Apostematozny pyelonephritis – the acute pyoinflammatory disease which is characterized by formation of multiple abscesses in a parenchyma (brain substance) of one or both kidneys. Symptoms are sharp temperature increase, a fever, pain in lumbar area, displays of the general intoxication (a headache, nausea, vomiting), a rigidnost of muscles of a stomach. Diagnostics is made on the basis of the general analysis of urine, a bacteriological research of an uric deposit, ultrasonography, a X-ray analysis, a magnetic and resonant tomography of kidneys. Treatment comes down to the emergency surgical intervention for elimination of the purulent centers and drainage, at severe forms the nefrektomiya is shown.
Apostematozny pyelonephritis is usually considered as one of severe forms of sharp purulent pyelonephritis. Some authors consider it a complication of this disease. The interrelation of pathology with other form of pyoinflammatory defeat of eliminative organs – a kidney anthrax is observed. There is an opinion that states "purulent pyelonephritis – an apostematozny inflammation – an anthrax – kidney abscess" are consecutive stages of the same pathological process. Exact prevalence is unknown, it is supposed that the disease arises in 5-12% of cases of sharp pyelonephritis. At overdue diagnostics and a late initiation of treatment the risk of development of pathology increases. At children's, young and mature age of the woman suffer several times more often than men, in age group is more senior than 60 years the picture of incidence is leveled.
Reasons of apostematozny pyelonephritis
Infection kidney a lokhanok the subsequent multistage penetration of microorganisms at first in tubules, and then and in a parenchyma of kidneys is virulent bacteria the main reason of development of an apostematozny inflammation. The source of an infection can be as in the patient's organism (abscesses and inflammations in other bodies), and beyond its limits. Allocate the ascending way of infection (from the external environment on urinary ways) and descending – with current of a lymph or blood from other centers. There is a number of the factors contributing to development of apostematozny pyelonephritis:
- Existence of the centers of an infection. Inflammatory and pyoinflammatory processes in various bodies can be a source to an infection which, getting into kidneys in the hematogenic or limfogenny way, leads to development of pathology. Cases of developing of a disease at distribution of process of carious teeth, the centers in a GIT, a bladder are described.
- Violations of an urodinamika. Stagnation or a reflux of urine in tubules, cup to system, mochetochnik creates conditions for accumulation of microorganisms and their penetration into tissues of kidneys. The urolithic disease, a spasm of a mochetochnik, bladder dyskinesia can act as the reason of violations of dynamics of urine, men have a prostate gland hypertrophy.
- Anatomic features. Because of certain features of an anatomic structure of urinogenital system purulent pyelonephritis arises at women more often. Urinary tract (in particular, an urethra) at them are wider and shorter that facilitates penetration of the ascending infection.
- Immunological features. It is established that an important role in pathogenesis of apostematozny pyelonephritis is played by the overdue immune reaction developing only at hit of the activator on a surface of an epithelium of wavy tubules. Perhaps, it is caused by genetic features of reactivity or the acquired and passing factors influencing activity of immunity.
If to consider this state as a complication of secondary purulent pyelonephritis, then it is possible to refer overdue or wrong treatment of the main disease to its reasons. Sometimes distinguish congenital features of blood supply of kidneys and structure of tubules, character and virulence of a bacterial infection from other factors influencing development of pathology.
At apostematozny pyelonephritis the hematogenic way of penetration of bacteria to fabrics of eliminative organs prevails. The repeating nature of bacteremia is important – single hit of the activator in balls does not lead to infection, but damages walls of capillaries. At the subsequent episodes of bacteremia microorganisms can get through a wall and get to a gleam of the capsule of a nefron and wavy tubules of the first order. At this stage the condition of an urodinamika is of great importance – at normal outflow of primary urine of a bacterium are allocated with it and do not manage to cause an inflammation. At stagnation rough reproduction of activators in a gleam of tubules is observed that increases risk of apostematozny purulent process.
Bacteria begin to get into walls of tubules, strongly damaging a kanaltsevy epithelium. Only at this stage there is an immunological reaction consisting in strong leykotsitarny infiltration of the struck nefron with death of cages of an epithelium and numerous ruptures of a basal membrane. Activators get to interweft fabric that leads to formation of the numerous peritubulyarny purulent infiltrates which are poorly delimited by an inflammatory shaft. Severe intoxication of an organism is noted by products of a purulent inflammation.
In process of the further course of pathology of a gnoynichka can merge among themselves, forming an anthrax or abscess. Sometimes the inflammatory shaft around them will be organized, observed growth of connecting fabric before total disappearance of an inflammation. Formation of sites of a sclerosis on the place of purulent infiltrates becomes an outcome of uncomplicated apostematozny pyelonephritis. The break of abscesses through a kidney membrane with involvement in pathological process of a peritoneum and surrounding fabrics is possible.
There are two options of classification of apostematozny pyelonephritis – on the etiologichesky nature of defeat and its distribution on one or both kidneys. Each type is characterized by certain features of the reasons of development, clinical manifestations, approaches to treatment and the forecast. Taking into account ethology of a disease allocate two main groups:
- Primary defeat. Unite the cases which developed against the background of earlier not struck, completely healthy eliminative organs in this group. The infection gets in the limfogenny or hematogenic way from far located inflammatory centers. A condition for development of a disease is high virulence of the activator and the lowered activity of immune system.
- Secondary defeat. To it, the type which more often is found, carry pathology episodes which are diagnosed against the background of a disease of kidneys or other bodies of an urinary system – an urolithic disease, cystitis, bladder dyskinesia. In emergence of a pathological state the large role is played by urodinamichesky violations.
On prevalence of defeat distinguish unilateral and bilateral forms of an apostematozny inflammation of kidneys. At once both bodies frequent massive bacteremia is the reason of involvement in process, such form is caused by hematogenic penetration of an infection and quite often has primary character. More widespread (in 95% of cases) unilateral defeat is more often again, is caused by frustration of an urodinamika in a concrete kidney. Decrease of the activity of immunity increases probability of development of all forms of a disease.
Symptoms of apostematozny pyelonephritis
There is a certain distinction in clinical manifestations of primary and secondary forms of pathology. Hematogenic primary type of pathology always begins sharply, with stupid morbidity in a waist, a fever, temperature increase to 39-40 degrees and above. From the first hours symptoms of the most severe intoxication of an organism are registered: headaches, loss of appetite, vomiting. In hard cases the lowering of arterial pressure, tachycardia, confusion of consciousness is noted. Waist pains sharply amplify for 5-6 day of a disease – it indicates involvement in process of the kidney capsule with its possible break.
The beginning of a disease at secondary apostematozny pyelonephritis seldom happens sudden – usually it is preceded by the period of renal colic lasting from several hours up to 2-3 days. Development of a disease after interventions on bodies of secretory system is sometimes observed. Other essential distinction is the nature of defeat – at primary inflammation it is more often bilateral, at secondary – unilateral. It is reflected in pain in a waist – at secondary type patients at first complain of the surrounding dull ache, but for 4-5 day it amplifies from defeat.
Further (in 4-6 days from the beginning of a disease) character of a course of pathology is approximately identical at any forms. There is a rigidnost of muscles of an abdominal tension that demonstrates involvement of a peritoneum. Kidneys become a source of a gnoyerodny infection – with current of blood and on lymphatic ways it can extend in lungs, a brain, a liver. It leads to development of pneumonia, purulent pleurisy, abscesses of a liver and brain. There is a sharp renal failure (SRF) which is characterized at first by total absence of urine (anury), and then sharp increase in a diuresis (polyuria). At damage of a liver jaundice, symptoms of an acute liver failure is observed.
OPN often develops even at unilateral apostematozny pyelonephritis because of toksiko-septic damage of the second kidney. Distinguish formation of abscesses and emergence of pyoinflammatory processes in a pleura, lungs from other widespread complications, to a liver because of an infection drift with blood or on lymphatic ways. The heaviest complication is considered . Fibrosis and wrinkling of a kidney which can become a cause of infringement of operation of the yukstaglomerulyarny device act as the remote consequences of pathology. Violations of an eritropoez (hypoplastic anemias, a politsitemiya), permanent increase in arterial pressure are a consequence of it.
Acuity of apostematozny pyelonephritis, its bystry development and high risk of terrible complications cause need of bystry and correct diagnostics. The doctor-urologist with obligatory involvement of the surgeon is engaged in definition of existence of pathology – it is necessary for saving of time, bystry confirmation of the diagnosis and an early initiation of treatment. Diagnostics includes the extensive list of tool and laboratory researches, consists of the following stages:
- Fizikalny survey and poll. The doctor analyzes complaints of the patient, collects the anamnesis of a disease, specifies whether the patient had diseases of secretory system what symptoms arose the first (pain or fever). The palpation reveals morbidity from the struck body, sometimes it is possible to define increase in a kidney.
- Laboratory researches. In the first several days in the general analysis of urine of change are observed seldom. Then the mikrogematuriya, emergence of protein (proteinuria), the expressed leykotsituriya is found, at microscopy of a deposit bacteria come to light. Results of the general blood test correspond to that at an acute inflammation – sharp increase in SOE, a neytrofiliya with strong shift to the left, the TANK confirms a gipoproteinemiya.
- Ultrasonic methods of a research. Increase in one or both bodies, hypostasis of surrounding cellulose, decrease in mobility at the forced breath is defined on ultrasonography of kidneys. In several days the giperekhogennost of a parenchyma in the thickness of which there is a set small (1-3 mm) gipoekhogenny educations is noted.
- Radio nuclide researches. The dynamic nefrostsintigrafiya confirms a radiopharmaceutical delay in the struck body up to a full stop of its removal at development of OPN.
Treatment of apostematozny pyelonephritis
In modern urology surgical methods of treatment of a disease are used. Other techniques play a supporting role, their application without surgery is justified only at the weakened patients to whom operation is contraindicated. The postoperative therapy directed to maintenance of the vital functions, reduction of the phenomena of intoxication, recovery of work of secretory system is important. The algorithm of treatment of apostematozny pyelonephritis looks as follows:
- Surgical intervention. In most cases consists in a kidney dekapsulyation, a drainage of abscesses and zabryushinny cellulose, formation of temporary ways for outflow of urine by means of a piyelostomiya. At unilateral defeats at patients of advanced age carrying out a nefrektomiya is shown.
- Antibiotic treatment. Antibacterial broad-spectrum agents are appointed right after specification of the diagnosis, after definition of character of the activator and its sensitivity to medicines transition to other antibiotics is possible. Reception of medicines is continued also during restoration after operation.
- Detoxication. Before carrying out surgical intervention to the patient appoint infusional therapy taking into account filtrational ability of kidneys. To the patient enter enzymes, vitamins, blood plasma, diuretics and other means.
- Hemodialysis. Need for a hemodialysis arises at a sharp renal failure, the frequency of its carrying out depends on urological indicators of the patient.
Duration of antibacterial treatment, infusional therapy and hemodialysis is defined individually with a condition of the patient. The decision on need and duration of functioning of a piyelostoma or nefropiyelostoma is accepted by the surgeon – quite often at unilateral defeat its creation refuse, keeping natural ways of outflow of urine. After operation constant control of function of kidneys – determination of level of creatinine, a daily diuresis and other indicators is necessary.
Forecast and prevention
The lethality at apostematozny pyelonephritis is rather high, in some cases reaches 10%. The forecast for life improves at the timely address to the doctor and an early initiation of treatment. The persons having chronic diseases of kidneys have to observe extra care (pyelonephritises, ) – at any signs of an aggravation of process it is necessary to address the expert urgently. Prevention of a state consists in timely elimination of the inflammatory centers in an organism (including not urological character). It is necessary to avoid overcooling of area of a waist, to follow rules of hygiene of genitalia, to perform full treatment of diseases of an urinary system.