This disease is one of the stages in the 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 renal cortex.
Primary form
Most often, apostematic pyelonephritis begins to develop with obstruction of the ureter, less often with undisturbed urinary outflow.
In the kidney, small abscesses are formed in the following way: microorganisms settle into the capillary loops of the glomeruli, into the terminal vessels of the kidney, and into the peritubular capillaries. In this case, bacterial thrombi form, they then serve as a source of pustules. They are located on the surface of the renal cortex, as well as under the fibrous capsule in large quantities. On examination, they are clearly visible. Apostems have a yellowish color, size up to 2 mm, can be arranged in groups or singly.
With apostematic pyelonephritis, the kidney increases in size, has a cherry color. Perinephric fiber has swelling, thickening of the fibrous capsule occurs. On the incision of the kidney, pustules are visible, you can also find them in the cerebral layer.
Apostematous pyelonephritis, carbuncle and kidney abscess
The second form of the disease is the kidney carbuncle. Purulent necrotic organ damage, kidney abscess occurs . Foci of necrosis are formed in the cortex. Carbuncle can occur with the hematogenous pathway of infection. In such cases, the causes of apostematic pyelonephritis are pustular diseases, carbuncle, furunculosis, mastitis, panaritium. The mechanism of carbuncle formation is as follows:
A bacterial thrombus enters the renal artery from a distant focus of pus, so a carbuncle occurs in one of the blood supply zones of the arterial branch or in smaller arterial branches.
A carbuncle can develop when a large intrarenal vessel is compressed by an inflammatory infiltrate or due to contact with a foci of inflammation in the vessel wall.
Most often, the development of the carbuncle is caused by such microorganisms as white and Staphylococcus aureus, Proteus and Escherichia coli.
On the incision of the kidney, the carbuncle is seen as a round-shaped bulging from the necrotic tissue, it is penetrated by fused small pustules, wedge-shaped deep into the parenchyma.
Acute apostematic pyelonephritis most often combines kidney carbuncle and apostematic pyelonephritis. In clinical manifestations, there is not much difference.
The clinical picture of apostematous pyelonephritis
Symptoms of apostematic pyelonephritis and carbuncle depend on how much the outflow of urine from the kidney is impaired.
Most often, the primary form of pyelonephritis occurs suddenly, usually after an intercurrent infection. Chills appear, high fever (up to 40 degrees), heavy sweat. The hectic nature of the fever predominates (a rise in temperature is replaced by a drop). Stunning chills can last up to one hour, more often occurs at the peak of fever. After chills with a drop in temperature, profuse sweating begins. These symptoms during the first three days may be mild.
Then lower back pain begins to intensify. On palpation, the kidneys are clearly painful, possibly an increase. Changes in urine occur on the fifth day, bacteriuria, proteinuria, leukocyturia appear.
The blood picture is characterized by leukocytosis, granularity in leukocytes, an increase in ESR, anemia.
With a progressive process, sepsis may develop, having metastatic foci of purulent inflammation in the liver, lungs, and brain.
Clinic of kidney carbuncle
If the urine outflow 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 stunning chills and heavy sweat. Weakness builds up, breathing quickens, nausea and vomiting, tachycardia occurs.
In the early days, often there is no back pain, bacteriuria, leukocyturia, dysuric disorders are not observed. Diagnosis is difficult. Patients can be treated in therapeutic, infectious, surgical departments. A doctor may mistakenly diagnose pneumonia, acute cholecystitis, typhoid fever and the like. Only a few days later, when local symptoms begin to appear (lower back pain, Pasternatsky’s symptom, pain on palpation), the doctor focuses 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 on palpation;
- laboratory tests: bacteriuria, leukocyturia, in the blood - a left shift of the leukocyte formula, leukocytosis, C-reactive protein, an increase in ESR;
- excretory urogram - a decrease in kidney function, an increase on the affected side;
- Ultrasound - limitation of mobility, an increase in the size of organs, a thickening of more than 2 cm of the parenchyma, its heterogeneous density; fluid in the perinephral space, the pyelocaliceal system expands with obstruction of the ureter ;
- MSCT, MRI, RKT - an increase in the size of the kidney, thickening of the parenchyma, its heterogeneity, the manifestation of foci of purulent destruction;
- dynamic and static nephroscintigraphy - an increase in the size of the kidneys; in the parenchyma, uneven accumulation of the isotope.
Purulent tissue destruction is more clearly detected with carbuncle. Ultrasound in the parenchyma clearly shows foci of increased density, as well as their mixed structure. This picture is clearly visible on MRI, CT. Spiral RCT with enhanced contrast makes it possible to see disturbances when contrast enters the foci of necrosis.
Assessment difficulties
Difficulties in assessing the condition of the patient may arise if, before admission to urology, the patient underwent antibacterial therapy with modern antibiotics for one to two weeks. Such treatment can smooth out the manifestations of apostematic pyelonephritis, however, a cardinal improvement in the condition does not occur. Body temperature decreases, pain decreases, chills rarely occur, their nature is less pronounced and prolonged. The number of leukocytes in the blood decreases, but the left shift of the leukocyte formula is still preserved, as is anemia and increased ESR. In other words, the disease manifests itself as sluggish sepsis. Such an “improvement” is the cause of patient misconduct. To prevent the development of severe sepsis, in the presence of a lesion in the kidney of the patient, the patient must be operated on.
Differential diagnosis
When identifying apostematic pyelonephritis, it is necessary to differentiate this disease with other infectious ones. With acute pancreatitis and cholecystitis, with a subphrenic abscess, acute appendicitis, acute cholangitis, acute adnexitis and acute pleurisy.
Kurbuncul kidney differentiates with a simple suppurative cyst of the kidney, with a tumor of the parenchyma, with acute diseases of the abdominal cavity.
What makes it possible to distinguish apestomatous pyelonephritis and kidney carbuncle?
- Leukocyturia. Bacteriuria.
- Lower back pain.
- Impaired renal function.
- Thickening of the parenchyma. Changes in its density.
- Painful palpation with enlarged kidney.
- Expansion of the pyelocaliceal system.
The data of ultrasound, MRI, and CT scan make it possible to distinguish apostematic pyelonephritis from various acute diseases of the peritoneum.
Treatment
The treatment of apostematous pyelonephritis and carbuncle is carried out exclusively by surgery. Most often, the operation is performed in an emergency. Preliminary short-term preoperative preparation with the participation of an anesthesiologist-resuscitator lasts no more than two hours. The preparation includes:
- Catheterization of the pelvis, intravenous administration of an 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. Life saving.
The secondary goal is to save the kidney.
Endotracheal anesthesia is used for pain relief.
During the operation, the contents of the abscesses and pelvis are sampled to sow microflora for 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 taking into account inhibition of renal function and intoxication. The patient is assigned:
- 10% glucose solution - 500 ml, with 10 units of insulin intravenously;
- solution of 9% sodium chloride - 1000 ml;
- hemodesis - 400 ml;
- cocarboxylase - up to 200 mg;
- Vitamin B6 - up to 2 ml;
- Vitamin C - up to 500 mg;
- korglikon solution of 0.06% to 1.0 ml;
- mannitol solution 15% to 50 ml;
- Lasix up to 60 mg;
- freshly frozen (native) plasma - 250 ml;
- clexane or fragmentin, taking into account the indicators of the coagulogram;
- erythrocyte mass with anemia (Hb less than 70).
With purulent intoxication, extracorporeal detoxification (plasmapheresis, hemosorption, plasma absorption) is used.
Mandatory antibiotic therapy using two antibiotics of the broadest spectrum of exposure.
When assessing the condition of the parenchyma, the most modern methods (MRI, CT, ultrasound) are used. This makes it possible to correctly assess the situation and choose the most appropriate volumes of the operation.