Apostematous pyelonephritis: causes, symptoms, diagnosis, treatment

This disease is one of the stages of development of acute pyelonephritis. With apostematous pyelonephritis, inflammatory processes occur, in which multiple purulent small abscesses (apostems) are formed. The main place of their localization is the kidney cortex.

Primary form

Most often, apostematous pyelonephritis begins to develop with obstructions of the ureter, less often - with undisturbed urinary outflow.

In the kidney, small pustules are formed in the following way: microorganisms settle into the capillary loops of the glomeruli, microorganisms settle in the terminal vessels of the kidney and into the peritubular capillaries. At the same time, bacterial thrombi form, and then they serve as a source of pustules. They are located on the surface of the bark of the kidneys, as well as under the fibrous capsule in large quantities. When examined, they are clearly visible. Apostems have a yellowish color, the size is up to 2 mm, can be arranged in groups or singly.

With apostematous pyelonephritis, the kidney increases in size, has a cherry color. Peripheral cellulose has swelling, a thickening of the fibrous capsule occurs. On a cut of a kidney pustules are visible, it is possible to find out them and in a medial layer.

Apostematous pyelonephritis, carbuncle and kidney abscess

The second form of the disease is the kidney carbuncle. There is a purulent necrotic organ damage, an abscess of the kidney. In the cortex, foci of necrosis are formed. Carbuncle can occur with hematogenous pathways of infection. In such cases, the causes of apostematous pyelonephritis are pustular diseases, carbuncle, furunculosis, mastitis, panaritium. The mechanism of carbuncle formation is as follows:

• Bacterial thrombus enters the renal artery from a distant focus of pus, so there is a carbuncle in one of the blood supply zones of the arterial branch or in smaller arterial branches.

• Carbuncle can develop by squeezing a large intrarenal vessel with an inflammatory infiltrate or because of contact with a focus of inflammation in the vessel wall.

The most common development of carbuncle is caused by microorganisms such as white and golden staphylococcus, Proteus and E. coli.

On the incision of the kidney, the carbuncle is seen as a rounded form of bulging out of necrotic tissue, it is permeated by merged small pustules that wedge outward into the parenchyma.

Acute apostematous pyelonephritis most often combines kidney carbuncle and apostematous pyelonephritis. In clinical manifestations, there is not much difference.

Clinical picture of apostematous pyelonephritis

Symptoms of apostematous pyelonephritis and carbuncle depend on how much the urine outflow is disturbed from the kidney.

Most often, the primary form of pyelonephritis occurs suddenly, usually after an intercurrent infection. There is a chill, a high fever (up to 40 degrees), a pouring sweat. The hectic nature of fever predominates (the rise in temperature is replaced by a fall). A tremendous chill can last up to one hour, often occurs at the peak of fever. After chills with a drop in temperature, a profuse sweating begins. These symptoms during the first three days may be poorly expressed.

Then the pain in the lower back begins to increase. At palpation kidneys are obviously morbid, probably increase. Changes in the urine occur on the fifth day, bacteriuria, proteinuria, and leukocyturia appear.

The blood picture is characterized by leukocytosis, granularity in leukocytes, an increase in ESR, anemia.

With a progressive process, sepsis may develop, which has metastatic foci of purulent inflammation in the liver, lungs, and the brain.

Clinic of kidney carbuncle

If the outflow of urine is not disturbed in the kidney, where the carbuncle develops, the clinical picture is similar to the acute infectious process. The temperature rises to 40 degrees, characterized by tremendous chills and torrential perspiration. There is a growing weakness, breathing becomes more frequent, nausea and vomiting, tachycardia occur.

In the early days there is often no pain in the lower back, no bacteriuria, leukocyturia, dysuric disorders. Diagnosis is difficult. Patients can get to treatment in therapeutic, infectious, surgical departments. The doctor mistakenly can diagnose pneumonia, acute cholecystitis, typhoid fever and the like. Only a few days later, when local symptoms begin to appear (pain in the lower back, a symptom of Pasternatsky, tenderness in palpation), the doctor concentrates on the kidneys.

Apostematous pyelonephritis, diagnosis

Diagnosis of the disease is based on the following indicators:

• Febrile period lasts more than three days;
• Enlarged painful kidney during palpation;
• Laboratory tests: bacteriuria, leukocyturia, in the blood - left shift of the leukocyte formula, leukocytosis, C-reactive protein, increased ESR;
• Excretory urogram - decreased kidney function, increase from the affected side;
• Ultrasound - restriction of mobility, increase in the size of organs, thickening of more than 2 cm of the parenchyma, its heterogeneous density; Fluid in the paranephric space, the cup-and-pelvic system with ureteral obstruction expands;
• MSCT, MRI, RKT - an increase in the size of the kidney, a thickening of the parenchyma, its heterogeneity, manifestations of foci of purulent disruption;
• Dynamic and static nephroscintigraphy - an increase in the size of the kidneys, in the parenchyma, the unequal accumulation of the isotope.

Purulent tissue is more clearly defined in carbuncles. On ultrasound in the parenchyma foci of increased density are clearly visible, as well as their mixed structure. This picture is clearly visible on MRI, RKT. Spiral CT with increased contrast makes it possible to see disturbances in the arrival of contrast in the foci of necrosis.

Difficulties in assessing

Difficulties in assessing the patient's condition can arise if, prior to admission to urology, the patient underwent antibiotic therapy with modern antibiotics for one to two weeks. Such treatment can smooth manifestations of apostematous pyelonephritis, however, cardinal improvement of the condition does not occur. The body temperature decreases, the pain syndrome decreases, there are rarely chills, their character is less pronounced and prolonged. In the blood, the number of leukocytes decreases, but the shift to the left of the leukocyte formula is still preserved, as is anemia and increased ESR. In other words, the disease manifests itself as a sluggish sepsis. This "improvement" is the cause of the wrong patient management. To prevent the development of severe sepsis, if there is a focus of destruction in the kidney, the patient must be operated.

Differential diagnostics

In detecting apostematous pyelonephritis, it is necessary to differentiate this disease from other infectious diseases. With acute pancreatitis and cholecystitis, with subdiaphragmatic abscess, acute appendicitis, acute cholangitis, acute adnexitis and acute pleurisy.

Kurbunkul buds differentiate from a simple festering kidney cyst, with a parenchyma tumor, with acute diseases of the abdominal cavity.

What makes it possible to distinguish between apostomatous pyelonephritis and carbuncle of the kidney?

• Leukocyturia. Bacteriuria.
• Pain in the lower back.
• Impaired renal function.
• Thickening of the parenchyma. Changes in its density.
• Painful palpation with enlarged kidney.
• Expansion of the cup-and-pelvis system.

The data of ultrasound, MRI, RKT make it possible to distinguish apostematous pyelonephritis from various acute diseases of the peritoneum.

Treatment

Treatment of apostematous pyelonephritis and carbuncle is carried out exclusively surgically. Most often, the operation is performed in an emergency. Preliminary short-term preoperative preparation with the participation of anesthesiologist-resuscitator lasts no more than two hours. The training includes:

• Catheterization of the pelvis, intravenous antibiotic.
• Transfusion of glucose and electrolytes.
• Stabilization of blood pressure.
• According to the testimony - cardiotonic.

The main goal of the operation is to prevent sepsis. Salvation of life.

The secondary goal is to save the kidney.

Endotracheal anesthesia is used for anesthesia.

During the operation, the contents of the abscesses and pelvis are collected, in order to make a culture for the determination of microflora for the further determination of sensitivity to antibiotics. The results will confirm purulent pyelonephritis, as well as determine further treatment tactics.

Postoperative period

After the operation, the patient receives treatment in view of oppression of kidney function and intokikatsii. The patient is assigned:

• 10% glucose solution - 500 ml, with 10 units of insulin intravenously;
• Solution of 9% sodium chloride - 1000 ml;
• Hemodez - 400 ml;
• Kokarboksilaza - up to 200 mg;
• Vitamin B6 - up to 2 ml;
• Vitamin C - up to 500 mg;
• 0.06% to 1.0 ml solution of Korglikon;
• A solution of mannitol 15% to 50 ml;
• Lasix to 60 mg;
• Freshly frozen (native) plasma - 250 ml;
• Cexane or fragin, given the coagulogram indices;
• Erythrocyte mass in anemia (Hb less than 70).

When purulent intoxication is used extracorporeal detoxification (plasmapheresis, hemosorption, plasmasorption).

Antibiotic therapy with two antibiotics of the widest range of effects is mandatory.

In assessing the condition of the parenchyma, the most modern methods (MRI, RVT, ultrasound) are used. This makes it possible to correctly assess the situation and choose the most appropriate volumes of the operation.