Acute and chronic calculous pyelonephritis: ICD code, symptoms, diagnosis, treatment

Calculous pyelonephritis is a secondary ailment in relation to urolithiasis. Inflammation significantly complicates recovery and, unfortunately, is very common. Pyelonephritis is called nonspecific inflammation of the kidney, affecting mainly the tubular organ system. This is the most common renal ailment. Calculous pyelonephritis is less common, is a secondary disease in relation to urolithiasis.

Calculous pyelonephritis

If in the usual case, the cause of pyelonephritis is infection in the kidney, most often hematogenous, the calculoform develops against the background of urolithiasis. Concrements in the kidney or urinary tract complicate the outflow of urine, and this environment is favorable for the development of microflora. Infection can penetrate the cup-and-pelvic system, into the urinary tract, into the parenchyma with blood from any inflammation focus. The most frequent pathogens include E. coli, Proteus microbes, Pseudomonas aeruginosa and others. Staphylococcal and streptococcal bacteria are of limited importance.

So, the combination of phosphoric calcium stones with proteome microbes leads to the formation of acute pyelonephritis with extremely painful symptoms. The fact is that microbes of the protein produce urease, which increases the pH of the urine. This promotes fermentation and decomposition of urine, which leads to accelerated formation of stones and the transition of inflammation to the purulent phase.

The appearance of calculous pyelonephritis is most often due to the fact that the patient may not know about the presence of stones. Kidney stones, especially in the first stages of the disease, do not manifest themselves in any way, but in combination with inflammation pose a serious threat to health.

Calculous pyelonephritis is more likely to affect women: they are sick in 2-3 more often than men, girls get sick 6 times more often than boys. In this case, kidney stones are common in women, and in men, stones in the ureters are more common.

In 70% of cases the inflammation is one-sided. As a complication, pyelonephritis is formed in 40% of cases of any kidney diseases. In 25% of cases leads to disability.

Code of disease according to ICD-10 - N20.9

Causes and pathogenesis of

Since the primary disease is urolithiasis, the causes of calculous pyelonephritis are the main causes of urolithiasis.

Most of these factors are completely eliminated:

• improper nutrition - lack of vitamins A and C, excessive increase in salt, canned, sublimed food leads to changes in the composition of blood and urine, which in turn provokes the deposition of stones and sand of all kinds;
• humid hot climate - constant sweating leads to an increase in the concentration of salts in the urine;
• supercooling is frequent, not single;
• bad water - excess or lack of certain salts in daily drinking inevitably leads to changes in the composition of urine and blood;
• prolonged bed rest - leads to violations of the circulation of organs, including kidneys, and this also contributes to the deposition of stones, and the development of a dangerous microflora.

A number of diseases, especially systemic ones, can also lead to the deposition of stones:

• chronic inflammation in the urinary tract can become both a cause of the appearance of stones and a source of pathogenic bacteria;
• diabetes mellitus, gout and other diseases associated with metabolic disorders;
• violation of outflow of urine for any reason, adenoma, stones, trauma.

The source of bacteria can be any chronic inflammatory disease - from the carious tooth to the infection of the urinary tract.

The nature of the stones - oxalate, phosphate, urate and so on, affect the course of the disease and the way of treatment. The nature of the stones does not influence the probability of inflammation itself.

Forms of

Classification of calculous pyelonephritis is associated with the characteristics of urolithiasis.

At the stage of inflammation is distinguished:

• acute - serous or purulent inflammation;
• chronic - does not have pronounced symptoms, but is much less treatable.

The number of stones is distinguished by an ailment caused by a single stone and multiple formations. Treatment of the first is much easier, because you only need to remove one stone.

Allocate one-sided and two-sided nature of the disease. The latter occurs in 30% of cases.

The infection, that is, the actual formation of inflammation, is possible in two ways:

• is hematogenous - the most common. The pathogenic microflora enters the kidneys with blood from the existing inflammation focus;
• is a urinogenic, ascending route, due to urinary tract infections;

The flow of calculous pyelonephritis is possible in three ways:

• the appearance of an acute form, usually associated with the obstruction of the urinary tract, then it passes into a chronic form;
• progression of a chronic inflammatory disease without exacerbations. Characteristic for stones in pelvis and cups, where they are less likely to interfere with the outflow of urine;
• chronic form with exacerbations associated with the movement and appearance of new stones.

Both acute and chronic form of pyelonephritis in its development passes through the following stages:

• latent - differs by a minimum of symptoms, often does not lead to pain or impairment in the outflow of urine;
• exacerbation is a marked deterioration in the condition. Symptoms are pronounced;
• remission is the stabilization of the condition against the background of the restoration of the normal outflow of urine. In the chronic course of the disease, exacerbations and remissions can alternate, significantly increasing the duration of treatment.

Signs and symptoms

The clinical picture of calculous pyelonephritis, especially chronic, is more like an exacerbation of urolithiasis than actual inflammation. At the latent stage, pronounced characteristic symptoms are not observed. At an exacerbation the symptoms of inflammation are superimposed on the characteristic signs of urolithiasis.

Symptoms can be divided into general and special.

Common - little different from the signs of any inflammatory disease:

• decreased appetite, weight loss, the latter is not always observed;
• poor sleep;
• weakness, headaches, loss of efficiency;
• possible increase in blood pressure;
  pallor of the skin and mucous membranes;
• facial pastosity - with chronic pyelonephritis this symptom is absent;
• may cause pain in the lower back with a deep breath.

Specific appear in the acute course of the disease or with exacerbation of chronic pyelonephritis.

They are characterized by a triad of signs:

• fever - chills, fever up to 39 C;
• pain in the lower back is aching, sometimes very severe, one- or two-sided, depending on the form of the disease. Pain can be given to the hip, abdomen, groin;
• dysuria - difficulty in urination, frequent desires. This sign is not so much the pyelonephritis itself, but the associated cystitis.

In addition, there are signs of intoxication: vomiting, nausea. If the disease is severe, the urine is cloudy, often with blood. When settled, gives a cloudy purulent precipitate.

Acute inflammation in the background of multiple stones is accompanied by all signs of urolithiasis during the period of exacerbation:

• renal colic is an acute severe back pain irradiating in the hypochondrium, in the groin. With the departure of the stone, the pain is markedly increased;
• hematuria - blood appears in the urine;
• departure of stones and sand;
• obstruction of the urinary tract if the stones are not located in the kidneys.

With the progression of the disease, symptoms of chronic renal failure are added to the described symptoms: polyuria, nocturia, a constant thirst.
On the video about the causes and symptoms of calculous pyelonephritis:

Diagnosis

In the latent stage, when the stones do not manifest themselves at all, and the symptoms of inflammation are very weak, the ailment is often found randomly - by examination. In case of flaccid flow or in an easy stage, the symptoms are also of low specificity, and for laboratory diagnosis it is necessary to conduct laboratory tests.

As a rule, the analysis of urine and blood can diagnose inflammation only during an exacerbation:

• A general blood test - leukocytosis, an increase in ESR, there are signs of anemia.
• General urine analysis - microhematuria, pronounced leukocyturia, protein can be detected. The more pronounced the disease, the more microbial bodies are found in the urine. However, with occlusion - blockage of outflow from one kidney, there is no change in urine.
• Characteristic changes in the acidity of urine: an alkaline reaction indicates the probability of formation of phosphate stones, acidic - the possible formation of oxalate and urate.

Special samples are more informative:

• Nechiporenko test demonstrates the prevalence of leukocyturia over erythrocytic;
• sample according to Zimnitsky - indicates a decrease in the density of urine;
• bacterial culture not only informs about the presence of pathogenic microflora, but also allows isolating the pathogen.

For diagnostics use several different methods:

• Overview radiography - chronic pyelonephritis leads to a change in the size of the kidney, which is clearly seen in the picture. However, some types of stones - urate, for example, while not being detected.
• ultrasound is the safest way. Identifies all kinds of stones and sand in the kidney and urinary tract.
• Excretory urography - allows you to detect changes in the shape and size of cups, forties, and decreased urinary tract tone.
• Radioisotope radiography - allows detecting a decrease in the secretory-excretory function of organs, from two or one side.
• Chromocystoscopy - with calculous pyelonephritis diagnoses a violation of excretory function.
• Renal angiography - the method is used in complex cases. With its help assess the state of the vessels in the kidneys.
• MRI and CT give the most complete picture of lesions and changes in the kidneys. Typically, this method is used in complex forms of the disease to choose a method of treatment.

Treatment of

Calculous pyelonephritis is a consequence of two active diseases. Accordingly, treatment should include both removal of stones, and methods to combat inflammation. Usually, conservative therapy is used - anti-inflammatory drugs and drugs for removing stones. With a large neglect of the disease resorted to crushing or even removing stones.

Conservative

The course of treatment is selected individually: the main clogging stage, the severity of the inflammatory process, the degree of obstruction of the urinary tract. Pathological disorders in the kidneys or their absence, the nature of bacterial microflora - all this determines the use of certain drugs. But, since it is a question of stones in the kidneys or ureters, the primary goal of therapy is to restore the normal outflow of urine.

• With a slight exacerbation or at a chronic stage, drugs are prescribed for the removal of stones. The choice of a medicine depends on the type of formations: for example, uralite is prescribed for the removal of urate stones, and bleach preparations for citric acid. As a more gentle method, the water load is used: the patient drinks 1.5-2 liters of warm tea for half an hour, and then spasticy is administered to him - 5 ml of baralgin, for example, and diuretics - 20-40 mg of furosemide.
• With renal colic, baralgin and thermal procedures are prescribed.
• Antibiotic therapy lasts from 2 to 6 weeks, conducted in courses of 7-10 days. The preparations are changed depending on the results of the repeated bacterial culture and the clinical effect. And, since the treatment of calculous pyelonephritis is possible even at home, the choice is also determined by this factor.

• In acute community-acquired pyelonephritis, penicillin group preparations are prescribed - amoxicillin, ampicillin, or oral cephalosporins - cephalexin, cefuroxime.
• In the case of acute nosocomial at the background of ongoing treatment, fluoroquinolines, as well as cephalosporins II-III, are included in the therapy.
• When outpatient treatment begins with protected penicillins - carbenicillin, amoxicillin, as well as oral cephalosporins.

Calculous pyelonephritis in a chronic form is prone to relapse. After the end of the main course of treatment, anti-relapse therapy is prescribed. They last from 3 to 12 months, 7-10 days a month. Drugs are prescribed depending on the nature of the illness.

Surgical methods

If conservative methods are not effective enough, resort to instrumental methods. The most common of these is lithotripsy, a method of removing stones without surgery.

There are 3 types of lithotripsy:

• remote - stones are crushed with shock waves. The method is used with an average size of formations - no more than 2 cm;
• contact - in the ureter or in the pelvis of the kidney, looking where the stone is located, enter the endoscope. Then, using ultrasonic waves, a stone is crushed into minute debris, which is simply washed away. It is possible to use pneumatic lithotripsy when a stone is broken by pulses or a laser - the latter ensures the removal of the largest and densest formations. However, when the patient is in a serious condition, the contact method is not allowed;
• percutaneous - endoscope is injected through the puncture of the skin in the lumbar region. This method is shown with coral stones, which are difficult to remove by other methods.

In general, surgical intervention is not indicated for this ailment. However, in case of a serious condition of the patient - purulent pyelonephritis, kidney decapsulation can be prescribed - removal of the fibrous capsule, pyelonephrosmus and the installation of drainage in the renal pelvis. This removal of stones is possible only if the action slightly increases the volume of the operation.

Purposeful removal of stones is carried out only if the ureter obstruction can not be eliminated in any other way.

In the most severe cases - xanthogranulomatous pyelonephritis, partial renal excision is performed.

Folk methods

Phytogens are only applicable during remission. In acute condition, diuretic herbal preparations will not improve the condition.

The most common means are mineral water of the appropriate type. In the period of remission patients are prescribed treatment at resorts of the Truskavets type. With a small amount of stones and no obstruction in the urinary tract, treatment with mineral water is sometimes sufficient.

It should be noted that the type of mineral water is selected depending on the nature of the stone. If the choice is wrong, you can achieve the opposite result - increasing the stones instead of reducing them.

Herbal preparations - kanefron, kidney tea, phytolysin, have a mild diuretic effect and prevent the deposition of stones.

Diet

It is compulsory to follow the prescriptions of a dietitian. And the nature of the diet is also determined by the type of stones.

• During an exacerbation the patient should observe table №7а, and later - №7.
• If urate stones were detected during the examination, the daily diet excludes smoked and roasted meat, by-products, dried fish and even broths.
• If phosphate stones are found, meat in the diet is compulsory. It is necessary to exclude dairy products, as well as beans - beans, peas, beans.
• With oxalate stones, consumption of sorrel, greens, tomatoes and tomato paste is limited.
• The amount of water is not limited. A minimum of 1.5-2 liters per day.

Forecasts

The prognosis is determined by the stage of development of the disease. With prolonged course, microbial resistance, purulent complications, and so on, a complete cure becomes very problematic. According to statistics, 10-20% of patients develop chronic renal failure.

In the absence of treatment, calculous pyelonephritis is complicated by hydronephrosis, parainfrit, anemia, acute renal failure, and so on.

One hundred percent recovery can be achieved only with the early diagnosis of the disease.

Calculous pyelonephritis is a fairly common complication of urolithiasis. Unfortunately, often secondary inflammation causes the patient to pay attention to aching pain and undergo a kidney examination.