By Dr Kenneth Orimma

CME, A&E, DEPT, PMH,

NASSAU BAHAMAS.
CASE PRESENTATION

63yr old black male from

Andros
CHIEF COMPLAINTS
 Right flank pain
 Mid back pain
 Nausea
 Vomiting
 Decreased appetite
 Frequency
 Poor urinary stream
HISTORY OF PRESENTING
COMPLAINTS
 3 days hx of right flank pain
 Pain sharp, radiating to groin & mid back
 Nausea, vomiting, frequency tremors,
poor stream
 Discharged from A&E 2days prior to
presentation
 Assessed as uncontrolled HTN, renal
insuff.
 Represented for worsening symptoms
HISTORY CONTINUED

PMH: HTN, BPH

PSH: Nil of note
SH: Nil of note
FH: HTN
Med Hx: Adalat 10mg
Lasix 40mg
Zantac 150mg
Prednesone 20mg
QUESTIONS

 What do you think

 What other information would you

like to know
DIFERENTIAL DIAGNOSIS

 Uraemia

 Obstructive uropathy

 Peri-nephric abscess

 Interstitial renal disease

PHYSICAL EXAMINATION
VITAL SIGNS:
 Temp 97.3

 Pulse 90/min

 BP 196/115

 Resp. Rate 20
PHYSICAL EXAMINATION

ABC: Airway normal

Breathing normal
Circulation normal
GCS 15/15

GEN: Acutely ill-looking

Severe painful distress
Restless, rolling all over the
bed
PHYSICAL EXAMINTION

RESP. NAD
CVS. NAD
ABD. Right flank tenderness
Point tenderness over [R]
renal angle
Kidney not ballotable
PR. Enlarged prostate, nodular,
firm, non-tender, no
blood on glove
 PHYSICAL EXAMINATION

MSS. NAD

CNS. NAD
QUESTION

What is the Diagnosis

WORKING DIAGNOSIS

 Acute renal failure secondary to

obstructive uropathy

 Uncontrolled HTN
INVESTIGATIONS

 FBC
 U&Es
 RBS
 ECG
 CXR
 AXR
TREATMENT
 IV baralgin 2.5g stat
 IV morphine 5mg
 IV maxalon 10mg
 Captopril 50mg po stat

 No pain relief
 Catheterized
 Putout 1.5 litres of urine
 Pain completely resolved
RESULTS
RESULT ON 1ST VISIT-1/04/09 RESULT ON 2ND VISIT-3/04/09
 WBC 8.3  WBC 17.9
 Hb 13.3  Hb 12.7
 HCT 36.5  HCT 36.1
 PLT 284  PLT 337

 Na 134  Na 131
 K 5.9  K 5.7
 CL 99  CL 96
 BUN 72  BUN 102
 Creat. 11.2  Creat 14.3
 Glu. 129  Glu 133
 Urinalysis NAD  Urinalysis NAD
DISPOSITION
Medical Consult
 Referred to med 2nd
 Assessment on review
 Acute medical problem as a result of a
chronic primary urological problem
 Urology to deal with primary pathology
Surgical Consult
 Referred to surgical 2nd
 Advised that should be discharged
 To follow up in urology clinic
DISPOSITION

Disposition contested
 Consultant in-charge informed
 Requested that case be referred
the surg. 3rd
Surgical 3rd review
 Assessment ; Renal failure ? Cause
 Advised urgent U/S
 Monitor urine out-put
 IVF
ULTRASOUND REPORT

 Both kidneys show pelvicalyceal dilatation

 Increased renal parenchymal echotexture
 Corticomedullary differentiation maintained
 Urinary bladder distended & thick wall
 Prostate not visualized
 Other organs normal
 Impression- hydronephrosis with cystitis
FINAL DISPOSITION

Patient was admitted to

urology service
OBSTRUCTIVE UROPATHY
INTRODUCTION
BACK GROUND
 Common cause of renal failure in ER
 Diff. pathological process cause this
uropathy
 Signs & symptoms are mild
 Requiring high index of suspicion
 Unilateral obstruction cause little or
no change in renal function
 Bilateral cause marked in renal
function
INTRODUCTION
PATHOPHYSIOLOGY cont’d
 Urine production in adult is about
1.5-2L/day
 Produced in the tubular systems &
empty into the calyces
 Pacemaker in the calyces generate
peristaltic forces
 This move urine in boluses into the
pelvis & further into the bladder
INTRODUCTION
PATHOPHYSIOLOGY cont’d

 This flow depends on 3 factors

-filtration pressure
-peristaltic pressure -20-
60cm water -hydrostatic
pressure -0-10cm water
INTRODUCTION
PATHOPHYSIOLOGY cont’d
 Acute obstruction at any level increase the
hydrostatic pressure
 Prolonged obstruction increase hydrostatic
pressure well above peristaltic pressure
 This high pressure is transmitted to the
nephrons resulting in injury & fall in GFR
 If obstruction is not relieved, thromboxane
A2 & angiotensin 2 are released which
decrease RBF and worsen GFR
INTRODUCTION

PATHOPHYSIOLOGY cont’d
 As RBF progressively falls
 Ischaemia & nephron loss results
 Obstructive uropathy results in
obstructive nephropathy
 Kidneys try to maintain excretory
function by urine re-absorption
called flow back
INTRODUCTION
PATHOPHYSIOLOGY cont’d
 This compensatory mechanisms are
-pyelosinus back flow
-pyelovenous back flow
-pyelolymphatic back flow

 Severity of nephropathy depends on

degree of obstruction & duration
INTRODUCTION
PATHOPHYSIOLOGY cont’d
 Study by Vaughan & Gillerwater
showed direct relationship b/w
duration of obstruction & loss of
renal function
 The study found that complete
recovery of RF occurred if
obstruction is relieved in 7days
 Permanent loss of RF occur if
obstruction last greater than 42
days
EPIDERMIOLOGY
FREQUENCY
 Annual incidence of unilateral
obstruction is 1:1000 in the US
 Approx. 12% of the population
develop calculi before age of 70yrs
 Bilateral obstruction is less common
with incidence of 1: 10,000
AGE
 Renal calculi 3rd decade of life,
recurrence rate 50% in 10yrs
 EPIDERMIOLOGY
SEX
 Urolithiasis, male: female ratio is 3:1
 Iatrogenic ureteral injury common
female
RACE
 Stones are more common in white
population in the US.
 Commonest in southeastern parts
 diet related
EPIDERMIOLOGY

MORTALITY
 Related to etiology, degree &
duration of obstruction
 Localized sequaele eg
perinephric abscess
 Systemic sequaele eg sepsis
 High mortality if untreated
CLINICAL PRESENTATION
HISTORY
 Abrupt diminution of urine flow
 Pain 2’ to stretching of the urinary
collecting system
 Alteration of patterns of micturition,
common with distal obstruction
 Acute or chronic renal failure
 Consider obstructive uropathy in
uremia without previous hx of renal
disease
CLINICAL FEATURES
HISTORY
 Microscopic or gross hematuria is
associated with stones, papillary
necrosis or tumors
 Recurrent UTI; should be
investigated for urinary obstruction
 Hx of recent gynecological or
abdominal surgery
 Pediatrics; recurrent UTI, voiding
dysfunction eg enuresis
 CLINICAL
HISTORY
FEATURES
 Occupational hx important in uropathy
 Bladder Ca is seen in factory workers eg
-textile
-rubber
-leather
-paint
-oil drilling
 Exposure to industrial chemicals
-N-benzidine,
-Phenacetin
-napthyline
CLINICAL FEATURES
PHYSICAL EXAMINATION
 Signs of dehydration
 Peripheral oedema, HTN, CCF
 Palpable kidneys
 Palpable bladder
 Rectal & pelvic exam shows
BPH/prostate ca
 External urethral exam may
show phimosis or meatal
stenosis
ETIOLOGY
OBSTRUCTIVE UROPATHY IN CHILDREN
 Urethral & bladder outlet obstruction
-urethral atresia
-phimosis
-meatal stenosis
-posterior urethral valve
-calculus
-blood clot
-neurogenic bladder
-ureterocele
OBSTRUCTIVE UROPATHY IN
CHILDREN
Urethral & bladder outlet obst. cont;’d
 Vesicoureteral reflux; more in female
 Ureterovesical jxn obstruction/stenosis
 Ureterocele
 Retroperitoneal tumour
 Megaureter as in prune belly syndrome
 Ureteropelvic jxn obstruction/stenosis
ETIOLOGY IN ADULTS
URETHRAL & BLADDER OUTLET
OBSTRUCTION
 Phimosis
 STD
 Trauma
 Blood clot
 Calculi
 BPH
 Ca prostate
 Ca Bladder
 Neurogenic bladder eg DM, spinal Dx,
MS
 OBSTRUCTIVE UROPATHY IN
ADULTS
URETERAL OBSTRUCTION cont’d
 Vesicoureteral reflux
 Calculi
 Blood clot
 Trauma
 Papillary necrosis-D.M, Sickle cell disease
OBSTRUCTIVE UROPATHY IN
ADULTS
EXTRA RENAL OBSTRUCTION
 Pregnant uterus
 Aortic aneurysm
 Ca ureter,ca colon, ca prostate, ca bladder
 Tuberculosis
 Sarcoidosis
 Petroperitoneal lymphoma
 Surgical ligation
 Fibroids
OBSTRUCTIVE UROPATHY

INTRARENAL OBSTRUCTION
 Crystal formation
-Sulfonamide
-acyclovir
 Protein casts
-multiple myeloma
-amyloidosis
 INVESTIGATIONS
IVU
 Goal standard for evaluating urinary
system
 Highly sensitive & specific
 Demonstrates structure & function

PLAIN RADIOGRAPHY
 Poor sensitivity & specificity
 Levine et al reported 45% sensitivity
for detecting ureteral calculi
INVESTIGATIONS
ULTRASOUND
 Detects renal calculi but poor at
detecting ureteral calculi
 Use limited to pregnant females
 Doppler sonography: measures
resistive index in renal arteries as
an indirect assessment of
obstruction
 Doppler also shows magnitude of
ureteral jet
 INVESTIGATIONS
CT SCAN
 Unenhanced helical CT has 95-98%
sensitivity & 96-100% specificity for
ureteral stone

 Detects both calcified & noncalcified

stones, shows their size & location
INVESTIGATION
NUCLEAR MEDICINE
 Radionucleotide is injected in a vein

 Passage through urinary tract is

monitored by gamma camera
 Demonstrates anatomy as well as
function
 Technique of choice is diuresis
renography
 Limitation- not performed in acute
setting
 MANAGEMENT OF OBSTRUCTIVE
UROPATHY
 Treatment of post renal or
obstructive ARF is urgent relief of
obstruction
 full renal recovery is said to be
possible after 1-2 weeks of total
obstruction in absence of infection
 serum creatinine level may not
return to baseline for several weeks
THANK YOU
 REFERENCES

 Allan BW. Renal failure, Rosen’s Emergency

medicine; concepts & clinical practice 6th
edition P1524-1555

 Andrew Krentz, Oxford handbook of clinical

and laboratory investigation. P423-458

 Samuel KM Emergency medicine on-call.

Lange publishers P414-416
 REFERENCES
 Richard L Degown. Diagnostic
examination McGraw Hill Publishers
P618-619

 Sameet Rao. Acute obstructive

uropathy, emedicine Radiology

 Michael Policastro etal; emedicine

Emergency medicine