- An abscess of the perinephric fat that abuts the renal cortex
- Can arise as a complication either a pre-existing pyelonephritis (majority) or from hematogenous seeding
|Necrotic Area||perinephric fat between the renal cortex and Gerota's fascia||renal parenchyma|
|Cause||Pyelonephritis (majority)||Pyelonephritis (vast majority)|
|Risk of morbidity||Higher||Lower|
- Sign/symptoms similar to pyelo (fever, CVAT, dysuria)
- Occurs in setting of ascending infection with obstructed pyelo
- Genitourinary infection
- Urethral issue
- Behavioral symptom without detectable pathology
- CBC - Although it is a non-specific finding, a leukocytosis is typically seen.
- Chemistry Panel - Lactic acidosis is a common finding and is seen earlier in the disease course in diabetic patients. Renal insufficiency is also commonly seen as well.
- Inflammatory markers - ESR and CRP are almost always elevated.
- Urinalysis - Will often show evidence of pyelonephritis, however if the perinephric abscess is secondary to hematogenous spread, the urine could be sterile. Therefore a negative U/A does NOT rule out a perinephric abscess.
- X-ray - Will sometimes show abnormalities that might suggest a perinephric abscess is present, however one or all of these findings may not be present, therefore it is suggested to use more invasive imaging to rule out a perinephric abscess if clinical suspicion is high. Abdominal X-ray findings that can suggest a perinephric asbcess include:
- Displaced or rotated kidney
- Scoliosis - Deviation of the spine will occur in the direction of the lesion
- Loss of the psoas margin, however the false positivity rate is about 10%
- An abdominal mass or displaced bowel gas
- Thoracic pathology - ipsilateral consolidative process, atelectasis, or pleural effusion
- Ultrasound - A fluid filled mass extending from the renal cortex into the perinephric fat can be seen.
- CT - Is the imaging modality of choice for evaluation of suspected perinephric abscess. Sensitivity of detecting a perinephric abscess is about 90%. CT can give an accurate measurement of the abscess and can also show involvement, if any, of any surrounding structures (liver, ipsilateral psoas muscle, vertebral bodies, intervertebral discs, etc.)
- MRI - Has limited utility in the Emgergency Room setting given the time it takes for the study to be completed and read. However, advantages over CT include better delineation of soft tissue structures (listed above), absence of radiation exposure, and better contrast sensitivity.
- Antibiotic therapy depends on the suspected cause
- Abscess drainage
- Abscess of ANY size requires IR for percutaneous drainage
- If any urological obstruction is suspected (nephrolithiasis, ureterolithiasis, external compression from abdominal cavity, presence of pre-existing ureteral stent), emergent urological consultation should be obtained
All patients suspected of having a perinephric abscess should be admitted with empiric antibiotic therapy (see above) initiated in the Emergency Room immediately after the blood and urine culture have been obtained. In addition, a discussion with the admitting service regarding percutaneous drainage occur.
- Liu XQ, et al. Renal and perinephric abscesses in West China Hospital: 10-year retrospective-descriptive study. World Journal of Nephrology. 2016 Jan;5(1):108-14.