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Kidney infection:

الكلية كلية الطب     القسم  الجراحة     المرحلة 4
أستاذ المادة محمد رضا جودي عبود جلو       17/12/2015 18:06:25

Acute pyelonephritis:
Example:
30 years women present with rt. flank pain associated with high temp. (39.c) with frequency dysuria urgency O/E rt. renal angle tenderness , GUE show pyuria ?

Inflammation of kidney parenchyma and renal pelvis the diagnosis usually clinically.

Presentation and finding:
chills ,fever
lower urinary tract symptoms(dysuria frequency urgency)
loin pain (cost vertebral angle tenderness).

dx.:
GUE: wbc ,RBC.
Leukocytosis ,increase ESR,
C-reactive protein elevation
Urine C/S:E. Coli ,klebsiella, proteus, enterobactcter, pseudomonas…..
Or gram positive :: streptococcus facalis S. aureus


Increase risk in reproductive women , sexually active , D.M, urinary incontinence.


Radiological DX.:
Contrast enhanced computed tomography( CT) scan is the best for diagnosis, it is not always indicated unless the diagnosis unclear or the patient not responding to therapy.
Radionuclide study sensitive
U/S is important to rule out concurrent urinary tract obstruction but not reliable for diagnosis of infection.


MANAGEMENT:
Depend on the severity:
In patients who have toxicity because of associated septicemia (which is the most important serious complication): hospitalization is indicated with empiric therapy is indicated with parenteral (ampicillin and aminoglygoside is effective( other alternative : amoxicillin with clavulanic acid or third generation cephalosporin can be used).
Fever may persist for several days despite antibiotic. So a parenteral therapy should be maintained until the patient defervesces.. parenteral treatment may for 7-10 days . then change for oral treatment for 10-14 days.

In not severely ill: outpatient treatment with oral anti biotic is appropriate(flouroqinolons or TMP-SMX) therapy should continue for
10-14 day.



Emphysematous pyelonephritis:
Example :
Diabetic female with lt. side loin pain ,high temp.(39.5) with chills . history of renal colic on the same side 2 weeks ago . no lower urinary tract symptom. O/E: tender kidney?

Is a necrotizing infection characterized by the presence of gas within the renal parenchyma or perinephric tissue. Associated with DM or urinary tract obstruction.
Presentation:
Fever flank pain vomiting , pneumturia
Cause: E.coli, klebsiella pneumonia and enterobacter cloacae.

Dx:
Radiologic examination (gas overlying the affected kidney
CT more sensitive.
Management:
Control of blood sugar
Relief urinary obstruction
Fluid resuscitation
Parentral antibiotics
Drainage by PCN
Nephrectomy





Chronic pyelonephritis:
Ex.:
Young male discovered accidently by routine U/S that one of his kidneys is smaller than normal with scarring , and his family gave a history of recurrent lower urinary tract infection in early childhood.

Result from repeated renal infection which leads to scarring, atrophy and subsequent renal insufficiency. So it is radiological entity rather than clinical entity.

Presentation:
Asymptomatic, but history of frequent UTI,( in children there is a strong relation between renal scarring and recurrent UTI.
Scarring rarely seen in adult kidney unless associated with obstruction
Complication due to renal insufficiency as hypertension ,head aches visual disturbance, fatigue, polyuria.
Dx:
Radiological investigation (U/S, EU….).
GUE: protein urea leukocytes.
Serum level of creatinine may reflect the severity of renal impairment
CT scan , radio isotopes scan study.


Management:
it is limited because renal damage incurred by chronic pyelonephritis is not reversible.
Eliminating the UTI
Identifying and correcting underlying anatomic or functional problem .
Long term prophylactic antibiotics. Nephrectomy.


Renal abscesses:
Sever infection that lead to liquefaction of renal tissue forming an abscess.

Perinephric abscesses:
when renal abscess rapture to perinepric space.
Paranephric abscesses:
when extend beyond gerotas fascia.

Result from hematogenous spread.
Staphylococcus, E.coli, proteus.

Presentation:
Fever , flank or abdominal pain, chill , dysuria may takes 2 week to diagnose.
May flank mass.

GUE: WBC.
Urine C/S : positive .
Blood C/S.

Dx :U/S, CT scan,
Excretory urography is less sensitive.

TREATMENT:
Antibiotics empiric therapy (ampicillin or vancomycin in combination with aminoglycoside or third generation cephalosporin.
PCN
Open drainage or nephrectomy.


Pyonephrosis:

it is bacterial infection of hydronephrotic , obstructed kidney which lead to suppurative destruction of the renal parenchyma and potential loss of renal function.
Presentation :
Fever , chills,
Flank pain
Lower tract symptom usually not present.
Bacteruria or pyuria my not present when there is complete obstruction of the affected kidney.

Dx:
U/S is sensitive also to see if there is a stone.

Management :
Immediate institution of antibiotics therapy and drainage of infected collecting system.
Usually use broad spectrum antibiotics,
Drainage : by using Dobell J stent if the patient not toxic.
If the patient is tired : PCN or open nephrostomy
Other Additional evaluation is needed to evaluate if any cause for urinary obstruction to be treated accordingly.


المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .