Hematuri IPD 2014(1)
-
Upload
arlannasution05 -
Category
Documents
-
view
219 -
download
0
Transcript of Hematuri IPD 2014(1)
-
8/10/2019 Hematuri IPD 2014(1)
1/36
HEMATURIABASIC COURSE OF DIAGNOSIS
CHOLINA TRISA SIREGAR
DEPARTEMEN KMB 2014
-
8/10/2019 Hematuri IPD 2014(1)
2/36
DEFINITION
- Darah yang ditemukan dlaam urin baik
mikroskopok maupun makroskopik.
- > 3 RBC/HP
Normal urine:
- Tidak ditemukan sel darah merah atau kurang
dari tiga sel darah merah yang.
-
8/10/2019 Hematuri IPD 2014(1)
3/36
According to the amount of RBC in the
urine, hematuria can be classified as:
microscopic hematuria:
normal colour with eyes
gross hematuria (macroscopic):
tea-colored, cola-colored, pink oreven red
-
8/10/2019 Hematuri IPD 2014(1)
4/36
HAEMATURIA
Macroscopic tejadi bila sedikitnya 1cc darah/liter urin.
Microscopic > 5 RBCs per high powered field Red urine
-
8/10/2019 Hematuri IPD 2014(1)
5/36
Causes of heme-negative red urine
Medications Food dyes Metabolities
Doxorubicin Beets (in selected patients) Bile pigments
Chloroquine Blackberries Homogentisic acid
Deferoxamine Food coloring Melanin
Ibuprofen Methemoglobin
Iron sorbitol Porphyrin
Nitrofurantoin Tyrosinosis
Phenazopyridine Urates
PhenolphthaleinRifampin
-
8/10/2019 Hematuri IPD 2014(1)
6/36
Haematuria
-
8/10/2019 Hematuri IPD 2014(1)
7/36
etiologi
A patients history of kidney or bladder
stones, urinary infection, or bladder tumors
may indicate that the problem has returnedand is the source of the bleeding. In some
cases, certain medicines, such as
anticoagulants that thin the blood or aspirin,can cause bleeding either from an
underlying medical condition or from the
upper or lower urinary tract.
-
8/10/2019 Hematuri IPD 2014(1)
8/36
ETIOLOGY
Diseases of the urinary systemthe mostcommon cause
Vascular
arteriovenous malformationarterial emboli or thrombosis
arteriovenous fistular
nutcracker syndrome
renal vein thrombosisloin-pain hematuria syndrom
cogulation abnormality
excessive anticogulation
-
8/10/2019 Hematuri IPD 2014(1)
9/36
kidney disease
abnormal blood coagulation
sickle cell disease
infection kidney stones
obstruction, blockage or injury of the
kidney or ureter
-
8/10/2019 Hematuri IPD 2014(1)
10/36
Glomerular
IgA nehropathy
thin basement membrane disease (incl.Alport syndrome)
other causes of primary and secondary glomerulonephritis
Interstitial
allergic interstitial nephritis
analgesic nephropathy
renal cystic diseasesacute pyelonephritis
tuberculosis
renal allograft rejection
-
8/10/2019 Hematuri IPD 2014(1)
11/36
Uroepithelium
malignancy
vigorous excise
trauma
papillary necrosis
cystitis/urethritis/prostatitis(usually caused by infection)parasitic diseases (e.g. schistosomiasis)
nephrolithiasis or bladder calculi
Mul tiple sites or source unknown
hypercalciuria
hyperuricosuria
-
8/10/2019 Hematuri IPD 2014(1)
12/36
System disorders
a. Hematological disorders
aplastic anemia leukemiaallergic purpura hemophilia
ITP (idiopathy thrombocytopenic purpura)
b. I nfection
infective endocarditis
septicemia
epidemic hemorrhagic fever (Hantaan virus)
scarlet fever (-hemolytic streptococcus)
leptospirosis (leptospire)
filariasis (Wuchereria bancrofti, Brugia malayi)
-
8/10/2019 Hematuri IPD 2014(1)
13/36
c. Connective tissue diseases
systemic lupus erythematosus (SLE)
polyarteritis nodosa
d. Cariovascular diseases
hypertensive nephropathychronic heart failure
renal artery sclerosis
e. Endocrine and metabol ism diseasesgout
diabetes mellitus
-
8/10/2019 Hematuri IPD 2014(1)
14/36
Diseases of adjacent organs to urinary tract
appendicitis salpingitiscarcinoma of the rectum
carcinoma of the colon
uterocervical cancer
Drug and chemical agents
sulfanilamides anticogulation
cyclophosphamide mannitol
miscellaneous
exercise idopathic hematuria
-
8/10/2019 Hematuri IPD 2014(1)
15/36
CLINICAL FEATURE
Color
depends on the amount of red blood cell
in the urine and the pH
normal: l ight yel low, pH 6.5
pH
acidic: more darker (brown or black)
alkaline: red
-
8/10/2019 Hematuri IPD 2014(1)
16/36
DIFFERENTIAL DIAGNOSIS
Polluted urine: menstruation
Drug and food: phenosulfonphtha lein (PSP),uric
acid, vegetable
Porphyrism: porphyrin in urine (+)
Hemoglobinuria
hemolysissoy-like, very few RBC under the microscopy
occult blood test (+)
-
8/10/2019 Hematuri IPD 2014(1)
17/36
Hematuria
Patient comes to your office complaining
that their urine is reddish in color...
What is your first step?
Good H+P
-
8/10/2019 Hematuri IPD 2014(1)
18/36
Hematuria
Is it really blood?
Urine Dipstick
Detects Hgb, myoglobin
Detects protein
-
8/10/2019 Hematuri IPD 2014(1)
19/36
Hematuria
Urinalysis
Definitive for the presence of RBC
-
8/10/2019 Hematuri IPD 2014(1)
20/36
Hematuria
Upper urinary tract glomerulus
collecting tubules
interstitium
Lower urinary tract calyx
pelvis
ureter
bladder
urethra
-
8/10/2019 Hematuri IPD 2014(1)
21/36
Differential Diagnosis
glomerular*prompt eval for kidney dz
with
proteinuria
extraglomerular
without
proteinuria
+ RBCs
Hgbmyoglobin
heme +
drugsdyes
heme -
- RBCs
Macroscopic Hematuria
obtain U/A
-
8/10/2019 Hematuri IPD 2014(1)
22/36
Glomerular Hematuria
brown, tea colored urine
proteinuria
deformed urinary RBCs
RBC casts
-
8/10/2019 Hematuri IPD 2014(1)
23/36
Glomerular Hematuria
RENAL
IgA nephropathy
Alport syndrome Thin glomerular BM disease
Post infectious
MPGN
MULTI-SYSTEM
SLE nephritis
HSP nephritis Wegener syndrome
Goodpasture syndrome
HUS
Sickle cell Disease
-
8/10/2019 Hematuri IPD 2014(1)
24/36
Extraglomerular Hematuria
Hematuria from lower urinary tract
terminal hematuria
blood clots
nl urinary RBCs
minimal proteinuria
-
8/10/2019 Hematuri IPD 2014(1)
25/36
Extraglomerular Hematuria
UPPER URINARY TRACT
pyelonephritis
ATN
papillary necrosis
nephrocalcinosis
thrombosis
malformation
SCD tumor
PCKD
LOWER URINARY TRACT
cystitis
urethritis
urolithiasis
trauma
coagulopathy
heavy excersise
UPJ obstruction ureterocele
Munchausen, MBP
-
8/10/2019 Hematuri IPD 2014(1)
26/36
LABORATORY TESTS
Three-glass test
Method:collecting the three stages of urine of
a patient during micturition
Result:
the initial specimen containing RBCthe urethra
the last specimen containing RBCthe bladder
neck and trianglar area, posturethra
all the specimens containing RBCupper urinary
tract, bladder
-
8/10/2019 Hematuri IPD 2014(1)
27/36
Phase-contrast microscopy
to distinguish glomerular from post glomerular
bleeding
post glomerular bleeding:normal size and shape
of RBC
glomerular bleeding:dysmorphic RBC(acanthocyte)
-
8/10/2019 Hematuri IPD 2014(1)
28/36
EXAMPLE OF PHASE-CONTRAST
MICROSCOPY TEST (non-glomerlar)
RBC MCV: 92.8 um3
-
8/10/2019 Hematuri IPD 2014(1)
29/36
-
8/10/2019 Hematuri IPD 2014(1)
30/36
EXAMPLE OF PHASE-CONTRAST
MICROSCOPY TEST (glomerlar)
-
8/10/2019 Hematuri IPD 2014(1)
31/36
-
8/10/2019 Hematuri IPD 2014(1)
32/36
ACCOMPANIED SYMPTOMS
Hematuria with renal colic
renal stone, ureter stone
if with dysuria, miction pause or staining to void: bladder
or urethra stone
Hematuria with urinary frequency,urgency and
dysuria
bladder or lower urinary tract (tuberculosis or tumor)
if accompanied by high spiking fever, chill and loin pain:
pyelonephritis
-
8/10/2019 Hematuri IPD 2014(1)
33/36
Hematuria with edema and hypertension
glomerulonephritis
hypertensive nephropathy
Hematuria with mass in the kidney
neoplasm
hereditary polycystic kidney Hematuria with hemorrhage in skin and
mucosa
hematological disorders
infectious diseases
Hematuria with chyluria
filariasis
-
8/10/2019 Hematuri IPD 2014(1)
34/36
Pasienbaru dgn hematuri mikroskopik asimtomatik
Singkirkan: menstruasi, olah raga over, sex activity, infeksi virus,
infeksi bakteri,trauma
Bila ditemuka 1 /lebih:Hematuri mikroskopik+proteinuria **,
Eritrosit, silinder eritrosit,
peningkatan kreatinin
Evaluasi penyakit ginjal perifer
Ada riwayat : merokok, bekerja dgnbahan kimia,
riwayat gross hematuri
- Usia > 40 tahun- gangguan penyakit urologi
- gangguan pengosongan blader
- ISK berulang
Evaluasi urologi
-
8/10/2019 Hematuri IPD 2014(1)
35/36
Physical Examination Findings and Associated
Causes of Hematuria
Physical examination finding Cause of hematuria
General (systemic) examination
Severe dehydration Renal vein thrombosis
Peripheral edema Nephrotic syndrome, vasculitis
Cardiovascular system
Myocardial infarction Renal artery embolus or thrombusAtrial fibrillation Renal artery embolus or thrombus
Hypertension Glomerulosclerosis with or without
proteinuria
Abdomen
Bruit Arteriovenous fistula
Genitourinary system
Enlarged prostate Urinary tract infection
Phimosis Urinary tract infection
Meatal stenosis Urinary tract infection
-
8/10/2019 Hematuri IPD 2014(1)
36/36