Clinical characteristics and therapeutic effect of perirenal abscess in a teaching hospital
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https://www.eduzhai.net Clinical M edicine and Diagnostics 2013, 3(4): 101-104 DOI: 10.5923/j.cmd.20130304.05 Clinical Characteristics and Treatment Outcome of Perinephric Abscess Treated in a Teaching Hospital Azhar Amir Hamzah1,*, Azreen Syazril Adnan2, Rashidi Ahmed3, Mohammad Nor Gohar Rahman1, Amer Hayat Khan4 1Urology Unit, Department of Surgery, Hospital University of M alaysia, Kubang Kerian, Kelantan, M alaysia 2Chronic Kidney Disease (CKD) Resource Center, School of M edical Sciences, University Science M alaysia, 16150 Kota Bharu, Kelantan, M alaysia 3Department Of Emergency M edicine, Hospital University of M alaysia, Kubang Kerian, Kelantan 4Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains M alaysia, 11800 Penang, M alaysia Abstract Perinephric abscess, have been associated with significant mo rbidity and mo rtality. A retrospectively, cross sectional study was designed in the tertiary level teaching hospital and reviewed all patients diagnosed to have perinephric abscess from the year 2001 until 2010. Perinephric abscess is a rare disease, with 21 cases documented over the period of 10 years. Female gender was found predominance, with male to female ratio 1:4.5. The incidence on the left side was higher than opposite side or bilateral. Most of them have 2 risk factors, including renal calculi (90%) and diabetes mellitus (66%). Of 21, 86% patients were presented with fever, and 47% of them have chills and rigors. Sixty three percent of the patient with perinephric abscess had white cell count ranged fro m 10-19 x 109 cells/l. Urine cultures were positive in 18 (86%) of patients. Fro m year 2007 onwards, all the cases suspected to have perinephric abscess for ulrasound were subjected to CT scan, which has increased the diagnostic sensitivity. Out of 21, 14 (66%) patients were treated with comb ination of antibiotics and percutaneous catheter drainage of the abscess. All patients were d ischarged eventually with one mortality. The clinical characteristics of perinephric abscesses have not changed significantly but improved imaging with CT allows increased diagnostic sensitivity. With accurate diagnosis, a variety of treatments can be successful, including antibiotics alone, or combination of antibiotics with percutaneous catheter drainage. In our series, there was only one patient posted for exploration and drainage. Essentially, th is should be considered if adequate drainage is not achieved percutaneously. Keywords Perinephric Abscess, Clinical Characteristic, Treat ment Outcome 1. Introduction Perinephric abscess, in the past, have been associated with significant morbidity and mortality. Despite aggressive surgical drainage, researcher reported 56% to 39% mortality rate with perinephric abscess.[2,3] The delay in making the diagnosis due to non-specific clin ical findings and limited specificity of imaging studies were important factors that associated with poor outcome.1 Hence, with the advancement of radio-imaging technology, especially the availability of computer to mography and magnetic resonance imaging facility has helped in accurately diagnosing the disease, which ultimately reduce the mortality. Furthermo re, percutaneous catheter drainage of intraabdomina l and retroperitoneal abscesses is now usually performed with min imu m morb idity and desirable results. * Corresponding author: email@example.com (Azhar Amir Hamzah ) Published online at https://www.eduzhai.net Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved These improvements in the diagnosis and treatment of perinephric abscesses are thought to have imp roved outcomes for this disease process. Authors share their experience treating patients with perinephric abscesses in the era of CT and interventional radio logical techniques. The study was designed to determine demographic characteristics, clinical profile and treatment outcome of patients with perinephric abscess in a teaching hospital. 2. Methods A retrospective, cross sectional study was designed and reviewed all cases of perinephric abscess who admitted into Hospital Universiti Sains Malaysia (HUSM) fro m the year 2001 till 2010. We searched such cases with the assistance of med ical record officer and by using the electronic database. Medical records of patients were obtained fro m the Record Depart ment after Ethical Co mmittee and Hospital Director approval. Pat ients with perinephric abscesses were included into the study, while those patients with renal abscesses were excluded. Pat ient characteristics were co mpiled as well as 102 Azhar Amir Hamzah et al.: Clinical Characteristics and Treatment Outcome of Perinephric Abscess Treated in a Teaching Hospital diagnostic, treat ment and outcome informat ion. Studied variables include age, sex, race, underly ing med ical illness, clinical features, types of antibiotic, length of hospital stay and death. These variables were recorded in the data collection sheet prior to its transfer to SPSS. 3. Results A total of 21 cases of perinephric abscess over the period of 10 years were found. The mean age of collected cases were 48 + 19.7 years with male to female ratio 1: 4.25. Tab le 1 revealed that the right side involvements were maximu m 11 (52%) and elder age mo re than 40 years were higher on risk 14 (67%). Table 1. Demographic Characteristics of the Patients Demographic variables Gender Male Female Smoker Yes No Unknown Age (Years) < 20 20-30 31-40 41-50 50-60 > 60 Sit e/Lo cat ion Left Right Bilateral No. (Percentage) 04 (19%) 17 (81%) 3 (14%) 13 (62%) 5 (24%) 1 (5%) 3 (14%) 3 (14%) 4 (19%) 6 (29%) 4 (19%) 14 (66%) 06 (29%) 01 (5%) Table 2. Predisposing factors associated with Patients Predisposing factors Renal calculi Diabet es mellit us Urinary tract infection End stage renal disease Trauma Liver disease No. of Patients (%) 19 (90) 14 (66) 12 (57) 3 (14) 2 (9) 2 (9) Table 2 shows past and present medical conditions of the patients. Renal calculi were found in maximu m patients 19 (90%), fo llo wed by diabetes mellitus 14 (66%), and some other factors were found as well. Majority of clin ical sign and symptoms were noticed like fever 18 (86%), Nausea & vomit ing 16 (76%), flank pain 14 (66%) and abdominal pain 10 (47%), as illustrated in table 3. Table 3. Clinical Presentation of Perinephric Abscess of the Patients Sign and Symptoms Weight Loss Abdominal pain Flank pain Nausea/vomit in g Chills & Rigors Urinary symptoms Fever Let hargy Anoraxia No (%) 6 (29) 10 (47) 14 (66) 16 (76) 10 (47) 5 (23) 18 (86) 8 (38) 12 (57) Results from microbiological diagnosis reflecting 18 patients had positive cultures. Urine was most often the only source of a positive culture and was statistically mo re sensitive than blood and abscess fluid cu ltures. CT was diagnostic in 19 (90%) of 21 cases, wh ile plain abdominal radiography and ultrasound were 25% and 71% sensitive, respectively. Plain X-ray was done for all cases and renal calculi were detected in 63.7% cases. All the patients had an ultrasound done. Fro m year 2007 onwards, all the cases suspected to have perinephric abscess fro m ultrasound were subjected to CT scan, wh ich has increased the diagnostic s ens itiv ity . In 14 patients the abscesses were drained by percutaneous catheter. The mean lesion size and time to abscess resolution was 11 cm. and 25 days, respectively. Mean hospitalization was 30 days. Ult imately, 4 patients initially treated with percutaneous drainage required open surgical exp loration and nephrectomy for persistent infection and minimal function of the affected kidney. In 3 patients with sma ll perinephric abscesses (less than 3 cm.) and associated hydronephrosis drainage of the urinary tract in conjunction with antib iotics was performed with complete resolution on subsequent CT. Mean hospitalization was 11 days without complications. All patients underwent subsequent ureteroscopy and stone removal. One patient underwent abdominal exp loration for sepsis and presumed intra-abdominal abscess, which was found to have originated from a perinephric source. Patient died 16 days after surgery of sepsis, leading to renal and hepatic failure. He had pre-existing alcoholic cirrhosis, and associated hepatic dysfunction and portal hypertension, for which he had undergone prior portocaval shunt. Table 4. Microbiological Findings Items No. Performed No. + ive * % Sensitivity Urine 19 18 72 Blood 20 10 56 Drain 12 9 50 *Involved Organisms were; Escherichia coli (9), Streptococcus (5), Enterococcus (4), Proteus (3), Staphylococcus aureus (3) and Klebsiella sp. (2) Clinical M edicine and Diagnostics 2013, 3(4): 101-104 103 Table 5. Patients Treatment and Outcomes Variables Antibiotics alone Antibiotics with percutaneous Drainage Antibiotics with urinary drainage Antibiotics with exp lorat io n Tot als No. Patients 4 No. Nephrectomy 0 14 3 2 0 1 0 21 3 No. Dead 1 0 0 0 1 Of 21, 14 (66%) patients were treated with comb ination of antibiotics and percutaneous catheter drainage of the abscess. Four were t reated with antibiotics alone and another two had open drainage of the perinephric abscess in addition to antibiotics. Duration of stay varied fro m 3 days to 86 days, and maximu m patients were discharged. 4. Discussion Perinephric abscesses are uncommon, but potential fatal is reported, if not recognized early. The difficu lty in diagnosing perinephric abscesses has been well docu mented. Till date, the diagnosis of perinephric abscess is still a challenge to physician despite advances in diagnostic and interventional radiology. The patients often presented with vague symptoms with long duration and the physical findings did not always reflect the severity of the infection. The spectrum of clinical symptoms and signs remains essentially unchanged, with fever and systemic symptoms such as anorexia, nausea, vomit ing, lethargy, and leukocytosis. Current patient showed most of the symptoms with a mean duration of 1 week, reflecting a delay in the recognition of perinephric abscesses. There was a remarkable similarity among patients’ clin ical characteristics, predisposing factors in our series and in previous reports[2, 6]. Most of the patients had renal calcu li (90.9%) and another 63.6% had diabetes mellitus. The bacteriology of the perinephric abscesses in our patients parallels that of all other reported experience in the post-antibiotic era[2, 6, 7]. At present, aerobic g ram-negative bacilli have beco me the most frequent isolated microorganis ms, particularly Proteus spp. and Escherichia coli[8, 9]. Our series showed Escherichia coli was the most common causative microorganism (27%) in the perinephric abscesses. Klebsiella sp. and Proteus mirabilis were responsible for 9% of the cases each. The widespread availability of imag ing studies, especially computer tomography (CT) in recent decades had significantly improved the diagnosis and treatment of perinephric abscesses. CT is a more sensitive and specific in detecting perinephric abscesses in all series rev iewed, with diagnostic performance within the range of 90%- 100% [9, 10]. Most of the perinephric abscesses received an interventional treatment besides medical therapy. Amongst these, percutaneous drainage was the treatment of choice with 81.8% of patients in our series underwent the procedure. Percutaneous drainage guided by CT or ultrasonography has proved to be an effective therapeutic tool that reduces the need for surgery in some patients. There was no mo rtality in our series. Having mentioned that, our series comprised of only ten patients. In the most recent series, the mortality rate varied fro m 1.5-15%[2, 11, 12]. 5. Conclusions The clin ical characteristics of perinephric abscesses have not changed significantly but improved imaging with CT allo ws increased diagnostic sensitivity. With accurate diagnosis, a variety of treatments can be successful, including antibiotics alone, or co mbination of antibiotics with percutaneous catheter drainage. In our series, there was only one patient posted for exploration and drainage. Essentially, this should be considered if adequate drainage is not achieved percutaneously. REFERENCES  M axwell v. M eng, Layla a. M ario and Jack w. M caninch. Current treatment and outcomes of perinephric abscesses. The journal of urology 2002; 168: 1337–1340  Salvatierra, O., Jr., Bucklew, W. B. and M orrow, J. W.: Perinephric abscess: a report of 71 cases. J Urol, 1967; 98: 296-97  Adachi, R. T. and Carter, R.: Perinephric abscess: current concepts in diagnosis and management. Am Surg, 35: 72, 1969  Gerzof, S. G. and Gale, M . E.: Computed tomography and ultrasonography for diagnosis and treatment of renal and retroperitoneal abscesses. Urol Clin North Am, 1982; 9: 185-91  Coelho, R., et al., Renal and Perinephric Abscesses: Analysis of 65 Consecutive Cases. World Journal of Surgery, 2007. 31(2): p. 431-436.  Sheinfeld, J., et al., Perinephric abscess: current concepts. J Urol, 1987. 137(2): p. 191-4.  Fower, J.E., Jr., Bacteriology of branched renal calculi and accompanying urinary tract infection. J Urol, 1984. 131(2): p. 213-5  Thorley, J.D., S.R. Jones, and J.P. Sanford, Perinephric abscess. M edicine (Baltimore), 1974. 53(6): p. 441-51.  Fower, J.E., Jr. and T. Perkins, Presentation, diagnosis and treatment of renal abscesses: 1972-1988. J Urol, 1994. 151(4): p. 847-51.  Sundaram, M ., et al., Utility of CT-guided abdominal aspiration procedures. AJR Am J Roent genol, 1982. 139(6): 104 Azhar Amir Hamzah et al.: Clinical Characteristics and Treatment Outcome of Perinephric Abscess Treated in a Teaching Hospital p. 1111-5.  Edelstein, H. and R.E. M cCabe, Perinephric abscess. 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