ultrasound pics - hydronephros, calculi in ureter??

Re: ultrasound pics - hydronephros, calculi in ureter??

Andrew Kent — Thu, 24 Apr 2014 09:26:24 GMT

[quote user="Stigen"]It`s not incontinent, so I doubt it`s ectopic ureter or persistent urachus. Congenital or pyelonephritis-induced Diabetes insipidus would fit the clinical signs very well. I think I`ll measure the plasma ADH and do a desmopressin trial.[/quote]

Not all ectopic ureters are incontinent.

I would advise against doing an desmopressin trial if you think this is related to infection - you need to resolve that rather that tx with desmopressin, otherwise a pyelonephritis could lead to permanent damage to the kidneys.

Re: ultrasound pics - hydronephros, calculi in ureter??

Anthony Todd — Thu, 24 Apr 2014 08:29:25 GMT

[quote user="Stigen"]Congenital or pyelonephritis-induced Diabetes insipidus would fit the clinical signs very well. I think I`ll measure the plasma ADH and do a desmopressin trial.[/quote]

How does that fit with the original ultrasound with, apparently, the fluid filled tract next to the bladder?

Re: ultrasound pics - hydronephros, calculi in ureter??

Stigen — Thu, 24 Apr 2014 08:10:23 GMT

[quote user="Andrew Kent"]

Did you do a retrograde vaginourethrogram as well or just the IVU? I'm only looking on a phone screen but can't see the insertion of the ureters into the bladder so would still consider an ectopic ureter to be possible with associated recurrent urinary tract infection.

Did you culture the most recent sample? Is the dog incontinent or just PuPd? Perhaps the low USG is due to secondary nephrogenic diabetes inspipidus due to pyelonephritis?

I think referral sounds a good plan and they could consider specialist ultrasound and potentially cystoscopy to look at the ureteral opening.

Andy

[/quote]

It`s not incontinent, so I doubt it`s ectopic ureter or persistent urachus. Congenital or pyelonephritis-induced Diabetes insipidus would fit the clinical signs very well. I think I`ll measure the plasma ADH and do a desmopressin trial.

Re: ultrasound pics - hydronephros, calculi in ureter??

Andrew Kent — Wed, 23 Apr 2014 21:49:18 GMT

Did you culture the most recent sample? Is the dog incontinent or just PuPd? Perhaps the low USG is due to secondary nephrogenic diabetes inspipidus due to pyelonephritis?

I think referral sounds a good plan and they could consider specialist ultrasound and potentially cystoscopy to look at the ureteral opening.

Andy

Re: ultrasound pics - hydronephros, calculi in ureter??

Anthony Todd — Wed, 23 Apr 2014 20:25:26 GMT

[quote user="Stigen"]I am reluctant to open it up as I don`t have a clue to what`s going on....any suggestion.....? [/quote]

Surely with a significant pyelonephritis or pyo you would have some blood changes; increased WCC, raised BUN etc. etc.

The sooner you open it up the sooner you'll have a clue and you just might be able to fix it.

Playing percentages it is likely to be some sort of congenital urinary disorder I mean how many pyos in an 8 month old bitch do you get?

If it is referred do you really think they'll fix the dog or just add a few more probables,possibles, and maybes?

It'll double the bill for very little cure before they finally do the ex. lap.

Re: ultrasound pics - hydronephros, calculi in ureter??

Stigen — Wed, 23 Apr 2014 17:56:24 GMT

So I did a contrast study before easter. Kidney looked ok,possibly slight enlargment. I could see clearly the upper part of one of the ureters,no distention, seemed to be intact. I had difficulty visualizing the entry point to the bladder due to the heavy thigh musculature covering this area. Bladder looks homogenous. The pics posted are from the contrast study, one of them shows the ureter quite nicely. The pics did`nt turn out well in this post, these are the direct links(why is it so horribly difficult to post pics in this forum??)
http://i59.tinypic.com/23magec.jpg
[http://i59.tinypic.com/eta8tj.jpg
http://i60.tinypic.com/2ueka5g.jpg

Ultrasound - did`nt see anything special, but don`t believe there is a hydronephros anymore.

So to update;

- 8 month old female Bichon Havanais with 3 month history of "urinary problems". Firstly just urinating more often, then started urinating inside, and now very Pu/pd - owner says drinking from every puddle of water she can find now. Last estrus was 4 months ago.

- blood sample - full biochemistry and hematology - nothing out of the ordinary

- repeated urinary samples,last ones by urocentesis- no blood,no protein,glucose,ketones,or anything else. No crystals found. low Sg -1.005-1.01. Some bacteria seen. First bacteriology from free catch showed lots of Klebsiella(possibly contamination). Was treated with 3 weeks amox/clauv. with no effect. On month later bacteriology from cysto-sample showed streptococcus(after enrichment). Convenia/Cefovecin was given one week ago,but has made no difference to the pu/pd.

-x-rays,ultrasound and contrast X-rays - no real findings.

I`m entirely unsure what I can do for that dog at this point. My only differentials at this point is psychogenic pu/pd or pyometra,although I should think the different antibiotics already given should have alleviated any symptoms of that. I`m considering refering it for a contrast Ct,but don`t know if they will find anything. I am reluctant to open it up as I don`t have a clue to what`s going on....any suggestion.....?

Re: ultrasound pics - hydronephros, calculi in ureter??

Anthony Todd — Tue, 15 Apr 2014 18:09:25 GMT

[quote user="Tim Charlesworth"]

It's far too easy to feel pressurised into doing an ex-lap in an attempt to meet owner's expectations but if you don't find anything or renal function deteriorates postoperatively you can be sure that the owner will sadly regard it as your fault...[/quote]

Yet , nowadays, you can do £500 worth of lab tests and imaging, faff about for a week, and also find nothing, yet be regarded as a hero; as opposed to £500 worth of ex-lap [or is the ultrasound not indicative of some gross pathology?] find out what exactly is going on in, at most, 2 hours.

That's why it's called an exploratory laparotomy, tell the owner first.....

Might even fix it at the same time.

I can't see why renal function with a bag full of dex/saline could deteriorate either, it's already had all the bloods possible which seemed pretty normal [a bit of dehydration etc. would put the BUN slightly up]

Re: ultrasound pics - hydronephros, calculi in ureter??

Tim Charlesworth — Tue, 15 Apr 2014 15:59:45 GMT

If you think the dog has a pyometra then take it to surgery. If you think that the dog has pyelonephritis then don't! If you're not sure then I would do more diagnostics or refer the case. You really don't want to ex-lap a pyelonephritis and you won't be able to rule out ectopic ureters etc unless you're planning to do a full cystotomy/urethrotomy to find the ureteric openings. It's far too easy to feel pressurised into doing an ex-lap in an attempt to meet owner's expectations but if you don't find anything or renal function deteriorates postoperatively you can be sure that the owner will sadly regard it as your fault...

Re: ultrasound pics - hydronephros, calculi in ureter??

Anthony Todd — Sat, 12 Apr 2014 16:30:52 GMT

[quote user="Stigen"]

Well ,she is expecting a surgery...and it might be the only thing that will make her really happy :)

[/quote]

Might make the dog happy too? Or were you referring to the dog?

Re: ultrasound pics - hydronephros, calculi in ureter??

Stigen — Sat, 12 Apr 2014 15:55:20 GMT

Well ,she is expecting a surgery...and it might be the only thing that will make her really happy :)

Re: ultrasound pics - hydronephros, calculi in ureter??

Anthony Todd — Sat, 12 Apr 2014 15:20:08 GMT

Perhaps I might risk hell-fire and, shock horror, even a red star and suggest an ex-lap and a quick look round.

They really don't do any harm and give you so much information.

I mean you can actually look at things with your eyes, in real-time, which usually eliminates guesswork and imagination.

You might even be able to fix the problem which, after all, is what you're trying to do.

Re: ultrasound pics - hydronephros, calculi in ureter??

Stigen — Sat, 12 Apr 2014 12:38:02 GMT

Although I do find it odd that there are no hematological changes in the case of a chronic infection....and no biochemical changes either!

Re: ultrasound pics - hydronephros, calculi in ureter??

Stigen — Sat, 12 Apr 2014 10:40:55 GMT

I don`t think it is an obstruction either anymore. My mind was looking at the pictures trying to find an interesting answer,and that was what came up. I am now thinking the most likely diagnosis is pyelonephritis,based on the large kidney and bacteria seen in urine after cystocentesis, or a weird form of pyometra, based on clinical signs, and ultrasound. I am thinking maybe those 2 fluid filled tubes seen on one of my Us pics next to the bladder might be distended utering horns...
I never saw pyometra in a 8 month old dog, but I did once see it in a 12 month old dog that I spayed.
I hope the owner will let me do the contrast study. I feel she is at the point of seeking second opinion as she was expecting a surgery after what I said the other day, and now I`ve said I`d like to sedate the dog again to do one more test...The fact is I would have done the contrast study the other day, but I did`nt have the contrast media as I needed to place an order for it...

Re: ultrasound pics - hydronephros, calculi in ureter??

Tim Charlesworth — Fri, 11 Apr 2014 14:51:31 GMT

I think that you've got a good plan there and I don't think that this is likely to be a ureteric obstruction but (just to be devil's advocate) don't rule it out based on normal creatinine as the other kidney will be functioning fine and preventing sig azotaemia developing..

Re: ultrasound pics - hydronephros, calculi in ureter??

Stigen — Fri, 11 Apr 2014 12:23:15 GMT

Your right Andrew, there should`nt be any dilatation of the distal ureter. Perhaps the fluid filled structure next to the bladder was something else, perhaps a uterine horn.
Pyelonephritis could also be a possibility, but there was no changes on the blood sample, and there was no response on 3 weeks of amox. +clauvanillic acid. . . I guess there should be an elevation to creatinine at least if there was a serious obstruction. I`m thinking more now that that little radiolucent particle is within the colon, not the ureter.
I think I`ll proceed with an iv contrast study, and see if I can get an experienced ultrasonographer to help me with the next Us-exam.
I`ll see also what the bacteriology says, maybe it is a resistant organism.

Re: ultrasound pics - hydronephros, calculi in ureter??

Stigen — Fri, 11 Apr 2014 12:10:08 GMT

Tamsulosin...I would have to look into that!
I think I would follow the general consensus now and keep on with more diagnostics. I would have done the IV contrast study if I would have had some contrast here...will order it in. That should give me a much clearer picture if there is actually anything in the kidney,ureter or bladder. The kidney certainly looks enlarged on the x-ray, but I will repeat the ultrasound exam to get a better look at it. Culture for bacteriology and mycology has been sent.
I`m also considering to do a contrast CT,and an ultrasonografy with someone with more experience.

It does`nt have the typical signs of ectopic ureter or patent urachus, as it has`nt really been incontinent, just been Pu/Pd now on and off for 3-4 months.

Re: ultrasound pics - hydronephros, calculi in ureter??

Andrew Kent — Fri, 11 Apr 2014 11:11:18 GMT

In terms of management of ureteral obstructions we give 24 hours of medical therapy (IVFT, analgesia, prazosin, amitriptyline) and then reassess with ultrasound. If we haven't shifted it they go to surgery for either ureteral stent placement of a SUB (ureteral bypass) placement, depending on the specifics of the case. This is not easy surgery but has good reported outcomes.

Our experience with ureteral obstruction is that the dilation of the ureter should be primarily proximal to the obstruction, which means the location of your stone doesn't really fit with your described ultrasound findings. Sometimes the dilation can be more diffuse if there have been multiple stones passed over time.

So I would think something like an ectopic ureter (+/- UTI/pyelonephritis) might fit more with what you have seen/are describing.

How's the case getting on?

Andy

Re: ultrasound pics - hydronephros, calculi in ureter??

Andrew Kent — Fri, 11 Apr 2014 10:50:22 GMT

[quote user="Anthony Todd"]

[quote user="Anthony Todd"]tamsulosin[/quote]

The urologists looked amazed when I told them I had had a ureteric stone removed via the urethra as a first option.

No body interested in tamsulosin??

[/quote]

We tend to use prazosin as our alpha-blocker due to familiarity with that drug, for the same reason as they would have given you tamsulosin. I am not sure anybody has tried tamsulosin in dogs but it is very receptor specific so may be less useful.

Andy

Re: ultrasound pics - hydronephros, calculi in ureter??

Anthony Todd — Fri, 11 Apr 2014 09:42:53 GMT

[quote user="Anthony Todd"]tamsulosin[/quote]

The urologists looked amazed when I told them I had had a ureteric stone removed via the urethra as a first option.

No body interested in tamsulosin??

Re: ultrasound pics - hydronephros, calculi in ureter??

Andrew Kent — Thu, 10 Apr 2014 22:46:44 GMT

Are you in the UK?

it is do difficult to draw much of a conclusion from still ultrasound so I don't think I can be that helpful. But, I'm not convinced that a ureteral obstruction is likely and if one were present then surgery is difficult (wet tend to use stents which you would have to source in advance).

could you send the dog for an ultrasound with a specialist imager? Failing that an ivu would be a good idea.

Re: ultrasound pics - hydronephros, calculi in ureter??

Utlendigur — Thu, 10 Apr 2014 19:08:43 GMT

When you say that the fluid filled structure was next to the bladder, do you mean lateral, dorsal or cranial to it? On the first and third views it looks almost congruent with the bladder and too close to it to be related to the "stone" on the xray - surely the dilation would be too far cranial to be adjacent to the bladder if the ureter was blocked at the level of the stone? Just a thought but could it be a patent urachus?

Re: ultrasound pics - hydronephros, calculi in ureter??

Tim Charlesworth — Thu, 10 Apr 2014 17:56:02 GMT

Dear Stigen, wouldn't rush to surgery with this one. 8 months is very young to have urolithiasis unless there is sig concurrent disease (e.g. portosystemic shunting). I'm not convinced that the radio-opaque "stone" overlying the desc colon on the lateral is within the ureter - do you have the other view?

If it is a ureteric stone then best to see if it moves with time + intravenous fluids. Some medics use amitryptilline as pro-kinetic and this may be of help. Ureterotomy is associated with high morbidity and so I wouldn't rush into this. Having said that if you do have acute ureteric obstruction that doesn't resolve then you need to act sooner rather than later before glomerular function is permanently lost.

I can't really make out the u/s pictures that you've posted but it's never as good as seeing the moving scan. If this is the ureter then congenital abnormality such as ectopic ureter with 2ndry hydro-ureter/nephrosis should remain on the ddx list.

If I had this case I would re-x-ray 24hours after the last rad + IVFT to establish if the "stone" has moved or not. If the stone has gone then rescan and if ureteric dilation is persisting then I would do a contrast series (pneumocystogram + IVU after enema) to establish where/what the ureters are doing.

Good luck with the case,

Tim

Re: ultrasound pics - hydronephros, calculi in ureter??

Anthony Todd — Thu, 10 Apr 2014 17:11:29 GMT

Having just been through a ureteric stone [and having had one removed via the urethra] I wonder whether the human drug tamsulosin, [Contiflo XL] is worth a try. It dilated my ureter nicely and the stone passed.

Early signs of hydronephrosis was seen on ultrasound in my case too.

It sounds as if it's the treatment of choice currently in humans.