Purulent pyelonephritis

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

Various pathogenic microorganisms - staphylococci, streptococci, E. Coli become the culprits of abscesses. A purulent infectious focus can be in an entirely different organ, but with blood and lymph flow to the kidney and cause the development of purulent pyelonephritis.

[1], [2], [3], [4]

Epidemiology

Due to the fact that the disease is difficult to diagnose and its symptoms are similar to manifestations of septic diseases, purulent pyelonephritis is established only in a quarter or one-third of all cases.

[5], [6], [7]

Causes of the purulent pyelonephritis

The causes of purulent pyelonephritis can be different, not related, this disease is referred to as polyethic. We shall name the most widespread among possible:

• apostematous nephritis, in which apoptosis occurs in the cortical layer of the kidney parenchyma - small purulent foci. This is the body's reaction to the appearance of microbes in the form of an increase in white blood cells, sometimes a capsule forms along the contour of the pustules - an abscess appears ;
• chronic foci of infection of other organs, more often destructive pneumonia and septic endocarditis;
• mechanical damage to the kidney as a result of injury or surgery;
• complication after urinogenous pyelonephritis (infectious agents get up on the lumen of the ureter).

Purulent pyelonephritis after surgery

One of the causes of purulent pyelonephritis after surgery, for example, to remove stones, is the entry into it of pathogenic bacteria that melt the tissues at the site of the inflammatory compaction - the infiltrate.

[8], [9], [10]

Risk factors

The risk factors for purulent pyelonephritis include:

• reduced immunity: the body is not able to withstand pathogens and viruses;
• trauma and surgery: infection as a result of a chop or cut wound, non-compliance with sterility during surgery;
• hemodynamic disorders in the kidney: collapse, shock, etc.

[11], [12]

Pathogenesis

The pathogenesis of the pathological process proceeds in different ways, but the common for all algorithms for the development of the disease is the melting of the parenchyma in places where the blood supply is reduced - ischemia and the formation of pustules, cavities filled with pus. If the necrotic tissue is surrounded by a granulation shaft, then this kind of abscess is less dangerous and easier to eliminate in an operative way. An independent breakthrough of the purulent capsule into fatty tissue, centered around the kidney, is possible, as a result of which purulent paranephritis occurs. Penetration of pus in the renal pelvis entails more favorable consequences than its exit into the abdominal cavity, because does not require surgical operation. The flow of pathology into a chronic form resembles tumor processes.

[13], [14], [15]

Symptoms of the purulent pyelonephritis

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

When palpation of the abdomen, muscles can be strained and painful.

Purulent pyelonephritis in children

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

Stages

Distinguish acute and chronic stage of purulent pyelonephritis. Acute develops as an ascending infection that occurs when pathogenic bacteria enter the bladder. The chronic form resembles the course of the tumor process in its symptoms, it is characterized by rapid fatigue, a temperature of 37-38 °, anemia, increased ESR.

[16], [17], [18], [19]

Forms

Purulent pyelonephritis is divided into kidney and perineal, solitary and metastatic by types. In the first case, the infectious process, provoked by staphylococcal bacteremia, affects the outer membrane of the kidney - the peripheral cortical layer of the kidney, but can penetrate deeper into the brain substance. From abscesses, a carbuncle can develop and break into the renal pelvis, forming a peripoint abscess. Its course is slower, sluggish and prolonged. Most often, this pathology affects diabetics and people with urolithiasis. Solitary abscesses are single and arise, as a rule, on one kidney, metastatic - plural and bilateral.

[20], [21], [22], [23], [24]

Complications and consequences

Consequences and complications of purulent pyelonephritis are associated with the possibility of spontaneous dissection of the abscess, which can entail peritonitis, and then sepsis - infection of the blood. There are cases of wrinkling of the organ. Such consequences give grounds to be registered with the nephrologist until the end of life.

[25], [26], [27]

Diagnostics of the purulent pyelonephritis

Diagnosis of purulent pyelonephritis includes a laboratory study of urine and blood, instrumental methods for determining pathology. The diagnosis is specified with the help of micro- and macro preparations. For this, fragments of damaged tissue are taken for examination and compared with the borderline. The micropreparation 0/20 corresponds to the abscess of the kidney: the purulent exudate resembles a creamy mass, the abscess cavity is limited by a pyogenous capsule whose inner layer of granulation, the outer one, may not exist. Endoscopic examinations are not applied because of the possibility of re-infection.

[28], [29], [30], [31], [32]

Analyzes

General tests of urine and blood will indicate the presence of an inflammatory focus in the body. A blood test will reveal an increase in white blood cells and an increase in ESR. Urine may contain leukocytes, red blood cells and traces of albumin, a protein fraction that performs important functions for the body. Elevated rates indicate the presence of infection. Also, in a specially colored urine sediment, many microorganisms are detected.

[33], [34]

Instrumental diagnostics

The most informative diagnosis is instrumental, although it does not give 100% accuracy. The safest study is the detection of purulent pyelonephritis on ultrasound. On the screen are visible pustules, uneven contours of their walls, rounded formations with subcapsular purulent cavities with reduced echogenicity. If such signs of an abscess are revealed, then to determine the localization of lesions, computer tomography using a contrast medium is used. In places of its reduced maintenance and there are ulcers. Isotope scintigram and retrograde pyelogram - clarifying methods that make sure that there is an abscess and whether there is a breakthrough of the purulent focus in the pelvis. To obtain a general picture of the state of the urinary system, an x-ray examination is used-a survey urogram and excretory urography. This is especially important if surgical intervention is necessary to determine the tactics of the operation.

Differential diagnosis

Differential diagnosis is most often carried out with acute and chronic neural pyelonephritis. Their symptoms are very similar. The difficulty of correctly diagnosing is that at the first stage of the disease development, the urine test does not show any changes. If the patency of the urinary tract is not disturbed, then in the urine there is leukocytosis, increased ESR. With difficulty in the outflow of urine - hyperleukocytosis, anemia, increase in protein content. Manifestations of bilateral purulent pyelonephritis resemble symptoms of sepsis and kidney or liver failure.

[35]

Treatment of the purulent pyelonephritis

Treatment of purulent pyelonephritis in most cases requires surgical intervention, except those that occur when the contents of the purulent capsule break into the renal pelvis, then the pus is discharged outward with urine through the urinary tract. After the operation, it becomes necessary to resort to antibacterial therapy and to remove intoxication of the body.

Medications

To drugs for the treatment of purulent pyelonephritis are antibiotics, which are prescribed after determining the sensitivity of bacteria to it. These can be antibiotics of the aminopenicillin group, which are well tolerated by patients: amoxicillin and penicillin; cephalosporin preparations of a wide spectrum of action: ceftazidime, eurozidim, fortazim, bestum; aminoglycoside - amikacin, gentamicin; fluoroquinolones - levoflonsacin, flobocin, ofloxacin.

Amoxicillin - available in tablets, suspensions, oral solution, dry substance for the preparation of injections. The dose is prescribed individually: children under 2 years 20 mg per kilogram of weight in 3 doses, 2-5 years - 0.125 g, 5-10 years - 0.25 g with the same frequency, over 10 and adults - 0.5 g three times a day. Possible adverse reactions: urticaria, rhinitis, conjunctivitis. It is not recommended for admission to people with hypersensitivity to the drug, be wary of treating pregnant women.

Ceftazidime is an antibacterial preparation, the release form is a solution for intravenous and intramuscular injections. With kidney disorders, the initial dose is 1g, but after surgery it can be half-increased 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, increased sensitivity to penicillins.

Gentamicin - is manufactured in solution for injection. The daily dose for adults is 3-5 mg per kg for 2-4 injections, children after two years are recommended the same dose 2-3 times a day. Treatment with the drug can cause allergies, drowsiness, nausea, changes in indicators characterizing the liver. With caution appoint babies and premature babies.

Ofloxacin - tablets, affects gram-negative bacteria. Admission is carried out at 0.3-0.4 g twice a day, the course of treatment is 7-10 days. Do not prescribe for epilepsy, pregnant and lactating women, children under 15 years. Drug tolerance is good, rarely allergies, nausea, anxiety, headaches.

Surgery

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

The recovery period after the operation with purulent pyelonephritis

The recovery period after purulent pyelonephritis lasts at least two weeks. Immediately after the operation, therapeutic methods of treatment are used to restore the normal functioning of the organ. These include antibacterial, anti-inflammatory medications, drugs that improve blood microcirculation, as well as antioxidant therapy: vitamins A, E, C, b-carotene, lycopene. And 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 is the timely response to manifestations of cystitis, pyelonephritis, it is important not to let the infection spread to the upper parts of the urinary tract. It is necessary to avoid hypothermia, eat right, drink alcohol sparingly.

[36], [37], [38]

Forecast

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

[39], [40], [41], [42]