Kidney abscess

Kidney abscess is a limited inflammation with melting of the kidney tissue and the formation of a purulent cavity, surrounded by a granulation shaft, which separates the purulent focus from the surrounding healthy tissues.

[1], [2], [3],

Causes of the kidney abscess

Kidney abscess can also be a consequence of fusion of abscesses with apostematous pyelonephritis, abscessing of carbuncle. Kidney abscess can be a direct consequence of the calculus in the pelvis or ureter or be formed after surgery on the kidney tissue for urolithiasis. In this case, the heavy course of the postoperative period, the formation of the urinary fistula A.Ya. The anther, et al. (1970) emphasize the abscess, which developed with urinogenic (ascending) pyelonephritis. In this case, the pathogen penetrates the kidney through the renal papilla. In some cases, the process is restricted to the papillae, while in others it spreads to other tissues, forming a large solitary abscess with the involvement of adjacent pericarp cell tissue. With such an abscess, lumps of sequestered kidney tissue are found among the accumulation of pus.

In some cases, when the abscess is located within the upper or lower segment of the kidney, sequestration of a large area of the renal parenchyma may occur. The cases of the formation of an abscess after knife injury of a kidney are described. Also observed are the so-called metastatic kidney abscesses, which occur when the infection is spread from the extrarenal foci of inflammation. The source of infection is most often localized in the lungs (destructive pneumonia) or the heart (septic endocarditis). Abscesses of the kidneys are rarely multiple and bilateral.

The resulting abscess of the cortical substance of the kidney can be opened through the capsule of the kidney into the pericardial cellular tissue and form a paraneural abscess. Sometimes it breaks into the cup-and-pelvis system and is emptied through the urinary tract system. In some cases, the abscess pours into the free abdominal cavity or takes a chronic course, simulating a kidney tumor.

[4], [5], [6], [7], [8], [9]

Symptoms of the kidney abscess

Symptoms of kidney abscess can resemble the symptoms characteristic of acute pyelonephritis, which makes it difficult to diagnose in time. Before surgery, only 28-36% of patients have a correct diagnosis. With patency of the urinary tract disease begins acutely, with a sharp rise in body temperature, the appearance of pain in the lumbar region. The pulse and breathing speed increase. The general condition of the patient is satisfactory or of moderate severity.

If urine passage is disturbed, the picture of acute purulent-inflammatory process in the kidney develops: body temperature of a hectic nature, tremendous chills, frequent pulse and breathing, weakness, malaise, headache, thirst, vomiting, often hysteria sclera, adynamia, pain in the kidney.

With bilateral abscesses of the kidneys, symptoms of severe septic intoxication, renal and hepatic insufficiency predominate.

With a solitary abscess, changes in the urine are often absent. With patency of the urinary tract, leukocytosis with a neutrophil shift of the blood formula to the left, an increase in ESR, a violation of the passage of urine hyperleukocytosis of blood, severe anemia, hypoproteinemia are noted. There is no change in urine. Or there is moderate proteinuria, microhematuria, bacteriuria and leukocyturia (with the breakthrough of the abscess in the renal pelvis). With objective examination, an enlarged painful kidney is probed. Symptom Pasternatsky positive. When the abscess is located on the anterior surface of the kidney and spreads to the parietal peritoneum, irritation symptoms of the peritoneum can be positive. Of the additional survey methods, use survey urography, excretory urography, ultrasound, CT.

[10], [11], [12], [13]

Diagnostics of the kidney abscess

On the surveyed urogram it is possible to detect the curvature of the vertebral column towards the pathological process and the absence of a shadow of the lumbar muscle on the same side, an increase in the kidney. Sometimes in the area of localization of the abscess, the bulging of its outer contour is noted. Excretory urograms determine the decrease in the excretory function of the kidney, the compression of the renal pelvis or calyx, their amputation, the restriction of the mobility of the kidney at the height of inspiration and after exhalation. More informative is CT, which reveals a kidney abscess in the form of a zone of reduced accumulation of contrast material in the kidney parenchyma in the form of single or multiple decay cavities, which, merging, turn into large abscesses. The abscess has the form of rounded formation of increased transparency with an attenuation coefficient from 0 to 30 HU. In the control study, there is a clear delineation of the focus of destruction from the kidney parenchyma.

With the breakthrough of pus in the cup-and-pelvis system on the urogram, a cavity filled with RVB is visible. Dynamic scintigrams in the abscess area reveal avascular vascular formation.

CT provides an opportunity to detect not only the kidney or perineal accumulations of fluid, but also the presence of gas in the cavity of the abscess. With the help of this method, it is also possible to establish ways of spreading the infection into surrounding tissues. These data can be useful when choosing the operative access and determining the amount of surgical intervention.

With ultrasound of the kidneys, the following signs of kidney abscess are revealed:

• hypoechoic foci in the parenchyma with dimensions from 10 to 15 mm and above;
• unevenness and swelling of the external contour of the kidney at the site of the abscess;
• a significant decrease in kidney excursions;
• decreased echogenicity of the parenchyma.

On dopplerograms, there is no vascular pattern in the abscess zone.

The clinical picture of metastatic kidney abscesses is often dominated by the symptoms of severe extrarenal inflammatory process (septic endocarditis, pneumonia, osteomyelitis, etc.). The basis for an active search for renal metastatic abscesses should be an "unmotivated" deterioration in the general condition of the patient.

[14], [15], [16], [17]

Treatment of the kidney abscess

Treatment of kidney abscess is operative. An emergency operation is shown. Treatment of kidney abscess consists in decapsulation of the kidney, dissection of the abscess, treatment of the purulent cavity with antiseptic solution, wide drainage of this cavity and retroperitoneal space. The abscess is most often located directly under the kidney capsule and is clearly visible. When it is localized in deeply lying layers, the swelling of the tissue is noted. As a rule, the formation is soft, fluctuates and when palpation it is felt that it has a cavity with a liquid.

Punctures and aspiration of pus help to correctly establish the diagnosis. The contents of the abscess are sent to a bacteriological study and to determine the sensitivity of microorganisms to antibiotics. The abscess is opened with a wide incision. If the passage of urine from the kidney is broken, the operation is completed with nephrostomy. In the postoperative period, intensive antibacterial and detoxification therapy continues. In recent years, for the treatment of abscesses, the kidneys have been suggested to perform a percutaneous puncture with evacuation of the contents, establishment of drainage and subsequent washing of the abscess cavity with antiseptics. With bilateral renal damage, the operation is performed on both sides.

Metastatic kidney abscesses are also subject to removal.

Prevention

Abscess of the kidney can be prevented if the timely and conservative and surgical treatment of patients with acute pyelonephritis.

[18], [19], [20], [21], [22]

Forecast

The prognosis for conservative treatment of kidney abscess is unfavorable, since in 75% of cases a lethal outcome is noted. With timely surgical intervention, patients, as a rule, recuperate.

[23], [24], [25], [26]