Perinephritis and Renointestinal Fistulas

Advanced perirenal infection may break through fascial boundaries to involve overlying bowel.6 The anatomic relationships of the kidneys, the enveloping fascial planes, and the colon are basic to an understanding of

Fascial Planes

Fig. 9—22. Displacement of the left colon by left renal carcinoma.

(a and b) Barium enema and CT show calcified left renal mass (M) producing anterior displacement of distal mesenteric transverse colon (TC). The anatomic splenic flexure (SF) is maintained.

NephrotomogramNephrotomogram

Fig. 9—23. Displacement of left colon by left renal cyst.

(a and b) The descending colon is displaced laterally and anteriorly (arrows) by a large cyst originating from the lower renal pole. The anatomic splenic flexure (SF) is unaffected.

(c) Intravenous urography confirms a huge cyst arising from the lower pole. (Reproduced from Meyers.2)

Nephrotomogram

Fig. 9—24. Displacement of stomach by left renal cyst.

(a) Smooth extrinsic pressure upon the greater curvature of the stomach.

(b) Nephrotomogram documents a large cyst arising from the left kidney. It can be presumed to be spherical, with as great an AP dimension to bring it into relationship to the stomach as its coronal dimension.

Fig. 9—24. Displacement of stomach by left renal cyst.

(a) Smooth extrinsic pressure upon the greater curvature of the stomach.

(b) Nephrotomogram documents a large cyst arising from the left kidney. It can be presumed to be spherical, with as great an AP dimension to bring it into relationship to the stomach as its coronal dimension.

the spread of inflammation (Figs. 9-30 and 9-31). The distal transverse colon courses anterior to the lower half of the left kidney. The splenic flexure demarcates the transition between the mesenteric transverse colon and the extraperitoneal descending colon. It lies on a plane posterior to the hepatic flexure and is attached to the diaphragm, opposite the 10th and 11th ribs, by the phrenicocolic ligament, which helps support the lower end of the spleen. The descending colon passes downward along the lateral border of the left kidney, turning somewhat medially toward the lateral border of the psoas muscle at the lower pole. At this level, the descending colon lies within areolar tissue in the anterior pararenal space behind the posterior parietal peritoneum. Normally, it is separated posteriorly from the kidney and perirenal fat by the anterior renal fascia; however, its medial and posterior walls face the left kidney and the richest deposit of perirenal fat, which resides behind and lateral to the lower renal pole.

The pathogenesis involves a site of renal infection that breaks through the capsule of the kidney to contaminate the perirenal space. The infection may spread through the perirenal fat as diffuse perinephritis, but coalescence into an abscess has a definite tendency to localize in the rich fat dorsolateral to the lower renal pole.7,8 The inflammatory process is usually confined to the perirenal

Peritoneal Deposits

Fig. 9—25. Displacement of stomach and small bowel by left renal cyst.

(a) The round mass elevates the greater curvature of the stomach and displaces the duodenojejunal junction medially and small bowel loops inferiorly.

(b) Selective inferior mesenteric arteriogram shows arcuate displacement of the ascending left colic artery and its branches by the renal mass as it bulges through into the peritoneal cavity.

(Reproduced from Meyers.2)

Fig. 9—25. Displacement of stomach and small bowel by left renal cyst.

(a) The round mass elevates the greater curvature of the stomach and displaces the duodenojejunal junction medially and small bowel loops inferiorly.

(b) Selective inferior mesenteric arteriogram shows arcuate displacement of the ascending left colic artery and its branches by the renal mass as it bulges through into the peritoneal cavity.

(Reproduced from Meyers.2)

Fig. 9—26. Displacement of small bowel by left renal cyst.

CT demonstrates jejunal loops displaced anteriorly by cysts arising from the lower pole of the left kidney.

Ptotic KidneyPtotic Kidney Radiology

Fig. 9—27. Displacement of the descending duodenum by a ptotic right kidney.

(a) The distal segment of the descending duodenum is displaced anteriorly and medially (arrows).

(b) Intravenous urogram shows a ptotic right kidney with rotation about its vertical axis. (Reproduced from Meyers.2)

Fig. 9—27. Displacement of the descending duodenum by a ptotic right kidney.

(a) The distal segment of the descending duodenum is displaced anteriorly and medially (arrows).

(b) Intravenous urogram shows a ptotic right kidney with rotation about its vertical axis. (Reproduced from Meyers.2)

Ptotic Kidney

Fig. 9—28. Displacement of small bowel by a ptotic right kidney.

(a) There is gentle arcuate displacement of ileal loops (arrows) by a soft-tissue right lower quadrant mass.

(b) Intravenous urogram shows a hydronephrotic, ptotic right kidney. (Reproduced from Meyers.2)-

Picture Soft Tissure Colon

Fig. 9—29. Direct invasion of the colon by left renal carcinoma.

(a and b) Two different cases showing extrinsic and intramural masses of the distal transverse and proximal descending colon with bulky polypoid intraluminal extensions. (b, reproduced from Meyers.2)

Fig. 9—29. Direct invasion of the colon by left renal carcinoma.

(a and b) Two different cases showing extrinsic and intramural masses of the distal transverse and proximal descending colon with bulky polypoid intraluminal extensions. (b, reproduced from Meyers.2)

Fig. 9—30. Frontal drawing illustrating the relationship of the descending colon (DC) to the left kidney (LK) distal to the splenic flexure.

P = pancreas; D = duodenum. (Reproduced from Meyers.6)

Cross Section FistulaHorizontal Section Through Left Ear

Fig. 9—31. Horizontal cross-section through the left flank demonstrating the anatomic relationships.

The anterior renal fascia (arrow) demarcates the extraperitoneal descending colon (DC) from the left kidney (LK), and perirenal fat. QL = quadratus lumborum. (Reproduced from Meyers. )

Fig. 9—31. Horizontal cross-section through the left flank demonstrating the anatomic relationships.

The anterior renal fascia (arrow) demarcates the extraperitoneal descending colon (DC) from the left kidney (LK), and perirenal fat. QL = quadratus lumborum. (Reproduced from Meyers. )

compartment by the renal fascia. More fulminating infections break through the fascial boundaries and spread to the overlying structures. On the left, the distal transverse colon and, particularly, the proximal or mid-descending colon and, on the right, the ascending colon are involved.

Changes reflecting at least inflammatory adherence may affect principally the medial or posterior contour of the colon or be circumferential. They are manifested primarily by spastic narrowing, scalloped induration, and inflammatory mucosal thickening6 (Figs. 9-32 through 9-35). In the descending colon, localization to the area distal to the splenic flexure overlaps the site involved in the extension of pancreatitis to the colon,9 but lack of associated changes involving the flexure itself is a helpful differential point. Extravasated pancreatic enzymes passing along the transverse mesocolon into the phrenicocolic ligament result in inflammatory changes affecting, most characteristically, the splenic flexure. The defects do not closely simulate either the ulcerations and pseudosacculations of granulomatous colitis or the mucosal edema and thumb-printing of ischemic colitis.

A gross extraperitoneal sinus communication represents advanced transmural erosion (Figs. 9-36 through 9-39). Most renointestinal fistulas are secondary to an underlying chronic kidney infection that establishes communication usually with the descending duodenum or left colon.10-14 Traumatic fistulas are not common but their relative incidence appears to be increasing.14 Although they may be immediately obvious, they may also appear insidiously months later. Rarely is the communication caused by a primary process ofthe bowel15 (Fig. 9-40).

Operative intervention is almost always indicated in renointestinal fistulas. In most cases, the affected kidneys have been the seat of parenchymal infection and stone disease for long periods before detection and have little if any remaining function. Most reported successes involve nephrectomy and bowel closure.11 Conservative methods are indicated for renointestinal fistulas detected before severe renal damage has occurred and in selected cases of fistulas.

Essentials of Human Physiology

Essentials of Human Physiology

This ebook provides an introductory explanation of the workings of the human body, with an effort to draw connections between the body systems and explain their interdependencies. A framework for the book is homeostasis and how the body maintains balance within each system. This is intended as a first introduction to physiology for a college-level course.

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