systemic circulatory system
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Ultrasonographic features of pyonephrosis:
 Dilated collecting system
 Echogenic debris in the in dependent areas of
collecting system
▪ Strong echoes with acoustic shadowing
▪ Change position when patient moves
 Air can be seen in these infections.
Ultrasonographic Evaluation of Renal Infections
Radiol Clin N Am 44 (2006) 763–775
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CT: depicts both hydronephrosis and often
the underlying cause
 Contrast-enhanced imaging is more desirable as
in infection parenchymal and functional changes
can be assessed.
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Pelvic and ureteral wall thickness
Renal enlargement
Perinephric fat stranding
Fluid–fluid levels and gas within the collecting system
Imaging of urinary tract infection in the adult
Eur Radiol (2004) 14:E168–E183
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Name: 徐O華
Sex: female
Age: 63-year-old
Occupation: nil
Chart number: 6425429
Date of admission: 2011/09/05
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Low abdominal pain for 4 days
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Underlying diseases: rheumatoid arthritis,
diabetes mellitus, and history of infectious
spondylitis with left anterior epidural abscess
post operation in 2011/03 (stool/urine
incontinence under foley use and bedridden
status since then)
Turbid urine, suprapubic and right flank pain
for 4 days; associated symptoms: poor
appetite, nausea/vomiting; no fever
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Underlying diseases:
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Rheumatoid arthritis
Hypertension
Diabetes mellitus
Osteoporosis
Iatrogenic adrenal insufficiency
History of infectious spondylitis with left anterior
epidural abscess post operation operation at 802
hospital in 2011/03
 No heart, liver, or other significant systemic
diseases
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Current medicine: from our Rheuma OPD
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Allergy: no known allergy
Alcohol: denied; betel-nut: denied; cigarette:
denied
Over-the-counter medication or chinese herb:
nil
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No family history of diabetes mellutis,
malignancy, bleeding diathesis, heart, liver,
kidney, or hereditary diseases
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Vital signs: blood pressure: 124/92mmHg; temperature: 36.6‘C;
pulse rate: 110/min; respiratory rate: 18/min
General apperance: acute ill looking
Eye: conjunctiva: mild pale, sclera: no icteric
Neck: supple, no lymphadenopathy or jugular vein engorgement
Chest: symmetric expansion
breathing sound: bilateral clear
heart sound: regular heart beats, no S3 or S4, no
murmurs
Abdomen: soft, flat, low abdominal tenderness, no muscle
guarding or rebounding
liver/spleen: impalpable
bowel sound: normoactive
Back: right flank knocking pain
Extremities: no lower limb pitting edema
Skin: intact, no rash
WBC
7.2x1000/ul
Creatinine
0.58 mg/dl
Hgb
9.6 g/dl
GPT
8 IU/L
Hct
29.2 %
NA
136 mEq/L
MCV
92.7 fl
K
3.9 mEq/L
PLT
258 x1000/uL
Sugar
104 mg/dl
Lactate
9.1 mg/dl
Segment
79.8 %
Color
Yellow
Blood
2+
Turbidity
Cloudy
bacteria
+
SP. Gravity
1.010
RBC
10/uL
PH
8.5
WBC
65/uL
Leukocyte
3+
Epithelial cell
5/uL
Nitrite
+
Protein
Trace
Glucose
-
Ketone
-
Urobilinogen
0.1
Bilirulin
-
9/3 urine culture: Proteus
mirabilis (>100,000)
 9/3 blood culture: negative
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Left Kidney Length: 10.2 cm
 One isoechoic band extending from the cortex to central
sinus
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Right Kidney Length: 10.4 cm
 One mass-like lesion (7.0x3.5cm) over middle portion
The both kidneys are normal in size and contour.
The cortical echogenicity and thickness are
normal.
 No evidence of renal stone or cyst exists.
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Multifocal ill-defined low denity of bilateral
renal parenchyma, C/W acute pylonepheritis
Dilatation of bilateral renal pelvis and ureters
to right middle ureter and left upper ureter
level
No definite dilatation of bilateral renal calyces
No definite ureteral stones or tumor could be
identified.
DDx: extrarenal pelvis, retroperitoneal
fibrosis/ adhesion, or ureteral stricture
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Ureteral catheter passing up to the left upper
ureter at L4 level and right middle ureter at S3
level
Mild bilateral hydronephrosis.
No obvious filling defect in the collecting
system. The right upper ureter and right renal
collecting system are not well opacified.
No definite radiopaque stone in the urinary
tract
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The presence of extrarenal calyces is a very
rare anomaly of the upper urinary tract.
 First described in 1925
 The total number of cases reported so far is only
20.
 Kidney with extrarenal calyces is usually
associated with other anomalies like bifid kidney,
renal ectopia, horseshoe kidney and renal
dysplasia.
Extrarenal calyces: A rare anomaly of the renal collecting system
Indian J Pathol Microbiol. 2009 Jul-Sep;52(3):368-9.
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The calyces were long and extrarenal in
position. They drained into a cystic structure
which represented either a grossly dilated
pelvis (pelviureteric junction) or a ureteral
cyst.
The exact cause of extrarenal calyces is not
very clear.
 Hypothesis: a disparity resulting from slow
development of the metanephric tissue or to a
relatively rapid development of the ureteric bud
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Many cases of collecting system anomalies
including extrarenal calyces are detected
incidentally or may be diagnosed because of
its complications.
Excretory urography often provides good
anatomic information.
 A false impression of hydronephrosis or chronic
pyelonephritis
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Rare disease, incidence of idiopathic form
about 0.1~1.3 per 100,000 person-years
Etiology:
 Idiopathic form: 70%, 40 ~ 60 years of age, 2 to 3:1
male-to-female predominance
 Secondary form
▪ Drugs: ergot-derivatives, methysergide, bromocriptine,
beta blockers, methyldopa, hydralazine, analgesics
▪ Malignancy: carcinoid, Hodgkin's and non-Hodgkin
lymphoma, sarcomas
 Infections: tuberculosis, histoplasmosis,
actinomycosis
 Radiation therapy for testicular seminoma, colon,
pancreatic cancer
 Surgery: lymphadenectomy, colectomy, aortic
aneurysmectomy
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Pathology:
 Macroscopically: a hard, white plaque of varying
thickness
▪ Typically, around the abdominal aorta and iliac vessels,
as well as the inferior vena cava and the ureters
 Microscopically: sclerosis and infiltration of
mononuclear cells in varying proportions,
depending on the stage of disease
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Pathogenesis: chronic inflammation,
fibroblast proliferation, and excessive
extracellular matrix deposition
Clinical manifestations:
 Early stage: pain in the lower back, flank or
abdomen; characteristically dull, noncolicky, in a
girdle distribution (> 90%)
▪ Other nonspecific symptoms: weight loss, malaise,
anorexia, testicular pain, claudication, edema, and gross
hematuria
 Late stage: vessel compromise and characterized
ureteral obstruction
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Laboratory abnormalities:
 Elevated ESR and CRP
 Positive ANA (60%)
 Anemia, possibly related to renal insufficiency or
chronic inflammation
 No hematologic or biochemical abnormalities
diagnostic of this condition.
 The urinary sediment is most often normal.
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Ultrasonography: a poorly
marginated, periaortic mass that is
typically echo-free or hypoechoic
and may be associated with
hydronephrosis
CT scan:
 The mass is confluent, encasing the
anterior and lateral sides of the aorta
and often encircling the inferior vena
cava.
 Similar attenuation numbers to that of
muscle
Magnetic resonance imaging:
comparable to those with CT
scanning
 Intravenous urography: proximal
hydroureteronephrosis, medial
deviation of the ureters, and extrinsic
compression of the ureters
 Retrograde or percutaneous
antegrade pyelography: a smooth
tapering of the ureters that is most
pronounced at the level of the pelvic
brim
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Biopsy: no guidelines
 The location of the mass is atypical
 Clinical, laboratory or radiologic findings suggest
the presence of an underlying malignancy or
infection
 Local experience is limited
 The patient does not respond to initial therapy.
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