By Dr Kenneth Orimma Cme, A&e, Dept, Pmh, Nassau Bahamas

By Dr Kenneth Orimma CME, A&E, DEPT, PMH, NASSAU BAHAMAS.

CASE PRESENTATION

63yr old black male from Andros

CHIEF COMPLAINTS  Right flank pain  Mid back pain  Nausea  Vomiting  Decreased appetite  Frequency  Poor urinary stream

HISTORY OF PRESENTING COMPLAINTS  3 days hx of right flank pain  Pain sharp, radiating to groin & mid back  Nausea, vomiting, frequency tremors,

poor stream  Discharged from A&E 2days prior to presentation  Assessed as uncontrolled HTN, renal insuff.  Represented for worsening symptoms

HISTORY CONTINUED PMH: HTN, BPH PSH: Nil of note SH: Nil of note FH: HTN Med Hx: Adalat 10mg Lasix 40mg Zantac 150mg Prednesone 20mg

QUESTIONS

 What do you think  What other information would you

like to know

DIFERENTIAL DIAGNOSIS  Uraemia  Obstructive uropathy  Peri-nephric abscess  Interstitial renal disease

PHYSICAL EXAMINATION VITAL SIGNS:  Temp 97.3  Pulse 90/min  BP

196/115

 Resp. Rate 20

PHYSICAL EXAMINATION ABC: Airway normal Breathing normal Circulation normal GCS 15/15 GEN: Acutely ill-looking Severe painful distress Restless, rolling all over the bed

PHYSICAL EXAMINTION RESP. NAD CVS. NAD ABD. Right flank tenderness Point tenderness over [R] renal angle Kidney not ballotable PR. Enlarged prostate, nodular, firm, non-tender, no blood on glove

PHYSICAL EXAMINATION MSS. NAD CNS.

NAD

QUESTION

What is the Diagnosis

WORKING DIAGNOSIS

 Acute renal failure secondary to

obstructive uropathy  Uncontrolled HTN

INVESTIGATIONS  FBC  U&Es  RBS  ECG  CXR  AXR

TREATMENT  IV baralgin 2.5g stat  IV morphine 5mg  IV maxalon 10mg  Captopril 50mg po stat  No pain relief  Catheterized  Putout 1.5 litres of urine  Pain completely resolved

RESULTS RESULT ON 1ST VISIT-1/04/09

   

WBC Hb HCT PLT

8.3 13.3 36.5 284

      

Na 134 K 5.9 CL 99 BUN 72 Creat. 11.2 Glu. 129 Urinalysis NAD

RESULT ON 2ND VISIT-3/04/09

   

WBC Hb HCT PLT

17.9 12.7 36.1 337

      

Na 131 K 5.7 CL 96 BUN 102 Creat 14.3 Glu 133 Urinalysis NAD

DISPOSITION Medical Consult  Referred to med 2nd  Assessment on review  Acute medical problem as a result of a chronic primary urological problem  Urology to deal with primary pathology Surgical Consult  Referred to surgical 2nd  Advised that should be discharged  To follow up in urology clinic

DISPOSITION Disposition contested  Consultant in-charge informed  Requested that case be referred the surg. 3rd Surgical 3rd review  Assessment ; Renal failure ? Cause  Advised urgent U/S  Monitor urine out-put  IVF

ULTRASOUND REPORT  Both kidneys show pelvicalyceal dilatation  Increased renal parenchymal echotexture  Corticomedullary differentiation maintained  Urinary bladder distended & thick wall  Prostate not visualized  Other organs normal  Impression- hydronephrosis with cystitis

FINAL DISPOSITION

Patient was admitted to urology service

OBSTRUCTIVE UROPATHY INTRODUCTION BACK GROUND  Common cause of renal failure in ER  Diff. pathological process cause this uropathy  Signs & symptoms are mild  Requiring high index of suspicion  Unilateral obstruction cause little or no change in renal function  Bilateral cause marked in renal function

INTRODUCTION PATHOPHYSIOLOGY cont’d  Urine production in adult is about 1.5-2L/day  Produced in the tubular systems & empty into the calyces  Pacemaker in the calyces generate peristaltic forces  This move urine in boluses into the pelvis & further into the bladder

INTRODUCTION PATHOPHYSIOLOGY cont’d  This flow depends on 3 factors

-filtration pressure -peristaltic pressure -2060cm water -hydrostatic pressure -0-10cm water

INTRODUCTION PATHOPHYSIOLOGY cont’d  Acute obstruction at any level increase the hydrostatic pressure  Prolonged obstruction increase hydrostatic pressure well above peristaltic pressure  This high pressure is transmitted to the nephrons resulting in injury & fall in GFR  If obstruction is not relieved, thromboxane A2 & angiotensin 2 are released which decrease RBF and worsen GFR

INTRODUCTION PATHOPHYSIOLOGY cont’d  As RBF progressively falls  Ischaemia & nephron loss results  Obstructive uropathy results in obstructive nephropathy  Kidneys try to maintain excretory function by urine re-absorption called flow back

INTRODUCTION PATHOPHYSIOLOGY cont’d  This compensatory mechanisms are -pyelosinus back flow -pyelovenous back flow -pyelolymphatic back flow  Severity of nephropathy depends on

degree of obstruction & duration

INTRODUCTION PATHOPHYSIOLOGY cont’d  Study by Vaughan & Gillerwater showed direct relationship b/w duration of obstruction & loss of renal function  The study found that complete recovery of RF occurred if obstruction is relieved in 7days  Permanent loss of RF occur if obstruction last greater than 42 days

EPIDERMIOLOGY FREQUENCY  Annual incidence of unilateral obstruction is 1:1000 in the US  Approx. 12% of the population develop calculi before age of 70yrs  Bilateral obstruction is less common with incidence of 1: 10,000 AGE  Renal calculi 3rd decade of life, recurrence rate 50% in 10yrs

EPIDERMIOLOGY SEX  Urolithiasis, male: female ratio is 3:1  Iatrogenic ureteral injury common female RACE  Stones are more common in white population in the US.  Commonest in southeastern parts  diet related

EPIDERMIOLOGY MORTALITY  Related to etiology, degree & duration of obstruction  Localized sequaele eg perinephric abscess  Systemic sequaele eg sepsis  High mortality if untreated

CLINICAL PRESENTATION HISTORY  Abrupt diminution of urine flow  Pain 2’ to stretching of the urinary collecting system  Alteration of patterns of micturition, common with distal obstruction  Acute or chronic renal failure  Consider obstructive uropathy in uremia without previous hx of renal disease

CLINICAL FEATURES HISTORY  Microscopic or gross hematuria is associated with stones, papillary necrosis or tumors  Recurrent UTI; should be investigated for urinary obstruction  Hx of recent gynecological or abdominal surgery  Pediatrics; recurrent UTI, voiding dysfunction eg enuresis

CLINICAL FEATURES HISTORY  Occupational hx important in uropathy  Bladder Ca is seen in factory workers eg

-textile -rubber -leather -paint -oil drilling  Exposure to industrial chemicals -N-benzidine, -Phenacetin -napthyline

CLINICAL FEATURES PHYSICAL EXAMINATION  Signs of dehydration  Peripheral oedema, HTN, CCF  Palpable kidneys  Palpable bladder  Rectal & pelvic exam shows BPH/prostate ca  External urethral exam may show phimosis or meatal stenosis

ETIOLOGY OBSTRUCTIVE UROPATHY IN CHILDREN  Urethral & bladder outlet obstruction -urethral atresia -phimosis -meatal stenosis -posterior urethral valve -calculus -blood clot -neurogenic bladder -ureterocele

OBSTRUCTIVE UROPATHY IN CHILDREN Urethral & bladder outlet obst. cont;’d  Vesicoureteral reflux; more in female  Ureterovesical jxn obstruction/stenosis  Ureterocele  Retroperitoneal tumour  Megaureter as in prune belly syndrome  Ureteropelvic jxn obstruction/stenosis

ETIOLOGY IN ADULTS URETHRAL & BLADDER OUTLET OBSTRUCTION  Phimosis  STD  Trauma  Blood clot  Calculi  BPH  Ca prostate  Ca Bladder  Neurogenic bladder eg DM, spinal Dx, MS

OBSTRUCTIVE UROPATHY IN ADULTS URETERAL OBSTRUCTION cont’d  Vesicoureteral reflux  Calculi  Blood clot  Trauma  Papillary necrosis-D.M, Sickle cell disease

OBSTRUCTIVE UROPATHY IN EXTRA RENAL OBSTRUCTION ADULTS  Pregnant uterus  Aortic aneurysm  Ca ureter,ca colon, ca prostate, ca bladder  Tuberculosis  Sarcoidosis  Petroperitoneal lymphoma  Surgical ligation  Fibroids

OBSTRUCTIVE UROPATHY INTRARENAL OBSTRUCTION  Crystal formation -Sulfonamide -acyclovir  Protein casts -multiple myeloma -amyloidosis

INVESTIGATIONS IVU  Goal standard for evaluating urinary system  Highly sensitive & specific  Demonstrates structure & function PLAIN RADIOGRAPHY  Poor sensitivity & specificity  Levine et al reported 45% sensitivity for detecting ureteral calculi

INVESTIGATIONS ULTRASOUND  Detects renal calculi but poor at detecting ureteral calculi  Use limited to pregnant females  Doppler sonography: measures resistive index in renal arteries as an indirect assessment of obstruction  Doppler also shows magnitude of ureteral jet

INVESTIGATIONS CT SCAN  Unenhanced helical CT has 95-98% sensitivity & 96-100% specificity for ureteral stone  Detects both calcified & noncalcified

stones, shows their size & location

INVESTIGATION NUCLEAR MEDICINE  Radionucleotide is injected in a vein  Passage through urinary tract is

monitored by gamma camera  Demonstrates anatomy as well as function  Technique of choice is diuresis renography  Limitation- not performed in acute setting

MANAGEMENT OF OBSTRUCTIVE UROPATHY  Treatment of post renal or

obstructive ARF is urgent relief of obstruction  full renal recovery is said to be possible after 1-2 weeks of total obstruction in absence of infection  serum creatinine level may not return to baseline for several weeks

THANK YOU

REFERENCES  Allan BW. Renal failure, Rosen’s Emergency

medicine; concepts & clinical practice 6th edition P1524-1555  Andrew Krentz, Oxford handbook of clinical

and laboratory investigation. P423-458  Samuel KM Emergency medicine on-call.

Lange publishers P414-416

REFERENCES  Richard L Degown. Diagnostic

examination McGraw Hill Publishers P618-619  Sameet Rao. Acute obstructive

uropathy, emedicine Radiology  Michael Policastro etal; emedicine

Emergency medicine