Obstructive Uropathy Practical 23-12-2014 Students 2

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Pathology of Urinary tract obstruction

ID# 3347 DEPARTMENT OF PATHOLOGY

Phase II Curriculum -4th year (2011 intake) Renal, Reproductive and Breast system module

Practical 4

23-12-2014 1.00-2.50

Weekly learning objectives

To explain the pathological findings in obstructive uropathy and correlate

with the clinical, radiological findings and effect on renal

function.

Objectives

Illustrate the pathological changes affecting the kidney and ureter seen in

urinary tract obstruction.

Describe the pathological features of the most important causes of

obstruction to urinary tract including: renal stones, ureteric structure, and

prostatic disease.

Case No. 1

A 45 year old Egyptian woman was admitted

to hospital with an attack of severe left flank pain. She was diagnosed in Egypt

earlier with renal calculi.

Her initial hospital evaluation showed the following:

BP 160 / 100 mmHg

Pulse rate 80 / min

Temperature 37.0 o C

24 hour urine output 900 ml

Urine microscopy normal

Hb 100 g/L (140-160g/L)

ESR 23 mm /1 hr (1-20 mm/hr)

Glucose 5.5 mmol/L (3.9-6.1)

BUN 6.2 mmol/L (2.5-6.6)

Creatinine 110 mmol/L (60-120)

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Abdominal X ray Normal

IVU See photograph

IVU

A left nephrectomy was performed on

the patient. The right kidney looked

normal during surgery.

Left nephrectomy specimen

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A tissue section from the

kidney showed the following

Chronic inflammatory cells (High power view)

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“Thyroidization”, due to dilation of tubules which

contain eosin-staining proteinaceous material (colloid). Microscopic Findings in left kidney:

• Thinning (atrophy) of renal parenchyma

• Chronic interstitial inflammation

• Interstitial fibrosis

• Arterial sclerosis

• Glomerular sclerosis

Left kidney hydronephrosis with Hydrourteter

complicated by chronic pyelonephritis

Diagnosis: 1. Name 4 different conditions which may give rise to unilateral hydronephrosis.

2. Name 3 different conditions which may give rise to bilateral hydronephrosis

3. What does the fact that this patient has unilateral hydronephrosis with hydroureter suggest to you?

4. Did this patient have renal failure? Explain.

Self study

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Case No. 2

A 40 year old man was investigated for repeated

colicky pains on the left side of abdomen for the

last 5 years.

Examination showed the following:

BP 180 / 100 mmHg

Pulse rate 90 / min


Hb 90 g/L (140-160g/L)

ESR 30 mm /1 hr (1-20 mm/hr)


BUN 6.0 mmol/L (2.5-6.6)


Ca 3.3 mmol/L (2.2-2.6)


A left nephrectomy was carried out

Investigations

Left Nephrectomy

Gross Findings

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Left kidney hydronephrosis secondary to

ureteric obstruction by stone.

Diagnosis: 1. Name 5 conditions that predispose to renal stone formation. Which one do you think is present in this patient?

2. What type of renal stones can be seen on routine abdominal X-ray?

3. What is the significance of serum Calcium value in this patient

4. Can you recall three common causes of elevated serum calcium level

5. List at least 2 findings in urine that may be seen as a complication of renal stones.

Self study

Case No.3

A 79 year old man who was recently diagnosed

with chronic kidney disease was found dead

at home .

Postmortem examination was performed.

His urinary bladder specimen shows the following

Macroscopic Findings

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A tissue section from his enlarged

prostate showed the following

Hyperplasia ( high power )

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Microscopic Findings of prostate

• Nodular architecture of prostatic tissue

• Hyperplasia of prostatic glands

• Hyperplasia of prostatic stromal tissue

Nodular hyperplasia of prostate

Diagnosis

Self study

1. Give two explanation for the development of

chronic renal disease in this patient, based on

the autopsy specimen provided.

2. If you were performing the postmortem

examination how would both kidneys grossly look?

Case No. 4

A 74 year old hypertensive and heavy tobacco smoker

was admitted to the emergency room in a state

of coma and died within 1 hour of admission. His

medical record showed that he passed red urine on

several occasions

A postmortem examination was carried out.

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He was hospitalized 3 month back and his clinical

notes on previous admission showed the following :

BP 170 / 110 mmHg

Pulse rate 100 / min



Urine microscopy 370 RBC/HPF

Hb 160 g/L (140-160g/L)

ESR 40 mm /1 hr (1-20 mm/hr)


BUN 4.5 mmol/L (2.5-6.6)


His kidney and bladder specimens are shown

Left Right

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Histology of normal urothelium Total architectural disorganization and significant cytologic atypia of urothelium

There is loss of nuclear polarity; considerable variation in nuclear

size, shape, and chromatin content; mitoses are frequent

Histopathological report on the urinary

bladder lesion:

High grade transitional cell carcinoma

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Hydronephrosis with hydroureter secondary to

obstruction by a transitional cell carcinoma of

urinary bladder

Final diagnosis Self study

1.Name 5 different causes that may give rise to red

colored urine. What is the cause of red urine in this

patient?

2. Can you explain the serum creatinine value in this

patient?

Case No.5

A 5 year old boy was investigated for recurrent

abdominal pain. All laboratory tests were normal.

An ultrasound showed distension of the pelvis of

left kidney. The other kidney was normal.

Following thorough investigations a left

nephrectomy was carried out.


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Ureteropelvic Junction Obstruction

Diagnosis

Self study

1. How common is this condition and at what age group is

it most prevalent?

2. What do you know about the etiology of this condition?

3. What would be the effect on the patient if the condition

was bilateral?

Case No.6

A 55 year old diabetic woman with a history of

recurrent attacks of upper urinary tract infection

(Acute pyelonephritis) that usually settles down with

intravenous antibiotic presented with dysuria and

frequency that became worse in the last two weeks.

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Section from kidney with acute pyelonephritis

from another patient showed the following

Acute pyelonephritis

Neutrophils are seen in the tubules and interstitium.

The neutrophils can coalesce in the distal tubules and collecting ducts

and passed in urine as WBC casts.

Ultrasound examination revealed the presence of a

large right sided stone with branching structure

within the pelvis that is starting to impinge on the

calyceal structure.

The stone was removed and the patient was

discharged.

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Large stone with branching structures Radiological and gross findings of another patient with similar presentation

Two year later more attacks of pyelonephritis occurred. Radiology

examination this time showed hydronephrotic changes and new

branching stone formation. Nephrectomy was done. Nephrectomy

specimen is shown

open kidney and staghorn calculi

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Chronic pyelonephritis with

formation of staghorn calculi

Diagnosis Self study

1. What is the chemical composition of staghorn calculi?

2. What type of organism is responsible for the

formation of this type of calculi?

Quiz

(To be answered during class)

1. What is the chemical composition of

this stone removed from kidney ?

a. Calcium oxalate

b. Magnesium ammonium

phosphate

a. Cystine

b. Uric acid

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2.What is the likely cause of

Right sided hydronephrosis

withhydroureter?

a. Carcinoma of bladder

b. Benign prostate hyperplasia

c. Ureteric stone

d. Ureteric stricture

3. Name the diagnosis on this kidney

a. Hydronephrosis

b. Acute pyelonephritis

c. Renal stone

d. Hydroureter

4. Section of kidney from a patient with recurrent urinary

tract infection.

Identify two important features present in this

photomicrograph

a. Interstitial chronic inflammatory cell infiltrate

b. Arteriolosclerosis

c. Thyroidization of tubules

d. Crescent formation

Obstructive Uropathy Practical 23-12-2014 Students 2

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