1 / 48

Approach to a Patient with Unilateral Flank Pain

RADIOLOGY INTERACTIVE CASE 7. Approach to a Patient with Unilateral Flank Pain. Geraldoy , Isabelle Reyna – Go, Marianne Rose Dr. C.O. Cruz and Dr. M.G. Santi FACILITATORS February 18, 2010. GENERAL DATA. D.B. 24 year old Male CC: right flank pain. HISTORY OF PRESENT ILLNESS.

vienna
Download Presentation

Approach to a Patient with Unilateral Flank Pain

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. RADIOLOGY INTERACTIVE CASE 7 Approach to a Patient with Unilateral Flank Pain Geraldoy, Isabelle Reyna – Go, Marianne Rose Dr. C.O. Cruz and Dr. M.G. Santi FACILITATORS February 18, 2010

  2. GENERAL DATA • D.B. • 24 year old • Male • CC: right flank pain

  3. HISTORY OF PRESENT ILLNESS

  4. PHYSICAL EXAMINATION

  5. URINALYSIS Normal Patient Amber colored Acidic RBC 100++/hpf Pus 60-70/hpf Bacteria 1+ Squamous cells- few Amorphous urates- few • Color: • pH: 4.6-6.5 • RBC: 0 • WBC: 0-2/hpf • (-) Bacteria • Squamous cells –few • Amorphous urates normal in acidic urine McPherson & Pincus: Henry's Clinical Diagnosis and Management by Laboratory Methods, 21st ed.

  6. 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

  7. URINARY TRACT OBSTRUCTION: CAUSES Harrison’s Principles of Internal Medicine 17thed

  8. 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 17thed

  9. SIGNS AND SYMPTOMS Unilateral Urinary Tract Obstruction Patient Acute (R) Flank pain Hydronephrosis (R) + kidney punch Hematuria Amber colored urine Bacteria in urine (?) • 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

  10. CLINICAL IMPRESSION Hydronephrosis due to Nephrolithiasis

  11. 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

  12. Source: MacMurry College, Illinois www.mac.edu

  13. 5-10%; Common in women 1%; Hereditary 75-85% 5-10% Radiopaque Radiolucent Source: Harrison’s Principles of Internal Medicine 17thed

  14. Diagnosis and Initial Management of Kidney Stones. American Family Physician . April 1, 2001, Vol. 63. Number 7

  15. Uric Acid Nephrolithiasis Mary Ann Cameron, MD and KhashayarSakhaee, MD

  16. INTRAVENOUS PYELOGRAM

  17. 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

  18. NORMAL IVP 10 minutes • 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.

  19. NORMAL IVP 15 minutes • At 15 minutes – contrast begins to empty into the ureters and travel to the bladder which has now begun to fill.

  20. Normal IVP • It normally takes around 45 minutes to an hour to fill the bladder with contrast.

  21. 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.

  22. IVP of the Patient Prolonged hyperintense right nephrogram 1 minute 5 minutes

  23. IVP of the Patient 15 minutes 40 minutes

  24. IVP OF THE PATIENT • Stasis of the contrast 45 minutes

  25. IVP of the Patient Full bladder Post void

  26. ULTRASOUND OF THE KIDNEY, URETER AND BLADDER

  27. ANATOMY OF THE KIDNEY • The kidneys are retroperitoneal organs that are protected by the lower ribs posteriorly.  • 3 layers: • Outer- fibrous outer cortex • Middle-medulla (pyramids) with surrounding cortex (columns of Bertin) • 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.

  28. Normal findings: • calyx- cup-shaped, acute angle, usually not visible • ureter- usually not visible • 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.

  29. HYDRONEPHROSIS • 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. Specimen of a kidney that has undergone extensive dilation due to hydronephrosis. Note the extensive atrophy and thinning of the renal cortex.

  30. UTZ OF PATIENT • 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 : normal • Echogenic renal sinus HYDRONEPHROTIC NORMAL

  31. Degrees of Hydronephrosis on Ultrasound

  32. DEGREE OF HYDRONEPHROSIS IN OUR PATIENT?

  33. GRADE OF HYDRONEPHROSIS IN OUR PATIENT?

  34. CT STONOGRAM

  35. MULTISLICECT 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

  36. MULTISLICECT 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

  37. MULTISLICECT SCAN R Hyperdense calculus

  38. MULTISLICECT SCAN • Hyperdense calculus at the proximal ureter of the right kidney

  39. DEFINITE DIAGNOSIS Hydronephrosis due to Calcium Nephrolithiasis

  40. TREATMENT Goal: To relieve symptoms and prevent further symptoms

  41. 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

  42. 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 • Percutaneousnephrolithotomy • 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

  43. 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

  44. Ethical Issues

  45. Informed consent • Non maleficencevs beneficence • Double effect

  46. 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 • Emedicinehttp://emedicine.medscape.com/article/437096-treatment

More Related