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THE RENAL TRACT 167 Table 7.1 Source of obstruction Intrinsic factors Stones Tumour Blood clot Papillary necrosis Infective processes Stricture Fungal balls Tuberculosis Congenital Idiopathic PUJ obstruction Posterior urethral valves Ureterocoele Outflow obstruction Prostate enlargement Urethral stricture Extrinsic pelvic mass Cervical carcinoma Causes of renal tract obstruction Characteristics Accompanied by renal colic. May be situated anywhere along the renal tract In the bladder, PCS or ureter From infection or trauma Sloughed papillae can travel down the ureter, causing obstruction Caused by chronic, repeated infection Rare Usually unilateral. PCS dilatation only Entire renal tract dilatation. Frequently diagnosed antenatally Unilateral hydronephrosis with hydroureter Benign or malignant May be iatrogenic, congenital or as a result of infection. Accompanied by disturbed micturition Proximity to the ureters causes obstruction Endometriosis Endometriotic lesions adhere to the peritoneal and/or ureteric surfaces, causing compression Others: lymphadenopathy, Always scan the kidneys to inflammatory bowel exclude obstruction when a masses, gynaecological pelvic mass is present masses Iatrogenic Postsurgical procedure Ligation of ureters in gynaecological procedures Trauma Can cause a stricture of the ureter or can cause the renal tract to be blocked by blood clot from damage to the kidney PCS = pelvicalyceal system; PUJ = pelviureteric junction. Further management of renal obstruction In the majority of cases the exact level and cause of obstruction are difficult to identify on ultrasound. Confirmation of the cause and identification of the exact level is traditionally best established on IVU; 10 however CT IVU is becoming a rapidly universally adopted first-line investigation. 11 A plain abdominal X-ray is useful in confirming the presence of calculi in the renal tract, but ultrasound may demonstrate stones which are nonopaque on X-ray; CT is probably the best overall test for stone detection. It is important to assess the function of the obstructed side, as a chronic, longstanding obstruction with no residual function cannot be treated, but a kidney which still has function is worth saving. A DTPA scan can assess the relative functions of the obstructed and non-obstructed side. Percutaneous nephrostomy (the placing of a tube into the PCS to drain the urine) in the case of unilateral obstruction is performed to relieve the obstruction, minimizing damage to the kidney and maintaining renal function and drainage. This may be done under either ultrasound or fluoroscopic guidance or a combination of both. The decision of whether to proceed to nephrostomy or cystoscopic stent will depend upon patient presentation and local factors and policies. Pyonephrosis Pyonephrosis is a urological emergency. An obstructed kidney is prone to become infected. High fever and loin pain can suggest obstructive pyonephrosis. Pus or pus cells may also be detected in the urine. Low level echoes can be seen within the dilated PCS on ultrasound, and may represent pus. Sometimes, however, the urine may appear anechoic, despite being infected. The clinical history should help differentiate pyo- from simple hydronephrosis (Fig. 7.13A). Percutaneous drainage by ultrasound or fluoroscopically guided nephrostomy is usually necessary, partly as diagnostic confirmation and partly as a therapeutic procedure.
168 ABDOMINAL ULTRASOUND A B RT KIDNEY C D E Figure 7.12 (A) Hydronephrosis of the left kidney, secondary to a large circumferential bladder tumour. (B) A ureteric stent is noted within the renal pelvis of (A) (arrow); however, a moderate degree of hydronephrosis is present and highly suggestive of partial or complete stent occlusion. (C) Moderate to marked hydronephrosis of the right kidney secondary to a pelvic lesion. The cortical thickness is normal suggesting the obstruction is relatively recent and that relief of obstruction should produce a significant improvement in renal function. (D) Hydronephrosis of the right kidney. The kidney however is small at 7.2 cm, the cortex echogenic and thinned, particularly at mid pole level. Appearances suggest this appearance is chronic. (E) TS of a left-sided hydronephrosis. Echogenic material is present within the collecting system. The patient was pyrexial. Pus was drained. Haemo-hydronephrosis Blood within the dilated PCS may be due to trauma or other local or semilocal pathological processes such as infection or tumour. It is not usually possible to determine whether obstruction is caused by a blood clot or whether the blood is the result of an obstructing lesion which is also causing bleeding. Renal colic as a result of obstruction by a blood clot in the absence of trauma or blood dyscrasia must naturally be thoroughly investigated to exclude an underlying lesion.
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Abdominal Ultrasound
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Abdominal Ultrasound How, Why and W
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v Contents Contributors Preface ix
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vii Contributors Rosemary Arthur FR
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ix Preface Ultrasound continues to
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ABBREVIATIONS xi MHA MHV MI MPV MRA
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Chapter 1 1 Optimizing the diagnost
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OPTIMIZING THE DIAGNOSTIC INFORMATI
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Chapter 2 17 The normal hepatobilia
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THE NORMAL HEPATOBILIARY SYSTEM 19
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Chapter 3 41 Pathology of the gallb
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PATHOLOGY OF THE GALLBLADDER AND BI
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Chapter 4 79 Pathology of the liver
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PATHOLOGY OF THE LIVER AND PORTAL V
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Page 130 and 131: PATHOLOGY OF THE LIVER AND PORTAL V
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Page 134 and 135: Chapter 5 121 The pancreas CHAPTER
Page 136 and 137: THE PANCREAS 123 the patient’s le
Page 138 and 139: THE PANCREAS 125 Acute pancreatitis
Page 140 and 141: THE PANCREAS 127 E F G Figure 5.3 c
Page 142 and 143: A C DISTANCE = 3.43 CM 5%. 13 Over
Page 144 and 145: THE PANCREAS 131 G H I Figure 5.5 c
Page 146 and 147: THE PANCREAS 133 head of pancreas.
Page 148 and 149: THE PANCREAS 135 pancreatic juice i
Page 150 and 151: Chapter 6 137 The spleen and lympha
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Page 166 and 167: Chapter 7 153 The renal tract CHAPT
Page 168 and 169: THE RENAL TRACT 155 As with any oth
Page 170 and 171: THE RENAL TRACT 157 A B q 0 LRA AO
Page 172 and 173: THE RENAL TRACT 159 junctions of or
Page 174 and 175: THE RENAL TRACT 161 A B Figure 7.5
Page 176 and 177: THE RENAL TRACT 163 carcinomas, the
Page 178 and 179: THE RENAL TRACT 165 the vesicourete
Page 182 and 183: THE RENAL TRACT 169 A B Figure 7.13
Page 184 and 185: THE RENAL TRACT 171 Table 7.2 Diffe
Page 186 and 187: THE RENAL TRACT 173 Ultrasound stil
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Page 190 and 191: THE RENAL TRACT 177 Xanthogranuloma
Page 192 and 193: THE RENAL TRACT 179 As with acute t
Page 194 and 195: THE RENAL TRACT 181 der with increa
Page 196 and 197: THE RENAL TRACT 183 ● ● Morphol
Page 198 and 199: THE RENAL TRACT 185 ● ● hydrone
Page 200 and 201: THE RENAL TRACT 187 A Figure 7.27 A
Page 202 and 203: THE RENAL TRACT 189 vascular reject
Page 204 and 205: THE RENAL TRACT 191 B A C Figure 7.
Page 206 and 207: THE RENAL TRACT 193 computerised ul
Page 208 and 209: Chapter 8 195 The retroperitoneum a
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Page 228 and 229: Chapter 9 215 The paediatric abdome
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THE PAEDIATRIC ABDOMEN 217 A B SPLE
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THE PAEDIATRIC ABDOMEN 219 B A B Fi
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THE PAEDIATRIC ABDOMEN 221 probe de
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THE PAEDIATRIC ABDOMEN 223 When the
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THE PAEDIATRIC ABDOMEN 225 + 78 A 2
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THE PAEDIATRIC ABDOMEN 227 A B C D
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THE PAEDIATRIC ABDOMEN 229 Table 9.
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THE PAEDIATRIC ABDOMEN 231 A LT B C
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THE PAEDIATRIC ABDOMEN 237 mesenter
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THE PAEDIATRIC ABDOMEN 239 E F G Fi
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THE PAEDIATRIC ABDOMEN 241 system i
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Chapter 10 The acute abdomen 243 CH
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THE ACUTE ABDOMEN 245 scan of the p
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THE ACUTE ABDOMEN 247 LIVER LS GB S
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THE ACUTE ABDOMEN 249 D A RT B C E
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THE ACUTE ABDOMEN 251 17. Patlas M,
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Chapter 11 253 Interventional and o
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INTERVENTIONAL AND OTHER TECHNIQUES
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275 Bibliography and further readin
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277 Index A Abdomen, acute gastroin
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INDEX 279 Continuous ambulatory per
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INDEX 281 Intravenous urography (IV
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INDEX 283 Phrygian cap, 29 Pneumobi
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