核心課程編號 : B33 腎臟內科許育瑞醫師 / 吳坤霖醫師 102 年 04 月 15 日第四版王涵恩醫師

Transcription

1 核心課程編號 : B33 血 尿 腎臟內科許育瑞醫師 / 吳坤霖醫師 102 年 04 月 15 日第四版王涵恩醫師

2 學習目標 PGY 1. 能對血尿患者作出初步處理 2. 在未確定病因前能與血尿患者合宜地說明診療計畫 3. 能對幾個引起血尿的常見疾病或狀況作出合宜的處理 4. 在確定病因後能與血尿患者合宜地說明診療計畫和預後 - UGY

3 ITE 考題

4 血尿 - 定義 presence of blood in the urine > 3 RBCs/HPF is significant considered > 5 RBCs/HPF to be evidence of significant microscopic hematuria 9% - 18% of normal individuals have some degree of hematuria JM Sutto. JAMA 263 (1990), p JB Copley. Am J Med Sci 291 (1986), p AJ Mariani et al. J Urol 141 (1989), p DN Mohr. JAMA 256 (1986), p

5 血尿 - 病理生理學 Normal unspun urine (<3 RBCs/HPF ) Dipsticks: (blood, protein, glucose, ketones, urobilinogen, WBC) 1. OB : hematuria, hemoglobinuria, myoglobinuria 2. Based on peroxidase-like activity of hemoglobin 3.False-positive: menstrual blood contamination, exercise, oxidizing agents, myoglobinuria 4.False-negative: reducing agents (high dose vit. C), urine ph<5.1

6 血尿 - 分類與特性 History Taking gross / microscopic timing of hematuria: initial, total, terminal association with pain: painful, painless presence of clots, shape of clots

7 Hematuria Nephrologic hematuria (glomerular disease): dysmorphic RBC, RBC casts, proteinuria Urologic hematuria (tubulointerstitial or renovascular renal disease): uniformly round shape RBC Systemic disorders

8 Nephrologic (glomerular disease) 20% will have hematuria alone without proteinuria or RBC casts Lab: Cr, CCr, daily protein loss Frequently, renal biopsy for precise diagnosis is necessary

9 Nephrologic (glomerular disease)

10 Nephrologic (glomerular disease)

11 Urologic (nonglomerular hematuria) Hematuria of any degree should never be ignored Should be regarded as a symptom of urologic malignancy until proved otherwise The most common cause of gross hematuria in a patient older than age 50 years is bladder cancer.

12 Urologic (nonglomerular hematuria) Urologic: 1. Tumor 2. Stone 3.BPH 4.UTI Medication: anticoagulant Hematologic disorder Exercise-induced Vascular disease

13 血尿 - 理學檢查 hypertension generalized edema palpable abdominal or flank mass flank tenderness flank laceration, contusion, rib fracture DRE

14 血尿 - 實驗室檢查 Urinary analysis (color, sp.gr, protein, leukocyte, nitrite, RBC casts, crystal) Urine culture Urine cytology: high-grade urothelial carcinoma Renal function test (BUN/Cr) CBC Coagulation profile/bleeding study Others: serum IgA, ANA, urine TB culture

15 血尿 - 影像檢查 KUB Ultrasound Excretory urography (IVU) RP CT or MRI Nuclear renal scans Cystography arteriography

16 KUB

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18 接下頁 Chen DL, Tsai DJ, Diagnostic Approach and Management of Hematuria Journal of Internal Medicine of Taiwan 2002

19 Chen DL, Tsai DJ, Diagnostic Approach and Management of Hematuria Journal of Internal Medicine of Taiwan 2002

20 IVU + PV

21 Kidney: collecting system

22 IVU + RP

23 0 min:kub 5min: the pyelogram 7 min post-voiding film

24 Ureter Length: cm Caliber: 5 mm 3 Parts: Lumbar ureter Iliac ureter Pelvic ureter: max 1 cm medial to bone margin

25 Ureter: filling defects 1. Normal 2. Vessel: band-like defect 3. Tumor: Burgman's sign 4. Radiolucent stone

26 Renal Tumor Vascular mass Calcifications: also seen in some benign disease Tumor shell: thick wall

27 Bladder filling defects Gas Stone Tumor Prostate Others

28 RCC

29 TCC of ureter

30 TCC of bladder

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32 血尿 - 特殊檢查 Cystourethroscopy RP Ureteroscopy (URS) Renal biopsy

33 UCa (TCC) Urothelical carcinoma of the renal pelvis: a retrograde pyelogram demonstrates an illdefined lobulated filling defect involving the upper-pole infundibulum and calyces.

34 BPH The upward displacement of intramural ureter: fish-hook sign prostate indentation

35 血尿 - 處置 Nonglomerular hematuria Surgical: Urologic tumors Stones BPH

36 血尿 - 處置 The standard urologic evaluation of hematuria: IVU, cystoscopy, urine cytology Additional testing based on clinical findings Always consider medical causes of hematuria based on presentation, lab data, or if evaluation for anatomic lesion is negative Gross hematuria usually requires urgent evaluation to prevent / treat clot retention Hydration Manage underlying problems

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