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468
K. Sterner and A. Krishnaraj
Fig. 42.6 Loculated pleural effusions. (a) Conventional radiograph of
the chest demonstrates bilateral oval opacities, which are consistent
with loculated pleural uid along the ssure as seen in CECT axial section through the level of the heart (arrows, b). Dotted arrows in (b) also
Conventional Therapy
Ascites
Medical therapy is the initial therapeutic strategy in most volume overload states [18]. The rst-line treatment in alcoholrelated cirrhosis is cessation of alcohol [18]. In both heart failure
and cirrhosis, sodium restriction and diuretics are used [12, 18].
Volume is removed via dialysis in renal failure. Management of
demonstrate trace-dependent simple pleural effusions. (c) Different
patient, CECT axial section through the chest illustrates a loculated
pleural effusion with lenticular shape (arrow)
malignant ascites initially involves chemotherapy and/or surgical debulking of the tumor depending on the type of cancer.
Key Point
Refractory ascites is dened as uid overload that is
unresponsive to medical management. TIPS may be
indicated in this patient population (refer to Chap. 38)
[12, 18].
42 Ascites andPleural Eusion
469
Fig. 42.7 Parapneumonic effusion. (a) Conventional radiograph dem-
onstrating left pleural effusion obscuring the left heart border (arrow) as
well as left upper and lower lobe consolidative opacities (circle). (b)
Fig. 42.8 (a, b) CECT axial section through the chest. There is a small empyema in the left pleural space as demonstrated by loculated pleural
uid (*) with thickened, enhancing pleura (arrows) indicating split pleura sign
Same patient, CECT axial section through the chest demonstrates a left
simple pleural effusion (ROI with HU of 5) and left upper and lower
lobe pneumonia (arrow)
Pleural Eusion
Medical treatment of pleural effusion is indicated when the
patient is symptomatic. Treatment options are aimed at
addressing the underlying disease: diuretics in CHF, dialysis
in renal failure, and optimized nutrition in nephrotic syndrome or hypoalbuminemia. Parapneumonic effusions typically resolve with appropriately targeted antibiotic therapy.
If a parapneumonic effusion persists or develops into an
empyema, percutaneous or surgical drainage is warranted.
Malignant pleural effusions are managed with treatment of
the underlying cancer. When standard chemotherapy and
radiation therapy fail, treatment options are typically palliative to manage the symptoms of the effusion.
Surgical options for malignant pleural effusion include
video-assisted thoracoscopic surgery (VATS) pleurodesis,
pleuroperitoneal shunting, or surgical pleurectomy/decorti-
470
K. Sterner and A. Krishnaraj
Fig. 42.9 Chest ultrasound (US). (a) Anechoic uid (*) is seen within
the pleural space, consistent with a simple pleural effusion. Thick arrow
points to the lung. (b) Additional chest US of a different patient demon-
cation [9]. Pleurodesis is the elimination of the pleural space
to prevent uid accumulation using a sclerosing agent such
as talc, bleomycin, or, less commonly, doxycycline [10].
Pleurodesis often fails when the lung is unable to be fully
re-expanded [10]. Thoracoscopic placement of a pleuroperitoneal catheter is rarely performed due to high rate of catheter failure, risk of infection, and tumor seeding. Pleurectomy
and decortication are options for refractory malignant pleural effusions; however there is a signicant morbidity and
mortality rate with this procedure [10].
Interventional Therapy
Ascites
Any new-onset ascites or ascites with new fever, encephalopathy, decreased renal function, metabolic acidosis, and/or
abdominal pain should be further investigated by paracentesis with ascites uid analysis [12]. Additionally, serial large
volume paracenteses (>5L) are performed for patients with
refractory ascites due to cirrhosis or malignancy. For patients
with refractory ascites, frequently palliative patients, a tunneled paracentesis catheter can be placed in a similar fashion
to a tunneled thoracentesis catheter so that they can remove
ascites uid without needing to come to the hospital.
Paracentesis is a minimally invasive procedure and
requires basic pre-procedure preparation. Prior to performance of the procedure, a thorough review of the patient’s
history, indication for procedure, history of prior procedures,
strates a complex pleural effusion indicated by anechoic uid pockets
(*) with septations (arrows)
surgeries, and medications should be conducted. Previous
imaging, if available, should be reviewed to assess volume of
ascites and anatomy. Pre-procedure labs including INR and
platelet count should be checked to assess bleeding risk.
Acceptable parameters based on consensus guidelines
include an INR ≤2.0 and platelets ≥50,000/μL [19, 20]. It is
important to review the patient’s medications and look for
any medication that may increase the patient’s bleeding risk.
Medications to hold include [19–21]:
• High-dose aspirin used for primary prevention: Hold for
7days prior to procedure
• Clopidogrel: Only hold if out of cardiac stent safety window. Hold for 5days before procedure.
• Warfarin: Hold for 5 days before procedure or reduce
dose until INR is between 1.5 and 2.0. If necessary,
bridge with heparin or low-molecular-weight heparin
(LMWH).
• Heparin: Hold for 2h before procedure.
• LMWH: Hold for 12h before procedure
Before the procedure begins, informed consent is obtained
from the patient. The only absolute contraindications to
paracentesis are disseminated intravascular coagulation and
brinolysis [5].
The patient is positioned supine in the procedure room.
The abdomen is examined for signs of infection, varices, surgical scars, or hematoma, which should be avoided when
performing the procedure. Ultrasound examination is recommended to assess the volume of ascites and help identify an
42 Ascites andPleural Eusion
471
appropriate location for the procedure [14]. The chosen site
should be devoid of bowel and blood vessels along the anticipated tract of the access needle. Ultrasound can also be used
to help guide the needle into the peritoneal cavity and ensure
appropriate anesthesia along the needle tract. Typical sites of
entry include the right lower quadrant, left lower quadrant, or
midline, 2cm below the umbilicus. The lower quadrants are
preferred in order to avoid underlying organs including the
liver and spleen and abdominal varices in cirrhotic patients.
When choosing a lateral approach, care should be taken to
avoid the inferior epigastric arteries by inserting the needle
lateral to the rectus sheath and assessing for these vessels via
color Doppler ultrasound.
The How To: Paracentesis
1. Choose appropriate site of needle entry by physical
exam, imaging review, and bedside ultrasound.
Evaluate with color Doppler to ensure lack of vas-
42.10a).
2. As with any procedure, lidocaine is essential for
patient comfort. It is important to make sure that the
parietal peritoneum is anesthetized adequately to
prevent procedure-associated pain
3. To help facilitate paracentesis needle entry, a No.11
dermatotomy.
4. A valved paracentesis catheter or catheter with a
syringe on the back is advanced through the anesthetized tract with or without ultrasound guidance. The
Z-track technique helps to facilitate skin closure and
prevent leakage of ascites: the skin is pulled in a caudal direction while the needle is being advanced. A
loss of resistance will be felt when the peritoneal
cavity is entered and the syringe or back of the nee-
42.10b).
5. Holding the hub of the needle in place, advance the
catheter over the needle followed by removal of the
needle.
6.
removed via wall suction into a canister, a negatively pressurized glass bottle, or by manual aspiration. Ultrasound can be used to assure complete
42.10c).
7. The catheter can then be safely removed and a sterile
bandage or Dermabond applied.
After the procedure is complete, the primary operator
should assess for bleeding or uid leakage. Patients should
also be given instructions on when to restart medications;
most medications can be restarted immediately or 12 h
after the procedure.
Complications are rare if proper technique is followed
[22]. Potential complications include pain, hemorrhage/
hematoma which in severe cases may require embolization
of the causative vessel, infection, intra-abdominal organ
injury, or persistent leakage of ascites [6]. Paracentesisinduced circulatory dysfunction (PICD) can occur after
large volume paracentesis. PICD is characterized by hypotension, hyponatremia, and increased plasma catecholamine and renin levels. A decrease in systemic vascular
resistance and accentuation of vasodilation lead to activation of the renin-angiotensin- aldosterone system, potentially resulting in hepatorenal syndrome and death. If 5 or
more liters of uid are removed, albumin is infused
(6–8g/L IV) at the end of the procedure to prevent PICD
[6, 23, 24].
Key Point
Complications following paracentesis:
• Hemorrhage/hematoma
• Infection
• Intra-abdominal organ injury
• Paracentesis-induced circulatory dysfunction
Pleural Eusion
Drainage of pleural uid collections is performed by a variety of methods and based on indication. A thoracentesis is
performed if a simple drainage of uid is required or a diagnostic sample must be obtained to further characterize a new,
unexplained effusion [10, 25]. A thoracostomy tube can be
placed for temporary continuous drainage, as in empyema or
unresolving parapneumonic effusion [25–27]. A tunneled
pleural catheter is used for patients with pleural uid that
reaccumulates despite drainage, e.g., malignant effusion
[25–27]. To accomplish this on an outpatient basis, the pleural catheter is tunneled through the skin to prevent infection
and allow the patient ease of access to the tube.
It is recommended that ultrasound guidance be used during
a thoracentesis to prevent complications as well as increase
472
K. Sterner and A. Krishnaraj
Fig. 42.10 Ultrasound-guided paracentesis of the right lower quadrant
(RLQ). (a) Color Doppler box demonstrates no vascularity in the
planned location of paracentesis. (b) The paracentesis needle (thin
success rate for small effusions [27–29]. The use of continuous ultrasound has been shown to reduce the risk of pneumothorax from 10 to 30% without image guidance to 0–5% with
image guidance [28, 29]. CT is an alternate imaging modality
which can be used for guidance; however it is typically more
costly, exposes the patient to ionizing radiation, limits patient
positioning, and may have limited availability.
Thoracentesis is a minimally invasive procedure with
similar pre- and post-procedure care as paracentesis. The
only absolute contraindication is uncorrectable coagulopathy. Relative contraindications for thoracostomy tube placement and tunneled pleural catheter placement include the
presence of a thick pleural peel, loculated collections, or a
central obstructing mass, as lung re-expansion may not be
achieved [25, 26].
arrows) is visualized traversing the subcutaneous tissues (block arrow),
peritoneum (dotted arrows), and into the ascites. (c) Status postparacentesis. The volume of ascites has signicantly decreased
The How To: Thorcentesis
1. Position the patient sitting upright on the edge of a
bed, leaning forward with arms resting on a bedside
table. Alternatively, the patient can be positioned in
a lateral recumbent or supine position if the patient
is unable to sit upright.
2.
Ideally, access should be obtained 1–2 intercostal
spine, and above the 9th rib to avoid subdiaphragmatic puncture. The site should be just above a rib
to avoid injury of the neurovascular bundle which
42.11a, b).
(continued)
42 Ascites andPleural Eusion
473
Fig. 42.11 Thoracentesis with and without pleural tube placement. (a)
Right chest ultrasound. There is a large right pleural effusion (*) with
collapsed lung (arrow). (b) Color Doppler demonstrates absent vascularity in the projected needle path. (c) Thoracentesis needle advanced
within the pleural space (arrow). (d) Post-procedure image demonstrates smaller pleural effusion (*) with re-expansion of the underlying
lung. (e) AP chest radiograph with pigtail pleural drain in the left lower
pleural space (arrow)
474
K. Sterner and A. Krishnaraj
3.
dermatotomy.
4. Attach a syringe to a rigid access needle with an
overlying catheter. Using ultrasound guidance,
advance the needle in the same path as the lidocaine
tract while holding negative pressure on the syringe.
42.11c).
5. While holding the needle still with one hand, use
the other to advance the catheter over the needle
and remove the needle.
6. If only a diagnostic sample is needed, attach a large
syringe via a three-way stopcock and aspirate the
appropriate volume. .
7. For large volume thoracentesis, attach drainage tubing to the stopcock and attach the other end to a oneway bag collection system or evacuation chamber.
with the syringe and push the syringe to drain into
the bag or evacuation chamber. Alternatively a negatively pressurized glass canister can be used to pull
patient starts to experience pain or excessive cough-
ing an initial encounter due to the small risk for
re-expansion pulmonary edema [30].
8. Once completed, remove the catheter during expiration. Cover the site with an occlusive dressing.
Post-procedure imaging can be performed using
42.11d).
The How To: Tube Thoracostomy
1.
instead of a thoracentesis needle.
2. Using the Seldinger technique, insert a guidewire
through the needle and remove the needle.
3. Advance the appropriate sized dilator for the pleural catheter being used over the wire followed by a
12–14G pleural catheter. Remove the guidewire.
Attach to a drainage unit with continuous suction at
O.
2
4. Suture the catheter to the skin and/or apply an
42.11e, f).
The How To: Tunneled Pleural Catheter
1.
guidewire is within the pleural cavity.
2.
pleural access site.
3. Anesthetize the entry site and projected tract of the
tunnel with 1% lidocaine.
4.
the pleural catheter and blunt dissect with a Kelly
clamp.
5. Advance the tunneler with catheter attached through
the skin nick and through the pleural entry site
while staying within the subcutaneous tissues.
Remove the tunneler from the catheter.
6. Advance dilator over the guidewire followed by a
peel-away sheath.
7. Remove the guidewire and quickly insert the
pleural catheter through the peel-away sheath.
“Crack” the peel-away sheath and remove while
maintaining forward pressure on the catheter.
Once the sheath is removed, the catheter should
-
be entirely under the skin. Attach the catheter to a
drainage bag.
8. Suture the catheter to the skin at the skin entry site.
Close the incision at the pleural entry site with a
subcutaneous suture or Dermabond.
After the procedure, it is important to monitor the patient
for 30min to 1 h to ensure that no complications, such as
pneumothorax, have occurred. A post-procedure radiograph
is typically obtained after a thoracentesis if the operator is
concerned for a complication or when a tube is placed to
ensure proper positioning. Pleural catheters are ushed every
8h with 5–15mL of saline and daily output is recorded [27].
When daily drainage has decreased to 100–200mL, a chest
radiograph is obtained to assess for a remaining collection
[28]. If the lung is appropriately re-expanded, the tube can be
removed or the patient can proceed with pleurodesis for
malignant effusions.
As in paracentesis, complications are uncommon [29].
The main complication is development of an iatrogenic
pneumothorax [26]. A pneumothorax develops when air
from the atmosphere ows into the pleural space through
the open needle or via injury to the lung during the procedure. When attaching the catheter or inserting guidewires,
make sure that the hub of the needle or catheter is covered at
42 Ascites andPleural Eusion
475
all times; this risk is mitigated with valved catheters.
Additional complications include bleeding, infection, pain,
intra- abdominal organ injury secondary to low access site,
and tube malfunction [26]. Tube malfunction occurs when
clot forms in the tube or if the tube is kinked or malpositioned. If the collection is loculated, the tube may not drain
appropriately. Fibrinolysis with tPA can be used in this situation. Rarely, re-expansion pulmonary edema can occur
after large volume thoracentesis [29]. This is characterized
by unilateral pulmonary edema after the lung has re-inated
status post- thoracentesis although the etiology for this complication is poorly understood. To minimize the risk of reexpansion pulmonary edema, it is advised to remove no
more than 1500 mL in a single session or no more than
500mL/hour in a continuous drainage system although this
may vary by institution [29, 30].
Key Point
Complications following thoracentesis:
• Iatrogenic pneumothorax
• Bleeding
• Infection
• Intra-abdominal organ injury
• Re-expansion pulmonary edema
References
1. Kumar V, Abbas AK, Fausto N, Aster JC.Pathologic basis of disease. 8th ed. Philadelphia: Saunders; 2010.
2. Runyon BA.Management of adult patients with ascites due to cirrhosis: update 2012. Hepatology. 57(4), 2013:1–26.
3. Kuiper JJ, van Buuran HR.Ascites in cirrhosis: a review of management and complications. Netherlands. JMed. 2007;65(8):283–8.
4. Pedersen JS, Bendtsen F, Moller S.Management of cirrhotic ascites. Ther Adv Chronic Dis. 2015;6(3):124–37.
5. Thomsen TW, Shaffer RW, White B, Setnik GS. Paracentesis. N
Engl JMed. 2006;355(19):e21.
6. McGibbon A, Chen GI, Peltekain KM, Veldhuyzen van Zanten
S.An evidence-based manual for abdominal paracentesis. Dig Dis
Sci. 2007;52:3307–15.
7. Froudarakis ME. Diagnostic work-up of pleural effusion.
Respiration. 2008;75:4–13.
8. McGrath EE, Anderson PB.Diagnosis of pleural effusion: a systematic approach. Am JCrit Care. 2011;20(2):119–27.
9. Medford A, Maskell N. Pleural effusion. Postgrad Med
J.2005;81:702–10.
10. Karkhanis VS, Joshi JM.Pleural effusion: diagnosis, treatment, and
management. OAEM. 2012;4:31–52.
11. Webb WR.The pleura and pleural disease. In: Webb WR, Higgins
CB, editors. Thoracic imaging. 3rd ed. Philadelphia: Wolters
Kluwer; 2017. p.660–98.
12. Gore RM, Silvers RI, Newmark GM, Gore MD.Ascites and peritoneal uid collections. In: Gore RM, Levine MS, editors. Textbook
of gastrointestinal radiology. 4th ed. Philadelphia: Elsevier; 2015.
p.2024–35.
13. Thoeni RF. The role of imaging in patients with ascites. AJR.
1995;165:16–8.
14. Bard C, Lafortune M, Breton G. Ascites: ultrasound guidance or
blind paracentesis. CMAJ. 1986;135:209–10.
15. Hanbidge AE, Lynch D, Wilson SR. US of the peritoneum.
Radiographics. 2003;23:663–85.
16. Management YH.Of pleural effusion, empyema and lung abscess.
Semin Intervent Radiol. 2011;28(1):75–86.
17. Soni NJ, Franco R, Velez MI, Schnobrich D, Dancel R, Restrepo
MI, etal. Ultrasound in the diagnosis and management of pleural
effusions. JHosp Med. 2015;10(12):811–6.
18. Pericleous M, Sarnowski A, Moore A, Fijten R, Zaman M.The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: a review of current guidelines and
recommendations. Eur JGastroenterol Hepatol. 2016;28(3):10–8.
19. Orman ES, Hayashi PH, Bataller R, Barritt AS.Paracentesis is associated with reduced mortality in patients hospitalized with cirrhosis
and ascites. Clin Gastroenterol Hepatol. 2014;12(3):496–503.
20. Patel IJ, Davidson JC, Nikolic B, Salazar GM, Schwartzberg MS,
Walker TG, etal. Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. JVasc Interv Radiol. 2012;23:
727–36.
21. O’Connor SD, Taylor AJ, Williams EC, Winter TC. Coagulation
concepts update. AJR. 2009;193:1656–64.
22. Barsuk JH, Cohen ER, Feinglass J, McGaghie WC, Wayne
DB.Clinical outcomes after bedside and interventional radiology
paracentesis procedures. Am JMed. 2013;126(4):349–56.
23. Sola-Vera J, Minana J, Ricart E, Planella M, Gonzalex B, Torras X,
etal. Randomized trial comparing albumin and saline in the prevention of paracentesis-induced circulatory dysfunction in cirrhotic
patients with ascites. Hepatology. 2003;37(5):1147–53.
24. Kwok CS, Krupa L, Mahtani A, Kaye D, Rushbrook SM, Phillips
MG, etal. Albumin reduces paracentesis-induced circulatory dysfunction and reduces death and renal impairment among patients
with cirrhosis and infection: a systematic review and meta-analysis.
Biomed Res Int. 2013;2013:1–8.
25. Lewandowski RJ, Desai SB, Nemcek AA. Treatment of effusions and abscesses. In: Mauro MA, Murphy KPJ, Thomson KR,
Venbrux AC, Zollikofer CL, editors. Image-guided interventions,
vol. 1. Philadelphia: Saunders; 2008. p.1615–27.
26. Hogg JR, Caccavale M, Gillen B, McKenzie G, Vlaminck J,
Fleming CJ, etal. Tube thoracostomy: a review for the interventional radiologist. Semin Intervent Radiol. 2011;28(1):39–47.
27. Patz EF, Erasmus JJ.Catheter drainage of intrathoracic collections.
In: Kandarpa K, Aruny JE, editors. Handbook of interventional
radiologic procedures. 3rd ed. Philadelphia: Lippincott Williams
and Wilkins; 2002. p.154–62.
28. McDermott S, Levis DA, Arellano RS. Chest drainage. Semin
Intervent Radiol. 2012;29(4):247–55.
29. Jones PW, Moyers P, Rogers JT, Rodriguez RM, Lee CG, Light
RW.Ultrasound thoracentesis. Chest. 2003;123(2):418–23.
30. Thomsen TW, DeLaPena J, Setnnik GS. Thoracentesis. N Engl
JMed. 2006;355(15):e16.
Obstructive Uropathy
LukeA.Byers andPaulJ.Rochon
Pathophysiology
Obstructive uropathy is a broad term to describe any obstruction
of the urinary tract: congenital or acquired, complete or partial,
temporary or permanent. Urinary obstruction can lead to the
development of hydronephrosis and subsequent renal injury.
The term hydronephrosis stems from Greek meaning “water
kidney condition.” The rst descriptions of an enlarged waterlled kidney date back to the time of Hippocrates. At that time,
urine was thought to be produced by the urinary bladder, and
thus the exact pathophysiologic mechanism was not well understood often leading to morbid treatments until a more modern
understanding emerged in the nineteenth century [1, 2].
Hydronephrosis is the result of inadequate drainage of urine
relative to the amount of urine produced by the kidney.
Inadequate drainage of the collecting system causes increased
pressure within the collecting system reected into the renal
tubules. In the acute setting (6–48h), increased pressure causes
increased intraparenchymal vascular resistance, but this phenomenon often normalizes after 48 h [3]. Long- standing
hydronephrosis can result in renal injury, brosis, and atrophy
of the affected kidney [4, 5]. When hydronephrosis is unilateral, the contralateral kidney hypertrophies to compensate for
the increased urine excretion. However, when both kidneys are
affected, urine will not be adequately excreted and can result in
electrolyte abnormalities and uremia, necessitating dialysis.
If the cause of the hydronephrosis is treated when the kidney
is still functioning with a GFR > 10mL/min/1.73 m
renal injury can be partially or completely reversible [6].
As such, determining acuity of the hydronephrosis and residual renal function is important for guiding management and
preserving renal function.
2
, the
43
Causes of hydronephrosis can be classied into functional
and obstructive etiologies. Functional hydroureteronephrosis
(kidneys + ureter dilation) is normally seen in 80–90% of
pregnancies, is more pronounced in primigravid patients, and
will resolve by 6weeks postpartum [7]. This is thought to be
due to ureteral compression at the pelvic brim with some
evidence suggesting hormone alterations, mainly progesterone, can enhance the collecting system dilation. The right
ureter is usually dilated more than the left due its acute angle
as it courses over the iliac vessels [8].
Obstructive hydronephrosis will have varying etiology
based on the patient’s age. In neonates and young children,
anatomic abnormalities including congenital stenosis at the
ureteropelvic/ureterovesicular junctions, vesicoureteral reux,
or posterior urethral valves are the most likely etiology. In
adults, the most common cause is urolithiasis; approximately
8.8% of adults in the United States have a history of at least
one urinary calculus with the highest incidence in obese white
males with a history of prior renal calculi [9]. In older adults,
benign prostatic hyperplasia and urothelial carcinomas should
also be considered, particularly in patients with hematuria.
Other causes include urinary tract injury (including iatrogenic), strictures, obstructing infections (nephritis, cystitis,
prostatitis), external compressing masses, and neurogenic
bladder with inadequate/ineffective voiding.
Key Point
Most common cause of obstructive hydronephrosis.
In neonates and young children:
• UPJ or UVJ congenital stenosis
• Vesicoureteral reux
• Posterior urethral valves
In adults:
L. A. Byers · P. J. Rochon (*)
University of Colorado, Department of Radiology,
Aurora, CO, USA
e-mail: luke.byers@ucdenver.edu; paul.rochon@udenver.edu
© Springer International Publishing AG, part of Springer Nature 2018
N. A. Keefe et al. (eds.), IR Playbook, https://doi.org/10.1007/978-3-319-71300-7_43
• Urolithiasis
• BPH
• Urothelial carcinoma
477
478
L. A. Byers and P. J. Rochon
Table 43.1 Signs and symptoms associated with hydronephrosis by
etiology
Urolithiasis Hematuria (gross or microscopic), ank pain,
Infection Fever, ank pain, costovertebral angle tenderness,
BPH LUTS
Urothelial
carcinoma
Neurogenic
bladder
a
Lower urinary tract symptoms (LUTS) – frequency, urgency, hesi-
tancy, incomplete voiding, nocturia, dribbling, poor stream
Table 43.2 Risk factors for causes of hydronephrosis
Urolithiasis Prior urolithiasis
Infection Age (prevalence increases in men with age,
Urothelial
carcinoma
Neurogenic
bladder
BPH Male
costovertebral angle tenderness, dysuria
pyuria, dysuria, frequency, incomplete voiding
a
Persistent hematuria, weight loss, fatigue, anemia,
frequency, urgency, incomplete voiding
Perineal anesthesia, LUTS
abuse/spinal cord injury/diabetes mellitus
Male > female
White race
Age
Hyperuricosuria
Hypercalciuria
Hyperoxaluria
Diabetes mellitus/metabolic syndrome
Gout
Urinary stricture/urinary stasis
decreases in women until age 65)
History of prior urinary tract infection
Diabetes mellitus
Recent sexual intercourse
Use of spermicide
Urinary stasis
Persistent bacteria in urine
Recent instrumentation or indwelling hardware
Age>65
Male >>female
Smoking
Industrial occupational history
Chronic cystitis
Lynch syndrome
Diabetes mellitus
Spinal cord injury
Multiple sclerosis
Pelvic surgery
Age
a
, history of alcohol
Hydronephrosis is often asymptomatic; however, when
symptoms are present, they can help narrow the etiology of
obstruction (Table43.1). Symptoms can be categorized into
upper urinary tract symptoms (innate to the kidney) and
lower urinary tract symptoms (LUTS, innate to the bladder
or prostate). Upper tract symptoms typically consist of ank
pain and costovertebral angle tenderness. LUTS presents
with frequency, urgency, hesitancy, incomplete voiding,
nocturia, dribbling, and poor stream. The presence of oliguria (<400–500mL per day in adults) or anuria (<50–100mL
per day in adults) in a well-hydrated patient should raise
concern for hydronephrosis. Risk factors for common
causes of obstructive uropathy in adults are listed in
Table43.2 [9–13].
Table 43.3 Society of Fetal Urology hydronephrosis classication
Grade 0 Normal
Grade 1 Mild dilated renal pelvis, normal parenchyma
Grade 2 Mild dilated renal pelvis and calyces with normal
pelvicalyceal pattern and parenchyma
Grade 3 Moderate dilated renal pelvis and calyces with blunting
and attening of the renal papilla ± mild cortical
thinning
Grade 4 Severe dilated renal pelvis and calyces with loss of
pelvicalyceal pattern and renal atrophy
Key Point
Oliguria is <400–500mL/day in adults.
Anuria is <50–100mL/day in adults.
In a well-hydrated patient, these raise the concern for
hydronephrosis.
Urologists grade the severity of hydronephrosis with
the anterior-posterior renal pelvic diameter (APRPD) system originating from the neonatal literature. Radiologists
use the Society of Fetal Ultrasound (SFU) grading system
(Table43.3), with several aspects also applied to the adult
patient. In order to use a consistent system, in 2014 a consensus statement endorsed by many pediatric urology and
radiology societies was published recommending the use
of a new urinary tract dilation (UTD) classication system
as a means to predict renal injury in neonatal hydronephrosis (Table43.4, Fig.43.1) [14, 15]. Despite these systems,
standard grading of hydronephrosis demonstrates low
inter-rater reliability in interpretation of severity when trying to differentiate different grades of moderate hydronephrosis [16].
Clinical Indication
With the many different causes of hydronephrosis, the
patient’s presentation can be very different depending on the
clinical scenario with hydronephrosis itself often being
symptomatically occult. The diagnosis is usually made on
subsequent imaging when urinary obstruction is suspected or
when biomarkers suggest the present of kidney injury (elevated creatinine or BUN, electrolyte abnormalities). Initial
testing can include transabdominal US ± Doppler or crosssectional imaging including CT. In patients with suspected
acute kidney injury, risk of further injury from intravenous
contrast should always be weighed against the diagnostic
utility added by IV contrast.
On US, hydronephrosis can be seen as increased renal
pelvis and calyceal size. In more chronic injury, the renal
cortex can become thinned, and the normal pelvicalyceal