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20 €нвар€ 2014, 11:32 644 +9

ѕиелонефрит острый 

√руппа заболеваний: болезни почек и мочевых путей
—межные болезни: абсцесс почки , апостематозный пиелонефрит, карбункул почки, остра€ почечна€ недостаточность, пиелонефрит хронический, пионефроз, хроническа€ почечна€ недостаточность, эмфизематозный пиелонефрит
¬рач в каталоге: нефролог
ѕораженный орган: почка
 

‘акторы риска

  • ќслабленный иммунитет
  • »нфекционные заболевани€ организма
  • ƒругие заболевани€ почек

ќписание

ѕиелонефрит (греч. πύέλός - корыто, лохань; νεφρός - почка) - неспецифический воспалительный процесс с преимущественным поражением клубочков системы почки, точнее почечной лоханки (пиелит), чашечек и паренхимы почки (в основном еЄ межуточной ткани). «аболевание чаще всего провоцируют вредноносные бактерии.

Ќа основании пункционной и эксцизионной биопсии почечной ткани вы€вл€ютс€ три основных варианта течени€ заболевани€:

” женщин молодого возраста пиелонефрит наблюдаетс€ в 5 раз чаще, чем у мужчин. ¬ 75% случаев заболевание у женщин возникает в возрасте до 40 лет, нередко во врем€ беременности, что св€зано с анатомо-физиологическими и гормональными особенност€ми женского организма.

 лассификаци€ пиелонефрита

ѕо количеству пораженных почек:

  • односторонний;
  • двусторонний.

ѕо услови€м возникновени€:

  • первичный (без каких-либо предшествующих нарушений почек и мочевых путей);
  • вторичный (в основе лежат органические или функциональные процессы в почках и мочевых пут€х, снижающие сопротивл€емость почечной ткани инфекции и нарушающие пассаж мочи).

ѕо характеру течени€:

ѕо пути проникновени€ инфекционного агента:

  • нисход€щий (реже);
  • восход€щий (чаще).

ѕо состо€нию проходимости мочевывод€щих путей:

  • необструктивный;
  • обструктивный.

‘ормы острого пиелонефрита:

  • серозный;
  • деструктивный.

ќстрый гнойный пиелонефрит встречаетс€ в виде:

—тадии течени€ хронического пиелонефрита:

  • латентна€;
  • гипертензивна€;
  • анемична€;
  • азотемична€;
  • бессимптомна€;
  • ремисси€.

»сходы острого пиелонефрита:

  • выздоровление;
  • хронизаци€ процесса.

»сходы хронического пиелонефрита:

ќсложнени€:

–едкие формы пиелонефрита:

ѕричины

ѕричиной пиелонефрита может быть один из патогенных или условно-патогенных возбудителей. —реди них - кишечна€ палочка (Escherichia coli), на ее счет относ€т около 75% внебольничных инфекций. ¬ остальных случа€х пиелонефрит вызывают протей (Proteus), энтерококки (Enterococcus), синегнойна€ палочка (Pseudomonas aeruginosa, энтеробактер (enterobacter). —тафилококки (Staphylococcus - см. изображение ниже) и стрептококки (Streptococcus), как причины острого пиелонефрита определены в 2-3% случаев приобретенных инфекций.

ƒл€ возникновени€ острого пиелонефрита недостаточно лишь проникновени€ микроорганизмов в почку. Ќеобходимы предрасполагающие факторы, такие как снижение иммунной реактивности организма, т€желые сопутствующие заболевани€ (при сахарном диабете пиелонефрит встречаетс€ в 4-5 раз чаще). »з местных факторов, предрасполагающих к развитию острого пиелонефрита, основным €вл€етс€ нарушение уродинамики. Ётому способствуют мочекаменна€ болезнь, различные аномалии почек и мочевых путей, доброкачественна€ гиперплази€ предстательной железы.

ѕути проникновени€ инфекции в почку могут быть весьма разнообразными - гематогенный, уриногенный и др.

ѕри гематогенном пути проникновени€ первичным очагом инфекции €вл€етс€ любой гнойно-воспалительный процесс в организме (например, пневмони€, сепсис и др.). 

”риногенный или восход€щий путь проникновени€ инфекции в почку св€зан с попаданием бактерий из близлежащих органов и систем¬ данном случае пиелонефрит развиваетс€ при разного рода обструкции мочевых путей: стриктуры, камни, опухоли, доброкачественна€ гиперплази€ предстательной железы, нейрогенный мочевой пузырь, аномалии развити€, пузырно-мочеточниковый рефлюкс, пиелоренальный рефлюкс. 

Ќарушение оттока мочи и возникновение повышенного внутрилоханочного давлени€ ведут к мочевой инфильтрации интерстициальной ткани почки, что сопровождаетс€ острым нарушением кровообращени€ в почке и гипоксией органа. Ѕактериури€ нередко бывает в пожилом возрасте: у мужчин из-за обструктивных уропатий и снижени€ бактерицидной активности мочи, а у женщин из-за нарушени€ опорожнени€ мочевого пузыр€ в св€зи с цистоцеле (грыжей мочевого пузыр€), пролапсом матки. ” женщин нарушение оттока мочи часто наблюдаетс€ при беременности, когда происход€т выраженные изменени€ гормонального баланса организма. 

—ущественную роль играют нервно-мышечные поражени€, инструментальные исследовани€ и катетеризаци€ мочевого пузыр€. ” больных сахарным диабетом (особенно с нейрогенным мочевым пузырем) риск развити€ восход€щей мочевой инфекции и острого пиелонефрита значительно повышен.

 ак развиваетс€ болезнь

ѕиелонефрит, €вл€€сь вначале очаговым процессом, с каждой новой атакой принимает диффузный характер. »нтерстициальна€ ткань играет весьма важную физиологическую роль в межклеточном обмене веществ. ѕосле исчезновени€ воспалительных инфильтратов в ней не происходит истинного восстановлени€ межуточной ткани; на месте погибших элементов почечной паренхимы развиваетс€ рубцова€ ткань. 

ѕервичный и вторичный острый пиелонефрит могут протекать вначале в виде серозного, затем гнойного интерстициального воспалени€. — учетом этого прин€то пользоватьс€ терминами «острый серозный пиелонефрит» и «острый гнойный пиелонефрит». ¬ то врем€ как острый серозный пиелонефрит наблюдаетс€ в 64 %, острый гнойный - только у 36 % больных острым пиелонефритом.

¬ стадии острого серозного воспалени€ почка увеличена, напр€жена. ѕаранефральна€ клетчатка значительно отечна. ћикроскопически в межуточной ткани обнаруживаютс€ многочисленные периваскул€рные инфильтраты. ѕод вли€нием соответствующего лечени€ эта стади€ претерпевает обратное развитие, но серозный острый пиелонефрит может перейти и в стадию гнойного воспалени€.

—имптомы

—начала острый пиелонефрит про€вл€етс€ признаками инфекционного заболевани€, что нередко осложн€ет диагностику.

ќбщие симптомы острого пиелонефрита:

  • повышение температуры тела до 38-40 °C;
  • озноб и лихорадка с выделением обильного пота;
  • тошнота;
  • рвота;
  • воспалительныe изменени€ в анализах крови.

ћестные симптомы острого пиелонефрита:

  • боль и напр€жение мышц в по€сничной области на стороне поражени€;
  • иногда дизури€;
  • хлопь€, муть в моче;
  • полиури€;
  • никтури€;
  • болезненность при поколачивании по по€снице. 

” лиц пожилого и старческого возраста часто развиваетс€ атипична€ клиническа€ картина либо со стЄртой клиникой, либо с выраженными общими про€влени€ми и отсутствием местной симптоматики.

ѕервичный острый пиелонефрит

ƒл€ первичного острого пиелонефрита характерна триада симптомов - высока€ температура тела, боль в по€сничной области и изменени€ в моче, характерные дл€ воспалительного процесса (лейкоцитури€, бактериури€). ¬ клинической картине первичного острого пиелонефрита различают общие и местные симптомы.

ѕервичный острый пиелонефрит сначала про€вл€етс€ общими симптомами: ознобом, повышением температуры тела до высоких цифр, обильным потоотделением и головной болью (преимущественно в лобных дол€х), болью в мышцах и суставах, тошнотой, рвотой, общим недомоганием. язык сухой, обложен. ѕульс частый. “акие признаки наблюдаютс€ при разнообразных инфекционных заболевани€х, поэтому возможны диагностические ошибки.

ћестные симптомы св€заны с по€влением болей в области почки, пораженной воспалительным процессом (т. е. впо€сничной области, в подреберье). Ѕоли могут быть интенсивными, но тупыми и нос€т посто€нный, а не приступообразный характер. “емпература тела по вечерам достигает 39-40 °— и снижаетс€ к утру до 37,5-38 °—. —имптом ѕастернацкого положительный. ћочеиспускание, как правило, не нарушено, кроме тех случаев, когда острый пиелонефрит €вл€етс€ осложнением острого цистита либо приводит к воспалительному процессу в мочевом пузыре.  оличество мочи чаще уменьшено вследствие обильного потоотделени€.

” детей, особенно раннего возраста, нередко острый пиелонефрит про€вл€етс€ высокой температурой тела, рвотой, возбуждением, менингеальными симптомами, лейкоцитурией. ѕодобна€ клиническа€ картина наблюдаетс€ у детей при р€де других инфекционно-воспалительных заболеваний, поэтому распознавание острого пиелонефрита у них в начале заболевани€ особенно сложно. Ќаиболее €рко эти симптомы выражены у новорожденных и грудных детей. —таршие дети жалуютс€ на головную боль, частые болезненные мочеиспускани€.

јпостематозный нефрит и карбункул почки

ќстрый гнойный пиелонефрит встречаетс€ в виде апостематозного нефрита, абсцесса и карбункула почки. јпостематозный нефрит - это метастатический нагноительный процесс, одна из последующих стадий острого пиелонефрита. ѕри этом корковое вещество почки как на поверхности, так и на разрезе усе€но мелкими гнойниками, имеющими вид бисера.

–ис. 1.  истозна€ почка. –ис. 2. “уберкулез почки. –ис. 3. —олитарный карбункул почки. –ис. 4. «астойна€ почка.

јпостематозный нефрит в 24 % случаев сочетаетс€ с карбункулом почки. Ёти два вида гнойного поражени€ почки представл€ют собой единый патологический процесс, про€вл€ющийс€ лишь в разной последовательности и интенсивности своего развити€. ≈сли дл€ апостематозного нефрита характерны множественные мелкие абсцессы, то дл€ карбункула почки - локализованный нагноительный очаг, отличающийс€ опухолевидным прогрессирующим ростом воспалительной инфильтрации без наклонности к большому абсцедированию. ѕо внешнему виду такой процесс в почке весьма напоминает карбункул кожи. Ёто обсто€тельство и дало основание Israel в 1891 г. назвать данное заболевание карбункулом почки

¬торичный острый пиелонефрит

¬торичный пиелонефрит отличаетс€ от первичного острого пиелонефрита по клинической картине большей выраженностью симптомов местного характера, что позвол€ет скорее и легче распознать заболевание.

«астой мочи и инфекци€ привод€т к более выраженной клинической картине острого пиелонефрита, чем при первичном воспалительном процессе в почке. —амочувствие больного быстро ухудшаетс€: повышаетс€ температура тела, котора€ удерживаетс€ на цифрах 38-39 °—, усиливаютс€ обща€ слабость, адинами€, головна€ боль, жажда, сухость во рту, по€вл€ютс€ рвота, эйфори€, тахикарди€. Ѕоли в по€сничной области принимают посто€нный интенсивный характер. ѕальпируетс€ увеличенна€ и болезненна€ почка. ”силиваетс€ и становитс€ «огненной» болезненность при пальпации в подреберье, резко выражен симптом ѕастернацкого. Ќаблюдаетс€ выраженное защитное напр€жение по€сничных мышц и мышц передней брюшной стенки.

” детей вторичный гнойный пиелонефрит про€вл€етс€ симптомами лихорадки: температура тела очень быстро достигает высоких цифр, чаще ремиттирующего характера. ѕо€вл€етс€ озноб потр€сающего характера, возникающий нередко в одни и те же часы суток по несколько раз в день. ¬след за ознобом повышаетс€ температура тела до 39-41 °—, резка€ головна€ боль, затем потливость с падением температуры тела. ƒо по€влени€ последующего озноба ребенок, особенно младшего возраста, находитс€ в состо€нии адинамии. ¬ отличие от взрослых у детей на первый план в клинической картине выступают общие симптомы, а не местные, что может затруднить диагностику. ƒл€ новорожденных и грудных детей характерна резка€ гиперпирекси€ с нечетко выраженными менингеальными признаками, жажда, быстрое снижение массы тела. ќтмечаетс€ болезненность при мочеиспускании. ѕри пальпации по€сничной области дети кричат и пытаютс€ отодвинуть руку врача. 

ƒиагностика

ƒиагностику провод€т на основании характерной клинической картины и результатов обследований и анализов.

ћетоды исследовани€ крови при пиелонефрите

  • ќбщий анализ крови. ќбщевоспалительные изменени€: лейкоцитоз, ускорение —ќЁ (скорость оседани€ эритроцитов), сдвиг лейкоцитарной формулы влево, при выраженном воспалении - анеми€.
  • Ѕиохимический анализ крови.¬озможно увеличение трансаминаз, гипергаммаглобулинеми€, при развитии €влений почечной недостаточности - повышение цифрмочевины, креатинина.

јнализы мочи при пиелонефрите

  • ќбщий анализ мочи. ќсновной признак — лейкоцитури€ — может отсутствовать при гематогенном пиелонефрите в первые 2—4 дн€, когда воспалительный процесс локализуетс€ преимущественно в корковом слое паренхимы почки, а также при обструкции мочевывод€щих путей на стороне поражени€; эритроцитури€ при пиелонефрите может наблюдатьс€ при наличии конкремента, вследствие некротического папиллита, повреждени€ форникального аппарата, при наличии €влений острого (геморрагического) цистита, послужившего причиной развити€ пиелонефрита.
  • Ѕактериологическое исследование мочи используетс€ дл€ точного определени€ возбудител€ и его чувствительности к антибиотикам.
  • ќкраска мочи по √раму €вл€етс€ важным этапом этиологической диагностики пиелонефрита, что позвол€ет быстро получить предварительные ориентировочные данные о характере возбудител€.  ультуральное исследование мочи (посев на питательные среды, выделение чистой культуры возбудител€ и определение его чувствительности к препаратам) желательно проводить во всех случа€х, особенно в стационаре. ѕри подозрении на бактериемию (при высокой лихорадке, ознобах), а также в отделени€х интенсивной терапии об€зательно исследование крови на стерильность. Ќеобходимым условием достоверности результатов бактериологического исследовани€ €вл€етс€ правильность забора мочи и крови.

»нструментальные методы исследовани€

  • ”льтразвуковое исследование (”«») почек в фазе серозного воспалени€ при остром первичном пиелонефрите может не вы€вить патологических изменений в почках, в серозной фазе по ”«» вы€вл€етс€ увеличение почек (или одной почки при одностороннем поражении) в размерах, уменьшение их подвижности при дыхании. ѕри апостематозном пиелонефрите ультразвукова€ картина така€ же, как в фазе серозного воспалени€ (увеличение почек в размерах, ограничение их подвижности). ƒл€карбункула почки при ”«» характерно наличие гипоэхогенного участка без четких контуров, иногда выбухание внешнего контура почки в этом месте. ѕри формировании абсцесса почки при ”«» определ€етс€ гипоэхогенный участок с четкими контурами (капсула абсцесса) иногда с неоднородными анэхогенными участками в центре (жидкий гной). ѕри выходе гнойного процесса за пределы капсулы почки (развитие паранефрита) при ”«» определ€етс€ нечЄткость паранефральной клетчатки с наличием в ней гипо- и анэхогенных компонентов.
  • –ентгенологические методы исследовани€:
    • ќбзорна€ и экскреторна€ урографи€ дополн€ют друг друга и провод€тс€ обычно вместе (обзорный снимок с последующим проведением экскреторной урографии). Ќа обзорном снимке может быть вы€влено увеличение размеров почки, выбухание еЄ контура (при карбункуле и абсцессе), нечЄткость контура большой по€сничной мышцы на стороне поражени€ (отЄк паранефральной клетчатки, паранефрит), наличие теней конкрементов (калькулЄзный пиелонефрит). Ќа экскреторных урограммах в фазе серозного воспалени€ уродинамика и функци€ почек чаще не нарушена, может определ€тьс€ увеличение почки, ограничение еЄ подвижности при ортопробе, умеренное сдавление чашечно-лоханочной системы отЄчной паренхимой почки. ѕри апостематозном пиелонефрите к перечисленным признакам серозного пиелонефрита добавл€етс€ снижение выделительной функции почки. ѕри карбункулах и абсцессах почки на экскреторных урограммах может определ€тьс€ выбухание контура, сдавление и деформаци€ лоханки и чашечек абсцессом, инфильтратом.
    • –етроградна€ пиелоуретерографи€ выполн€етс€ при отсутствии на экскреторных урограммах функции почки или если по каким-либо причинам экскреторна€ урографи€ не может быть проведена (т€жЄлое состо€ние больного, наличие острой или хронической почечной недостаточности).
    • јбдоминальна€ аортографи€ , селективна€ почечна€ артериографи€, компьютерна€ томографи€ примен€ютс€, главным образом, дл€ проведени€ дифференциальной диагностики пиелонефрита и другой почечной патологии.
  • –адионуклидные методы исследовани€ (нефросцинтиграфи€, непр€ма€ ангиографи€, ренографи€) при остром пиелонефрите используютс€ как вспомогательные методы диагностики. ќни могут быть использованы в динамике через 3-5 суток дл€ оценки эффективности проводимой терапии.

ƒиагностика первичного острого пиелонефрита

¬ диагностике первичного острого пиелонефрита основными критери€ми €вл€ютс€ клиническа€ симптоматика и результаты лабораторных исследований. ѕри диагностике острого пиелонефрита обращают внимание на наличие в анамнезе больного гнойных очагов в организме (как, например, фурункул, гайморит (синусит), пульпит, мастит, остеомиелит и др.), а также на перенесенные инфекционные заболевани€ (такие как грипп, ангина, пневмони€, холецистит, энтероколит, аппендицит, грипп, брюшной тиф и др.). ¬ тех случа€х, когда имеютс€ характерные симптомы первичного острого пиелонефрита (повышение температуры тела, боли в по€сничной области и изменени€ в моче, указывающие на воспалительный процесс), распознавание заболевани€ не вызывает трудностей.

¬ первую очередь вы€вл€ют бактериурии и лейкоцитурии с определением их степени, активных лейкоцитов мочи и клеток Ўтернгеймера - ћальбина. јктивные лейкоциты - это лейкоциты, попавшие в мочу из очага воспалени€ в мочевых пут€х, активно фагоцитирующие бактерии. ѕри микроскопии осадка мочи отмечаетс€ броуновское движение протоплазмы. ѕри добавлении к осадку мочи капли метиленового синего нар€ду с броуновским движением протоплазмы отмечаетс€ бледно-голубое окрашивание лейкоцитов в св€зи с поступлением красител€ внутрь дл€ выравнивани€ осмотической концентрации внутри и вне клетки (клетки Ўтернгеймера - ћальбина).  ак активные лейкоциты, так и клетки Ўтернгеймера - ћальбина свидетельствуют о наличии активного воспалени€ в мочевых пут€х.

Ѕактериологическое исследование мочи имеет целью не только вы€снение характера микрофлоры, но и количественное ее определение, т. е. подсчет количества микроорганизмов в 1 мл мочи. ¬ насто€щее врем€ установлено, что в моче у здоровых людей нередко можно обнаружить микроорганизмы, в том числе и условно-патогенные (такие как кишечна€ палочка и протей), так как в дистальном отделе мочеиспускательного канала и у женщин, и у мужчин посто€нно вегетирует микрофлора. ќднако если у здоровых лиц в свежевыпущенной моче, как правило, обнаруживают не более 2 × 103 микроорганизмов в 1 мл мочи, то при возникновении инфекционного процесса в почках или мочевых пут€х происходит существенное увеличение степени бактериурии - 105 и более микроорганизмов в 1 мл мочи.

”коренившеес€ мнение о необходимости вз€ти€ мочи дл€ бактериологического исследовани€ у женщин путем катетеризации мочевого пузыр€ неверно, так как при проведении катетера по уретре происходит инфицирование мочевого пузыр€. ¬ св€зи с этим дл€ исследовани€ берут среднюю порцию мочи при самосто€тельном мочеиспускании после предварительной тщательной обработки наружных половых органов в области наружного отверсти€ мочеиспускательного канала ватным шариком, смоченным антисептическим раствором (раствор фурацилина 1: 5000, 2%-ный раствор борной кислоты и др.). ѕосев мочи должен быть произведен при комнатной температуре или не позднее 4 ч при хранении в холодильнике (+4 °—).

ќпределение степени бактериурии в диагностике острого первичного (гематогенного) пиелонефрита играет исключительно важную роль, так как этот симптом по€вл€етс€ в первые дни заболевани€, гораздо раньше лейкоцитурии, и в р€де случаев может быть единственным характерным его признаком. Ёто исследование может быть выполнено с использованием различных упрощенных методик посева мочи на плотную питательную среду (агар), методом химической реакции с ““’ (трифенилтетразолий-хлорид), когда по интенсивности окраски можно судить о степени бактериурии, и с помощью микроскопии осадка мочи, предпочтительнее с фазово-контрастными устройствами ‘  и ћ‘ј-2.

¬ последние годы по€вилась возможность определ€ть степень бактериурии в течение 2-6 ч по изменению оптической плотности мочи или с помощью специальных пластин (урикульт). ќдновременно производитс€ определение чувствительности микроорганизмов к антибиотикам и химиопрепаратам различными методиками. 

¬ажно сочетать при диагностике острого пиелонефрита бактериологические и бактериоскопические методы вы€влени€ бактериурии. ” некоторых больных с острым первичным пиелонефритом после применени€ антибактериальных препаратов спуст€ 12-24 ч посев мочи уже не дает роста микроорганизмов, хот€ микроскопи€ осадка мочи позвол€ет еще обнаружить 105 и более бактерий в 1 мл.

—ущественным признаком острого пиелонефрита €вл€етс€ лейкоцитури€, котора€ бывает значительной (более 30-40 лейкоцитов в поле зрени€), активные лейкоциты вы€вл€ют у всех больных, клетки Ўтернгеймера - ћальбина - более чем у половины из них. ѕротеинури€ наблюдаетс€ у большинства больных, но количество белка в моче не превышает 1 г/л. –еже отмечаетс€ небольша€ цилиндрури€, котора€ указывает на вовлечение в воспалительный процесс клубочкового аппарата. »зменени€ со стороны крови выражаютс€ в виде лейкоцитоза со сдвигом влево формулы белой крови и увеличением —ќЁ.

¬озрастание степени воспалительной интоксикации сопровождаетс€ увеличением токсичности крови: прогрессивное увеличение уровн€ средних молекул, β-2-микроглобулина, уменьшение времени жизни простейших (парамеций) в крови - менее 20-24 мин.

”читыва€ принципиальную разницу в лечебной тактике при первичном и вторичном остром пиелонефрите, дл€ их дифференциальной диагностики в первую очередь необходимо определить характер оттока мочи из почек. ≈сли он не нарушен, то имеет место первичный пиелонефрит, если нарушен - вторичный. ƒл€ этих целей примен€ют ультразвуковое исследование почек (как менее инвазивный и малотравматичный метод), экскреторную урографию, радиоизотопную урографию и хромоцистоскопию.

Ќормальное выделение индигокармина при хромоцистоскопии позвол€ет высказатьс€ в пользу первичного воспалительного процесса в почке. ќднако с большей уверенностью установить этот диагноз можно с помощью экскреторной урографии, котора€ вы€вл€ет нормальную или незначительно сниженную функцию пораженной почки и отсутствие преп€тствий оттоку мочи. »сследование необходимо начинать с обзорной рентгенографии мочевого тракта.

ƒиагностика вторичного острого пиелонефрита

¬ анамнезе обращают внимание на бывшие ранее приступы почечной колики и отхождение конкрементов, расстройства мочеиспускани€, травмы, перенесенные ранее простатит, уретрит. »з объективных данных наиболее ценными дл€ диагностики вторичного острого пиелонефрита €вл€ютс€ высока€, гектического характера температура тела и особенно потр€сающий озноб, а также перечисленные выше местные симптомы в области пораженной почки.

ƒл€ подтверждени€ диагноза большое значение имеют лабораторные методы исследовани€.

Ѕактериури€ и лейкоцитури€ всегда выражены, кроме случаев полной окклюзии мочеточника пораженной почки. ¬ моче содержитс€ большое число активных лейкоцитов (50% и более), и у большинства больных обнаруживают клетки Ўтернгеймера - ћальбина. Ѕактериури€ чаще, чем при первичном остром пиелонефрите, обусловлена бактери€ми группы проте€ и синегнойной палочкой. „асто наблюдаетс€ протеинури€ с содержанием белка около 1 г/л. »ммунохимический анализ мочи вы€вл€ет наличие среди уропротеинов белков, молекул€рна€ масса которых не превышает 200 000. “убул€рный тип протеинурии сочетаетс€ с ее селективным характером. »сследование мочи необходимо проводить несколько раз в течение суток, так как нередко у детей пиури€ определ€етс€ не во всех порци€х мочи.

 ак правило, имеютс€ высокий лейкоцитоз крови и сдвиг лейкоцитарной формулы крови влево с нейтрофилезом за счет увеличени€ палочко€дерных нейтрофилов (до 15-20%, а иногда и более) и с по€влением более юных форм. —ќЁ всегда увеличена в среднем до 40-45 мм/час. –езко выражена токсичность крови (повышение содержани€ средних молекул и β-2-микроглобулина в 3-4 раза, врем€ жизни парамеций в крови менее 20 мин). ƒл€ детей с острым гнойным пиелонефритом характерна анеми€, обусловленна€ гемолитическим воздействием инфекции и угнетеним функции кроветворной системы в св€зи с интоксикацией.

ƒл€ установлени€ стороны заболевани€ при одностороннем пиелонефрите или наибольшего поражени€ при двустороннем процессе диагностическую ценность имеет определение сравнительного лейкоцитоза. ѕодсчитывают количество лейкоцитов в крови, вз€той из пальца и обеих по€сничных областей. Ѕолее высокий лейкоцитоз указывает на сторону заболевани€.

—одержание мочевины в сыворотке крови бывает повышено примерно у 25-30% больных т€желым вторичным острым пиелонефритом, так как у многих из них имеетс€ двусторонний воспалительный процесс в почках. ѕри одностороннем заболевании повышение содержани€ мочевины в сыворотке крови может зависеть от резорбции мочи из пораженной почки вследствие лоханочно-почечных рефлюксов и токсического воздействи€ на контралатеральную почку.

’ромоцистоскопи€ у больных вторичным острым пиелонефритом в р€де случаев позвол€ет установить наличие, степень и причину нарушени€ пассажа мочи из почки. ”даетс€ вы€вить буллезный отек усть€ мочеточника при камне в интрамуральном отделе мочеточника или уретероцеле как причину нарушени€ пассажа мочи.

–ентгенологические методы исследовани€ занимают наиболее важное место в диагностике вторичного острого пиелонефрита. ќбзорна€ рентгенографи€ мочевой системы позвол€ет вы€вить дополнительные тени, подозрительные на камни в почке или мочеточнике, а также увеличенные размеры пораженной почки, нечеткость контура по€сничной мышцы и легкий сколиоз позвоночника в сторону поражени€. Ќа экскреторных урограммах у больных с окклюзией мочевых путей тень рентгеноконтрастного вещества в пораженной почке и по ходу мочеточника или вовсе не определ€етс€, или (при частичной непроходимости) по€вл€етс€ позже, заполн€€ расширенные выше преп€тстви€ мочеточник, лоханку и чашечки. Ёто лучше определ€етс€ на более поздних урограммах (через 40-50 мин, 1,5 ч и позже). ”льтразвуковое исследование вы€вл€ет расширение чашечно-лоханочиой системы, нередко с наличием в ней конкремента.

–етроградную уретропиелографию следует выполн€ть только по строгим показани€м. ќна необходима при рентгенонегативных камн€х или других причинах нарушени€ пассажа мочи, которые не удаетс€ четко установить без данного исследовани€, а в то же врем€ нужно срочно решить вопрос об оперативном вмешательстве. ѕри этом катетеризаци€ мочеточника может иметь одновременно и лечебное значение.

ƒифференциальна€ диагностика пиелонефрита

ќстрый первичный пиелонефрит чаще всего приходитс€ дифференцировать с общими инфекционными заболевани€ми (сепсисом, гриппом и др.), а также с острым аппендицитом и острым холециститом. “рудности в дифференциальной диагностике возникают обычно в первые дни заболевани€, когда отсутствуют его характерные клинические симптомы. ¬ажное значение в дифференциальной диагностике острого пиелонефрита с перечисленными заболевани€ми имеют результаты исследовани€ мочи. Ћейкоцитури€, значительна€ бактериури€ и большое количество активных лейкоцитов в моче – патогномоничные признаки острого пиелонефрита.

“ак как основным фактором в развитии острого вторичного пиелонефрита €вл€етс€ обструкци€ мочевых путей, то ранним клиническим симптомом €вл€ютс€ боли в области пораженной почки, нередко типа почечной колики. Ёто обсто€тельство облегчает дифференциальную диагностику острого вторичного пиелонефрита с общими инфекционными заболевани€ми, острым аппендицитом и острым холециститом.

ѕальпируемость почки, положительный симптом ѕастернацкого, дизури€, бактериури€, лейкоцитури€, большое количество активных лейкоцитов в моче, снижение или отсутствие функции почки на стороне заболевани€ свидетельствуют в пользу острого вторичного пиелонефрита. ≈сли его причиной €вл€етс€ камень в нижней трети мочеточника, то в р€де случаев необходима дифференциальна€ диагностика с острым воспалением придатков матки (у женщин).

Ѕоли внизу живота, сопровождающиес€ симптомами раздражени€ тазовой части брюшины, увеличенные и болезненные придатки матки при влагалищном исследовании, отсутствие лейкоцитурии и бактериурии, ненарушенный пассаж мочи позвол€ют диагностировать острый аднексит. Ѕольшую помощь в дифференциальной диагностике оказывают ультразвуковое исследование почек, экскреторна€ урографи€ и хромоцистоскопи€, вы€вл€ющие нарушение оттока мочи при вторичном остром пиелонефрите. 

Ћечение

Ћечение острого пиелонефрита на современном этапе представл€ет р€д трудностей, св€занных с наличием антибиотикоустойчивых форм бактерий, изменени€ми видового состава микрофлоры, аллергизацией значительного числа больных. ¬ каждом отдельном случае необходимо определить форму пиелонефрита - первичную или вторичную.

ѕри первичном пиелонефрите антибактериальна€ терапи€ в сочетании с дезинтоксикационной и стимулирующей, как правило, бывает эффективной. ѕри вторичном пиелонефрите эффект возможен только при обеспечении дренировани€ почки, а то и удалении очага нагноени€. ѕоказанно назначение противомикробных препаратов (особенно обладающих широким спектром действи€) до восстановлени€ оттока мочи €вл€етс€ грубейшей ошибкой, котора€ может стоить больному жизни в результате развити€ €трогенного бактериемического шока (ј. ¬. јйваз€н, ј. ћ. ¬ойно-ясенецкий, 1985; ё. ј. ѕытель, ». ». «олотарев, 1986; ј. ¬. Ћюлько и соавт., 1989).

¬ св€зи с тем что в патогенезе острого пиелонефрита ведущим €вл€етс€ нарушение пассажа мочи, лечение больных следует начинать с незамедлительного восстановлени€ оттока мочи из почки путем катетеризации мочеточника, применени€ самоудерживающихс€ катетеров типа стента. ѕоследний более широко используют у женщин, в том числе беременных. “олько после восстановлени€ пассажа мочи можно назначать антибактериальные средства. ѕрименение антибактериальной терапии без восстановлени€ пассажа мочи недопустимо, так как чревато развитием бактериемического (бактериотоксического) шока.

ѕри отсутствии в течение суток эффекта от консервативной терапии на фоне восстановленного пассажа мочи показано экстренное оперативное вмешательство (удаление конкремента, наложение нефростомы). јнтибактериальна€ терапи€ приводит и к затушевыванию клинической картины заболевани€, а в некоторых случа€х даже и к реальному улучшению, но при вторичном остром пиелонефрите такое улучшение кратковременное, поэтому показани€ к оперативному лечению должны ставитьс€ шире. «ачастую сложность клинической картины, отсутствие уверенности в том, что в почках происход€т большие изменени€, привод€т к колебани€м относительно показанности хирургического вмешательства. ѕри этом тер€етс€ драгоценное врем€, локальный процесс переходит в сепсис, что резко ухудшает прогноз. Ќельз€ отказывать больному в единственном шансе на выздоровление даже в тех случа€х, если имеютс€ противопоказани€ к операции со стороны других органов и систем. ќпасность прогрессировани€ процесса, особенно при гнойных его формах, столь велика, что превышает операционный риск.

ѕри лечении больных острым пиелонефритом следует учитывать, что острое гнойное воспаление может развитьс€ на фоне серозного или ранее существовавшего воспалени€ интерстициальной ткани. ё. ј. ѕытель и ». ». «олотарев (1985) считают, что с клинической точки зрени€ острый пиелонефрит следует рассматривать как острый гнойный процесс. “акой подход позвол€ет избежать т€желых осложнений.

ќперативное лечение больных острым пиелонефритом заключаетс€ в выполнении нефростомии, декапсул€ции почки и дренировании за брюшинного пространства. ¬о врем€ органосохран€ющих операций показаны биопси€ почки, посев почечной ткани и мочи из лоханки. Ёто не удлин€ет операцию, дает ценную информацию дл€ проведени€ в послеоперационный период целенаправленной антибактериальной терапии, котора€ при пиелонефрите €вл€етс€ этиотропной.

ѕри вторичном остром пиелонефрите, вызванном окклюзией верхних мочевывод€щих путей, т€желом общем состо€нии или у больных преклонного возраста примен€ют чрескожную пункционную нефростомию. ќсобенно она эффективна при ультразвуковом контроле. Ёту минимально травматичную операцию примен€ют в качестве временного способа дренировани€ почки и подготовки больного к радикальному оперативному вмешательству. „рескожна€ пункционна€ нефростоми€ особенно ценна в тех случа€х, когда характер окклюзии не позвол€ет дренировать почечную лоханку путем ее катетеризации и стентировани€.

јнтибактериальную терапию при остром пиелонефрите следует начинать сразу же после восстановлени€ пассажа мочи и ее бактериологического исследовани€.

ћедикаментозное лечение пиелонефрита

ќсновные возбудители пиелонефрита чувствительны к следующим уроантисептикам:

  •  ишечна€ палочка: высокоэффективны левомицетин, ампициллин, цефалоспорины, карбенициллин, гентамицин, тетрациклины, налидиксова€ кислота, нитрофурановые соединени€, сульфаниламиды, фосфацин, нолицин, палин. 
  • Ёнтеробактер: высокоэффективны левомицетин, гентамицин, палин; умеренно эффективны тетрациклины, цефалоспорины, нитрофураны, налидиксова€ кислота. 
  • ѕротей: высокоэффективны ампициллин, гентамицин, карбенициллин, нолицин, палин; умеренно эффективны левомицетин, цефалоспорины, налидиксова€ кислота, нитрофураны, сульфаниламиды. 
  • —инегнойна€ палочка: высокоэффективен гентамицин, карбенициллин. 
  • Ёнтерококк: высокоэффективен ампициллин; умеренно эффективны карбенициллин, гентамицин, тетрациклины, нитрофураны. 
  • тафилококк золотистый (не образующий пенициллиназы): высокоэффективны пенициллин, ампициллин, цефалоспорины, гентамицин; умеренно эффективны карбенициллин, нитрофураны, сульфаниламиды. 
  • —тафилококк золотистый (образующий пенициллиназу): высокоэффективны оксациллин, метициллин, цефалоспорины, гентамицин; умеренно эффективны тетрациклины, нитрофураны. 
  • —трептококк: высокоэффективны пенициллин, карбенициллин, цефалоспорины; умеренно эффективны ампициллин, тетрациклины, гентамицин, сульфаниламиды, нитрофураны. 
  • ћикоплазменна€ инфекци€: высокоэффективны тетрациклины, эритромицин. 

ƒозировку и препараты назначает врач. јктивное лечение уроантисептиками необходимо начинать с первых дней обострени€ и продолжать до ликвидации всех признаков воспалительного процесса. ѕосле этого показан противорецидивный курс лечени€.

“ечение и прогноз первичного острого пиелонефрита

” большинства больных при рано начатом лечении течение острого первичного пиелонефрита благопри€тное. ” некоторых больных при неблагопри€тных услови€х (особо вирулентна€ инфекци€, значительное ослабление иммунобиологических сил организма) первичный острый пиелонефрит может протекать бурно; через 2–3 суток развиваетс€ апостематозный пиелонефрит или возникают множественные карбункулы почки, вследствие чего необходимо прибегать к оперативному вмешательству – декапсул€ции почки, вскрытию гнойников, а при тотальном поражении – нефрэктомии.

ѕри благопри€тном течении острого первичного пиелонефрита больные наход€тс€ на стационарном лечении в среднем 10–12 дней, после чего продолжают непрерывный прием антибактериальных препаратов до 6 недель в амбулаторных услови€х под систематическим наблюдением уролога и контрол€ анализов мочи.

ѕосле клинического выздоровлени€ следует сделать перерыв в антибактериальном лечении на 2–3 недели. «атем необходимо произвести детальное контрольное исследование мочи и крови больного. »сследование мочи должно включать в себ€ общий анализ, количественный подсчет лейкоцитов, эритроцитов и цилиндров по одной из методик, а также определение степени бактериурии и характера микрофлоры мочи с чувствительностью ее к антибактериальным средствам и химиопрепаратам.

ѕри наличии у больного ремиссии заболевани€ провод€т курсы противорецидивного антибактериального лечени€ продолжительностью 7–10 дней ежемес€чно в течение 6 мес€цев. ƒл€ лечени€ целесообразно использовать те препараты, к которым ранее была вы€влена чувствительность возбудител€ пиелонефрита. ¬ последующем при отсутствии признаков обострени€ заболевани€ контрольные обследовани€ больного провод€т 1 раз в 3 мес€ца на прот€жении 2 лет.

Ќеобходимость противорецидивного лечени€ и длительного контрольного диспансерного наблюдени€ за больными, перенесшими острый первичный пиелонефрит, обусловлена тем, что при обследовании этих больных в отдаленные сроки (через 2–2,5 года после атаки пиелонефрита) устанавливают хроническую форму заболевани€ у 20–25% из них.

“ечение и прогноз вторичного острого пиелонефрита

ѕри вторичном остром пиелонефрите прогноз менее благопри€тен, чем при первичном, так как у этих больных воспалительный процесс в почке гораздо чаще переходит в хроническую форму либо осложн€етс€ гнойно-деструктивными изменени€ми в почке, требующими нефрэктомии. ”спех лечени€ пиелонефрита, а следовательно, и его прогноз в основном завис€т от своевременности восстановлени€ оттока мочи из почки. 

ѕри вторичном остром пиелонефрите лечение следует начинать с восстановлени€ пассажа мочи из почки, что €вл€етс€ принципиальным.

ѕри остром пиелонефрите, вызванном окклюзией мочеточника камнем небольших размеров, что позвол€ет наде€тьс€ на его самосто€тельное отхождение в дальнейшем, и в ранние сроки (от 1 до 3 суток. от начала острого воспалительного процесса в почке попытка восстановлени€ оттока мочи может быть предприн€та с помощью катетеризации мочеточника. ≈сли удаетс€ провести катетер мимо камн€ в лоханку, эвакуаци€ ее содержимого приводит к быстрому купированию атаки пиелонефрита. ≈сли же катетеризаци€ лоханки по тем или иным причинам (чаще всего в св€зи с непреодолимым преп€тствием в месте нахождени€ в мочеточнике камн€) не удаетс€, а лекарственна€ терапи€ не приводит к ликвидации атаки пиелонефрита в течение первых 3 суток, то производ€т экстренное оперативное вмешательство – уретеролитотомию, либо дренирование почки малотравматическим чрескожным пункционным методом под контролем ультразвука (чрескожна€ пункционна€ нефростоми€).

ѕри окклюзии лоханочно-мочеточникового сегмента или мочеточника камнем, размеры которого не позвол€ют наде€тьс€ на его быстрое самосто€тельное отхождение, сразу примен€ют оперативное лечение. ¬ процессе подготовки больного к операции дл€ уменьшени€ степени гнойной интоксикации как временна€ мера допустима катетеризаци€ мочеточника или лоханки почки. ѕо показани€м, с учетом возраста больного и его состо€ни€, особенно у детей, в услови€х значительно дилатированной чашечно-лоханочной системы целесообразно прибегнуть к чрескожной нефростомии, позвол€ющей получить адекватный отток мочи из лоханки.

ѕрименение самоудерживающегос€ мочеточникового катетера (стента) позвол€ет не только купировать атаку пиелонефрита, но и произвести экстракорпоральное дробление камн€ в лоханке почки энергией ударной взрывной волны.  роме этого, камень может быть извлечен из почки с помощью чрескожной пункционной нефростомии (механически, специальным инструментом) либо раздроблен в лоханке ударными волнами (через чрескожную нефростому). ƒанный катетер (стент) обеспечивает свободный отток мочи из почки после дроблени€ камн€, исключает окклюзию мочеточника фрагментами конкремента и способствует профилактике острого вторичного пиелонефрита.

ћочеточниковый катетер обеспечивает отток мочи из лоханки почки, и на этом фоне целенаправленна€ интенсивна€ антибактериальна€ терапи€ приводит к улучшению состо€ни€ больного, снижению температуры тела до нормальных цифр, исчезновению озноба, уменьшению болей в области почки, снижению лейкоцитоза крови. јтака острого вторичного пиелонефрита купируетс€. ќднако в моче больных всегда содержитс€ большое количество слизисто-гнойных хлопьев, которые могут окклюзировать просвет мочеточникового катетера и вновь нарушить пассаж мочи. Ёто, как правило, приводит к новому обострению воспалительного процесса в почке и €вл€етс€ показанием к операции.

ѕри вторичном остром пиелонефрите в ранней стадии заболевани€ (2–3 суток), когда предполагают наличие серозного или незначительного гнойного воспалительного процесса в почке, можно ограничитьс€ удалением камн€ из лоханки или мочеточника без дренировани€ лоханки почки. ¬ более поздние сроки заболевани€ (4–6 суток), когда уже возник гнойно-некротический процесс в почке, удаление камн€ почки или мочеточника должно сопровождатьс€ об€зательным дренированием лоханки почки путем пиело– или нефростомии с одновременной декапсул€цией почки.

¬ еще более поздние сроки гнойно-воспалительного процесса в почке с признаками выраженной интоксикации организма основна€ цель оперативного вмешательства состоит в дренировании и декапсул€ции почки, а устранение причины возникновени€ вторичного острого пиелонефрита (например, удаление камн€ мочеточника) допустимо лишь в том случае, если оно не усложн€ет операции и не от€гощает состо€ни€ больного. ѕри множественных карбункулах почки, гнойном расплавлении ее паренхимы, пионефрозе и хорошей функции контралатеральной почки прибегают к нефрэктомии.

 онсервативное лечение с острым пиелонефритом при наличии окклюзии мочевых путей не приносит успеха, несмотр€ на применение самых мощных антибиотиков и химических антибактериальных препаратов. » наоборот, своевременное устранение преп€тстви€ оттоку мочи или самосто€тельное отхождение мелкого камн€ в мочеточнике приводит к быстрому купированию атаки острого пиелонефрита. ¬ св€зи с этим основной задачей лечени€ больных острым вторичным пиелонефритом €вл€етс€ быстрое восстановление оттока мочи. 

 
–едакци€ портала
20 €нвар€ 2014, 11:32
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