CASES

1. CASES DR ARCHA 10-04-08

2. CASE 1

3. A 42yrs old female presented with long h/o right flank pain, hematuria and worsening renal function • Her CT abdomen show right sided hydronephrosis and ureteral stricture with no e/o of any calculus. left kidney was normal. No other abnormality was found. • Rt. Renal nephrostomy and ante grade nephrostomogram were performed

4. Image shows opacification of club shaped cavities in the renal papillae via their communication with the calyces

5. Delayed image shows no progress of contrast past on area of smooth tapering where the iliac vessels cross the ureter

6. Differential diagnosis • Renal tuberculosis • Sickel cell disease • Retroperitoneal fibrosis causing ureteral stricture

7. Diagnosis • Renal and ureteral tuberculosis

8. Renal TB • It is the most common site of extrapulmonary involvement of tuberculosis. • Although definitive diagnosis of genitourinary tuberculosis is established by positive results on urine culture or histologic examination of biopsy or surgical specimens, diagnosis is often difficult and delayed. • Therefore, radiologic examination is used widely to determine the presence or absence of disease and to monitor the therapeutic efficacy in a clinical situation.

9. Tuberculosis of the kidney results from hematogenous seeding of M tuberculosis in the glomerular and peritubular capillary bed from a pulmonary site of primary infection • Despite hematogenous seeding of both kidneys, clinically and radiologically significant disease is usually limited to one side • Small granulomas form in the renal cortex bilaterally, adjacent to the glomeruli. A high rate of perfusion and favorable oxygen tension increase the likelihood of bacilli proliferating in this location

10. MYCO BACT. In blood stream from active site Microscopic granulomas in the cortices of both kidneys Enlargement of the tubercle Spontaneous resolution Complete healing Fibrosis Calcification Normal partial

11. Enlargement of tubercle Within the cortices Rupture in the nephrons Granuloma in the medulla & papillae TBbacilliuria Granuloma in the calyx, pelvis, ureter Coalescence & form cavity Which can communicate with the pelvicalyceal system Papillary necrosis Ulceration heal Or rupture into the perinephric space Perinephric abscess Stricture hydronephrosis / infundibular Stricture Hydrocalitosis / Hiked up pelvis

12. Ureteral changes • Ureteral changes are commonly encountered. • Initially, dilatation--as a result of vesicoureteral reflux due to bladder wall disease or stricture at the distal ureter. • ureteral filling defects (= mucosal granulomas) • Small ulcerations in the ureter may cause irregularity.

13. late changes: • "beaded ureter"=alternating areas of strictures + dilatations • "corkscrew ureter"=marked tortuosity with strictures + dilatations • "pipestem ureter"=rigid aperistaltic short thick and straight ureter • vesicoureteral reflux through "fixed" patulous orifice • ureteral calcifications

14. Renal damage from strictures is more than that by tuberculomas • THREE DANGER POINTS FOR FIBROSIS– • lower ureter • PUJ • neck of calyx---hydrocalicosis • So ureteric stenting is required in c/o stricture otherwise kidney will lose its function.

15. End stage renal TB • due to obstructive uropathy –leads to auto nephrectomy • Two types --- • Caseocavernous autonephrectomized kidneys –caseous filled sac with / without calcification • Shrunken,fibrotic, calcified kidney

16. Clinical features • The symptoms and signs -- dysuria, frequency and nocturia, gross hematuria, and flank pain. • Nonspecific systemic symptoms such as fever, anorexia, fatigue, and weakness may occurs. A p/O of pulmonary or other extraurogenital tuberculosis • an abnormalchest radiograph has been reported in up to 50% of patients • The definitive diagnosis is made only by demonstrating Mycobacterium tuberculi in urine or tissue specimen

17. PLAIN X-RAY Shows The dystrophic mottled and amorphous renal calcifications 1. small and scattered 2. linear / curvilinear lie in large diffuse areas involving most of the kidney.(25%) a "ground-glass" appearance. 3. lobar distribution –calcific rims along periphery or putty kidney is diagnostic for the renal TB 4. Triangular ring like calcifications within the collecting system are characteristic of papillary necrosis

18. Shows The dystrophic mottled and amorphous renal calcifications

19. STAGHORN STONE • Pelvic component • present (staghorn) • Dense calcification LOBAR CALCIFICATION • No pelvic component • Pelvis is scarred • Parenchyma is damaged • Ground glass appearance • ( calcified caseous tissue very homogenous) Schistosomiasis Lower ureteric calcification occurs Renal TB Renal & upper ureteric calcification suspect tuberculosis

20. Calcifications may be seen overlying the renal contour • Renal calculi (10%)—scarred calculi may seen —due to pelvis scaring , calculi take up shape of deformed pelvis – hiked up pelvis • Tuberculous changes of spineand calcifications in a Para spinal or psoas abscess can be seen • Calcification of granuloma in the liver or spleen, and calcified lymph nodes or adrenals may be seen

21. Completely caseated kidney with lobular calcification k/a putty kidney as a result of long standing obs and Putty kidney with beaded calcification of ureter

22.   Tuberculous pyonephrosis. Retrograde pyelogram shows filling of the dilated hydronephrotic lower and middle pole of the right kidney. The collecting system has irregular margins (straight solid arrow) and shows irregular filling defects (curved arrow)from necrosis of the parenchyma. Upper pole calcification is also seen

23. IVP • IVP can show a broad range of findings, depending on the severity of infection • In the earliest stages, the excretory urogram may be normal. 10%–15% (1) First minor calyces involved --in form of dilatation. • Slight loss of sharpness of calyx due to mucosal oedema. • Displacement of collecting system secondary to tuberculoma (initial infection).

24. (2) f/b--destruction of the papilla-- irregularities of the calyces similar to papillary necrosis-- k/a "moth-eaten ,"fuzzy, or feathery--- first sign of tuberculosis. Left pyelogram shows marked irregularity of the calices and infundibula in the left lower pole. "moth-eaten" appearance of the calices

25. (3)As the papillary lesions progress, they enlarge to form cavities & communicate with collecting system. Single or multiple cavities seen Egg in cup due to contrast in cavity

26. (4)Narrowing or complete stenosis of one or more infundibula: • If stenosis is incomplete, it causes dilatation of the proximal calyx- hydrocalycosis • if obstruction is complete, total exclusion or nonopacification of the dilated calyx.- phantom calix

27. Nephrotomogram shows decreased nephrographic opacity and nonfilling • of the collecting system elements (phantom calices) in the lower pole of the left kidney

28. Ureteric TB CORK SCREW URETER Showing multiple strictures & beaded dialtation

29. PIPE STEM URETER IN URETERAL TB

30. BLADDER TB Film 1 THICKENED BLADDER WALL IN BLADDER TUBERCULOSIS

31. Bladder tuberculosis. Intravenous urogram demonstrates a thickened, contracted, low-capacity bladder (thimble bladder) (arrowhead) with minimal dilatation of both ureters.

32. USG • May be normal B/L in 30% cases • The early and acute changes include devlopment of the B/L tuberculomas. Seen as Focal renal lesions –small (5-15 mm) are echogenic or echogenic border with central hypoechoic area --large (15 mm)have mixed echogenicity with poorly defined borders • most will heal sponteneously or with AKT.

33. Sonogram of left kidney shows 1.5-cm hypoechoic nodule (arrowhead) in cortexContrast-enhanced CT scan shows hypoattenuated nodules in left kidney (arrowheads). CT scan also shows multiple hypoattenuated nodules in liver (arrows).

34. Focal calcification —echogenic areas with after shadowing s/o healed granulomas • Papillary changes - • echogenic nonshadowing mases at few calyces –sloughed off calyceal wall— • Focal caliectasis —infundibular stenosis –dilated focal collecting system • Diffuse HN or pyonephrosis –when stricture in pelvis

35. Sonogram shows severe nonuniform caliectasis (arrows).Contrast-enhanced CT scan of left kidney shows uneven caliectasis caused by varying degrees of stricture at various sites.

36. Renal and perirenal abscess—semisolid echotexture with irreg & thick ill-defined wall • Air within collecting system s/o enteric fistula. • a communicating tract is seen as sonoluscent line • Densely calcified kidney • Thick walled hydro/pyonephrosis without evidence of pelvis dilatation (without pelvic calculi) Good pointer of renal TB

37. Ct will show…. • Caliectasis • Urethelial thickening • TB granuloma –solid mass with little or minimal enhancement • Densely calcified kidney • abscess • Spread to retriperitoneum & adjacent structures

38. Renal Parenchyma • Renal parenchymal involvement in tuberculosis usually is associated with collecting system involvement. • Localized tissue edema and vasoconstriction caused by active inflammation result in focal hypoperfusion as seen on contrast-enhanced CT or MRI. • This finding is similar to that of acute pyelonephritis caused by other organisms.

39. 55-year-old man with urinary tuberculosis involving renal parenchyma and calices. CT focal caliectasis (arrows) and hypodense lesion s/o hypoperfusion

40. Contrast-enhanced CT scan of right kidney shows severe hydronephrosis. Right kidney looks like multiple thin-walled cysts or a multiloculated cyst.

41. End stage renal tuberculosis:(autonephrectomy)shows small,shrunken & destroyed kidney

42. CT scan shows dense calcification replacing right kidney, so-called "putty kidney."

43. Renal tuberculosis. Axial contrast-enhanced CT scan demonstrates left tuberculous pyonephrosis (straight solid arrow) with extension of the inflammatory process into the perinephric space (curved arrow) and accompanying peritoneal disease (open arrow).

44.   Bladder tuberculosis. Axial contrast-enhanced CT scan demonstrates a thickened and deformed bladder with an enhancing wall (straight arrow). There is extension of the inflammatory process to the anterior abdominal wall

45. RETROGRADE PYELOGRAPHY • when kidney fails to function, retrograde pyelograph helps to delineate pathologic changes within the collecting system. • one side should be examined at a sitting with accurate positioning of the catheter tip and low pressure injection. When no function of kidney obtained • Ureteral strictures better visualized • To identify diseased segment in c/o surgery • Pyelocavitatory / pyelocancerous backflow—filling of irregular cavity communicating with collecting system

46. Retrograde ureteropyelogram shows globular calcific areas of increased opacity in the medial upper pole of the right kidney (arrowheads). The calices are markedly enlarged with ill-defined margins (white arrows). Small, irregular of extracaliceal collections contrast material are also present (black arrows). (b) Magnified view from a retrograde ureteropyelogram of the right ureter shows mucosal irregularities and erosions (arrowheads).

47. CHANGES OF TB….

48. CASE 2

49. 67 year old male presented with vague mid-epigastric pain.

50. CT scan shows two small discrete cystic lesions in the body & head of the pancreas.