Infeccion vias urinarias

3.  Infección bacteriana mas común en escenario ambulatorio.  USA: 8.6 millones de consultas (84% mujeres)  A los 32 años: el 50% de las mujeres han tenido un episodio de IVU

4.  Poco valor en forma rutinaria  Fiebre después de 3 días de tratamiento antimicrobiano activo  Hombre  Diabetes  IVU recurrente  Síntomas de urolitiasis

5.  Común  Síntomas de infección de tracto inferior  Fiebre + dolor y sensibilidad en flanco  Leucocitos y bacterias  Leucocitosis  Sepsis  En general respuesta rápida a antibióticos no ocupan imagen

6.  Limitada  Cálculos en tracto urinario  Gas en sistema colector (Pielonefritis enfisematosa)

7.  Poco sensible (solo 25% muestran anormalidades)  Partículas en sistema colector  Gas  Ecogenicidad anormal  Zonas hipoecoicas  Masas  Útil: hidronefrosis, absceso, infarto, colección perinefrica.

10.  Método mas sensible para tracto renal  Cálculos  Gas  Defectos en perfusión  Colecciones  Obstrucción

11.

12.

13. Older RA, Bassignani M. Teaching Atlas of Urologic Imaging. Thieme Medical Pub. (2008) ISBN:1604060166

14.  Embarazo  Imágenes hipointensas en T1  Hiperintensas en T2

15.

16.

17.

18.  Infección renal mórbida con formación de gas dentro o alrededor de riñón.  Progresión a Sepsis fulminante  Alta mortalidad

19.  Síntomas urinarios  Fiebre  Obstrucción de tracto urinario  Leucocitosis  Hiperglucemia (DM)  Trombocitopenia: mal pronostico

20.

21.

22.

23.

24.

25.

26.  Técnica de acceso percutaneo a riñón guiada por imagen con opcion a colocar catéter de drenaje permanente

27.  Obstrucción  Lesión de tracto urinario  Procedimientos (litos, stent)  Diagnostico (pielografia anterógrada) Contraindicaciones relativas • Trastornos en coagulación • Paciente no cooperador • Patología respiratoria severa

28.  Consentimiento informado  Vía de acceso venoso  Monitoreo continuo  Prono  Técnica de asepsia  Premedicar

29.  Ultrasonico o fluoroscopio  Anestesia local  Aguja calibre 18  Guía de 0.38  Medio de contraste soluble  Dilatadores de 7’9 Fr  Drenaje cola de cochino 8 Fr. Dyer RB, Regan JD, Kavanagh PV et-al. Percutaneous nephrostomy with extensions of the technique: step by step. Radiographics. 22 (3): 503-25.

30.

31. Dyer RB, Regan JD, Kavanagh PV et-al. Percutaneous nephrostomy with extensions of the technique: step by step. Radiographics. 22 (3): 503-25.

32. Dyer RB, Regan JD, Kavanagh PV et-al. Percutaneous nephrostomy with extensions of the technique: step by step. Radiographics. 22 (3): 503-25.

33.  Pattologia frecuente, mas en mujeres  Metodos de imagen recomendados en sospecha de complicaciones  Fiebre persistente a pesar del tratamiento

Editor's Notes

Urinary tract infection is the most common bacterial infection encountered in the ambulatory care setting in the United States, accounting for 8.6 million visits (84% by women) in 2007.1 The self-reported annual incidence of urinary tract infection in women is 12%, and by the age of 32 years, half of all women report having had at least 1 urinary tract infection. The incidence of cystitis (bladder infection) was 0.70 episodes per person-year in a study of college women starting a new contraceptive method3 and 0.07 episodes per person-year in a population-based study of postmenopausal women.4 Among young, healthy women with cystitis, the infection recurs in 25% of women within 6 months after the first urinary tract infection,5 and the recurrence rate increases with more than 1 prior urinary tract infection.6,7 Acute uncomplicated pyelonephritis is much less common than cystitis (estimated ratio, 1 case of pyelonephritis to 28 cases of cystitis),7 with a peak annual incidence of 25 cases per 10,000 women 15 to 34 years of age.8
Urinary tract infection is the most common bacterial infection encountered in the ambulatory care setting in the United States, accounting for 8.6 million visits (84% by women) in 2007.1 The self-reported annual incidence of urinary tract infection in women is 12%, and by the age of 32 years, half of all women report having had at least 1 urinary tract infection. The incidence of cystitis (bladder infection) was 0.70 episodes per person-year in a study of college women starting a new contraceptive method3 and 0.07 episodes per person-year in a population-based study of postmenopausal women.4 Among young, healthy women with cystitis, the infection recurs in 25% of women within 6 months after the first urinary tract infection,5 and the recurrence rate increases with more than 1 prior urinary tract infection.6,7 Acute uncomplicated pyelonephritis is much less common than cystitis (estimated ratio, 1 case of pyelonephritis to 28 cases of cystitis),7 with a peak annual incidence of 25 cases per 10,000 women 15 to 34 years of age.8
Nevertheless, routine performance of imaging studies in UTI are reported to be of little value, because the incidence of underlying abnormalities is low [10]. In particular, it has been advocated to perform radiologic imaging to those who remain febrile despite receipt of 3 days of active antimicrobial treatment [10–14]. Furthermore, imaging might be considered in men, diabetic persons, and patients with relapsing UTI or symptoms of urolithiasis [9, 15–17]. However, the scientific basis of these recommendations predominantly relies on expert opinion and small, observational, single-cen- Fever in patients with urinary tract infection (UTI) represents the presence of tissue inflammation that is considered to reflect acute pyelonephritis or urosepsis syndrome [1, 2]. It usually presents with mild disease, but it may cause substantial morbidity and mortality [3, 4]. Therefore, in clinical practice, the risk of complications should be assessed and alertness for under lying urologic abnormalities is part of the approach to the individual patient [5]. In this respect, ultrasonography of the urinary tract is frequently performed. It is noninvasive, readily available, portable, radiation free, and sensitive in detecting urinary obstruction and pyonephrosis [6–8]. Computed tomography (CT) is considered to be superior, but its use is limited as it requires potentially nephrotoxic contrast-enhancement [8, 9].
Acute bacterial pyelonephritis remains common and continues to have significant morbidity in certain patients groups. Epidemiology The incidence of acute pyelonephritis parallels that of lower urinary tract infections: approximately five times more common in females with a sharp increase following puberty 6. Clinical presentation Clinical presentation is fairly specific and classical in most cases, consisting of rapid onset of high fevers and flank pain and tenderness. In many instances less specific or non-urinary symptoms and signs may also be present which may lead to clinical confusion 1. White cells and bacteria are usually present in the urine, and blood tests reveal the expected changes: increased WCC, CRP and/or ESR. In severe cases, systemic sepsis may be present. In many instances patients respond promptly to antibiotics and no imaging is required.
Plain film Plain films have a limited role to play, especially if patients are likely to go onto CT. They may demonstrate obstructing urinary tract calculi and occasionally demonstrate gas within the collecting system (emphysematous pyelonephritis).
Ultrasound Ultrasound is insensitive to the changes of acute pyelonephritis, with most patients having 'normal' scan, and abnormalities only identified in ~25% of cases 1. Possible features include: particulate matter in the collecting system gas bubbles (emphysematous pyelonephritis) abnormal echogenicity of the renal parenchyma 1 focal/segmental hypoechoic regions mass like change Ultrasound is however useful in assessing for local complications such ashydronephrosis, renal abscess formation, renal infarction, perinephric collections, and thus guiding management.
Diffusely hypoechoic and thickened cortex with compressed renal sinuses.
A lobar nephronia refers to an intermediate stage between acute pyelonephritis andrenal abscess, and is a focal region of interstitial nephritis. It appears as a wedge of poorly perfused renal parenchyma, without a cortical rim sign. The condition is discussed further as part of the article on acute pyelonephritis. echogenic foci in the left kidney (upper pole lesion is mass-like and lower pole more wedge-shaped). Note absence of blood flow on colour Doppler Case Discussion: Lobar nephronia is a focal area of infection in the kidney prior to abscess formation. The swelling associated with infection in lobar nephronia causes reduced blood due to extrinisic compression of blood vessels traversing the region.
CT CT is the most sensitive modality for the renal tract, able to assess for renal calculi, gas, perfusion defects, collections and obstruction. Unfortunately it does have a significant radiation burden and should be used sparingly, especially in young patients. There is usually no need for a three or four phase CT IPV (CT urography). A single 45-90 second post contrast scan usually suffices, although clinical accumen is required to optimise the scan time and limit radiation 1,3. For example, if renal colic is suspected then a non contrast scan is often required to assess for renal calculi. If renal ischaemia is suspected than an arterial scan (15-25 seconds) is ideal to assess perfusion 3. Non-contrast CT Often the kidneys appear normal. Affected parts of the kidney typically may appear swollen and of lower attenuation. Renal calculi or gas within the collecting system may be evident.
Large BMI. Uncooperative patient. Ultrasound technically challenging. CT undertaken. Multiple focal low attenuation areas in the right kidney, suggestive of a pyelonephritis and a subcapsular collection, with maximum depth of 3.5cm. Poor venous access, resulted in a sub-optimal contrast enhanced scan - diagnostic discussion if subcapsular or perinephric collection. Mass effect from the collection, giving rise to a Page kidney.
At contrast enhanced CT or MR imaging, a thin (1-3 mm) rim of subcapsular enhancement is seen paralleling the renal margin. This is considered to be as a result of preserved perfusion of the outer renal cortex by capsular perforating vessels. The finding may be partial or total depending on the level of vascular occlusion. The cortical rim sign is useful in distinguishing lobar nephronia from a segmentalrenal infarct and is seen on contrast enhanced CT or MRI. The wedges of reduced enhancement seen in the setting of acute pyelonephritisrepresent oedema and ischaemia which involves the whole wedge or renal parenchyma, from medulla to the capsule. This sign seen as a result of cortical necrosis may also be seen in conditions like renal transplant rejection, intravascular haemolysis, shock, and as a consequence of obstetric complication.3 In segmental infarcts, the later blood supply to the very outer aspect of the cortex is derived from perforating branches of the renal capsular artery which is an early branch of the renal artery. As such, when a branch of the renal artery is occluded (by thromboembolism, dissection etc..) perfusion is preserved to a thin rim (2-4mm) of cortex which enhances normally. Unfortunately the cortical rim sign is only seen in approximately half of renal infarcts.
A striated nephrogram, originally described on plain film urography, but just as easily seen on CT urography represents linear bands of contrast extending from the medulla of the kidney towards the cortex. Pathology Striations result from stasis of contrast material in oedematous tubules that demonstrates increasing attenuation over time 4. Aetiology It is seen in a number of conditions: Unilateral striated nephrogram acute ureteric obstruction acute pyelonephritis acute renal vein thrombosis acutely following renal contusion acute radiation therapy to the kidney Bilateral striated nephrograms autosomal recessive polycystic kidney disease (ARPCKD) acute pyelonephritis acute tubular obstruction acute tubular necrosis hypotension
MRI MRI is usually reserved for patients who are pregnant, and findings mirror those seen on CT. The kidney demonstrates wedge shaped regions of altered signal: T1 - affected region(s) appear hypointense compared to normal kidney parenchyma T2 - hyperintense compared to normal kidney parenchyma T1 C+ (Gd) - reduced enhancement A fast inversion recovery sequence obtained after contrast administration has been shown to be particularly effective in outlining affected regions which appear hyperintense compared to the low signal parenchyma. The contrast is thought to represent a combination of local oedema, and decreased T2 signal due to Gadolinium in the perfused 'normal' portions 2.
26-year-old woman undergoing MRI evaluation of possible urethral diverticulum. A, Midline sagittal T2-weighted turbo spin-echo image (TR/effective TE, 6,000/116; flip angle, 180°) obtained at rest shows normal urethra and no evidence of prolapse. Solid line = pubococcygeal line, B = bladder, dotted line = urethra, U = uterus, V = vagina, R = rectum. B, Midline sagittal true fast imaging with steady-state free precession image (3.9/1.9; flip angle, 70°) obtained at maximal strain shows tricompartment prolapse, marked urethral hypermobility, and moderate cystocele. Solid line = pubococcygeal line, B = bladder, dotted line = urethra, C = cervix, arrow = anorectal junction. (See also Fig. S5B, cine loop, in supplemental data at www.ajronline.org.)
FIGURE 10. Hydronephrosis and pyelonephritis on a 31-year-old woman at 36 weeks of pregnancy with acute right-sided abdominal pain and fever. Axial steady state gradient-echo MR image (A) shows physiologically prominent parauterine vessels, seen bilaterally. The appendix is not reliably demonstrated. Coronal SSFSE T2W MR image through the cecum (arrow, B). The appendix cannot be identified. Axial contrast-enhanced CT image (C) shows mild right hydronephrosis and subtle, reduced perfusion in the right kidney. The appendix was not seen at CT, but the renal findings were considered suggestive of pyelonephritis. Urinary culture was found to be positive, and symptoms resolved with antibiotic treatment.
Emphysematous pyelonephritis (EPN) is a morbid infection of kidneys, with characteristic gas formation within or around the kidneys. If not treated early, it may lead to fulminant sepsis and carries a high mortality.
Flank pain, urinary tract obstruction with fever. Leukocytosis and hyperglycemia (in diabetics) are prominent lab findings. Thrombocytopenia is particularly associated with poor prognosis 3. Pathology Aetiology It tends to be commoner in females. Approximately 90% of patients have uncontrolled diabetes1 . It may however also be seen in immunocompromised individuals or associated with urolithiasis, neoplasms or sloughing of papilla. Causative organisms include E. Coli - usually considered the commonest causative organism 3 Klebsiella pneumonia Proteus mirabilis
Plain film and fluoroscopy (IVP) May show mottled gas within renal fossa or crescentic gas collection within Gerota's fascia. Linear gas shadows along paraspinal region may also be seen, representing retroperitoneal air. with renal failure. The scout CT film shows pockets of air collection in right renal fossa. The NECT confirms the air collection to be in the perinephric space. Contrast study was not done due to poor renal parameters. Figuras 1 y 2. Radiografía PA de abdomen con presencia de gas en sistema pieloureteral derecho sin identificar en izquierdo por gas intestinal. Sonda vesical.
Left kidney is enlarged with poor corticomedullary differenciation. Linear air shodow is noted in left renal lower parenchymal and in perinephric region. Mobile debris is noted in urinarry bladder.
CT scan upper abdomen There are air pockets in right perinephric space.The right kidney was enlarged.
Percutaneous nephrostomy is a technique in which percutaneous access to thekidney is achieved under radiological guidance. The access is then often maintained with the use of an indwelling catheter. Indications urinary tract obstruction urinary diversion (e.g. ureteric injury; urine leak) access for percutaneous procedures (e.g. stone treatment; ureteric stenting) diagnostic testing (e.g. antegrade pyelography) 7 Contraindications Absolute contraindications usually none Relative contraindications uncorrectable bleeding diathesis (abnormal coagulation indices) uncooperative patient severe respiratory disease Procedure Pre-procedure evaluation review all available imaging to confirm the indication for the procedure and assess renal anatomy and establish safe access route to the kidney check full blood count and coagulation profile to assess the risk of haemorrhage obtain informed consent for the procedure obtain good peripheral IV access administer broad-spectrum IV antibiotics 1-4 hours prior to the procedure, if needed; septic patients are often already on parenteral antibiotics Positioning The procedure is performed with the patient in prone, prone oblique or lateral position, depending on clinical circumstances and patient comfort. Regular monitoring of the vital signs by a suitably trained staff member is recommended during the procedure. Clean skin with antiseptic solution and drape to maintain sterility for the procedure. Equipment ultrasound machine or fluoroscopy local anaesthesia with 1% or 2% lidocaine 18 gauge puncture needle, an alternative would be to use micropuncture set with a 21 or 22 gauge needle 0.38 stiff guidewire (an 0.018 guidewire is also used with a micropuncture set) water-soluble contrast media dilators ranging from 7-9 French pigtail drain (typically 8 French) Medications prophylactic antibiotics - typically a 3rd generation cephalosporin in selected patients, antibiotic use is not routine 3 analgesia (e.g. pethidine; fentanyl) - not routinely used, but can aid in co-operation in selected patients sedation - a short acting benzodiazepine (e.g. midazolam) may be used in selected patients Technique Two common techniques exist. The choice of technique depends on both operator and patient factors. One method utlilises a two- or three-part puncture needle and the other a micro-puncture kit. Using aseptic technique and following infiltration of local anaesthetic agent, the calyx (usually posterior calyx at the mid or lower pole) is punctured with an 18 gauge, two-part needle under ultrasound guidance. In the presence of renal tract obstruction, urine drains freely on removal of the stylet from the needle. A small volume of water-soluble contrast material can be injected to confirm correct needle position using fluoroscopy. A 0.035 guidewire is used to exchange the needle for a dilator and typically an 8 French pigtail drain is placed within the renal pelvis over the guidewire. On occasion a 6F or 12F catheter may be used, on an individual case basis. A urine sample can be sent off to the laboratory for microbiological studies. The catheter is left to drain freely. Postprocedural care Bed rest (typically 2-4 hours) with regular monitoring vital signs, provision of adequate analgesia are routinely indicated in the first few hours following the procedure. Fluid balance is regularly monitored, particularly in cases of urinary tract obstruction. Indwelling nephrostomy catheters are usually exchanged every three months 4, 7. It is essentially normal for the urine to be partly blood stained for the first 48-72 hours5. The patient should take great care with the nephrostomy tube, to avoid mal-positioning, despite the internal pigtail of the locked drain, skin anchoring stitch and adhesive plaster. Slippage is not uncommon but if alerted to medical staff early, nephrostomy salvage can be performed without re-puncture. Complications bleeding pneumothorax bowel injury and peritonitis urine leak catheter displacement - reported at ~20% after a few months 7
Percutaneous nephrostomy is a technique in which percutaneous access to thekidney is achieved under radiological guidance. The access is then often maintained with the use of an indwelling catheter.
Indications urinary tract obstruction urinary diversion (e.g. ureteric injury; urine leak) access for percutaneous procedures (e.g. stone treatment; ureteric stenting) diagnostic testing (e.g. antegrade pyelography) 7 Contraindications Absolute contraindications usually none Relative contraindications uncorrectable bleeding diathesis (abnormal coagulation indices) uncooperative patient severe respiratory disease
Procedure Pre-procedure evaluation review all available imaging to confirm the indication for the procedure and assess renal anatomy and establish safe access route to the kidney check full blood count and coagulation profile to assess the risk of haemorrhage obtain informed consent for the procedure obtain good peripheral IV access administer broad-spectrum IV antibiotics 1-4 hours prior to the procedure, if needed; septic patients are often already on parenteral antibiotics Positioning The procedure is performed with the patient in prone, prone oblique or lateral position, depending on clinical circumstances and patient comfort. Regular monitoring of the vital signs by a suitably trained staff member is recommended during the procedure. Clean skin with antiseptic solution and drape to maintain sterility for the procedure. Medications prophylactic antibiotics - typically a 3rd generation cephalosporin in selected patients, antibiotic use is not routine 3 analgesia (e.g. pethidine; fentanyl) - not routinely used, but can aid in co-operation in selected patients sedation - a short acting benzodiazepine (e.g. midazolam) may be used in selected patients
Equipment ultrasound machine or fluoroscopy local anaesthesia with 1% or 2% lidocaine 18 gauge puncture needle, an alternative would be to use micropuncture set with a 21 or 22 gauge needle 0.38 stiff guidewire (an 0.018 guidewire is also used with a micropuncture set) water-soluble contrast media dilators ranging from 7-9 French pigtail drain (typically 8 French)
Puncion de calices en polo inferior con aguja 18 Retirar estilete Contraste soluble para confirmar por fluoroscopia Guia y dilatador Cateter permanente Technique Two common techniques exist. The choice of technique depends on both operator and patient factors. One method utlilises a two- or three-part puncture needle and the other a micro-puncture kit. Using aseptic technique and following infiltration of local anaesthetic agent, the calyx (usually posterior calyx at the mid or lower pole) is punctured with an 18 gauge, two-part needle under ultrasound guidance. In the presence of renal tract obstruction, urine drains freely on removal of the stylet from the needle. A small volume of water-soluble contrast material can be injected to confirm correct needle position using fluoroscopy. A 0.035 guidewire is used to exchange the needle for a dilator and typically an 8 French pigtail drain is placed within the renal pelvis over the guidewire. On occasion a 6F or 12F catheter may be used, on an individual case basis. A urine sample can be sent off to the laboratory for microbiological studies. The catheter is left to drain freely.
Postprocedural care Bed rest (typically 2-4 hours) with regular monitoring vital signs, provision of adequate analgesia are routinely indicated in the first few hours following the procedure. Fluid balance is regularly monitored, particularly in cases of urinary tract obstruction. Indwelling nephrostomy catheters are usually exchanged every three months 4, 7. It is essentially normal for the urine to be partly blood stained for the first 48-72 hours5. The patient should take great care with the nephrostomy tube, to avoid mal-positioning, despite the internal pigtail of the locked drain, skin anchoring stitch and adhesive plaster. Slippage is not uncommon but if alerted to medical staff early, nephrostomy salvage can be performed without re-puncture. Complications bleeding pneumothorax bowel injury and peritonitis urine leak catheter displacement - reported at ~20% after a few months 7
Conclusiones

Infeccion vias urinarias

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