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A case of acute perinephric abscess due to chronic parenchymal disease and calculi is presented. During percutaneous drainage a reno-splenic vein communication developed acutely. The aetiology and treatment complications of perinephric abscesses are reviewed.
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The perinephric space is a cone-shaped retroperitoneal compartment containing the kidney, adrenal gland, perinephric fat, fibrous bridging septa, and a rich network of perirenal vessel and lymphatics. Perinephric space pathology may originate from within or outside the confines of the perirenal fascia. Most intrinsic perinephric space disease arises from the kidney or adrenal gland, and secondarily involves the perinephric space. Disease originating outside the cone of renal fascia may spread to the perinephric space via lymphatics (i.e., metastatic spread) or by directly transgressing perirenal fascial planes (e.g., invasive tumor or infections). Additionally, infiltrating soft tissue or rapidly accumulating retroperitoneal fluid may travel into or out of the perinephric space via perinephric bridging septa and renal fascia. In this article, we review the normal anatomy of the perinephric space and renal fascia, emphasizing the significance of retroperitoneal interfascial planes and perinephric bridging septa as a potential conduit for retroperitoneal disease spread. This review of normal anatomy and pathways of disease spread serves as background for a discussion of a variety of specific pathologic conditions that may involve the perinephric space and retroperitoneal fascia, including pancreatitis, retroperitoneal hematoma, urinoma, metastatic disease, and perirenal varices.
PURPOSE: We performed a retrospective study to determine computerized tomography (CT) findings associated with perinephric angiomyolipomas or perinephric liposarcomas. MATERIALS AND METHODS: During the last 7 years 6 patients with perinephric angiomyolipoma and 12 with perinephric liposarcoma were seen at our hospital. Two radiologists who were blinded to the pathological diagnosis retrospectively evaluated the CT characteristics of perinephric angiomyolipoma and perinephric liposarcoma. The relationship of each CT characteristic with tumor type was compared using Fisher's exact test. RESULTS: The CT characteristics of perinephric angiomyolipoma were intratumoral linear vascularity (p = 0.001), aneurysmal dilatation (p = 0.025), bridging vessel sign (p = 0.005), hematoma (p = 0.025), beak sign (p = 0.001) and discrete intrarenal fatty tumors (p = 0.025). The CT characteristic of perinephric liposarcoma was a nonfatty soft tissue mass (p = 0.005). There was no significant difference in the presence of calcifications in both groups. CONCLUSIONS: This retrospective study suggests that analysis of CT characteristics (linear vascularity, aneurysmal dilatation, bridging vessel sign, hematoma, beak sign and discrete intrarenal fatty tumors) may help to differentiate perinephric angiomyolipoma from perinephric liposarcoma.
Perinephric abscess commonly arises from rupture of an intrarenal abscess into the perinephric space. It rarely results from gastrointestinal pathology. We report two pediatric patients with retrocecal appendicitis that presented with perinephric abscess. A 3-year-old girl presented with high fever and right flank pain for more than 1 week. Ultrasonography showed a right perinephric fluid collection with normal renal parenchyma and collecting system. A perinephric abscess extending from a ruptured retrocecal appendix was diagnosed by abdominal computed tomographic (CT) scan. Her hospital course was complicated with empyema, peritonitis, and pericardial effusion. A 6-year-old girl had lower abdominal pain for 3 days and high fever on the day of admission. Ultrasonography showed a right perinephric abscess with a normal renal contour and a fecalith in the enlarged appendix in the right lower quadrant of the abdomen. Appendectomy and drainage of the perinephric abscess were performed in both cases. We suggest that a ruptured retrocecal appendix must be considered in cases of perinephric abscess, especially in patients with gas bubbles in the abscess and a normal urogenital appearance. Ultrasonography and abdominal CT scan are the preferred diagnostic tools. Prolonged antibiotics and drainage of the abscess are mandatory to decrease morbidity and mortality.
PURPOSE: To determine whether the extent of perinephric edema on helical computed tomographic (CT) images without contrast material enhancement can be used to predict the degree of ureteral obstruction in patients with acute ureterolithiasis. MATERIALS AND METHODS: Nonenhanced helical CT and excretory urographic images in 82 patients with flank pain were retrospectively reviewed. For each patient, a radiologic diagnosis was established, and the degree of ureteral obstruction determined on urograms was compared with the extent of perinephric edema assessed on CT images. RESULTS: None of 29 patients with no abnormalities seen at urography had evidence of perinephric edema at CT. Of six patients with noncalculous disease, two with acute pyelonephritis had perinephric edema at CT. Of 47 patients with acute ureterolithiasis, eight had no perinephric edema at CT and a nonobstructing calculus at urography, 21 had limited edema at CT and low-grade obstruction at urography, and 15 had extensive edema at CT and high-grade obstruction at urography. Three patients had extensive perinephric edema at CT but low-grade obstruction at urography. The extent of edema allowed accurate prediction of the degree of ureteral obstruction in 44 (94%) of 47 patients with acute ureterolithiasis. CONCLUSION: The extent of perinephric edema on nonenhanced helical CT images can be used to predict the degree of ureteral obstruction in acute ureterolithiasis.
The perinephric space is not a simple fat-filled chamber through which fluid may be distributed unhindered. It is divided into multiple compartments by fibrous lamellae, the bridging septa. Some of these structures arise from the renal capsule and extend to the perinephric fascia; others are attached only to the renal capsule and are arranged more or less parallel to the renal surface. Still others connect the anterior to the posterior leaves of the perinephric fascia. The resulting compartments exert an important influence on pathologic processes, resulting, for example, in limitation of the spread of pus and tamponade of bleeding points. The configuration of many perinephric collections can only be understood by knowledge of the existence and arrangement of these lamellae. The current criteria for differentiation of subcapsular from perinephric hematomas are shown to be in error, and a new sign for such differentiation is described. There are also implications regarding therapeutic drainage of perinephric abscesses, particularly by the percutaneous route. A new classification of the perinephric fascia is proposed.
PURPOSE: We characterize the treatment and outcomes of perinephric abscesses in a contemporary cohort of patients. MATERIALS AND METHODS: We reviewed the experience with perinephric abscesses at a single community based hospital. Abdominal computerized tomography (CT) was widely available during the study period and experience with radiographic guided percutaneous drainage was extensive. Therapy and intervention for individual patients were dictated by the treating physician. RESULTS: Of the 25 patients identified with perinephric abscesses 3 (12%) ultimately died. Although 40% had multiple risk factors for perinephric abscesses only 35% were identified at presentation. Urine cultures were positive in 72% of patients and CT had a diagnostic sensitivity of 92%. Ten patients with a mean abscess size of 1.8 cm. were treated with antibiotics alone (mean hospitalization 10 days) while 11 with a mean abscess size of 11 cm. received antibiotics and initial percutaneous drainage (mean hospitalization 30 days). Of the 11 patients treated with percutaneous drainage 4 ultimately required surgical exploration and nephrectomy. CONCLUSIONS: The clinical characteristics of perinephric abscesses have not changed significantly but improved imaging with CT allows earlier diagnosis and treatment, which likely contributed to the reduced mortality in our cohort compared to historical series. With accurate staging and careful followup, a variety of treatments can be successful, including antibiotics alone or in conjunction with percutaneous drainage and urinary drainage. Open surgical drainage and nephrectomy may eventually be required in some patients and should be considered if adequate drainage is not achieved.
BACKGROUND: We present a case to illustrate controversies in percutaneous drainage of infected, perinephric haematoma in a tetraplegic patient, who had implantation of baclofen pump in anterior abdominal wall on the same side as perinephric haematoma. CASE PRESENTATION: A 56-year-old male with C-4 tetraplegia had undergone implantation of programmable pump in the anterior abdominal wall for intrathecal infusion of baclofen to control spasticity. He developed perinephric haematoma while he was taking warfarin as prophylactic for deep vein thrombosis. Perinephric haematoma became infected with a resistant strain of Pseudomonas aeruginosa, and required percutaneous drainage. Positioning this patient on his abdomen without anaesthesia, for insertion of a catheter from behind, was not a realistic option. Administration of general anaesthesia in this patient in the radiology department would have been hazardous. RESULTS AND CONCLUSION: Percutaneous drainage was carried out by anterior approach under propofol sedation. The site of entry of percutaneous catheter was close to cephalic end of baclofen pump. By carrying out drainage from anterior approach, and by keeping this catheter for ten weeks, we took a risk of causing infection of the baclofen pump site, and baclofen pump with a resistant strain of Pseudomonas aeruginosa. The alternative method would have been to anaesthetise the patient and position him prone for percutaneous drainage of perinephric collection from behind. This would have ensured that the drainage track was far away from the baclofen pump with minimal risk of infection of baclofen pump, but at the cost of incurring respiratory complications in a tetraplegic subject.
Serum angiotensin converting enzyme (ACE) activity and plasma renin activity (PRA) were studied during the development of the widespread necrotic arterial disease that occurs in the induction phase of one-kidney perinephritis hypertension. Control serum ACE activity was significantly higher in rabbits developing many arterial lesions than it was in rabbits developing relatively few arterial lesions. Serum ACE decreased 7 days after the production of unilateral perinephritis in all rabbits. Following contralateral nephrectomy, serum ACE decreased further in rabbits devloping many arterial lesions but returned toward control values in rabbits developing relatively few arterial lesions. Significant inverse correlations were demonstrated for the total number of arterial lesions that developed relative to a) the decrease in serum ACE activity 7 days after the production of unilateral perinephritis, b) the lowest or the average serum ACE activity during the period of development of the arterial lesions after contralateral nephrectomy, and c) the change in serum ACE activity during the period of development of the arterial lesions. Chronic treatment with SQ 20,881, a synthetic nonapeptide inhibitor of ACE activity, during the period of development of the hypertension and the arterial lesions significantly reduced the serum ACE activity and the hypertension but did not change interrelationships between serum ACE activity and the number of arterial lesions that developed. PRA significantly decreased after the production of perinephritis and decreased somewhat further during the induction period of the hypertension after contralateral nephrectomy. No relationships were demonstrated between PRA, or changes in PRA, and the development of arterial lesions. The increase in blood pressure during the incubation period of the hypertension did not correlate with the number of arterial lesions that developed. These finding indicate that serum ACE activity reflects importantly on the capacity to develop necrotic arterial lesions during the induction phase of one-kidney perinephritis hypertention and on functional events relating to their pathogenesis.
STUDY DESIGN: Retrospective chart review. OBJECTIVES: To document the occurrence and management of large perinephric abscesses in neurologically impaired patients at high risk for this infectious complication. SETTING: US Veterans Affairs hospital. METHODS: The records, radiographs, operative findings and outcomes of all patients who presented with perinephric abscesses evident on physical exam within the last 5 years were reviewed. RESULTS: Four patients presented with large perinephric abscesses evident on physical examination. All had severe neurologic impairment with high sensory levels; three had spinal cord injuries, one had advanced multiple sclerosis. All had neurogenic bladders and recurrent urinary tract infections. The diagnosis was made through a combination of history, physical examination and computed tomography (CT) examination. All were found to have upper tract obstruction. All were managed with immediate abscess drainage and three had elective nephrectomy once the infection had resolved. No patients died of their perinephric abscess. CONCLUSIONS: These four cases illustrate that although advances in antibiotics, imaging and percutaneous management have improved the speed of diagnosis and reduced the mortality in patients with perinephric abscesses, the neurologically impaired population continues to remain at significant risk for the development and the delayed diagnosis of these morbid renal infections.
A 3-year-old castrated male domestic ferret was evaluated for abdominal distention. Survey lateral and dorsoventral abdominal radiographs were made. There were two soft tissue radiopacities consistent with grossly enlarged kidneys displacing small bowel and colon cranially, ventrally and caudally. Abdominal ultrasound was performed and revealed bilateral perinephric pseudocysts and polycystic kidneys. The perinephric pseudocysts were found to be dilated renal capsules on exploratory surgery and were drained. On follow up examinations, the pseudocysts were drained by ultrasound-guided paracentesis. The perinephric cyst fluid was distinguished from urine by measuring creatinine concentration and plans were made to resect the renal capsules due to rapid re-accumulation of pseudocyst fluid. The ferret's condition deteriorated and euthanasia was performed. Post-mortem examination was declined by the owner. Perinephric pseudocysts are rare and this is the first published report in a ferret. Ultrasound examination is the most rapid, accurate and non-invasive method for diagnosis of perinephric pseudocysts.
The records of 47 patients with a perinephric abscess diagnosed from 1975 to 1986 at 8 San Francisco Bay Area hospitals were reviewed. The mean age was 51 years. Fifty-five percent were females and 45%, males. The left kidney was affected in 47% of cases, the right kidney in 40%, both in 4%, and a transplanted pelvic kidney in 9%. Fever (55%), chills or diaphoresis (47%), flank pain (40%), abdominal pain (40%), and nausea or vomiting (32%) were the most common presenting symptoms. About half the patients had symptoms for 1 week or less and 12% had no symptoms. Fever was documented before diagnosis in 88% of patients. Abdominal mass (13%) or tenderness (49%), and flank mass (9%) or tenderness (42%) were seen less frequently, and 11% of patients did not have fever, flank, or abdominal findings. The most frequent underlying conditions included previous urologic surgery (45%), previous urinary tract infection (38%), diabetes mellitus (36%), and urinary tract stones (36%). Cultures of perinephric abscesses yielded gram-negative aerobes in 52% of patients, primarily Escherichia coli. Staphylococcus aureus was isolated in 26% of patients and anaerobes in 17%. A single pathogen was isolated in 71% and multiple isolates in 29%. Of interest and great potential therapeutic importance was culture of anaerobes, primarily Bacteroides spp. in 17%, Enterococcus spp. in 7%, and Candida albicans in 7%. Positive blood and urine cultures identified perinephric abscess organisms exactly in 58% and 37% of cases, respectively. Routine laboratory tests such as the white blood cell count and urinalysis were insensitive and non-specific for perinephric abscess. Leukocytosis and anemia at admission were seen in slightly more than half of the patients. For radiologic diagnosis, computerized tomographic scanning was most helpful. Ultrasound and intravenous pyelography were falsely negative in about one-third of cases. Mortality (13%) was low in this series when compared with earlier studies, and probably reflects modern medical care. Six patients (13%) died during hospitalization, 2 of whom had diagnosis of PNA established only at autopsy. Drainage of the perinephric abscess was carried out by open surgical drainage in 64% of patients, percutaneous drainage in 19%, and both in 13%. The initial procedure, whether open surgical drainage or percutaneous catheter drainage, was usually successful. Late complications included nephrocutaneous fistulas in 3 patients and disseminated candidiasis in 1 patient.
Page kidney is the name ascribed to a rare syndrome of hyperreninemic hypertension caused by unilateral compressive perinephritis. Blood or fluid that accumulates in the perinephric subcapsular space compresses the renal parenchyma leading to ischemia. This syndrome is analogous to the description of cellophane-induced perinephritis by Page in 1939. Page kidney typically presents in healthy young men after blunt trauma to the flank or abdomen, although cases have been noted after medical or surgical interventions. We report a case of a Page kidney in a young man with hepatitis B virus-associated polyarteritis nodosa. The patient presented with severe hypertension, hypokalemia, hyperreninemia, and radiographic evidence of a unilateral subcapsular hematoma. Perinephric hemorrhage developed because of necrotizing vascular inflammation and spontaneous or traumatic vascular rupture. In patients who present with new-onset hypertension and hypokalemia with a history of trauma or coexisting vasculitis, the presence of a Page kidney should be considered.
Spontaneous perinephric hematoma is a rare condition that is usually caused by benign and malignant renal tumors, vascular abnormalities and inflammatory disorders. However, a few patients in whom there is no apparent underlying disease are described as having idiopathic spontaneous perinephric hematoma. We report on a middle-aged patient with diabetes mellitus who was hospitalized for sudden onset of right upper flank pain. A large tender mass was palpable in the right upper abdominal quadrant. The hematocrit decreased from 32% on admission to 23% during the following hours. Computerized tomography of the abdomen revealed a large perinephric mass, which was denser than the adjacent renal parenchyma and hypodense after intravenous iodine injection, findings which were compatible with perinephric hematoma. The patient underwent exploratory laparotomy because of hemodynamic instability. Uncontrollable bleeding from a discolored apical renal lesion led to nephrectomy. On pathological examination this apical lesion proved to be a renal infarct with considerable bloody inhibition of perirenal tissues. Extensive search for an underlying disease that led to the infarction was unsuccessful.
Perinephric abscess is a life-threatening but treatable process. Most infections of the perinephric space occur as a result of extension of an ascending urinary tract infection, commonly in association with nephrolithiasis or urinary tract obstruction. A large portion of the mortality is the result of failure to diagnose this entity in a timely fashion. This failure may be because of the frequently obscure or nonspecific nature of the clinical presentation. Blood cultures as well as urine cultures may fail to identify correctly the bacterial pathogens responsible for the abscess. Perinephric abscess should be considered in the differential diagnosis of any patient presenting with a urinary tract infection that fails to respond promptly to antibiotic therapy, particularly in those known to have anatomical abnormalities of the urinary tract or diabetes mellitus. Consideration of this diagnosis should enter into the differential diagnosis of fever with abdominal pain or flank pain. Early recognition of perinephric abscess and prompt drainage, either percutaneously or surgically, in combination with appropriate antibiotic coverage, should reduce dramatically the morbidity and mortality from this infection.
Perinephric hemorrhage is a rare complication of autosomal dominant polycystic kidney disease (ADPKD). Of 66 patients in our series, it occurred in two (3%) and their clinical and radiologic findings are described. Computed tomography accurately delineated both hematomas and revealed an underlying ruptured hemorrhagic renal cyst in one patient. Computed tomography did not show the cause of hemorrhage in the other patient, but magnetic resonance (MR) imaging detected an underlying hemorrhagic cyst. Perinephric hemorrhage in ADPKD probably results from rupture of hemorrhagic renal cysts into the perinephric space. Computed tomography is the optimal method for its evaluation. However, MR may supplement CT findings since it detects more hemorrhagic cysts than CT and helps distinguish them from carcinomas. Perinephric hemorrhage in ADPKD can usually be managed conservatively.