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1041015

核心課程編號： B33

學習目標

PGY UGY1. 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。

-

ITE考題

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), p2475–80JB Copley. Am J Med Sci 291 (1986), p101-11 AJ Mariani et al. J Urol 141 (1989), p350-355DN Mohr. JAMA 256 (1986), p224-229

血尿-病理生理學

Normal unspun urine (

血尿-分類與特性

History Taking

gross / microscopictiming of hematuria: initial, total, terminalassociation with pain: painful, painlesspresence of clots, shape of clots

Hematuria

Nephrologic hematuria (glomerular disease): dysmorphic RBC, RBC casts, proteinuria Urologic hematuria (tubulointerstitial or

renovascular renal disease): uniformly round shape RBCSystemic disorders

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

Nephrologic(glomerular disease)

Nephrologic(glomerular disease)

Urologic (nonglomerular hematuria)

Hematuria of any degree should never be ignored Should be regarded as a symptom of

urologic malignancy until proved otherwiseThe most common cause of gross

hematuria in a patient older than age 50 years is bladder cancer.

Urologic(nonglomerular hematuria)Urologic:

1.Tumor2.Stone3.BPH4.UTI

Medication: anticoagulantHematologic disorderExercise-inducedVascular disease

血尿-理學檢查

hypertensiongeneralized edemapalpable abdominal or flank massflank tendernessflank laceration, contusion, rib fractureDRE

血尿-實驗室檢查

Urinary analysis (color, sp.gr, protein, leukocyte, nitrite, RBC casts, crystal)

Urine cultureUrine cytology: high-grade urothelial carcinomaRenal function test (BUN/Cr)CBCCoagulation profile/bleeding studyOthers: serum IgA, ANA, urine TB culture

血尿-影像檢查

KUBUltrasoundExcretory urography (IVU)RPCT or MRINuclear renal scansCystographyarteriography

KUB

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

接下頁

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

IVU + PV

Kidney: collecting system

IVU + RP

5min: the pyelogram 7 min0 min:KUB

post-voiding film

Ureter

Length: 25-30 cmCaliber: 5 mm3 Parts: Lumbar ureter Iliac ureterPelvic ureter: max 1

cm medial to bone margin

Ureter: filling defects

1. Normal2. Vessel: band-like defect

3. Tumor: Burgman's sign

4. Radiolucent stone

Renal Tumor

Vascular massCalcifications: also

seen in some benign disease

Tumor shell: thick wall

Bladder filling defects

GasStoneTumorProstateOthers

RCC

TCC of ureter

TCC of bladder

血尿-特殊檢查

CystourethroscopyRPUreteroscopy (URS)Renal biopsy

UCa (TCC)

Urothelical carcinoma of the renal pelvis: a retrograde pyelogram demonstrates an ill-defined lobulated filling defect involving the upper-pole infundibulum and calyces.

BPH

The upward displacement of intramural ureter: fish-hook sign

prostate indentation

血尿-處置

Surgical: Urologic tumorsStonesBPH

Nonglomerular hematuria

血尿-處置The “standard” urologic evaluation of hematuria:

IVU, cystoscopy, urine cytologyAdditional testing based on clinical findingsAlways 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

HydrationManage underlying problems