Purulent pyelonephritis

Purulent pyelonephritis is a severe and dangerous disease, which, fortunately, is not very common. Like any abscess, it is an abscess on the kidney, located in a special capsule and protecting healthy tissue from the purulent focus (kidney abscess).

Various pathogenic microorganisms - staphylococci, streptococci, E. coli - become the culprits of abscesses. A purulent infectious focus may be located in a completely different organ, but with blood and lymph it can be transferred to the kidney and cause the development of purulent pyelonephritis.

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Epidemiology

Due to the fact that the disease is difficult to diagnose and its symptoms are similar to those of septic diseases, purulent pyelonephritis is diagnosed in only a quarter to a third of all patients.

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Causes purulent pyelonephritis

The causes of purulent pyelonephritis can be different, not related to each other, this disease is classified as polyetiological. Let's name the most common among the possible ones:

• apostematous nephritis, in which apostems - small purulent foci - appear in the cortical layer of the renal parenchyma. This is the body's reaction to the appearance of microbes in the form of an increase in leukocytes, sometimes a capsule forms along the contour of the pustules - an abscess appears;
• chronic foci of infection of other organs, most often destructive pneumonia and septic endocarditis;
• mechanical damage to the kidney as a result of injury or surgery;
• complication after urinogenic pyelonephritis (infectious agents enter by rising through the lumen of the ureter).

Purulent pyelonephritis after surgery

One of the reasons for the occurrence of purulent pyelonephritis after surgery, for example, to remove stones, is the entry of pathogenic bacteria into it, which melt the tissue at the site of the inflammatory compaction - the infiltrate.

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Risk factors

Risk factors for the development of purulent pyelonephritis include:

• reduced immunity: the body is unable to resist pathogenic microbes and viruses;
• trauma and surgery: infection as a result of a puncture or cut wound, failure to maintain sterility during surgery;
• hemodynamic disturbances in the kidney: collapse, shock, etc.

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Pathogenesis

The pathogenesis of the pathological process proceeds in different ways, but common to all algorithms of disease development is the melting of the parenchyma in places of reduced blood supply - ischemia and the formation of pustules, cavities filled with pus. If the dead tissue is surrounded by a granulation shaft, then this type of abscess is less dangerous and is easier to eliminate surgically. An independent breakthrough of the purulent capsule into the fatty tissue concentrated around the kidney is possible, resulting in purulent paranephritis. Penetration of pus into the renal pelvis entails more favorable consequences than its exit into the abdominal cavity, since it does not require surgery. The transition of pathology into a chronic form resembles tumor processes.

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Symptoms purulent pyelonephritis

Symptoms of purulent pyelonephritis largely depend on the location of the abscesses and the presence of aggravating pathologies of the organ. If there are no factors that impede the outflow of urine, then the first signs of the disease are common for any inflammation: high temperature, chills, weakness, sweating, poor appetite, low blood pressure, rapid heartbeat. Only pain in the lower back can indicate the involvement of kidney pathology in this condition. If the ureter is blocked, then the intoxication of the body increases, the symptoms resemble the manifestations of sepsis: health deteriorates sharply, tachycardia increases, breathing becomes noisy, blood pressure drops sharply. Most often, purulent pyelonephritis of the left or right kidney occurs, extremely rarely, but still occurs bilateral. In this case, symptoms of renal or hepatic insufficiency are evident: the sclera of the eyes and skin turn yellow, swelling appears, urine contains blood impurities, its formation slows down.

When palpating the abdomen, the muscles may be tense and painful.

Purulent pyelonephritis in children

Young children may lag behind their peers in their development due to pathological processes in the kidneys. Older children may experience nocturnal enuresis and urinary incontinence.

Stages

There are acute and chronic stages of purulent pyelonephritis. Acute pyelonephritis develops as an ascending infection caused by pathogenic bacteria entering the bladder. The chronic form resembles the course of a tumor process in its symptoms, it is characterized by rapid fatigue, temperature of 37-38°, anemia, and increased ESR.

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Forms

By type, purulent pyelonephritis is divided into renal and perirenal, solitary and metastatic. In the first case, the infectious process caused by staphylococcal bacteremia affects the outer shell of the kidney - the peripheral cortex of the kidney, but can penetrate deeper, into the medulla. A carbuncle can arise from abscesses and break through into the renal pelvis, forming a perirenal abscess. Its course is slower, sluggish and prolonged. Most often, diabetics and people with urolithiasis are susceptible to this pathology. Solitary abscesses are single and usually occur on one kidney, metastatic ones are multiple and bilateral.

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Complications and consequences

The consequences and complications of purulent pyelonephritis are associated with the possibility of spontaneous opening of the abscess, which can lead to peritonitis, and then sepsis - blood poisoning. There are also cases of organ shrinkage. Such consequences give grounds to be registered with a nephrologist for the rest of your life.

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Diagnostics purulent pyelonephritis

Diagnosis of purulent pyelonephritis includes laboratory testing of urine and blood, instrumental methods for determining pathology. The diagnosis is clarified using micro- and macropreparations. For this, fragments of damaged tissue are taken for examination and compared with the borderline. Micropreparation 0/20 corresponds to a kidney abscess: purulent exudate resembles a creamy mass, the abscess cavity is limited by a pyogenic capsule, the inner layer of which is granulation, the outer layer may not be there. Endoscopic studies are not used due to the possibility of re-infection.

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Tests

General urine and blood tests will indicate the presence of an inflammatory focus in the body. A blood test will reveal an increase in leukocytes and an increase in ESR. Urine may contain leukocytes, erythrocytes and traces of albumin, a protein fraction that performs important functions for the body. Increased values indicate the presence of an infection. Many microorganisms are also detected in a specially colored urine sediment.

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Instrumental diagnostics

The most informative diagnostics is instrumental, although it does not provide 100% accuracy. The safest examination is the detection of purulent pyelonephritis by ultrasound. The screen shows pustules, uneven contours of their walls, rounded formations with subcapsular purulent cavities with reduced echogenicity. If such signs of an abscess are detected, then to clarify the localization of lesions, computed tomography with a contrast agent is used. Abscesses are located in places of its reduced content. Isotope scintigram and retrograde pyelogram are clarifying methods that allow you to make sure that there is an abscess and whether there is a breakthrough of the purulent focus into the pelvis. To obtain a general picture of the state of the urinary system, they resort to X-ray examination - an overview urogram and excretory urography. This is especially important in case of the need for surgical intervention to determine the tactics of the operation.

Differential diagnosis

Differential diagnostics is most often carried out with acute and chronic non-purulent pyelonephritis, since their symptoms are very similar. The difficulty in making a correct diagnosis is that at the early stages of the disease, urine analysis does not show changes. If the patency of the urinary tract is not impaired, then leukocytosis and increased ESR are present in the urine. If urine outflow is difficult, hyperleukocytosis, anemia, and increased protein content are present. Manifestations of bilateral purulent pyelonephritis resemble symptoms of sepsis and renal or hepatic failure.

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Treatment purulent pyelonephritis

Treatment of purulent pyelonephritis in most cases requires surgical intervention, the exception being those cases when the contents of the purulent capsule break through into the renal pelvis, then the pus is excreted with urine through the urinary tract. After surgery, it becomes necessary to resort to antibacterial therapy and remove intoxication from the body.

Medicines

Medicines for the treatment of purulent pyelonephritis include antibiotics, which are prescribed after determining the sensitivity of bacteria to it. These may be antibiotics of the aminopenicillin group, which are well tolerated by patients: amoxicillin and penicillin; broad-spectrum cephalosporin drugs: ceftazidime, eurosidime, fortazim, bestum; aminoglycosides - amikacin, gentamicin; fluoroquinolones - levoflon, flobocin, ofloxacin.

Amoxicillin is available in tablets, suspension, oral solution, and dry substance for injection. The dose is prescribed individually: for children under 2 years old, 20 mg per kilogram of weight in 3 doses, 2-5 years old - 0.125 g, 5-10 years old - 0.25 g with the same frequency, over 10 and adults - 0.5 g three times a day. Possible side effects: urticaria, rhinitis, conjunctivitis. It is not recommended for use by people with hypersensitivity to the drug; pregnant women should be treated with caution.

Ceftazidime is an antibacterial drug, the release form is a solution for intravenous and intramuscular injections. In case of kidney disorders, the initial dose is 1 g, but after surgery it can be increased by half and controlled so that the concentration of the drug in the blood serum does not exceed 40 mg / l. The interval between injections should be 10-12 hours. The drug can cause allergic reactions, dizziness, headache, nausea, diarrhea, colitis. Contraindicated in renal failure, in the first trimester of pregnancy, newborns up to two months, hypersensitivity to penicillins.

Gentamicin is produced in a solution for injections. The daily dose for adults is 3-5 mg per kg in 2-4 injections, for children over two years old the same dose is recommended 2-3 times a day. Treatment with the drug can cause allergies, drowsiness, nausea, changes in indicators characterizing the state of the liver. Prescribe with caution to infants and premature babies.

Ofloxacin - tablets, affects gram-negative bacteria. The drug is taken at 0.3-0.4 g twice a day, the course of treatment is 7-10 days. It is not prescribed for epilepsy, pregnant and lactating women, children under 15 years old. The drug is well tolerated, allergies, nausea, anxiety, headaches rarely occur.

Surgical treatment

Surgical treatment of purulent pyelonephritis is almost inevitable. The surgeon's sequence of actions is as follows: the fibrous capsule in which the kidney is located is cut, and purulent cavities become visible. Abscesses are cut, cleaned and disinfected with antiseptic agents, capturing the surrounding tissues. After this, drainage is placed in the cavity and retroperitoneal space to remove the pus that appears during the healing process. Its samples are examined for sensitivity to bactericidal drugs and thus an antibiotic suitable for treatment is found. A special tube - a nephrostomy is installed to drain urine, after recovery, the fistula is healed. Simultaneously with the opening of the abscess, a stone can also be removed in case of urolithiasis. Modern techniques make it possible to avoid abdominal surgery, as an alternative - percutaneous puncture with drainage.

Recovery period after surgery for purulent pyelonephritis

The recovery period after surgery for purulent pyelonephritis lasts at least two weeks. Immediately after surgery, therapeutic treatment methods aimed at restoring normal organ functioning are used. These include antibacterial, anti-inflammatory medications, drugs that improve blood microcirculation, as well as antioxidant therapy: vitamins A, E, C, b-carotene, lycopene. They also resort to infusion therapy - drip infusions (intravenously or subcutaneously) of drugs and biological fluids to restore the water-electrolyte and acid-base balance in the body.

Prevention

Prevention of purulent pyelonephritis consists of timely response to manifestations of cystitis, pyelonephritis, it is important not to allow the infection to spread to the upper urinary tract. It is necessary to avoid hypothermia, eat right, and drink alcohol in moderation.

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Forecast

The prognosis for purulent pyelonephritis is not entirely favorable. Death from purulent pyelonephritis occurs in 75% of cases with conservative treatment of the disease, and in 15% with surgical treatment.

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