Paranephrite — infectious and inflammatory defeat of okolopochechny cellulose. It is shown by pain, various on intensity, in the waist, an abdominal cavity amplifying at the movements and on a breath, fever, a fever, weakness, local pastosity and hyperaemia of skin in the affected kidney compelled by position of the patient (a backbone bend, bending of a leg). It is diagnosed by means of ultrasonography and KT of kidneys, survey, excretory urography, a punktsionny biopsy. A basis of conservative therapy of paranephrite is purpose of antibacterial medicines. Surgical treatment is directed to sanitation of the purulent centers by methods of a lyumbotomiya, punktsionny drainage.
For the first time the clinic of an inflammation of paranefralny cellulose in 1839 was described by the French dermatologist Pierre Raille. Prevalence of paranephrite does not exceed 0,3%. Prior to 80% of cases arises against the background of the existing renal pathology (an urolithic disease with obstruction of urinary tract, purulent pyelonephritis, anomalies of development of urinary bodies, the undergone kidney operations). Paranephrite is usually diagnosed for patients of 16-52 years, mainly men. More often a back part of okolopochechny cellulose suffers, pathological process, as a rule, is unilateral and affects the left kidney. On observations of experts in the sphere of urology, the probability of development of a disease increases at patients with diabetes.
Direct activators of a pararenalny inflammation are pathogenic and opportunistic bacteria. In 70% of cases paranephrite is caused by various strains of stafilokokk, is more rare — colibacillus, Proteus, streptococci, pneumococci, gonokokka, pseudo-monads, tubercular mikobakteriya, other microorganisms. The microbic obsemeneniye of a paranefron is promoted:
- Pyoinflammatory renal pathology. Are complicated by paranephrite apostematozny nephrite, , the anthrax, kidney abscess, purulent perinefrit, renal tuberculosis, an urolithic disease.
- Diseases of the next bodies. Purulent fusion of the fatty capsule of a kidney comes at spread of an infection from the inflamed appendix, the blind and ascending obodochny gut. The inflammation can also develop against the background of hepatic abscess, purulent cholecystitis, pancreatitis, paracystitis, a parametritis, retroperitonitis, etc.
- Remote purulent centers. Developing of paranephrite at patients with furuncles, an anthrax, felons, quinsy, chronic tonsillitis, purulent otitis, osteomyelitis, a pulpitis is possible. Formation of an okolopochechny hematoma owing to a bruise of lumbar area becomes a provocative factor often.
In rare instances the inflammation is caused by microorganisms which live in the external environment or on skin. They get to paranefralny cellulose at the direct getting wounds during accidents, falling on sharp objects, during the carrying out a puncture of renal fabric, attacks with use cold and firearms. In some cases primary infectious center remains unspecified.
The fatty kidney capsule can be infected in the contact, limfogenny, hematogenic way. In the presence of the remote purulent centers infectious agents (most often — golden staphylococcus) extend gematogenno to intact pararenalny cellulose that leads to development of primary paranephrite. More rare it the beginning is promoted by treatment of fatty tissue blood at the closed injuries. At the patients having urological pathology, inflammatory processes in an abdominal cavity, zabryushinny and pelvic cellulose infection occurs kontaktno, on lymphatic vessels and anastomoza, and paranephrite is secondary.
Usually the first the lymph nodes located in more developed cellulose behind a kidney are involved in an inflammation. From lymph nodes of a bacterium get directly to fatty tissue, causing classical inflammatory reaction. Processes of alteration promote an ekssudation of intra vascular liquid and leukocytes in cellulose with developing of infiltrative paranephrite which at adequate therapy often is reversible. In more hard cases there is a focal or total purulent abstsedirovaniye to further fusion of mezhfastsialny partitions and distribution of inflammatory process. The acute inflammation comes to the end with a phase of restoration or gets a chronic current with the subsequent growth of the inflammatory changed fatty tissue and a sklerozirovaniye.
Except allocation of primary and secondary forms of an inflammation paranephrite is classified taking into account localization, the nature of pathological changes, features of development of a clinical picture. Such approach allows to estimate correctly the forecast of development of a disease and to choose optimum therapeutic tactics. On the basis of features of an arrangement in pararenalny cellulose distinguish the top (endodiafragmalny), lower, back, forward, total inflammation of a paranefron. As pathological process paranephrite can be infiltrative, purulent (abstsediruyushchy or flegmonozny), cicatricial (fibrous and sclerous or fibrous ). Taking into account features of a current and symptomatology distinguish:
- Sharp paranephrite. It is observed more often. It is characterized by a rough clinical picture with infiltrative and purulent processes, high risk of heavy complications with distribution in zabryushinny space, a possibility of synchronization of process and development of a productive inflammation. At adequate treatment is exposed to the return development.
- Chronic paranephrite. Meets less often. Is an outcome sharp or initially chronic. In the absence of a sharp phase usually complicates the course of recurrent kalkulezny pyelonephritis or tuberculosis of kidneys. Can be "armor-clad" (with education in okolopochechny cellulose of massifs of connecting fabric) or fibrous .
Acute primary inflammation of a paranefron usually begins with sudden emergence of the general intoksikatsionny symptomatology. Body temperature increases to 39-40 °C, the patient tests a fever, the general weakness, perspiration. Appetite worsens, swelling, a lock is often noted. The local symptomatology arises for 2-3 day of a disease. Patients with sharp paranephrite complain of intensive pain in a waist, a stomach, is more rare — in a podreberye. Painful feelings amplify at a deep breath, walking, the movements. The local tension of muscles in a projection of the affected kidney is observed.
The compelled position of the patient with pulling up to a stomach of the leg bent in a knee on the party of defeat is characteristic of the lower and back paranephrite. The local hyperthermia, pastosity of fabrics, reddening of skin is found. Sometimes the backbone of a skolioticheska is bent in the healthy party. At rather rare top paranephrite because of involvement in process of poddiafragmalny cellulose the diaphragm excursion is limited, there is short wind and feeling of shortage of air. Increase of an inflammation is followed by weighting of a condition of the patient — emergence of an oglushennost, confusion of consciousness, increase of breath and heartbeat.
The sharp form of secondary paranephrite is often shown by aggravation of already existing clinic of damage of kidneys, belly or pelvic bodies with strengthening of morbidity in a waist and a hyperthermia. At chronic process patognomonichny symptoms usually are absent, stupid morbidity in kidneys becomes the only complaint of patients. Squeezing of the backs of spinal nerves passing a row with developing of pain, a sleep, pricking, feeling of crawling of goosebumps in lumbar and sacral area, a hip is possible, is more rare — shins. It is sometimes noted subfebrilitt.
At untimely diagnostics and insufficient therapy paranephrite usually is complicated by distribution of an inflammation with development of zabryushinny phlegmon or break of abscess in belly, pleural cavities, a small pelvis, a rectum, a bladder, under skin in the 12th edge or over a crest of a podvzdoshny bone. At such patients peritonitis, an empiyema of a pleura is observed, paraproktit, a parametritis, renal fistulas are formed. At hematogenic generalization of process sepsis and infectious and toxic shock is possible. Sdavleny a kidney parenchyma and vessels at chronic sclerous and fibrous paranephrites provokes development of nefrogenny arterial hypertension.
At a chronic current and at an infiltrative stage of sharp paranephrite when the local symptomatology is absent, diagnosis is often complicated. A part is played by the fizikalny inspection allowing to define visually reaction from skin and muscles, a curvature of a spine column palpatorno to reveal infiltrate, features of an arrangement and character of a surface of kidneys, Pasternatsky and Izrael's positive symptoms. Tool methods are most informative for diagnosis of paranephrite:
- Ultrasonography of kidneys. The Sonografichesky research gives the chance to find and to accurately localize the centers of purulent fusion presented by gipoekhogenny or anekhogenny roundish educations with an accurate contour. At chronic option of paranephrite heterogeneity of an ekhostruktura of fabrics is defined. More exact data manage to be obtained during KT of kidneys.
- Survey urography. The spine column quite often of a skolioticheska is bent in lumbar department, the contour of a lumbar muscle near the affected kidney is clearly maleficiated or is not looked through. Depending on localization and the sizes of paranefralny infiltrate the kidney has a normal or smoothed contour. Sometimes the kidney parenchyma in a x-ray picture is not visualized.
- Excretory urography. Mochetochnik on the party of paranephrite is often rejected lateralno or medially. When carrying out a research during breath considerable restriction or lack of mobility of the affected kidney comes to light. Because of squeezing inflammatory infiltrate of a lokhanka and a cup can look deformed.
- Diagnostic puncture. It is carried out seldom, mainly in cases of accurately delimited infiltrate. Detection of pus serves as direct confirmation of paranephrite in the okolopochechny fatty capsule. The received material is investigated microbiological for definition of the activator and establishment of its sensitivity to antibiotics.
The supporting role at inspection is played by roentgenoscopy by means of which limited mobility and high standing of a diaphragm, existence of a pleural exudate is confirmed from defeat. For assessment of a functional condition of renal fabric the nefrostsintigrafiya is appointed. In all-clinical blood test all-inflammatory changes are found: significant increase in maintenance of leukocytes, shift of a leykotsitarny formula to the left, high SOE. Levels of erythrocytes and hemoglobin can decrease. Leykotsituriya, a bakteriuriya in the general analysis of urine come to light only at primary defeat of a kidney parenchyma. At the heavy course of paranephrite signs of toxic damage of the filtering device are possible: mikrogematuriya, tsilindruriya, albuminuriya.
The inflammation of a paranefron is differentiated with pionefrozy, tumors and cysts of kidneys, zabryushinny phlegmon of other origin, paracolitis, hepatic and poddiafragmalny abscess, appendicitis, appendicular infiltrate, retrotsekalny abscess, sharp cholecystitis, pleurisy, pneumonia. At heavy options of a current and lack of local "kidney" symptoms in the first days of a disease differential diagnosis of paranephrite with flu, typhus, malaria can be required. According to indications the urologist or the nephrologist appoints consultations of the abdominal surgeon, the pulmonologist, the gastroenterologist, the infectiologist, the phthisiatrician, the oncologist.
Treatment of paranephrite
Patients with an acute inflammation of a paranefron are recommended to be hospitalized urgently in an urological hospital. At chronic options of paranephrite perhaps pre-hospital inspection with the subsequent planned out-patient or hospitalization. The choice of conservative or operational tactics of maintaining the patient depends on the nature of inflammatory changes and a form of a course of a disease:
- At sharp infiltrative paranephrite. Treatment begins with prescription of antibiotics. Identification of grampolozhitelny flora serves as the indication for use of semi-synthetic penicillin, macroleads, tsefalosporin of the 2-3rd generation in a combination with sulfanylamide medicines. For elimination of gramotritsatelny microorganisms aminoglycosides and ftorkhinolona are recommended. Reception of antibacterial means is supplemented dezintoksikatsionny, immunomodulatory and vitamin therapy.
- At sharp purulent paranephrite. Surgical sanitation of the center of an infection is required. For removal of pus carry out punktsionny drainage more often, is more rare — broad opening of abscess (lyumbotomiya). At patients with back paranephrite carrying out intervention through intermuscular access is possible. At a combination of a paranefralny inflammation with pionefrozy at first the nefrostomiya, and then a nefrektomiya is carried out. After operations appoint antibacterial therapy medicines of a wide range taking into account activator type.
- At chronic paranephrite. Treatment can be both conservative, and surgical. In the absence of the osumkovanny purulent center and a pionefroz usually apply antibiotics in combination with glucocorticosteroids, the rassasyvayushchy, all-strengthening means, physiotherapeutic procedures. Surgical intervention for removal of an abscess is chosen by the same principles, as at an acute inflammation. Sdavleny kidneys at a sklerozirovaniye of cellulose is the indication for excision of a paranefron.
Therapy of all forms of paranephrite is effectively supplemented by physiotherapy: diathermy, UVCh, mud and paraffin applications, massage, Ural federal district. It is in the presence purulent - septic complications with the expressed intoksikatsionny syndrome and violation of a kidney filtration carrying out an extracorporal detoxication — haemo sorption, a plasma exchange is recommended, to a plazmosorbtion, a hemodialysis.
Forecast and prevention
Timely identification and adequate antibacterial therapy allow to stop the majority of cases of sharp paranephrite at an initial infiltrative stage without carrying out operation. The right choice of a way and time of performance of surgical intervention at a purulent inflammation provides bystry sanitation of abscess and preservation of a kidney. The forecast of chronic paranephrite is defined by a condition of kidney functions and urodinamik. Prevention of a disease is directed to timely treatment of urological diseases, sanitation of the centers of a chronic infection, the prevention of widespread purulent complications at abdominal and pelvic pathology, immunity strengthening.