Approach to a Patient with Unilateral Flank Pain
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Approach to a Patient with Unilateral Flank Pain
Geraldoy, Isabelle Reyna – Go, Marianne RoseDr. C.O. Cruz and Dr. M.G. Santi
FACILITATORSFebruary 18, 2010
RADIOLOGY INTERACTIVE CASE 7
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GENERAL DATA
• D.B.• 24 year old• Male• CC: right flank pain
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HISTORY OF PRESENT ILLNESS3
wee
ks P
TCSudden onset of right flank pain(-) hematuria(-) dysuria
1 da
y PT
CPersistence prompted consult at OPDUrinalysis: hematuriaUTZ: hydronephrosis
Cons
ultPhysical
ExaminationUrinalysisIVP, KUB, CT Stonogram
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PHYSICAL EXAMINATION
Supple neck, no palpable cervical
lymph nodes
Symmetrical chest expansion, no
retractions, clear breath sounds
Adynamic precordium, AB 5th
LICS MCL, no murmurs
Flabby abdomen, normoactive bowel sounds, (+) kidney
punch, right
Pulse were full and equal
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URINALYSIS
Normal• Color: • pH: 4.6-6.5• RBC: 0• WBC: 0-2/hpf• (-) Bacteria• Squamous cells –few• Amorphous urates normal
in acidic urine
Patient• Amber colored• Acidic• RBC 100++/hpf• Pus 60-70/hpf• Bacteria 1+• Squamous cells- few• Amorphous urates- few
McPherson & Pincus: Henry's Clinical Diagnosis and Management by Laboratory Methods, 21st ed.
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URINARY TRACT OBSTRUCTION• Causes– Intrinsic blockade– Extrinsic blockade– Functional defects
• Sites of narrowing are common sites of obstruction– Ureteropelvic and
ureterovesical junctions– Bladder neck– Urethral meatus
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URINARY TRACT OBSTRUCTION: CAUSES
Congenital
• Ureteropelvic or ureterovesical junction narrowing or obstruction
• Bladder neck obstruction, ureterocoele
• Posterior or anterior urethral valves
• Stricture• Meatal stenosis• Phimosis
Intrinsic Mechanical Blockade
• Calculi• Inflammation• Infection• Trauma• Sloughed papillare
from ureter• Tumor • Blood clots• Uric acid crystals• Stricture• Cancer of prostate,
bladder• Spinal cord disease• BPH
Extrinsic Mechanical Blockade
• Pregnant uterus• Retroperitoneal
fibrosis• Aortic aneurysm• Carcinoma of cervix,
colon, uterus, prostate, bladder, rectum
• Trauma
Harrison’s Principles of Internal Medicine 17th ed
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URINARY TRACT OBSTRUCTION• ACQUIRED DEFECTS
– Most common• Pelvic tumors
• 24 years old• Urethral strictures
• Below the bladder: BILATERAL• No history trauma or surgery
• Nephrolithiasis • Flank pain• Hematuria• Pyuria
Harrison’s Principles of Internal Medicine 17th ed
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SIGNS AND SYMPTOMSUnilateral Urinary Tract Obstruction• Pain
– Distension of the collecting system or renal capsule
• Renal Colic– Steady and continuous– Radiates to lower abdomen, testes, labia– Acute supravesical obstruction: stone
• Hydronephrosis• Murphy’s punch sign or kidney punch
– CVA tenderness– Tapping disturbs the inflamed tissue,
causing pain• Frequency, urgency, hematuria• Abnormal urine color• Urinary Tract Infection
Patient• Acute (R) Flank pain
• Hydronephrosis (R)• + kidney punch
• Hematuria• Amber colored urine• Bacteria in urine (?)
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CLINICAL IMPRESSION
Hydronephrosis due to Nephrolithiasis
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NEPHROLITHIASIS
• One of the most common urological problems• Stones become symptomatic when they enter
the ureter or occlude the ureteropelvic junction, causing pain and obstruction
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Source: MacMurry College, Illinoiswww.mac.edu
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Nephrolithiasis
Calcium stones
Uric acid stones
Struvite Stones
Cystine Stones
5-10%;Common in women
1%;Hereditary75-85% 5-10%
Source: Harrison’s Principles of Internal Medicine 17th ed
Radiopaque Radiolucent
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Diagnosis and Initial Managementof Kidney Stones. American Family Physician . April 1, 2001, Vol. 63. Number 7
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Uric Acid NephrolithiasisMary Ann Cameron, MD and Khashayar Sakhaee, MD
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INTRAVENOUS PYELOGRAM
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INTRAVENOUS PYELOGRAM
• An x-ray examination of the kidneys, ureters, and urinary bladder
• Uses iodinated contrast media injected into the veins
• Injected dye bloodstream kidneys and urinary tract radiopaque on radiograph
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NORMAL IVP
• Immediately after the contrast is administered, it appears as a ‘renal blush’ (contrast being filtered through the cortex).
• At an interval of 5 minutes – the renal blush is still evident but the calices and renal pelvis are also visible.
10 minutes
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NORMAL IVP
• At 15 minutes – contrast begins to empty into the ureters and travel to the bladder which has now begun to fill.
15 minutes
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Normal IVP
• It normally takes around 45 minutes to an hour to fill the bladder with contrast.
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IVP IN HYDRONEPHROSIS
• Earliest change: flattening of the normal concavity of the calyx and blunting of the sharp peripheral angle produced by the papilla as it just into the calyx.
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IVP of the Patient
1 minute 5 minutes
Prolonged hyperintense right nephrogram
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IVP of the Patient
15 minutes 40 minutes
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IVP OF THE PATIENT
• Stasis of the contrast
45 minutes
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IVP of the Patient
Full bladder Post void
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ULTRASOUND OF THE KIDNEY, URETER AND BLADDER
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ANATOMY OF THE KIDNEY-The kidneys are retroperitoneal organs that are protected by the lower ribs posteriorly. - 3 layers: 1. Outer- fibrous outer cortex2. Middle-medulla (pyramids) with
surrounding cortex (columns of Bertin)
3. Inner- renal sinus that contains the calyces and renal pelvis with larger blood vessels, lymphatics and fatty tissue.
- The whole renal complex including the kidney, adrenal gland, renal hilum and perinephric fat is surrounded by a fascial layer, called Gerota’s fascia.
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Normal kidney on ultrasound
-The normal kidney will have a bright area surrounding it which is made up of Gerota’s fascia and perinephric fat.
- The periphery of the kidney will appear grainy gray which is made up of the renal cortex and pyramids
-The central area of the kidney, the renal sinus, will appear bright (echogenic) and consists of the calyces, renal pelvis and the renal sinus fat.
-Normal findings:- calyx- cup-shaped, acute
angle, usually not visible- ureter- usually not visible
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HYDRONEPHROSIS
Specimen of a kidney that has undergone extensive dilation due to hydronephrosis. Note the extensive atrophy and thinning of the renal cortex.
-Hydronephrosis is distension and dilation of the renal pelvis and calyces , usually caused by obstruction of the free flow of urine from the kidney
- Abnormal collection of urine within the renal pelvis. It usually indicates some obstruction to urine drainage.
-In severe cases leading to progressive atrophy of the kidney.
- In case of hydroureteronephrosis, there is distention of both the ureter and the renal pelvis and calices.
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HYDRONEPHROTIC NORMAL
•Dilatation of renal pelvis, calyx
•Urine generates no echoes on ultrasounsd since it’s a uniform liquid. It appears as a black (anechoic) area on the ultrasound image.
•The hilum of the kidney appears as a large black area
•LEFT kidney : normalEchogenic renal sinus
UTZ OF PATIENT
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Degrees of Hydronephrosis on Ultrasound
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DEGREE OF HYDRONEPHROSIS IN OUR PATIENT?
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GRADE OF HYDRONEPHROSIS IN OUR PATIENT?
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CT STONOGRAM
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MULTISLICE CT SCAN• Most sensitive radiologic examination for the
detection, localization, and characterization of urinary calcifications
• Faster and no contrast agent is needed • Able to detect radiolucent calculi such as uric acid
stones• Unlike UTZ, CT Scans can image the entire ureter and
differentiate among the various causes of ureteral obstruction
• Can detect stones as small as 3 mm
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MULTISLICE CT SCAN
• Stones in the collecting system may be obscured by contrast material, nonenhanced CT is usually performed
• Patients with stones are often young and because stone disease may recur, minimizing the radiation dose is critical
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Hyperdensecalculus
MULTISLICE CT SCAN
R
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• Hyperdense calculus at the proximal ureter of the right kidney
MULTISLICE CT SCAN
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DEFINITE DIAGNOSIS
Hydronephrosis due to Calcium Nephrolithiasis
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TREATMENT
Goal: To relieve symptoms and prevent further symptoms
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• Large amount of urine• Pain relievers• Medications• Surgery– The stone is too large to pass on its own– The stone is growing– The stone is blocking urine flow and cuasing an
infection or kidney damage
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• Extracorporeal shock-wave lithotripsy – To remove stones slightly smaller than a half an inch that are located near
the kidney– Uses ultrasonic waves or shock waves to break up stones
• Percutaneous nephrolithotomy – For large stones in or near the kidney, or when the kidneys or surrounding
areas are incorrectly formed– The stone is removed with an endoscope that is inserted into the kidney
through a small opening• Ureteroscopy
– For stones in the lower urinary tract• Standard open surgery (nephrolithotomy)
– If other methods do not work or are not possible
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General Advice• Fluid intake
– Drink at least 10 glasses of fluid/day (at least five glasses should be water)– Avoid grapefruit juice and apple juice– Goal is urine output exceeding 2 L/day
• Sodium intake– Restrict to 2 to 3 g/day
• Animal-protein intake– Restrict to 1 g/kg body weight/day
• Oxalate-restricted diet (for hyperoxaluric patients)– Avoid cocoa, beets, spinach, rhubarb, chard, kale, okra, sweet potatoes, endive,
peanuts, chocolate• Low-purine diet (for hyperuricosuric patients)
– Avoid kidney, liver, sweetbreads, herring, salmon, sardines, mussels, scallops– Limit all meat, poultry, seafood, beans, lentils, spinach
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Ethical Issues
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• Informed consent• Non maleficence vs beneficence• Double effect
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Sources:
• Hall, P.M. (2009). Nephrolithiasis: Treatment, causes, and prevention. Cleveland Clinic Journal of Medicine October 2009 vol. 76 10 583-591.
• Liang, B.A. (1999). Management and Prevention of Nephrolithiasis. Hospital Physician February 1999.
• Medline plus http://www.nlm.nih.gov/medlineplus/ency/article/000458.htm
• Emedicine http://emedicine.medscape.com/article/437096-treatment