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RENAL UNIT CASE 8 |
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Clinical History: A Southern Colorado rancher was first seen at the age of 33 with fever of 39.2°C and severe pain in the right flank. Three weeks previously he had noted some dysuria and cloudiness in the urine. On examination a very tender, non-movable mass of about 3 cm. was palpated in the right flank. A diagnosis of right perirenal abscess was made and the abscess was drained. E. Coli was grown from the abscess and the urine. He was treated with antibiotics and 16 days later was discharged with no symptoms. Over the next few years he had occasional episodes of dysuria, frequency and right flank pain, for which a physician prescribed antibiotics. At age 38 he had similar symptoms, this time accompanied by severe right flank pain which radiated to the groin on urination and shaking chills. He presented with temp. 38.8°C. He had poor skin turgor and a dry tongue. Except for marked CVA tenderness, the rest of the P.E. was normal. Urine and blood cultures grew E. Coli. He was treated with Ampicillin, and an excretory urogram was done. Figure 1 shows the X-ray taken after 30 minutes. Two weeks later, the fever cleared and the urine was clear and sterile. However, he still had flank pain. A needle was placed in the right renal pelvis where the pressure was found to be 23 cm. of water greater than that in the bladder (measured with a Foley catheter). He was taken to surgery. Scar tissue related to the remote perirenal abscess prevented a surgical repair of the uretero-pelvic junction obstruction and a nephrectomy was done. Figure 2 and Figure 3 show the gross aspect of the right kidney and Figure 4 & Figure 5 the microscopic examination. His subsequent course has been unremarkable and his creatinine has remained at 1.2 mg/dl. Questions: 1. How do you interpret the excretory urogram? 2. What pathological diagnoses would you make? 3. What are potential causes of uretero-pelvic junction obstruction? 4. Besides infection, what are some ways in which UPJ obstruction can present? 5. What is the most common cause of urinary tract obstruction in males? 6. If urinary tract obstruction is very severe, the affected kidney may not be visualized by the IVP. How would you establish a diagnosis of obstruction in this situation? 7. Other questions for discussion and study:
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