Urinary Tuberculosis is secondary to other parts of the body TB lesions, which is the main renal tuberculosis. In the urinary tuberculosis in renal tuberculosis is the most common, the first occurred after the spread from the kidney to the urinary system. Therefore renal tuberculosis has actually represent the significance of urinary tuberculosis.
[Diagnosis]
Renal tuberculosis disease process has been very slow, in clinical performance is to stimulate bladder symptoms. So the diagnosis of renal tuberculosis is cystitis symptoms (frequency, urgency, Niaotong) for clues. Apart from the obvious cause cystitis reasons, should consider the possibility of renal tuberculosis, the need for further systematic inspection.
(1) history of chronic medical examination and analysis of the frequency, urgency, Niaotong and hematuria, or the general anti-inflammatory treatment of cystitis prolonged Buyu, should consider changing the existence of renal tuberculosis. Especially young men in urinary tract infection, urine culture nor the general growth of bacteria, should be carried out more inspections of urinary tuberculosis. Caution should be taken when a medical examination in the body the TB lesions, in particular the male reproductive tract check the prostate, vas deferens, epididymis whether nodules. In the urinary tract areas should check whether renal mass, whether a higher angle ridge rib pain.
(2) laboratory inspection
1. Urine routine examination of urine was often acidic reaction, with a small amount of protein, in the majority of patients can be seen under the microscope a small or medium of red or white cells. But in the event of mixed urinary tract infection when alkaline urine can be a reaction, were found a large number of leukocytes, or abscess ball.
2. Urine ordinary bacterial culture renal tuberculosis is the specific urinary tract infection. Urine ordinary bacterial culture should be negative. However, a considerable part of the renal tuberculosis existence of the mixed urinary infection, urine ordinary bacterial culture can be positive, it was reported mixed with renal tuberculosis, urinary tract infection up to 1 / 3 to 1 / 2.
3. Urine checks of Mycobacterium tuberculosis
(1) 24-hour urine acid-fast bacilli Mycobacterium tuberculosis check is in a kind of acid-fast bacilli. 24 hour urine concentration of acid-fast staining for direct smear after AFB inspection method is simple, rapid results, the positive rate of 50 ~ 70%, but Baopigou bacillus, Mycobacterium grass is often in the urine AFB, acid-fast bacilli in the urine does not mean that Mycobacterium tuberculosis. But many times this inspection, the same can find AFB, and the combination of clinical history and characteristics of the reference, in the diagnosis of renal tuberculosis or some reference value.
(2) urinary tuberculosis urine culture of Mycobacterium tuberculosis culture in the diagnosis of renal tuberculosis decisive role. TB-positive urine culture can be sure of the diagnosis of renal tuberculosis. But training for quite a long time to 1 to 2 months to get the results, the positive rate can be as high as 90%.
(3) animal inoculation urinary tuberculosis animal urine tuberculosis vaccination results in diagnosis of renal tuberculosis highly valued and can be used as the basis for the diagnosis of renal tuberculosis, the positive rate is as high as 90 percent. However, a longer time-consuming, long, can be two findings.
4. Urine TB Nassau IgG antibody detection of tuberculosis, and other activities were found in a certain amount of specific antibody. Grauge and other certificates for the specific antibody IgG category. First Affiliated Hospital of Hubei Medical College reported to polymerization OT as antigen using ELISA of IgG antibodies in urine tuberculosis, renal tuberculosis patients with tuberculosis in urine IgG antibody positive rate of 89.1%. Prove that the checks have a certain sensitivity and specificity for the diagnosis of renal tuberculosis considerable clinical significance. But for advanced renal function and renal tuberculosis serious damage does not secrete urine, or renal tuberculosis with ureteral obstruction, and not from urine disease side, seized by the urine from the contralateral kidney, there may be false negative.
5. Tuberculin test tuberculin test is to check whether the body by Mycobacterium tuberculosis infection in a method, the most commonly used TB, but other organs of the body the TB change also be a valuable reference.
(1) tuberculin any of the following categories: ① old tuberculin; ② pure tuberculin; ③ atypical Mycobacterium made of purified protein derivatives; ④ Calgary streptozotocin four. General old tuberculin test.
(2) Old tuberculin (old tuberculin, OT) made: TB-employment training two months, heating inactivated, filtered dead bacteria, evaporation of the original volume to 1 / 10, namely, tuberculin dope. After 1952 by the World Health Organization require each containing 10 ml tuberculin units (TUberculin unit, TU), equivalent to 1000 mg.
(3) Test Method: Using the old tuberculin standardization of the first with 1 / 1000 or 1 / 2000 (each containing 0.1 ml respectively 10.5 TU) dilution of 0.1 ml injection in the left forearm in the medial 1 / 3 Paper within. 48 ~ 72 hours after the observation of reaction, such as negative, then 1 / 100 (0.1 per 100 ml containing TU) dilution repeat test results and determine response.
(4) The positive tuberculin test standards
(5) the significance of positive tuberculin reaction: ① BCG vaccination and the artificial immune. ② infected with Mycobacterium tuberculosis, but need to further confirm or activities except tuberculosis. ③ children positive significance: 8 years of age, active tuberculosis may be greater than 50%. 4 years of age, almost all active TB may be. Under 3 years of age, not only will the active TB, if not treated, the prognosis may be bad. Under 1 year of age, have active tuberculosis, if not treated, the prognosis definitely bad. ④ strong positive tuberculin test, there are active tuberculosis, must be checkups.
6. ESR examination of renal tuberculosis is a long-term chronic disease, a wasting disease, increased erythrocyte sedimentation rate checks to be fast. Li Zhe 300 cases reported in 255 cases of renal tuberculosis have increased erythrocyte sedimentation rate faster phenomenon. But ESR examination of renal tuberculosis disease no specificity, ran on cystitis patients with erythrocyte sedimentation rate by block often suggested that the possibility of a renal tuberculosis, they can be used as a reference check.
7. Renal function tests
(1) urea nitrogen, creatinine, uric acid determination: the side of renal tuberculosis does not affect renal function tests, if the serious side of renal tuberculosis and involvement from the contralateral kidney or renal function caused by water while the renal function checks can display higher. Kidney function tests, though not directly on the diagnosis of renal tuberculosis indicators, but on renal tuberculosis to deal with a very important reference value, it must be done routinely.
(2) radionuclide renography inspection: kidney lesions confined without prejudice to the secretion of all renal function, the kidneys showed normal. If a considerable scope of renal parenchymal damage, kidney, which shows the blood supply or inadequate secretion excretion longer. Suffering from serious kidney damage, was non-functional kidney plans horizon. Contralateral renal tuberculosis caused hydronephrosis, renal map can show that the stagnant water, obstruction curve. The inspection did not have specific diagnostic value, but the method is simple, there is no pain to the patient, it also as a routine clinical examination.
(C) cystoscopy cystoscopy renal tuberculosis is an important diagnostic tool, can be seen directly in the bladder typical changes in established diagnosis of tuberculosis. Early bladder mucosa tuberculosis that have edema and congestive TB nodules, lesions of multiple lesions on the ipsilateral kidney in the ureteral orifice around the bladder after Triangle area and other parts of the spread. Tuberculosis more serious bladder mucosa widely visible congestion and edema, TB nodules and ulcers, ureteral orifice upward retraction was cave-like changes. Through intravenous indigo rouge observation from both sides of the ureteral orifice blue, respectively understanding of the situation on both sides of renal function. In cystoscopy at the same time for both sides also retrograde intubation, respectively bilateral ureteral catheter inserted into the renal pelvis, a collection of bilateral renal pelvic examination and urine culture and Mycobacterium tuberculosis animals vaccinated. As a result of these inspections is the renal data, and therefore more meaningful diagnostic value. Retrograde intubation in the bilateral ureteral catheter can be injected contrast agent (12.5% sodium iodide or meglumine diatrizoate) retrograde pyelography, renal understanding of the situation. Most patients can clear the nature of diseases, the location and severity. If TB serious bladder, bladder contraction capacity of less than 100 ml difficult to see the bladder, it is not appropriate for this inspection.
(4) X-ray examination and X-ray examination shoulder TB is the main diagnostic methods. X-ray images typical of TB can be established in the diagnosis of renal tuberculosis. The conventional X-ray examination as follows:
1. Urinary-ray film that increases or kidney shape was lobulated. 4.5 ~ 31% of the renal tuberculosis showed patchy clouds or patchy floccosum calcified lesions. Its irregular distribution, not stereotypes, and often confined to the side of the kidney. If renal calcification across all tuberculosis, and even ureter, which formed the so-called “cut-off since the kidney.”
2. IVP IVP called excretion or descending urography. For the use of intravenous injection of contrast agent, secreted by the kidney excretion, when contrast agent filling renal calyceal, when uptake pelvis X-ray. Commonly used contrast agent for meglumine diatrizoate (Urografin), the Pan Ying sodium (Hypaque) Diodrast (Diodrast). Application development has been non-ionic contrast agent, such as Iopamiro, Omipaque, Ulfravist, can greatly reduce the toxicity of administering iodine administering iodine and reduce the reaction. The contrast agent is secreted from the kidney showed urinary system, this method in addition to renal lesions can be clear, but also to understand renal function. Typical performance of TB that renal parenchymal damage. The limit in the kidney and renal papillary lesions as small beacon of coarse edge, vary, such as Huizhu like change, or its funnel of the inflammatory lesions or scars because of contraction, small beacon deformation, narrow or disappear. If extensive lesions, we can see that renal calyceal completely destroyed, caseous necrosis showed marginal missing “Miantao like” empty tuberculosis. If the whole kidney damage, renal abscess formation, and loss of renal function, renal vein, Bangladesh performed not suffering from renal enhancement. Ureteral TB X-ray angiography can show that the wall irregular, uneven lumen size, loss of normal soft curvature, showing rigidity cords of pipeline.
3. Large dose intravenous pyelography: If a patient’s total poor renal function, the general IVP not show good kidney, may increase the amount of contrast agent for the high-dose intravenous pyelography. Likely to show that the original developer unclear lesions clear. Application of the method usually per kg body weight for 50% of the meglumine diatrizoate contrast agent 2 ml, by adding the equivalent of 5% glucose water or saline, 5 to 8 minutes of rapid intravenous infusion. Contrast before having cut water, angiography without pressure ureter. However, contrast agent volume of not more than 140 ml.
4. Retrograde pyelography through cystoscopy ureteral catheter inserted into the renal pelvis, from the catheter within the retrograde pyelography to inject contrast agent uptake in the X-ray, known as retrograde pyelography. General with 12.5% iodine contrast agents; if there are allergic to iodine, is available to 25% of the 12.5 sodium bromide. The injection of contrast agent may need to adjust the concentration of contrast agent injected and the number of renal lesions to show more clearly, it can improve the diagnosis rate of intravenous pyelography or not suitable for not satisfied with the image, but not like IVP can understand that the changes in renal function.
5. Pelvis puncture of the vein contrast antegrade or retrograde pyelography not, difficult to clear lesions, and lesions nature can not be sure, can be direct puncture pelvis after contrast agent injection, the same can show that the renal tuberculosis or other diseases typical X-ray performance, decided to play the role of diagnosis. In the pelvis can also be puncture after puncture after kidney contents of the various checks and tuberculosis laboratory examination. At present, owing to the improvement of ultrasound technology can be guided puncture of the pelvis, the more accurate security.
[Treatment]
Renal tuberculosis secondary to systemic disease, it must attach importance to the treatment of local and systemic treatment of lesions comprehensive consideration, if it is satisfied with the results.
(1) systemic treatment of systemic therapy including proper rest and full medical and sports nutrition and necessary medication (including renal tuberculosis of the body other than the treatment of TB lesions).
(2) drug treatment as local lesion of renal tuberculosis and the scope of the extent of the damage are very different, for the treatment of localized lesion in all cases are also different. In the discovery of streptomycin and other anti-TB drugs before clinical diagnosis of renal tuberculosis Once established, the only treatment is nephrectomy. In the 1940s, the streptomycin, Liu ammonia acid have been transformed, many clinical cases of renal tuberculosis drug treatment alone can be cured. After the 1950s, high efficiency, low toxicity and low cost of isoniazid there has taken a combination, the efficacy of renal tuberculosis has greatly improved, almost all early TB can be cured change. 1966 rifampicin to clinical application because the results significantly, and fewer side effects, and the shared use of other drugs, the efficacy of renal tuberculosis raise more. At present due to renal tuberculosis and the need to nephrectomy cases has been greatly reduced. But in some poor sanitary conditions, inadequate medical conditions, there are still the occurrence of renal tuberculosis, and even some advanced patients found. The diagnosis of renal tuberculosis patients, regardless of their degree of disease, whether or not they will need surgery, anti-TB drugs must be taken by certain programmes.
1. Indication of the anti-tuberculosis drug
(1) clinical stage renal tuberculosis.
(2) limitations in a large group within the renal calyceal unilateral or bilateral renal tuberculosis.
(3) isolated renal tuberculosis.
(4) with the activities of other parts of the body tuberculosis temporarily unfit renal tuberculosis surgery.
(5) double focus of renal tuberculosis is not the surgery.
(6) both renal tuberculosis other parts of the serious illness temporarily unfit surgery.
(7) with surgical treatment, as a pre-operative medication.
(8) the post-operative renal tuberculosis conventional medication.
2. Commonly used anti-TB drugs for a variety of types of anti-tuberculosis drugs has its pharmacological characteristics of the drug application requirements and also pay attention to different points. Is a brief introduction commonly used anti-TB drugs is as follows:
(1) Streptomycin: Mycobacterium tuberculosis have bactericidal effect, the concentration in the range of 1.0 μ g / ml effective. Intramuscularly one hour after the largest concentration of the serum, three hours after a decrease of 50 percent, about 60 ~ 90% of the urine from the kidney. PH7.7 role in the system of ~ 7.8, the strongest, lower than the 5.5 ~ 6.0 role decreased significantly. At the same time as the urine alkaline sodium bicarbonate can be taken to enhance its efficacy. Ordinary daily adult dose of 1.0 g, intramuscular injection at 2 with other anti-TB drugs combined, 2 g weekly injection, or every 1 g on the 3rd injection. The treatment allows TB lesions streptomycin fibrosis. If Baixiejitong lesions in the urinary tract, such as the ureter, etc., it could easily lead to shrinkage local fibrosis, the formation of obstruction, should be noted. Streptomycin injection after weeks of mouth numbness, if not serious continue to apply, and often in use gradually disappear. The main side effects of the eighth cranial nerve vestibular-effects. A few cases, there may be allergic shock.
(2), isoniazid (1 NH, Jérémie letters): Mycobacterium tuberculosis suppress and kill role. Daily serving 200 to 300 mg can be satisfactory bactericidal concentration. Oral 1 ~ 2 hours of peak serum concentration. Half-life of six hours, 24 hours can be measured in blood effective inhibitory concentration. General dose to 300 mg daily, a suitable use. This little dose of adverse reactions, it may take a long time, even several years. After taking isoniazid rapid absorption infiltration, fibrosis and cheese of the lesions also easy to infiltrate through the TB lesions promote angiogenesis will enable easier access to anti-TB drugs lesions. The main side effects of the spirit of excitement and multiple peripheral neuritis, it is believed that with increased vitamin B6 or interference from Pyridoxine metabolism and therefore should be combined with isoniazid served vitamin B65 ~ 10mg, to prevent the occurrence of side effects. Serum transaminase medication can be increased, but not to cause liver damage.
(3) ammonia Liu acid (PAS, ammonia acid): Mycobacterium tuberculosis have antimicrobial effect. Medication after 1 to 2 hours up to the peak plasma concentration, 4 to 6 hours after the last trace of blood. Daily dose of 8 ~ 12 g, three to four times taking. The drug less effective alone, but to strengthen isoniazid and streptomycin resistance of Mycobacterium tuberculosis, drug-resistant and can delay occurred. Therefore, in clinical use two or three anti-TB drugs combined to play a role in its treatment. Main side effects are nausea, vomiting, diarrhea and gastrointestinal reactions, it now has been rifampicin, ethambutol replace trend. The goods should not be combined with rifampicin.
(4) rifampicin (RifamPin, RFP): Semi-synthetic broad-spectrum oral antibiotics, the strong growth of cells inside and outside there are strong Killing of Mycobacterium tuberculosis, streptomycin than the ammonia Liu acid, the role of ethambutol stronger, resistant Mycobacterium tuberculosis also effective. Medication 2 ~ 4 hours after drug concentration peak, 12 hours after the serum concentration remains high. Daily dosage of 600 to 900 mg, 1 to 2 minutes, taking fasting. And other non-cross-resistance to anti-TB drugs, isoniazid and ethambutol or combination can be mutually reinforcing role. Few side effects, gastrointestinal reactions and the occasional rash. In recent years have found a few cases of liver damage, increased serum transaminase, such as jaundice.
(5) ethambutol (Ethambutol, EMB): For all types of Mycobacterium tuberculosis have antimicrobial effect. Oral 2 to 4 hours after the peak plasma concentration, and 24 hours after kidney from 50 percent, a small portion of the stool from. Normal renal function had no role in stock. Drug absorption and tissue penetration better, the cheese fiber lesions can also penetrating. Its toxicity is the major role of the ball after optic neuritis, a blurred vision and can not distinguish colors (especially on the green) or a narrow field of vision, severe cases can cause blindness. Optic neuritis is reversible, and more can resume after treatment. The incidence of toxicity and dose. General daily dosage of 600 mg, three times or an oral dose, in this context, less toxic reaction. In the course of treatment should be regularly checked and colour recognition of the vision.
(6) kanamycin: Department of broad-spectrum antibiotics is the main inhibitory effect of Mycobacterium tuberculosis. Oral not absorbed by the gastrointestinal tract, the general amount of 0.75 to 1.0 g daily intramuscular injection. After injection of 30 to 60 minutes of peak blood concentration can maintain about six hours, from the urine within 24 hours from about 90%. Of streptomycin, isoniazid and ammonia Liu acid-resistant Mycobacterium tuberculosis application kanamycin still inhibited. Individual use of easily generate resistance. Streptomycin between unidirectional and cross-resistance, that is, streptomycin-resistant strains can be sensitive to kanamycin, and kanamycin-resistant strains of streptomycin is not sensitive. Therefore, not only with streptomycin or resistant Mycobacterium tuberculosis has been and will be considering applications. Its toxicity is the eighth cranial nerve damage, to permanent deafness may also degeneration of nerve fibers. Slight damage to the kidneys, urine may be a type of protein.
(7), Cycloserine (Cycloserine, Seromycim): broad antibacterial spectrum, a system of Mycobacterium tuberculosis bacteria. But only effective human tuberculosis, TB and to the animals in the test tube tuberculosis is very limited. Of isoniazid, streptomycin, Liu ammonia acid-resistant Mycobacterium tuberculosis by Cycloserine effective. Its role equivalent to ammonia Liu acid, worse than streptomycin. A daily oral dose of not more than 500 mg, general and isoniazid, streptomycin combination. More serious side effects, mainly affecting the central nervous system, such as dizziness, depression, seizures, such as epileptic seizures.
(8) pyrazinamide (Pyrazinamide, PZA): is a new use of old drugs. 1970s found after the oral absorption Pyrazine acid, the effective man-TB can be hidden in the cell to kill the stubborn bacteria. Resistance is expressed very quickly, usually in the medication after one to three months can happen. And rifampin, isoniazid combination treatment can be shortened. For the toxic side effects on the liver, can cause serious acute liver yellow atrophy. Commonly used dose of 1.5 to 2.0 g per day.
In addition to the drugs, there are purple adriamycin (viomycin), B sulfur Isonicotinic amine (ethionamide, 1314), the amount of 0.5 to 0.8 g per day, at 2 to 3 times taking. Ammonia thiourea (P-acetyl aminobenzaldebyde, thiosemica-rbazone, TB1) daily dosage of 500 mg oral dose of 2 points. Tendril adriamycin (capromycin). TB release actinomycin, and other anti-TB drugs and, if necessary, could consider selection.
3. Use of anti-tuberculosis drugs in the clinical application of anti-TB drugs early, generally a single-drug treatment, and now that two or more anti-TB drugs combined. Alone in the treatment of the biggest drawbacks is easy to become drug resistant, but also prone to toxicity. If the combination of two drugs, the emergence of drug resistance time can be extended twice, and can be extended by three drugs three to four times.
(1) anti-TB drugs combined with the choice: a wide range of anti-tuberculosis drug, the ideal should be sensitive to Mycobacterium tuberculosis, in the blood or to be a system of the concentration of sterilization, and the body can endure. The past will streptomycin, isoniazid, as the first-line drugs, ammonia Liu acid as a second-line drugs, others as a third-line drugs. When medication is the preferred first and second-line drugs, and only three drugs in the first line, second-line drugs ineffective or some of them resistant to drugs, before considering the use of. But now the various anti-tuberculosis drugs in-depth study of effect of that isoniazid, rifampin, pyrazinamide, and streptomycin is the first line anti-tuberculosis drugs. Isoniazid strong kill Mycobacterium tuberculosis, Mycobacterium tuberculosis cells both inside and outside the breeding kill, and to thoroughly dry acid into the lesions and macrophages. Rifampin can be split in the short term in the killing of Mycobacterium tuberculosis, and access to renal empty cells and macrophages. Pyrazinamide in the acidic environment of a stronger bactericidal effect can thoroughly into macrophages. Macrophages in the low pH, which is pyrazine amine kill bacteria play a role of the establishments. Streptomycin on tuberculosis split exuberant have a good kill, it thoroughly into TB Vomica.
On the specific application of anti-TB drugs, are now using two or three anti-TB drugs combined. Application abroad streptomycin, isoniazid, Liu acid ammonia three important anti-TB drugs gradually the era of the past, replaced by the new drugs, the new joint. These three drugs in the country is still often used, but also the trend was replaced by rifampin, isoniazid, however in the position of anti-tuberculosis drugs did not change. Now the general isoniazid and rifampicin the two joint, or combined with rifampicin and ethambutol. And streptomycin, rifampicin, pyrazinamide or isoniazid, streptomycin, rifampicin, or isoniazid, streptomycin, ethambutol or isoniazid, rifampicin, ethambutol, etc. the three combined are usually chosen for the clinical.
(2) the application of anti-TB drug treatment: With new and effective anti-TB drugs continue to emerge. Clinical anti-tuberculosis drug treatment has also noticeably changed. In the treatment must adhere to the early, combination, adequate, and adequate period of the Five Principles of medication to obtain the best therapeutic effect. Now used in treatment programmes are as follows:
Long-term therapy: on the application of anti-TB drugs, domestic and international long-term therapy were powered by continued use 18 to 24 months. At least in more than a year. Recognized the efficacy of this method reliable, less opportunity recurrence. Lattimer renal tuberculosis in accordance with the classification of anti-tuberculosis drug treatment, in clinical stage renal tuberculosis medication treatment 1, the lights in a single renal lesions typical of TB medication to two years, and three or more renal calyceal changes to a wide range of tuberculosis require medication for more than three years. Petkovio advocated unilateral renal tuberculosis treatment should last for two years, bilateral renal tuberculosis drug efficacy and the longer the better, it was recommended to last for four to five years, or even more than six years. Now Toman that rifampin and ethambutol composed of “two therapy programme,” and to strengthen the pre-start phase 1 ~ 3, the application of isoniazid, rifampicin and ethambutol or streptomycin three - Joint TB drug use later to continue to stage every four to 12 months of isoniazid and rifampicin, ethambutol or two between the use of anti-tuberculosis drugs, such use, the effects can be significantly enhanced, even if delivery period of 12 months can be achieved within a good effect. Long-term therapy is the main shortcomings of medication for too long, which patients can not adhere to the rules of medication, and often Youlou clothes, and clothes, clothes, and other phenomena of chaos, resulting in bacterial resistance, reduced drug efficacy, positive or urine Mycobacterium tuberculosis sustained TB control After another relapse. According to reports the rules of anti-TB treatment success rate was 90.3%, instead of the rules of treatment success rate of 43.7%.
Short-term therapy: short course’s basic aim is to kill as soon as possible TB lesions in Mycobacterium tuberculosis, a disease tissue repair lasting clinical cure. In recent years the emergence of a new anti-tuberculosis drug sterilization, a range of anti-TB treatment can be. Short-term drug treatment of renal tuberculosis research began in 1970, to 1977 Gow, and other studies to determine short-term drug treatment programme laid the foundation. Now a short course of treatment for four months, two months early for pyrazinamide 25 mg / (kg d) (maximum daily dose of 2 g), isoniazid 300 mg / d, rifampicin 450 mg / d, such as serious kidney and bladder disease Streptomycin may increase by intramuscular injection, 1 g daily; after two months as isoniazid 600 mg three times a week, rifampicin 900 mg three times a week. Gow, in addition to the 140 cases, not one case of medication and relapse, have been cured, in the two months when the medication urinary tuberculosis are to negative, minor drug toxicity. It should be noted, isoniazid, rifampicin and pyrazinamide have liver toxicity, when there are jaundice and elevated liver transaminases should stop until the return to normal again after treatment. Dutt and Sfead application of short-term programme for September, the use of isoniazid and rifampin. For the first month of 300 mg isoniazid, rifampicin 600 mg daily for 1; after eight months to isoniazid and rifampicin 900 mg 600 mg, 2 times a week, results were very good. In short short-term therapy to be successful, needs at least two application modules bactericidal drugs, such as isoniazid, rifampicin, coupled with a semi-sterilization unit drugs, such as pyrazinamide, streptomycin and other. Broad range therapy has the following advantages: ① longer-therapy treatment cut by half or more the time. ② reduce total drug. ③ reduce the chance of chronic poisoning. ④ cost savings. ⑤ easy access to the patients, medication may be rules.
As Mycobacterium tuberculosis growth of a certain degree of regularity, and to 13 / 4 to 31 / 2 days, and Mycobacterium tuberculosis in contact with anti-tuberculosis drugs inhibited their growth, such as contact with streptomycin, pyrazinamide, rifamycin equality, After could delay were growing 8 to 10 days, 5 to 10 days, and 2 to 3 days, the application of anti-TB drugs under intermittent use these features will be intermittent administration in time more than one day, can be achieved Continuous long-term therapy with the same effect. General in the country in the first three months of therapy on long-term medication, later switching to intermittent drug treatment, but the amount of drug therapy with the same long-range, fewer side effects, as well as better efficacy.
(3) the withdrawal of anti-tuberculosis drugs in the standard anti-TB drugs in the course of treatment, must pay close attention to changes in condition, all regular inspection to disease has been cured, they may consider to stop medication. Think we can stop the current standards are as follows:
A. general condition improved significantly, the normal erythrocyte sedimentation rate, body temperature normal.
B. voiding symptoms completely disappear.
C. repeated urine routine examination normal.
D.24-hour urine concentration investigation AFB, long-term inspections are negative.
E. Training urinary tuberculosis, urinary animal inoculation View Mycobacterium tuberculosis were negative.
FX line of urinary performed stability or healed lesions.
G. thorough medical check-no other TB lesions.
After the cessation of medication, the sick need to continue to stress long-term follow-up study, regular urine and urinary inspection performed at least 3 to 5 years.
(C) Although the anti-tuberculosis drug treatment can now be treated in the majority of renal tuberculosis can be cured control, but there is still not part of the patient drug to be effective, and treatment remains to be done. Including full nephrectomy surgery, and some nephrectomy, such as removal of kidney lesions in several ways, depending on the scope of diseases, the extent of damage and the effects of drug therapy chosen.
1. Whole nephrectomy
(1) Full-nephrectomy indications: ① unilateral renal lesions of tuberculosis in the destruction of more than 50 per cent larger. ② destruction of the entire renal tuberculosis renal function has been lost. ③ tuberculosis renal abscess. ④ bilateral renal tuberculosis, and severely damaged the side and the other side for the very mild tuberculosis, with a need to serious side, mild lesions side by drug treatment. Since the cut-off plaster ⑤ renal calcification.
(2) nephrectomy before and after the application of anti-tuberculosis drugs: As the body of renal tuberculosis is part of tuberculosis, TB is the secondary, urinary tuberculosis is a part of the period when nephrectomy can be a result of surgery Damage to reduce the resistance of the body, other than the result of renal tuberculosis or TB lesions caused Disseminated, in nephrectomy before and after the application of anti-TB drugs must be controlled.
1) nephrectomy before antituberculotics preoperative preparation: antituberculosis drugs before surgery by the preparations for the selection of varieties and medicinal doses, with the same general anti-tuberculosis treatment. But in the use of methods and the use of the time to be different. Such as isoniazid 100 mg three times daily oral, streptomycin 0.5 g, 2 times a day intramuscular injection, rifampicin 300 mg orally twice a day, every day for the application of application, sustained two weeks, and reoperation. If patients with systemic poor, or any other organ tuberculosis, as appropriate, should extend the preoperative preparation of anti-tuberculosis drugs, and sometimes preoperative medication may be extended to three to four months. Needed after such application until after physical rehabilitation, about two weeks after the turn around conventional anti-TB treatment.
2) nephrectomy after the application of anti-tuberculosis drugs: the urinary tuberculosis, renal tuberculosis is the primary lesion, when after resection of renal disease, urinary system will be only the original lesion resection, there are still remnants of tuberculosis after Variable presence of these residues ureter and bladder Tuberculosis Tuberculosis Tuberculosis other organs or body still needs the light of the choice of anti-TB drugs and long-term or short-term treatment of schedule until the complete urinary tuberculosis control and stop.
2. Part nephrectomy
(1) of nephrectomy indications: ① confined to the kidney to a pole in the 1 to 2 small renal calyceal the devastating disease, the long-term anti-tuberculosis drug treatment was ineffective. ② 1,2 small renal calyceal TB Department narrow funnel to poor drainage. ③ bilateral renal tuberculosis destruction轻而long-term drug therapy ineffective. If kidney function is the only required part of renal surgery, should be retained at least 2 / 3 of the renal tissue, so as to avoid postoperative renal insufficiency caused.
(2) of nephrectomy before and after the application of anti-tuberculosis drugs: As the anti-tuberculosis drug treatment often received good results, some less nephrectomy, the patients suitable for this operation should be a longer period of time antituberculotics prepared before implementation. General preoperative preparation to use 3 to 6 months. Preoperative angiography yet again, the decision to establish lesions after surgery.
I left after surgery because of the kidney and urinary organs TB, it will continue to use anti-TB drugs for at least one year to consolidate the effect.
3. Removal of kidney lesions
(1) removal of the kidney lesions indication: the essence of the kidney in renal calyceal confined formed by tuberculosis empty, and often filled with cheese - like substance. Antituberculosis drugs can not enter the hollow, empty and there are still activities in the presence of Mycobacterium tuberculosis. It is necessary to open empty, remove cheese - like tuberculosis, reuse antituberculotics cavity.
(2) before and after operation also required a longer period of application of anti-TB drugs, and to prevent disseminated tuberculosis treatment after the consolidation.
(D) the treatment of bladder contraction TB bladder contraction of cystitis serious consequences, often in serious bladder tuberculosis healing process gradually taking shape. Treatment methods as follows:
1. By nephrectomy in the treatment of tuberculosis, or TB control variable, seeking to expand the bladder. Contracture in a lesser individual cases, the patient gradually extended training time between urination, bladder capacity is gradually increasing. Can use this method of cases less serious contracture is not used.
2. Drug treatment due to serious inflammation of the bladder tuberculosis alternating with the healing process, in the urinary tract treatment of primary lesion, it should proceed with the treatment. The author has introduced a more Yu (guaiazulene), pyrazinamide (ZA), oxygen chlorine acid (clorpactin XCB), the treatment of bladder tuberculosis, and expand the capacity of the bladder to prevent the occurrence of contracture. Oxygen chlorine acid is an effective fungicide for use in the bladder irrigation water can be released from hypochlorite (hypochlorous acid) to achieve sterilization purposes, removal of bladder lesions in the necrotic tissue from expanding creative use of the normal mucosa without any damage, lesions can heal, bladder capacity increased. But now bladder scar contraction, despite washing can not increase capacity. Lattimer highlighted in the local irrigation, yet at the same time application in the treatment of systemic anti-tuberculosis.
3. Surgery for a clear diagnosis of bladder contraction, in 50 ml capacity below, and not the conservative treatment of bladder capacity to expand, it should consider expanding bladder surgery. Bladder approach is to expand the use of free-intestinal and bladder anastomosis, free of the past is the application of the ileum, although free of the ileum of the activities of large, easy and bladder contraction for anastomosis, but because many of the ileum after expanding bladder patients will ileum of the expansion, loss of tension, to pass urine retention in the expanded bladder not emptying, so now basically have not adopted. Applications currently are generally free of the colon to expand the bladder. Colon to the merits of strong contraction. Colon applications within 12 cm in length. Bladder coincide with the approach adopted cat-tail anastomosis. If patients in bladder contraction while tuberculosis ureter stenosis or Lower Ureteral stricture tuberculosis, should be expanded in the bladder, ureter will narrow over the cut, top ureteral re-anastomosis with a free colonoscopy. If the bladder contraction of the urethral stricture of tuberculosis exist unless it can urethral stricture expansion to be resolved, otherwise it is not appropriate to expand the contracture bladder surgery, only to abandon the purposes of the bladder and urinary diversion suitable.
(5) the treatment of contralateral hydronephrosis contralateral hydronephrosis need to be addressed, the urinary system must have a comprehensive understanding of, such as the degree of hydronephrosis and ureter expansion of the state, lower ureter, the narrow whether ureteral orifice, bladder whether contracture, and the extent of contracture. Finally choose the right treatment options. General treatment options have the following categories:
1. Contralateral kidney ureter mild to moderate expansion of the merger water bladder contraction: in the treatment of bladder contraction in accordance with the surgical treatment of sigmoid colon and bladder, ureter and expand the colon for anastomosis.
2. Contralateral kidney ureter mild to moderate expansion without water bladder contraction (by water or ureteral orifice by the Lower Ureteral stricture): treatment for a cut or ureteral dilatation of the stricture of the distal ureter or expansion . If expansion can not succeed, they may consider a cut after the ureter and bladder re-anastomosis.
3. Contralateral kidney ureter expansion of water caused severe renal dysfunction: kidney should be held water drainage operation. There are two methods of operation:
(1) temporary kidney stoma surgery: kidney, ureter severe water can be used for renal stoma surgery. Stoma in the urine drainage for a considerable period of time, if the expansion narrow, water change or disappear, renal function returned to normal, can only expand further bladder surgery in the transplant ureter bladder wall in the expansion. Subsequent removal of the kidney stoma catheter.
(2) permanent drainage: If renal stoma after water has not changed, nor narrow the ureteropelvic expansion can be renal catheter permanent stoma remain in the pelvis, long-term drainage. If the renal pelvis and ureter expansion of water and there is no serious chance of urinary repair the original channel can be directly ostomy permanent kidney or ureter expansion of the purposes of the skin graft or bladder with ileum (Bricker surgery). Consider drainage and difficult to restore permanent normal urinary voiding following several conditions: ① urethra with severe tuberculosis, it is estimated that difficult to repair the urinary patency. ② bladder contraction extremely serious, it is estimated that difficult to expand the bladder. ③ merger intestinal tuberculosis, peritoneal tuberculosis or other gastro-intestinal diseases. ④ water renal serious obstacle to the resumption of operation is estimated to be competent minor electrolyte disordered. ⑤ The patient is in very poor and can no longer implement molding surgery.
(6) TB spontaneous rupture of the bladder because of the treatment of bladder tuberculosis spontaneous rupture of renal tuberculosis is a serious late complications. Often in the bladder rupture patients before symptoms of urinary tuberculosis, and often rupture after acute abdomen cases. If not diagnosed early exploratory laparotomy should be clear to avoid bungled rescue time. For TB spontaneous rupture of the bladder should be implemented as soon as possible surgery to repair the bladder perforation, and bladder ostomy. Before and after surgery should be routinely taking anti-TB drugs. According to subsequent renal tuberculosis lesions for further processing.
[Pathogenesis]
Renal tuberculosis pathogens mainly from tuberculosis, but also from bone and joint tuberculosis, intestinal tuberculosis and other organs tuberculosis. Mycobacterium tuberculosis spread to the kidneys of four ways: ① blood disseminated: is the main routes of infection. Mycobacterium tuberculosis from invasive pulmonary TB lesions in the renal blood flow and dissemination; ② urinary tract infection: In fact, Mycobacterium tuberculosis in the urinary system is the spread. To the side of urinary tuberculosis change occurred after the return of Mycobacterium tuberculosis from lower urinary tract increased spread to the other side of the kidney; ③ lymphatic infections: the body of TB lesions or lesions of the lymph nodes lymphatic disseminated Mycobacterium tuberculosis through the kidneys; ④ direct spread: in the vicinity of organs such as kidneys spine, intestinal lesions of TB spread directly involved kidneys.
A large number of experimental studies, and clinical observation of the autopsy confirmed that blood is disseminated the main renal tuberculosis infection methods. Mycobacterium tuberculosis with invasive renal blood flow. When the kidneys have a certain sensitivity (such as local blood circulation obstacles, trauma and other factors), or the increase in the number of bacteria form emboli, in the first part of the renal cortex of the outer pair of glomerular capillary formation of TB lesions. 90% occurred in the cortex, 10% occurred in the medulla. This outer layer of TB is multiple, almost at the same time both sides involved. But often at this time because the body’s systemic immunization and the strengthening of local resistance, the number of bacteria and bacterial virulence factors such as drop, the vast majority of cases the full healing lesions may not give rise to any symptom, and not be found. However, in this period, in the urine can be examined and see Mycobacterium tuberculosis, the period known as the “pathological clinical stage renal tuberculosis or renal tuberculosis.” Lesions in renal outer exist, because at that time the body resistance decreased, increased or bacterial virulence factors such as local, non-union individual lesions and further development to the so-called “clinical stage renal tuberculosis.” TB patients in about 1 to 2 per cent of this clinical stage renal tuberculosis. TB lesions in renal outer layer only 3 to 7% in the clinical stage renal tuberculosis stage.
General from asymptomatic renal tuberculosis pre-clinical development of clinical stage renal tuberculosis requires a longer time, and in this period the lungs or other organs of the original TB lesions may have been recovered, a considerable part of the renal tuberculosis can not found that the primary lesion. If the clinical stage renal tuberculosis lesions healing is not a limited proliferation or spread to the downward along the tubular layer in the medulla of the kidney, renal papillary ulcers occur when lesions gradually expanding rupture, or invasive renal calyceal or pelvis. This intrusion of kidney renal tuberculosis from clinical cases, more than 85 percent of the lesions is unilateral, bilateral renal tuberculosis about 15 percent. Clinical the bilateral renal tuberculosis, both bilateral directly from the early development of the pathology of renal tuberculosis come, but also by the side of the other side of renal tuberculosis and subsequent healing illusion developed, and can also be clinical side of the urine renal tuberculosis Road to the spread of infection from the contralateral.
[Pathological changes:
Pathological changes in renal tuberculosis and other organs of the body the TB same variable can be divided into ① nodular type; ② ulcer empty; ③ fiber calcified. Early clinical stage renal tuberculosis into a miliary tuberculosis in the glomerular-gray TB nodules, nodules often occur cheese central necrosis of tuberculosis around the granulation tissue from a group of epithelial-like cells mixed with a few multinucleated giant cells (Langhan giant cell) and lymphocytes, and fiber cells. If unable to heal diseases and the spread of expansion, the development of a clinical stage renal tuberculosis.
TB clinical stage renal glomerular pathology changes in the miliary tuberculosis-like nodules gradually extend to the renal papilla Huipo, after renal calyceal mucosal involvement, forming irregular ulcers, lesions through renal calyceal, directly to the renal pelvis or distant spread Mycobacterium tuberculosis from the kidneys of lymphatic spread to the entire pipeline kidney. When the renal papilla of the tuberculosis-like nodules central necrosis of cheese liquefied substances discharged into the pelvis after a tuberculosis empty, and this can be limited to the empty part of the kidney may also affect the entire kidney and become a "tuberculosis renal abscess." This type of pathological changes in clinical practice most common. In the part of patients, the body of the resistance if the increase can not concentrated cheese - like substance and caused extensive liquefaction in the fibrous tissue hyperplasia and calcification, clinical known as the "cut-off from kidney" or "stucco kidney." Although lesions in the clinical development of the latest stage of the calcification, but the actual pathological cheese is often empty, fiber atrophy, the existence of mixed sclerosis calcification in the cheese - like substance in the presence of Mycobacterium tuberculosis can have.
Renal directly down the spread of tuberculosis or change in the lesion may be disseminated Mycobacterium tuberculosis involving urine ureteral mucosa, submucosa and even muscle caused TB nodules, caseous necrosis and ulceration. Followed by a fibrous tissue hyperplasia, resulting in cavity of the ureter atresia, the uneven thickness, intracavity rough. Lesions can be spread widely throughout ureter, as a rigidity of the cable to reduce the ureter, urinary bladder, ureter leading to the shrink and I was up holes Depression.
Stage clinical stage renal tuberculosis and tuberculosis invasion and luminal patency yet ureteral occlusion period, the direct spread of tuberculosis or change in the TB contact disseminated bladder, the bladder can lead to the occurrence of tuberculosis. The first is caused by congestive mucosal edema, after the formation of nodules or ulcers tuberculosis, which in the early bladder disease often Bureau
Limited to the ipsilateral kidney disease around the ureteral orifice later spread to the entire bladder. Such as disease, can invade the myometrium, causing bladder tissue fibrosis, the bladder wall contraction lose flexibility, capacity reduction, the final form of bladder contraction, and involved the contralateral kidney and ureter expansion formation water.
[Clinical]
Most renal tuberculosis in adults, our comprehensive statistics 75% of the cases occurred in between 20 to 40 years of age, but also in childhood and old age. Slightly higher than the incidence of male female. The clinical manifestations of renal tuberculosis and violations of the lesion location and the extent of the damage organization is different. Kidney disease confined to the early part of the clinical symptoms of a little urine test only when abnormal findings. Mycobacterium tuberculosis can be found in urine. When tuberculosis from the impact of the bladder and kidney, bladder causing tuberculosis, there are a series of symptoms, the main performance:
(A) stimulate the bladder to stimulate bladder symptoms of renal tuberculosis is the most important, the most important is also the earliest symptoms. When the mycobacterium tuberculosis of the bladder mucosa causing inflammation, patients begin to have frequency, the frequency of urination during the day and at night have increased gradually, by the dozens every day to several serious cases, several times per hour to urinate until Urinary incontinence may be a similar phenomenon. About 75 to 80 percent have symptoms of frequency. In the frequency at the same time, there will be urgency, Niaotong, voiding can not wait, we must immediately discharged, it is difficult patient. Urination at the end suprapubic bladder or urethral there are burning feeling. Increasingly serious bladder disease, the symptoms are more significant.
(B) hematuria hematuria renal tuberculosis is the second major symptoms, the incidence was about 70 to 80 per cent. General and frequency, urgency, Niaotong symptoms at the same time. Most of the sources of hematuria from bladder disease, but it can also come from the kidney itself. Hematuria varying degrees, mostly mild gross hematuria or microscope hematuria, but there are 3% of the cases, there is gross hematuria and is the only initial symptom.
Most of the emergence of hematuria end hematuria, bladder TB is the inflammation and ulceration in voiding the bladder contraction caused bleeding. If hematuria from the kidney, the entire process can be as hematuria.
(C) pyuria because of the kidney and bladder inflammation tuberculosis, causes tissue damage, urine can be a large number of Nongxibao, at the same time in the urine can be mixed with cheese - like substance so that the urine turbidity unclear, a serious Mitang kind pyuria. Pyuria the incidence rate of about 20 percent.
(4) low back pain serious kidney tuberculosis change tuberculous abscess can cause kidney and kidney volume increased, in the existence of mass waist, a low back pain. Information on the occurrence of domestic rate of 10 per cent. If the contralateral hydronephrosis, in the contralateral symptoms can occur waist. In a small number of patients blood clots, septic block can be caused by Shenbu ureteral colic.
(5) As renal tuberculosis systemic symptoms of TB in the body is an integral part, it can become a general symptoms of TB. Such as anorexia and wasting, fatigue, night sweats, fever, renal tuberculosis can be more serious when the emergence of tuberculosis or other organs caused.
(6) other symptoms due to renal tuberculosis secondary to tuberculosis or other organs with other organs tuberculosis, thus the emergence of some other organs TB symptoms, such as bone tuberculosis cold abscess, the sinus nuclear lymph nodes, intestinal tuberculosis diarrhea, abdominal pain , especially with the male reproductive tract tuberculosis, sarcoidosis epididymis are there.
[Complications]
(1) of bladder contraction
1. Bladder contraction and the cause pathological changes come from renal tuberculosis mycobacterium tuberculosis often repeated invasive bladder, causing serious TB cystitis, the bladder muscle of the bladder mucosa have congestion and edema, Tuberculosis sarcoidosis, tuberculosis ulcer, tuberculosis granulation, a large number of lymphocyte infiltration and formation of fibrous tissue, which causes bladder contraction. Contracture in the bladder, the loss of normal bladder wall flexibility, capacity significantly reduced. Generally believed that the capacity of the bladder contraction in the following 50 ml. Serious bladder can shrink to a few ml capacity. The bladder often repeated by Mycobacterium tuberculosis infection, the bladder is the pathological changes of acute and chronic inflammation and fibrosis of the repeated reference to both miscellaneous process. The incidence of bladder contraction According to the Shanghai Zhongshan Hospital 837 cases of renal tuberculosis statistics to 9.67 percent.
2. Symptoms of bladder contraction of the bladder contraction caused bladder capacity significantly reduced in frequency in patients. Contracture due to the process of gradual, it will gradually increase the frequency. Voiding frequency can be Shituci to dozens of times every day, or even a few minutes, that voiding so that the patients are extremely painful. Contracture due to the regular inclusion of acute tuberculosis bladder inflammation, and even non-specific merger mixed bacterial infection, so evident in the frequency of patients should be non-specific acute TB infection and inflammation in the anti-inflammatory and anti-TB drugs is the only real control Bladder capacity and voiding symptoms. Another bladder contraction often can be ureteral orifice, Zhou TB intramural ureteral change impacts, including about the ureteral orifice role destruction, a “dysraphism” phenomenon, resulting in voiding the result of ureteral expansion ureteral reflux, hydronephrosis. During this period the patient urination, can occur in the urine of bladder emptying after Ureteropelvic immediately in the urine of bladder filling and voiding again, it is the first urine from the urinary or intermittent phenomenon should also consider the bladder contraction symptoms, we must further clarify inspection. Another bladder contraction can produce ureteral orifice and / or intramural ureteral obstruction caused ipsilateral renal pelvis and ureter water.
3. Diagnosis of bladder contraction in the above-mentioned symptoms, the need to rely on X-ray examination. Bladder contrast to the appearance of the bladder can show significantly reduced. Especially the delay in bladder angiography can be observed that the anti-ureteral orifice flow and contralateral renal pelvis and ureter the expansion of water (Figure 4). At that time, the inspection should pay attention to the availability of acute bladder inflammation there. Bladder with the presence of acute inflammation, while not suitable for bladder imaging, contrast agent on the other hand can be stimulated to bladder contraction, resulting in the false impression of bladder contraction, it should be taken to avoid misdiagnosis.
(B) contralateral hydronephrosis contralateral renal tuberculosis hydronephrosis is the late complications from bladder caused by tuberculosis. According to Wu (1954) reported that the incidence rate of 13 per cent; 1963 Comprehensive 4,748 cases of renal tuberculosis patients, the contralateral hydronephrosis secondary to 13.4 per cent.
1. Contralateral hydronephrosis and pathology reasons for the occurrence of tuberculosis caused by bladder following pathological changes affecting the contralateral kidney urine drainage, resulting expansion of the contralateral renal pelvis and ureter water.
(1) contralateral ureter stenosis: Tuberculosis of cystitis side from the disease around the ureteral orifice spread to the entire bladder violations to the contralateral ureteral orifice, the extent of the inflammatory lesions, ulcers and to fibrosis, helps contralateral ureteral I happen narrow, from the impact of urine to the contralateral renal pelvis and ureter expansion in stagnant water.
(2) contralateral ureteral orifice tricuspid regurgitation: normal ureter through the bladder to the ureter of the intramural Although there is no formal opening sphincter exists, but is included with the sphincter about the same role. If the side of TB spread to the bladder and ureter contralateral to the affected population, including about the role of causing damage to the contralateral ureteral orifice formed the tricuspid regurgitation, so when bladder-voiding the bladder contraction pressure, urine from the contralateral tricuspid regurgitation ureteral reflux mouth to the renal pelvis and ureter, resulting in the contralateral kidney, ureter expansion of stagnant water.
(3) contralateral Lower Ureteral stricture: urinary side after suffering from tuberculosis, Mycobacterium tuberculosis returning upward from lower urinary tract, urinary tract infection the other side of the lower ureter and bladder or ureter contralateral near the mouth of tuberculosis directly change the mucosal surface spread or submucosal invasion, the ureteral orifice over a period of ureteral have tuberculosis change, and then by a narrow scar formation caused the contralateral kidney and ureter expansion of stagnant water.
(4) bladder contraction: Serious cases of tuberculosis last cystitis caused bladder contraction, and urine in the bladder filling contracture, bladder pressure increased. Bladder with a long-term high pressure can block the contralateral renal pelvis and ureter from the urine. Contracture or in the urinary bladder voiding the contralateral reflux caused contralateral renal pelvis and ureter expansion of stagnant water.
2. Contralateral hydronephrosis symptoms contralateral hydronephrosis is the late complications of renal tuberculosis, renal tuberculosis patients in general presentation of the clinical symptoms. Hydronephrosis and contralateral to the symptoms hydronephrosis as the extent to which, the less water can be asymptomatic, signs, water clear and serious, there will be full abdominal pain, or low back pain, as well as abdominal or There are mass waist.
3. Contralateral hydronephrosis diagnosis
(1) Analysis of history: while the contralateral renal tuberculosis patients with hydronephrosis, basically tuberculosis side of serious kidney damage, loss of function completely, the patient’s life depends on the maintenance of the contralateral kidney. If the contralateral hydronephrosis a lesser extent, the clinical symptoms is not clear if the contralateral severe hydronephrosis, renal dysfunction can arise, the symptoms of uremia. Often the occurrence of contralateral hydronephrosis in the application of anti-TB drugs after a considerable period of time. Bladder and ureter TB lesions in the control of anti-TB drugs are in the TB lesions in the process of healing fibrosis gradually emerging distal ureter or ureteral orifice of the narrow ureter and renal secondary water, if narrow gradually increased, the water level would gradually development. Thus the total renal dysfunction in patients with renal tuberculosis suggested that water may have contralateral kidney should be further checks.
(2) phenol red (PSP) test: conventional phenol red test: in four of their urine specimens (15,30,60,120 minutes) the concentration of phenol red. When hydronephrosis mildly affected, phenol red from the delay, the first two samples from the small, and the latter two specimens from higher. If serious side hydronephrosis is not discharged phenol red, four are rare specimens from phenol red.
(3) radionuclide renography: hydronephrosis that contralateral renal excretion was delayed plans curve curve or function curve.
(4) Ultrasonography: ultrasonic inspection method is simple, the patients had no pain, detectors the size of the contralateral kidney, water and the extent of the renal parenchyma thickness to provide reference information.
(5) X-ray inspection: X-ray examination is essential in the diagnosis of the contralateral kidney stagnant water will have a decisive role in any of the following methods used several:
1) delay IVP: general methods of intravenous pyelography water pelvis expansion of the renal dysfunction patients can not be satisfied with the show pelvis forms. If suspected water in the contralateral kidney should be intravenous pyelography in radiography time in accordance with phenol red excretion extension of the time to 45 minutes, 90 minutes or even 120 minutes so that the contrast agent pelvis accumulated more when the number of intake X-ray, can renal pelvis and ureter lights show clear patterns. If renal SHANG Jia, in the injection of contrast agent used in the high-dose intravenous pyelography way, the images show more clearly.
2) Delayed bladder angiography: Bladder angiography can show bladder forms. If the ureter is tricuspid regurgitation, the contrast agent can be reflux from the bladder to the ureter and even renal pelvis and ureter and renal pelvis revealed that the morphology. In contrast, if the bladder so that the contrast agent injected into the bladder in the bladder in a short period of time delay so that anti-contrast agent into the kidneys of some more after the X-ray film, the water will form ureteropelvic show more clearly. For the prevention of contrast agent reflux caused retrograde infection, in contrast agents need to add the appropriate antibiotics.
3) puncture renal angiography (anterograde IVP): If poor renal function, intravenous pyelography not that serious and bladder diseases, retrograde renal pelvis angiography can not succeed, no bladder reflux contrast, renal angiography is the only puncture understanding of the renal pelvis and reliable method. Under the guidance of ultrasound in the rib section 12 under the sacral spinal muscular puncture the lateral edge of the renal pelvis, puncture after the success of urine specimens can draw all the necessary checks and from the needle into the appropriate amount of contrast agent uptake after X-ray, clearly the nature of kidney disease.
(C) TB spontaneous rupture of the bladder less spontaneous rupture of the bladder see, but in the breakdown of TB cases to the maximum. 80 cases reported in the literature abroad in 10 cases (12.5%), domestic reported 23 cases in 15 cases of tuberculosis for the spontaneous rupture of the bladder, it should be on the clinical importance.
1. Tuberculosis spontaneous rupture of the bladder etiology and pathology of bladder TB spontaneous rupture of the bladder, is the main reason for the change serious and widespread tuberculosis, TB depth of myometrial ulcer inflammation involving the whole of the bladder wall, if at lower urinary tract obstruction , bladder contraction, or a sudden increase intra-abdominal pressure and other factors can cause spontaneous rupture. More than the site of rupture or posterior wall at the top, almost all of the peritoneum.
2. Tuberculosis bladder symptoms of spontaneous rupture of the bladder is often a spontaneous rupture of acute onset of the disease process. Trauma patients in the absence of a sudden pain in the lower abdomen, and no voiding or attack from a small number of hematuria, peritoneal irritation of the abdomen. However, as is the tuberculosis patients with bladder, in the event of breakdown of the past, the history of the existence of
