Approach to a Patient with Unilateral Flank Pain

Geraldoy, Isabelle Reyna – Go, Marianne RoseDr. C.O. Cruz and Dr. M.G. Santi

FACILITATORSFebruary 18, 2010

RADIOLOGY INTERACTIVE CASE 7

GENERAL DATA

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

HISTORY OF PRESENT ILLNESS3

wee

ks P

TCSudden onset of right flank pain(-) hematuria(-) dysuria

1 da

y PT

CPersistence prompted consult at OPDUrinalysis: hematuriaUTZ: hydronephrosis

Cons

ultPhysical

ExaminationUrinalysisIVP, KUB, CT Stonogram

PHYSICAL EXAMINATION

Supple neck, no palpable cervical

lymph nodes

Symmetrical chest expansion, no

retractions, clear breath sounds

Adynamic precordium, AB 5th

LICS MCL, no murmurs

Flabby abdomen, normoactive bowel sounds, (+) kidney

punch, right

Pulse were full and equal

URINALYSIS

Normal• Color: • pH: 4.6-6.5• RBC: 0• WBC: 0-2/hpf• (-) Bacteria• Squamous cells –few• Amorphous urates normal

in acidic urine

Patient• Amber colored• Acidic• RBC 100++/hpf• Pus 60-70/hpf• Bacteria 1+• Squamous cells- few• Amorphous urates- few

McPherson & Pincus: Henry's Clinical Diagnosis and Management by Laboratory Methods, 21st ed.

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

URINARY TRACT OBSTRUCTION: CAUSES

Congenital

• Ureteropelvic or ureterovesical junction narrowing or obstruction

• Bladder neck obstruction, ureterocoele

• Posterior or anterior urethral valves

• Stricture• Meatal stenosis• Phimosis

Intrinsic Mechanical Blockade

• Calculi• Inflammation• Infection• Trauma• Sloughed papillare

from ureter• Tumor • Blood clots• Uric acid crystals• Stricture• Cancer of prostate,

bladder• Spinal cord disease• BPH

Extrinsic Mechanical Blockade

• Pregnant uterus• Retroperitoneal

fibrosis• Aortic aneurysm• Carcinoma of cervix,

colon, uterus, prostate, bladder, rectum

• Trauma

Harrison’s Principles of Internal Medicine 17th ed

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 17th ed

SIGNS AND SYMPTOMSUnilateral Urinary Tract Obstruction• 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

Patient• Acute (R) Flank pain

• Hydronephrosis (R)• + kidney punch

• Hematuria• Amber colored urine• Bacteria in urine (?)

CLINICAL IMPRESSION

Hydronephrosis due to Nephrolithiasis

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

Source: MacMurry College, Illinoiswww.mac.edu

Nephrolithiasis

Calcium stones

Uric acid stones

Struvite Stones

Cystine Stones

5-10%;Common in women

1%;Hereditary75-85% 5-10%

Source: Harrison’s Principles of Internal Medicine 17th ed

Radiopaque Radiolucent

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

Uric Acid NephrolithiasisMary Ann Cameron, MD and Khashayar Sakhaee, MD

INTRAVENOUS PYELOGRAM

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

NORMAL IVP

• 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.

10 minutes

NORMAL IVP

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

15 minutes

Normal IVP

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

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.

IVP of the Patient

1 minute 5 minutes

Prolonged hyperintense right nephrogram

IVP of the Patient

15 minutes 40 minutes

IVP OF THE PATIENT

• Stasis of the contrast

45 minutes

IVP of the Patient

Full bladder Post void

ULTRASOUND OF THE KIDNEY, URETER AND BLADDER

ANATOMY OF THE KIDNEY-The kidneys are retroperitoneal organs that are protected by the lower ribs posteriorly. - 3 layers: 1. Outer- fibrous outer cortex2. Middle-medulla (pyramids) with

surrounding cortex (columns of Bertin)

3. 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.

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.

-Normal findings:- calyx- cup-shaped, acute

angle, usually not visible- ureter- usually not visible

HYDRONEPHROSIS

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

-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.

HYDRONEPHROTIC NORMAL

•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 : normalEchogenic renal sinus

UTZ OF PATIENT

Degrees of Hydronephrosis on Ultrasound

DEGREE OF HYDRONEPHROSIS IN OUR PATIENT?

GRADE OF HYDRONEPHROSIS IN OUR PATIENT?

CT STONOGRAM

MULTISLICE CT 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

MULTISLICE CT 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

Hyperdensecalculus

MULTISLICE CT SCAN

R

• Hyperdense calculus at the proximal ureter of the right kidney

MULTISLICE CT SCAN

DEFINITE DIAGNOSIS

Hydronephrosis due to Calcium Nephrolithiasis

TREATMENT

Goal: To relieve symptoms and prevent further symptoms

• 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

• 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

• Percutaneous nephrolithotomy – 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

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

Ethical Issues

• Informed consent• Non maleficence vs beneficence• Double effect

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

• Emedicine http://emedicine.medscape.com/article/437096-treatment