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Radiology Review Manual

6th Edition
2007 Lippincott Williams & Wilkins

Urogenital Tract
Differential Diagnosis of Urogenital Disorders
Renal failure

= reduction in renal function


rise in serum creatinine >2.5 mg/dL

Acute Renal Failure

= clinical condition associated with rapid steadily increasing azotemia oliguria (<500
mL urine per day) over days / weeks
Etiology:
A. PRERENAL
= renal hypoperfusion secondary to systemic illness
1. Fluid + electrolyte depletion
2. Hemorrhage
3. Hepatic failure + hepatorenal syndrome
abnormally elevated resistive
index
4. Cardiac failure
5. Sepsis
resistive index <0.75 in 80% of
kidneys
B. RENAL (most common)
1. Acute tubular necrosis:
ischemia, nephrotoxins, radiographic contrast, hemoglobulinuria,
myoglobulinuria, myocardial infarction, burns
resistive index 0.75 in 91% of
kidneys
2. Acute glomerulonephritis + small vessel disease:
acute poststrep glomerulonephritis, rapidly progressive
glomerulonephritis, lupus, polyarteritis nodosa, Schnlein-Henoch
purpura, subacute bacterial endocarditis, serum sickness,
Goodpasture syndrome, malignant hypertension, hemolytic uremic
syndrome, drug-related vasculitis, abruptio placentae
normal resistive index <0.70
3. Acute
tubulointerstitial nephritis:

drug reaction, pyelonephritis, papillary necrosis


abnormal resistive index
4. Intrarenal precipitation (hypercalcemia,
urate, myeloma protein)
5. Arterial / venous obstruction
6. Acute cortical necrosis
C. POSTRENAL (5%)
= result of outflow obstruction (rare)
1. Prostatism
2. Tumors of bladder, retroperitoneum, pelvis
3. Calculus
4. hydronephrosis
D. CONGENITAL
bilateral renal agenesis / dysplasia / infantile polycystic kidney disease,
congenital nephrotic syndrome, congenital nephritis, perinatal hypoxia
Incidence: ATN + prerenal disease account for 75% of acute renal failure

Chronic Renal Failure (CRF)

= decrease in renal function over months / years


Incidence: end-stage renal disease in 0.01% of U.S. population; 85,000 patients/year
undergo hemodialysis; 8,000 renal transplantations/year
Etiology:
A. INFLAMMATION / INFECTION
1. Glomerulonephritis
2. Chronic pyelonephritis
3. Tuberculosis
4. Sarcoidosis
B. VASCULAR
1. Renal vascular disease
2. Bilateral renal vein thrombosis
C. DYSPROTEINEMIA
1. Myeloma
2. Amyloid
3. Cryoglobulinemia
4. Waldenstrm macroglobulinemia
D. METABOLIC
1. Diabetes
2. Gout
3. Hypercalcemia
4. Hyperoxaluria
5. Cystinosis
6. Fabry disease
E. CONGENITAL
1. Polycystic kidney disease
2. Multicystic dysplastic kidney

3. Medullary cystic disease


4. Alport syndrome
5. Infantile nephrotic syndrome
F. MISCELLANEOUS
1. Hepatorenal syndrome
2. Radiation

Musculoskeletal Manifestations of CRF


1. Renal osteodystrophy = combination of 2 HPT, osteoporosis, osteosclerosis,
osteomalacia, soft-tissue and vascular calcifications
2. Aluminum toxicity (130%)
o Cause: ingestion of aluminum salts phosphate-binding antacids (to control
hyperphosphatemia)
o aluminum serum level >100 ng/mL
o signs of osteomalacia (>3 insufficiency fractures with
predominant involvement of ribs)
o avascular necrosis
o

lack of

osteosclerosis
less evidence of subperiosteal resorption
3. Amyloid deposition
o Path: amyloid consists of 2-microglobulin
o Organs: bone, tenosynovium (carpal tunnel syndrome), vertebral disk, articular
cartilage + capsule, ligament, muscle
4. Destructive spondyloarthropathy (15%)
o diskovertebral junction erosion + sclerosis
o

vertebral body compression


P.878

disk space narrowing

formation
lack of osteophytosis

Schmorl node

o facet involvement
with subluxation
5. Tendon rupture
6. Crystal deposition disease
o Type: calcium hydroxyapatite, CPPD, calcium oxalate, monosodium urate
7. Osteomyelitis + septic arthritis
8. Avascular necrosis (in up to 40%)

Diabetes insipidus

= characterized by daily production of very large volume of dilute urine (specific gravity
<1.005, <200 mOsm/L)

Pituitary Diabetes Insipidus

= Hypothalamic Diabetes Insipidus


= vasopressin-sensitive diabetes insipidus
= vasopressin (ADH) production is reduced to <10%
Cause:
a. idiopathic (27%)
septooptic dysplasia / rare familial (autosomal dominant X-linked) /
sporadic disorder
Histo: atrophic supraoptic nucleus
never associated with anterior pituitary dysfunction
b. pituitary destruction by tumor / infiltrative disorder (32%):
in
childhood:

hypothalamic glioma, tuber cinereum hamartoma,


craniopharyngioma, Langerhans histiocytosis,
germinoma, leukemia, complication of meningitis

in
adulthood:

sarcoidosis, TB, metastasis

in 60% associated with anterior pituitary dysfunction


c. pituitary destruction by surgery (20%)
always associated with anterior pituitary dysfunction
d. head injury (17%)
in 20% associated with anterior pituitary dysfunction
A lesion in the posterior pituitary will NOT produce diabetes insipidus, because
it is simply the storage space for vasopressin!

Psychogenic Water Intoxication

= compulsive intake of large amounts of fluid, which leads to inhibition of normal


vasopressin production
water deprivation test

Nephrogenic Diabetes Insipidus

= poor reabsorption of water in collecting ducts due to end-organ resistance to


vasopressin
Cause:

a. congenital
1. Rare X-linked recessive genetic disorder with unresponsiveness of tubules
+ collecting system to vasopressin (in infants + young males) with
variable expression
2. Autosomal dominant form (rare)
b. acquired = nephrogenic DI syndrome
= disorders affecting the medulla / distal nephrons:
medullary + polycystic disease, sickle cell nephropathy,
postobstructive uropathy, reflux nephropathy, chronic uremic
nephropathy, unilateral renal artery stenosis, acute tubular necrosis,
drug toxicity, analgesic nephropathy, hypokalemic +
hypercalcemic nephropathy, amyloidosis, sarcoidosis
symptoms in infancy:
vomiting secondary to hypernatremic dehydration
mental retardation
caloric growth failure (water favored over formula)
symptoms after infancy:
increased fluid intake
avoiding urination
bilateral hydroureteronephrosis
Rx: thiazide diuretics, low-salt diet, encouragement of frequent
micturition, indomethacin

Hypercalcemia

mnemonic: SHAMPOO DIRT


o Sarcoidosis
o Hyperparathyroidism, Hyperthyroidism
o Alkali-milk syndrome
o Metastases, Myeloma
o Paget disease
o Osteogenesis imperfecta
o Osteopetrosis
o D vitamin intoxication
o Immobility
o Renal tubular acidosis
o Thiazides

Polycythemia

Cause: increased level of erythropoietin (acting on erythroid stem cells) secondary to a


decrease in pO2; erythropoietin precursor is produced in juxtaglomerular epithelioid cells
of kidney + converted in blood
A. RENAL
a. intrarenal
1. Vascular impairment

2. Renal cell carcinoma (5%)


3. Wilms tumor
4. Benign fibroma
5. Simple cyst (14%)
6. Polycystic kidney disease
b. postrenal
1. Obstructive uropathy (14%)
B. EXTRARENAL
a. liver disease
1. Hepatoma
2. Regenerating hepatic cells
b. adrenal disease
1. Pheochromocytoma
2. Aldosteronoma
3. Cushing disease
C. CNS DISEASE
1. Cerebellar hemangioblastoma
D. Large uterine myomas
NOT in: renal vein thrombosis, multicystic dysplastic kidney, medullary sponge kidney

P.879

Arterial hypertension
A. PRIMARY / ESSENTIAL HYPERTENSION (8590%)
B. SECONDARY HYPERTENSION
a. Renal parenchymal disease (510%)
b. Potentially curable secondary hypertension (12%)
vascular
1. Renovascular disease

0.184.4%

2. Coarctation

0.6%

hormonal
1. Pheochromocytoma

0.040.2%

2. Cushing syndrome

0.3%

3. Primary aldosteronism

0.010.4%

4. Hyperthyroidism
5. Myxedema
renal
1. Unilateral renal disease

Renovascular Hypertension

= normalization of blood pressure following nephrectomy /


reestablishment of normal renal blood flow (Dx made in
retrospect)
Incidence: 15% of general population; 2nd most common
cause of potentially curable hypertension
Pathophysiology:
o usually >50% stenosis at any level in renovascular bed
leads to mildly reduced pressure in glomerular afferent
arteriole (pressure falls precipitously in >80% stenosis);
reduced pressure stimulates release of renin followed by
angiotensin-II, and aldosterone causing
a. constriction of efferent glomerular arterioles
b. increase in systemic hypertension
c. sodium retention
Cause:
1. Atherosclerosis (6090%) in individuals >50 years of age
2. Fibromuscular dysplasia (1035%) in women <40 years
of age
3. Neurofibromatosis
4. Pheochromocytoma
5. Fibrous bands (congenital stenosis, retroperito neal
fibrosis, postradiation artery stenosis)
6. Arteritis (Buerger disease, polyarteritis nodosa, Takayasu
disease, thrombangitis obliterans, syphilitic arteritis)
7. Arteriovenous malformation / fistula
renin-mediated hypertension (due to renal ischemia
distal to fistula)
8. Thromboembolic disease (eg, atrial fibrillation, prosthetic
valve thrombi, cardiac myxoma, paradoxical emboli,
atheromatous emboli)
9. Renal artery aneurysm
10.
Extrinsic compression (eg, renal cyst, neoplasm,
chronic subcapsular hematoma) = Page kidney

11.
Middle aortic syndrome, aortic dissection, dissecting
aortic aneurysm
12.
Posttraumatic renovascular hypertension
. occlusion of main renal artery
a. significant stenosis by intimal flap
b. severe renal contusion
c. segmental renal artery branch injury
Renal artery stenosis is present in 77% of hypertensive
patients!
Renal artery stenosis is present in 32 49% of
normotensive patients!
1520% of patients remain hypertensive after
restoration of normal renal blood flow!
Clinical findings that suggest renovascular disease:
1.
2.
3.
4.

Onset of HTN <30 years and >50 years of age


Hypertension refractory to therapy
Accelerated / malignant hypertension
Unexplained large increases in blood pressure above
previously controlled / baseline values
5. Symptomatic hypertension