血尿1041015 by 王涵恩.ppt [相容模式] · IVU, cystoscopy, urine cytology Additional testing...
Transcript of 血尿1041015 by 王涵恩.ppt [相容模式] · IVU, cystoscopy, urine cytology Additional testing...
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血 尿
腎臟內科 許育瑞醫師/ 吳坤霖醫師102年04月15日 第四版王涵恩醫師1041015
核心課程編號: B33
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學習目標
PGY UGY1. 能對血尿患者作出初步處理。2. 在未確定病因前能與血尿患者合宜地說
明診療計畫。3. 能對幾個引起血尿的常見疾病或狀況作
出合宜的處理。4. 在確定病因後能與血尿患者合宜地說明
診療計畫和預後。
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ITE考題
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血尿-定義
• presence of blood in the urine• > 3 RBCs/HPF is significant• considered > 5 RBCs/HPF to be evidence of significant microscopic hematuria•9% - 18% of normal individuals have some degree of hematuria
JM Sutto. JAMA 263 (1990), p2475–80JB Copley. Am J Med Sci 291 (1986), p101-11 AJ Mariani et al. J Urol 141 (1989), p350-355DN Mohr. JAMA 256 (1986), p224-229
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血尿-病理生理學
Normal unspun urine (
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血尿-分類與特性
History Taking
gross / microscopictiming of hematuria: initial, total, terminalassociation with pain: painful, painlesspresence of clots, shape of clots
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Hematuria
Nephrologic hematuria (glomerular disease): dysmorphic RBC, RBC casts, proteinuria Urologic hematuria (tubulointerstitial or
renovascular renal disease): uniformly round shape RBCSystemic disorders
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Nephrologic (glomerular disease)
20% will have hematuria alone without proteinuria or RBC casts Lab: Cr, CCr, daily protein loss Frequently, renal biopsy for precise
diagnosis is necessary
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Nephrologic(glomerular disease)
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Nephrologic(glomerular disease)
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Urologic (nonglomerular hematuria)
Hematuria of any degree should never be ignored Should be regarded as a symptom of
urologic malignancy until proved otherwiseThe most common cause of gross
hematuria in a patient older than age 50 years is bladder cancer.
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Urologic(nonglomerular hematuria)Urologic:
1.Tumor2.Stone3.BPH4.UTI
Medication: anticoagulantHematologic disorderExercise-inducedVascular disease
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血尿-理學檢查
hypertensiongeneralized edemapalpable abdominal or flank massflank tendernessflank laceration, contusion, rib fractureDRE
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血尿-實驗室檢查
Urinary analysis (color, sp.gr, protein, leukocyte, nitrite, RBC casts, crystal)
Urine cultureUrine cytology: high-grade urothelial carcinomaRenal function test (BUN/Cr)CBCCoagulation profile/bleeding studyOthers: serum IgA, ANA, urine TB culture
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血尿-影像檢查
KUBUltrasoundExcretory urography (IVU)RPCT or MRINuclear renal scansCystographyarteriography
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KUB
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Chen DL, Tsai DJ, Diagnostic Approach and Management of Hematuria Journal of Internal Medicine of Taiwan 2002
接下頁
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Chen DL, Tsai DJ, Diagnostic Approach and Management of Hematuria Journal of Internal Medicine of Taiwan 2002
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IVU + PV
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Kidney: collecting system
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IVU + RP
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5min: the pyelogram 7 min0 min:KUB
post-voiding film
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Ureter
Length: 25-30 cmCaliber: 5 mm3 Parts: Lumbar ureter Iliac ureterPelvic ureter: max 1
cm medial to bone margin
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Ureter: filling defects
1. Normal2. Vessel: band-like defect
3. Tumor: Burgman's sign
4. Radiolucent stone
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Renal Tumor
Vascular massCalcifications: also
seen in some benign disease
Tumor shell: thick wall
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Bladder filling defects
GasStoneTumorProstateOthers
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RCC
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TCC of ureter
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TCC of bladder
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血尿-特殊檢查
CystourethroscopyRPUreteroscopy (URS)Renal biopsy
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UCa (TCC)
Urothelical carcinoma of the renal pelvis: a retrograde pyelogram demonstrates an ill-defined lobulated filling defect involving the upper-pole infundibulum and calyces.
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BPH
The upward displacement of intramural ureter: fish-hook sign
prostate indentation
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血尿-處置
Surgical: Urologic tumorsStonesBPH
Nonglomerular hematuria
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血尿-處置The “standard” urologic evaluation of hematuria:
IVU, cystoscopy, urine cytologyAdditional testing based on clinical findingsAlways consider “medical” causes of hematuria
based on presentation, lab data, or if evaluation for anatomic lesion is negative
Gross hematuria – usually requires urgent evaluation to prevent / treat clot retention
HydrationManage underlying problems