METHODS OF FUNCTIONAL DIAGNOSTICS OF RESPIRATORY SYSTEM

Respiration, which means “breathe again”, is very critical for life because it is necessary to supply all parts of de body with oxygen and to get rid of the produced carbon dioxide. When oxygen supply is too low, cells are unable to produce enough energy for normal functions. Also, when carbon dioxide is carried away inefficiently, its accumulation leads to acidosis.

The process of respiration can be divided into five stages:

·  pulmonary ventilation; the movement of air in and out of the lungs

·  exchange of oxygen and carbon dioxide between the lungs and the blood in de pulmonary capillaries (external respiration)

·  the transport of the gases through the body by blood

· exchange of oxygen and carbon dioxide between tissue cells and the blood in systemic capillaries (internal respiration)

·utilization of oxygen and production of carbon dioxide by tissue cells (cellular respiration)

 

 

 

 

 

Pneumotachymetry is the technique used for measuring peak velocities of air streams in forced inspiration and expiration and is intended to determine the condition of bronchial patency.

Pneumotachygraphy is measuring the volumetric rate at various phases of respiration (both normal and forced). The instrument used for the purpose is known as a pneumotachygraph. The technique is based on recording pressures of air streams at various points and during different phases of the respiratory cycle. Pneumotachygraphy is used to determine the volumetric rate of air streams during both inspiraion and expiration (iormal breathing it is about 300-500 ml/s, and in breed respiration 5000-8000 ml/s), the length of the inspiration and expiration phases, the minute volume, intra-alveolar preassure, resistance of the air ducts to the air stream, distensibility of the lungs and the chest wall, the mechanism of respiratory movements, and some other indices.

healthy side. Tachycardia isobserved. Arterial pressure may be decreased. Dizziness, faints, etc., sometimes occur because of the marked toxicosis.

 

Spirogram in respiratory failure shows decreased vital lung capacity and reserve inspiratory volume

 

Method and technique of spirography, its diagnostic value

 

 

Main signs of diseases determined with examination of  external respiratory function:

1+5+6 – VC – vital capacity ; 8 – FVC – forced vital capacity  

Diminishing is observed in respiratory failure and when lungs fail in ability to expand during inspiration

10 – MVV – maximal voluntary ventilation –

Diminishing is observed when lung fail in ability to expand during inspiration and in weakening of respiratory muscles (pulminary emphysema, interstitial diseases of lungs)

RV – residual volume

Increasing is observed in pulmonary emphysema

9 – FEV1 – forced expiratory volume in 1 sec

 FEV1/FVC % – ratio of forced expiratory volume in 1 sec and forced vital capacity  

Diminishing is observed in  narrowing of bronchial lumen which makes expiration difficult. These changes are typical for bronchial asthma, chronic obstructive pulmonary disease (chronic obstructive bronchitis)

FEV 25-75% – mean forced expiratory flow during the middle –  PEF – peak expiratory flow –

Diminishing is  caused by narrowing of bronchial lumen but cannot detect degree of obstruction. The changes are typical for bronchial asthma, chronic obstructive pulmonary disease (chronic obstructive bronchitis)

1) FEF (MEF)25% -mean forced expiratory flow during the 25% of FVC –

2) FEF (MEF)50% -mean forced expiratory flow during the 50% of FVC – 3) FEF (MEF)75% -mean forced expiratory flow during the 75% of FVC –

 

 

SPIROMETRY. SPIROGRPHY.

TEST  of VC ( Vital Capacity of lungs):

VC – Vital Capacity –  the greatest volume of air that can be expired from the lungs after a maximal inspiration

IRV – inspiratory reserve volume)   (the  volume of air which can be inspired by maximum effort after completion of a normal expiration.

ERV – Expiratory Reserve Volume–the  volume of air which can be expired by maximum effort after completion of a normal expiration.

IC – inspiratory capacity – the  volume of inspiration   –   (IC = RV + IRV)

RV – respiratory volume –is the volume of air inspired and expired duringnormal  breathing. It is 500 ml on the everage varyng from 300 to 900 ml. 

ОЗЛ (TV = tidal volume) – volume of lung closure

ФОЕЛ (FRC = functional residual capacity) –  FRC= ERV+ RAV

RAV – residual volume the air that remains in the lungs after maximum expiration.  

 

 

TLC – total lung capacity –  (volume of air accumulated in the lungs at the top of maximal inspiration). TLC =  RV+ ERV + IRV+ RAV

TEST  FEVC(forced expiratory vital capacity)

FEVC = FEVC exp (FVC = forced vital capacity) – (test  Tiffeneau). = Forced vital capacity – volum of air,that is expired during the fastest and the strongest expiration.
 FEV05 = forced expiratory volume in 0.5 sec – volume  of  forced expiration  during 0,5 sec.

 
FEV1 = forced expiratory volume in 1 sec) — volume  of  forced expiration  during 1 sec  

 FEV3 = forced expiratory volume in 3 sec) – volume  of  forced expiration  during 3 sec.
 

In pulmonary function studies a number of abbreviations and symbols have become standardized. Some frequently used ones are listed in the table below:

 

 

Spirograms of a healthy individual (a) and of patients with obstructive (b) and restrictive (c) respiratory insufficiency.

 

Spyrography is used for study the external respiration function. It lets to determine the respiratory volume and the vital lung capacity and some other dynamic indices for diffferential diagnostics of the type of respiratory insufficiency.

Spirography gives more reliable information on respiratory volumes. A spirograph can be used not only to measure various respiratory volumes but also some additional ventilation characteristics such as the respiratory volume, minute volume, maximum ventilation of the lungs, and the volume of forced expiration. A spirograph can also be used with a bronchoscope to determine all indices separately for each lung (bronchospirography). Using an absorber of carbon dioxide, it is possible to determine oxygen absorption per minute.

The main respiratory volumes have to be determined by spyiography are:

1.     The respiratory volume (RV) is the volume of air inspired and expired during normal breathing. It is 500 ml on the average varying from 300 to 900 ml.

2.      The expiratory reserve volume (ERV) (1500-2000 ml). This is the volume of air which can be expired by maximum effort after completion of a normal expiration.

3. The inspiratory reserve volume (IRV) (1500-2000 ml). This is the volume of air that can be inspired after a normal inspiration.

4. The vital capacity (VC) is found by summation of the IRV and ERV and the respiratory volume (3700 ml on the average). This is the greatest volume of air that can be expired from the lungs after a maximum inspiration. The vital capacity of the lungs can be calculated by multiplying the tabulated (optimal) volume of basal metabolism by an empirically found factor 2.3. The deviation from the expected (optimum) vital capacity calculated by this method should not exceed ± 15 per cent.

Respiratory volumes can be used to assess possible compensation of respiratory insufficiency by increasing respiratory depth at the expense of expiration and inhalation and residual volume.

Normal respiratory volume is about 15 per cent of the vital lung capaci­ty; expiratory and inspiratory air volumes are 42-43 per cent (inspiratory air usually slightly exceeds expiratory air volume); residual air is about 33 per cent of the vital capacity of the lungs. The VC slightly decreases in patients with obstructive hypoventilation, while expiratory and residual air volumes increase at the expense of decreased inspiratory air. RAV (especially the RAV: TLC ratio) increases in some cases to 50 per cent of the TLC (in lung emphysema, bronchial asthma, to a lesser degree in aged persons). VC in patients with hypoventilation also decreases because of the decreased IRV, while the RAV changes only insignificantly.

5. The minute volume (MV) is calculated by multiplying the respiratory volume by respiratory rate; it is about 5000 ml on the average. More accurately the MV can be determined by a Douglas bag or using a spirograph.

6. The maximum lung ventilation (MLV) is the amount of air that can be handled by the lungs by maximum effort of the respiratory system. It is determined by spirometry during deepest breathing at a rate of 50 r/min; normal ventilation is 80—200 1/min. According to Dembo, the predicted value of the maximum ventilation is the vital capacity of the lungs multiplied by 35 (MLV = VC x 35).

The study of this mechanics is necessary for determining changes in the inspiration to expiration ratio, the respiratory effors at various respiratory phases, and other indices.

6.     The forced expiratory vital capacity (FEVC). According to Votchal-Tiffeneau this is determined like the vital capacity except that the forced expiration should be performed as fast as possible. The FEVC is 8-11 per cent (100-300 ml) lower than the VC in healthy persons, mainly due to the increased resistance of fine bronchi to the passage of air. When this resistance increases due to bronchitis, bronchospasm, emphysema, etc., the difference may be as great as 1500 ml and more. The volume of forced expiration per minute is also determined. In healthy persons it is 82.7 per cent of the VC. The length of the forced expiration until the moment it slows abruptly is also determined. These investigations can only be done with a spirograph. Broncholytics (e.g. using theophedrine) to determine the FEVC or the various modifications of this test enable us to assess the role of bronchospasm in the aetiology of the respiratory insufficiency and de­creased values of the above indices. If, after giving theophedrine, the fin­dings remain markedly subnormal bronchospasm is not the cause of their reduction.

 

 

 

Spirometry

A wet Spirometer measures lung volumes based on the simple mechanical principle that air, exhaled from the lungs, will cause displacement of a closed chamber that is partially submerged in water. The spirometer consists of two chambers: (1) a larger chamber which is filled with water and has a breathing hose attached to it, and (2) a smaller chamber which is inverted inside the first and “suspended” in water. A counterweight and indicator are attached to the inverted chamber. Air blown into the inverted chamber causes it to rise and move an indicator along a scale. The scale is calibrated in liters to give lung volume measurements (Figure 1). The various lung volumes are defined below and illustrated in Figure 2.

Figure 1: Wet spirometer

 

 

Figure 2: Principle of using a wet spirometer to measure lung volumes

Figure 3. Lung Volumes and Capacities.

 

Clinical significance of spirometry

Measurement of lung volumes and forced expiratory flow rates are useful in the clinical setting. Two types of lung disorders can be identified by spirometry measurements:

1. Obstructive lung disorders such as bronchitis and asthma. In these conditions, there is an obstructive process in the airways (the bronchi) of the lung and this is detected by a decreased ability to empty the lungs quickly during a forced expiration. This is measured as the FEV₁/VC ratio.

2. Restrictive lung disorders are characterized by a decrease in lung compliance, in diseases such as emphesyma, which results in reduced alveolar volume. Abnormal VC measurements are not necessarily accompanied by alteration in the FEV₁/VC ratio.

Lung diseases are not of one specific type, but rather result from a combination of the above two disorders or in combination with a variety of factors that lead to compromised respiratory functions. These factors can include neuromuscular disorders which compromise the inspriatory and expiratory muscles, dysfunction of the respiratory control center in the brain stem, or some other defect relating to gas exchange across the lung airways or in the blood.

 

Spirometry
Spirometry assesses the mechanical properties of the respiratory system. It measures expiratory volumes and flow rates. This test requires that the patient makes a maximal inspiratory and expiratory effort, so it may cause some patients discomfort. The patient is asked to sit and breathe into a mouthpiece with nose clips placed to prevent air leaks. To obtain good results from spirometry, it is important that the patient gives a full effort during testing. Three tests of acceptable effort are performed to ensure valid results.

Graphs showing the result of a typical spirometry study are shown below. Flow on the Y-axis is plotted against volume on the X-axis to display a continuous loop from inspiration to expiration. The shape of the flow volume loop is important for interpreting the spirometry results

Normal spirogram.

FEV₁ = forced expiratory volume in the 1st second of forced vital capacity maneuver; FEF_25–75% = forced expiratory flow during expiration of 25 to 75% of the FVC; FVC = forced vital capacity (the maximum amount of air forcibly expired after maximum inspiration).

 

 

 

 

 

 

Normal lung volumes.

TLC = total lung capacity; VT = tidal volume; ERV = expiratory reserve volume; IRV = inspiratory reserve volume; FRC = functional residual capacity; IC = inspiratory capacity; VC = vital capacity; RV = residual volume; FRC = RV + ERV; IC = VT + IRV; VC = VT + IRV + ERV.

 

Normal Flow vs Volume Spirogram

Mild Obstructive Flow vs Volume Spirogram

Severe Obstructive Flow

Table 1: Definitions of lung volumes

Lung volume	Definition
Tidal volume (TV)	The volume of air moved during normal quiet breathing (about 0.5 L).
Inspiratory reserve volume (IRV)	The volume of air that can be forcefully inspired following a normal quiet inspiration. (about 2.5 – 3.5 L).
Expiratory reserve volume (ERV)	The volume of air that can be forcefully expired after a normal or resting expiration (about 1.0 L).
Residual volume (RV)	The volume of air remaining in the lungs after a forceful expiration (about 1.0 L).
Vital capacity (VC)	The greatest extreme in air volume moved between inspiration and expiration (about 4.5 L).
Inspiratory capacity (IC)	The amount of air that the lungs will hold after a normal expiration (i.e. inspiratory reserve + tidal volume).
Functional residual capacity (FRC)	The amount of air remaining in the lungs after a normal quiet expiration (i.e. expiratory reserve volume + residual volume).

Table 2: Typical Volume and flow rate patterns (mL)

Volume (ml)	Normal	Obstructive disease	Restrictive disease
Total lung capacity (TLC)	6000-7500	8000	5000
Vital Capacity (VC)	6000	4000	4000
FEV1	4800	1800	3500
FEV1/VC (%)	80	50	88

 

 

 

 

 

Bronchoscopy as a method of examination,

its diagnostic value

Bronchoscopy is used tо inspect the tracheal and bronchial mucosa of the second and  IIIrd order It is performed by means of a special apparatus known as а bronchoscope.Photography can also be made whenever necessary.

Flexible bronchofibroscope.

1-controllable distal end, 2-flexible rod; 3- instrument body with an eye piece and control handle; 4-fibre-optic cable.

Patient’s position during examination by rigid bronchoscop

 

Bronchoscopy:

а – in horizontal position of a patient

б – in sitting position

в – through intubation tube

г – the cheme of inserting of a bronchoscop through the nose (1) and mouth (2)

Bronchoscopy is used for diagnosing erosions and ulcers of the bron­chial mucosa and tumours of the bronchial wall, removing foreign bodies, extracting polyps, and treating bronchiectasis and centrally located abscesses of the lungs. Sputum containing pus is first aspirated through the bronchoscope, and then antibiotics are administered into the bronchial lumen or cavity.

 

Laboratory examination of sputum, bronchial washings and pleural fluid, diagnostic value of obtained data

Sputum is a pathological material that is expelled from the respiratory organs during the coughing act. Sputum may contain mucoid secretions, serous fluid, blood cells, desquamated respiratory epithelium, protozoa, and, in rare cases, helmints and their ova. The study of the sputum gives information concerning the pathology of the respiratory organs and in some cases helps establish its aetiology.

The morning sputum taken before breakfast (after mouth rinsing) is the best material for examination. If the sputum is scarce, it should be collected during one or two days for examination for the presence of tuberculosis mycobacteria. Saprophytic flora rapidly multiplies in sputum to destroy the formed blood elements. Special calibrated bottles provided with screw caps should be used for gathering sputum.

The study begins with observation of the sputum first in a transparent bottle and then in a Petri dish which is placed alternately on the black and white surface. General properties, colour, and consistency of the sputum are noted. Mucoid sputum is usually colourless; it occurs in acute bron­chitis. Serous sputum is also colourless, liquid, and foamy; it occurs in pulmonary oedema. Mucopurulent sputum is yellow or greenish and tenacious; it is characteristic of chronic bronchitis, tuberculosis, etc. Purulent uniform semiliquid sputum with a greenish-yellow tint is typical of the ruptured lung abscess. Sputum may contain blood. It occurs in pulmonary haemorrhage (tuberculosis, cancer, bronchiectasis). Sputum may also be mucopurulent with streaks of blood (in bronchiectasis), serous blood-stained foamy (in lung oedema), mucous bloody (in lung mfarction or in congestion in the lesser circulation), or bloody purulent (in gangrene and abscess of the lung). If blood is not expectorated from the respiratory tract immediately but stays there for some time, the haemoglobin converts into haemosiderin to give a rusty hue to the sputum, which is characteristic of acute lobar pneumonia.

Sputum may form layers on standing. Three-layer sputum is characteristic of chronic purulent processes. The upper layer is mucopurulent, the middle one serous, and the lower layer is pus. Purulent sputum is sometimes separated into two layers, i.e. serous and purulent.

Sputum is usually odourless. Foul odour of freshly expectorated sputum depends on the putrefactive decompositon of tissues (gangrene, degrading cancer tumour) or on the decomposed protein of the sputum re­tained in various cavities (abscess, bronchiectases).

The following elements can be seen in the sputum by an unaided eye:

Curschmann spirals (in the form of small dense twisted threads); fibrin clots (whitish and reddish branching elastic formations, occurring in fibrinous bronchitis and sometimes in pneumonia); compact lenticular greenish-yellow formations consisting of calcified elastic fibres, cholesterol crystals and soaps containing tuberculosis mycobacteria; Dittrich’s plugs, that resemble the lenticular formations in appearance and composition but free of tuberculosis mycobacteria and having offensive odour on pressing (occur in gangrene, chronic abscess, and fetid bronchitis); lime grains, that are found during decompositon of old tuberculosis foci; actinomycete drusen in the form of yellow formations resembling coarse flour; necrotized pieces of lung tissues and tumours; food remains.

The medium of the sputum is alkaline as a rule; it becomes acid in the presence of gastric juice and during decomposition; this helps differentiate between haemoptysis and haematemesis.

Microscopic study of the sputum can be done with native and stained preparations. In the first case, small clots or white threads of the purulent and blood stained material are taken from a sputum sample and transferred onto an object to make a thin semitransparent preparation which is covered by another glass. Examination begins with general observation at a small magnification in order to identify Curschmann spirals. Formed elements are then differentiated at a greater magnification. Curschmann spirals are mucous threads consisting of a dense central filament and a spiral mantle containing leucocytes (often eosinophils) and Charcot-Leyden crystals. Curschmann spirals are found in the sputum during bronchial spasms, mostly in bronchial asthma, less frequently in pneumonia and lung cancer.

Following cellular elements can be revealed as:

Leucocytes can be found iative preparations at large magnification. A small quantity of leucocytes can be found in any sputum, while their large amounts are characteristic of inflammatory and especially purulent processes.

Eosinophils can be identified in the native preparation by their uniform large lustrous grains, but they are better identified by staining.

Erythrocytes (red blood cells) appear during decomposition of lung tissue, in pneumonia, congestion in the lesser circulation, lung infarction, etc.

Squamous epithelium gets into the sputum mostly from the mouth and is diagnostically unimportant. Columnar ciliated epithelium is contained in small quantity in any sputum, but its large amounts are found in bronchitis, bronchial asthma, and other affections of the respiratory ducts.

Alveolar macrophages are large cells (twice or thrice as great as leucocytes) of reticulohistiocyte aetiology. Small quantities of alveolar macrophages are contained in any sputum but their large amounts are found in inflammatory diseases.

Malignant tumour cells are often present in the sputum, especially so if the tumour degrades or grows endobronchially. These cells can easily be identified by their atypical view :they are mostly large and disfigured, their nuclei are large; several nuclei are sometimes found in one cell.

Heart-disease cells occur where erythrocytes get into the alveolar cavities (in congestion of the lesser circulation, especially in mitral stenosis, lung infarction, and also in acute lobar pneumonia).  

Elastic fibres  are found in the sputum during decomposition of the lung tissue in tuberculosis, cancer and abscess. Elastic fibres are fine formations of two dichotomically branching filaments of the uniform thickness.

Actinomycetes are separated from small yellow compact grains (drusen) of sputum.

Candida albicans affects the lungs during prolonged antibiotic therapy of asthenic patients.

Charcot-Leyden crystals – colourless octahedra of various size, resembling the pointer of a compass. They consist of protein released during decomposition of eosinophils and are therefore found in the sputum containing much eosinophils. Old sputum contains greater amount of these crystals. Haematoidin can be found in the sputum after pulmonary haemorrhage (provided blood is not liberated with the sputum immediately). Crystals of haematoidin are rhombic or needle-shaped brown-yellow formations.

Curschmann spirals (in the form of small  dense twisted threads);

Fibrine clots (whitish and reddish branching  elastic  formations,  occurring in fibrinous bronchitis  and sometimes  in  pneumonia);

Compact lenticular greenish-yellow formations consisting of calcified elastic fibres,

Cholesterol crystals and soaps containing tuberculosis mycobacteria;

Dittrich’s pllugs  resemble the lenticular formations in appearance and composition but free of tuberculosis mycobacteria and having offensive odour on pressing (occur in gangrene, chronic abscess, and fetid bronchitis);

 

Curschmann’s spirals and  Charcot-Leyden crystals in sputum.

 

Microscopy of stained preparations is carried out to study microbial flora of the sputum and of some of its cells.

    If bacterioscopy fails to reveal tuberculosis mycobacteria the sputum because of their scarce quantity, other techniques  should be used. In luminescent microscopy a common fixed smear is coloured with a  luminescing dye (rhodamine, acridine orange) and then with another stain (acid fuchsine, methylene blue),  that masks the background luminescene. Luminescence of mycobacteria  in  the ultraviolet rays of a  luminescent microscope is so brigh that mycobacteria can be seen in a dry lens (40x ). It covers a larger field  of vision than the immersion lens.  There exist various  techniques  to concentrate mycobacteria. Flotation is the most popular one. The sputum is homogenized with alkali, shaken with toluene, xylene  or  benzine,  and  mycobacteria entrapped in  the  droplets of the solvents float to the surface. Cream-like layer which separates on standing is transferred by a pipette onto a warm glass, drop by drop (on one site) The preparation is allowed  to dry and then fixed and stained after Ziehl-Neelsen. Another concentration  method is electrophoresis. As direct current passes through the liquefied sputum, tuberculosis mycobacteria move toward  the cathode. Smears are  taken  from the cathode and stained after Ziehl-Neelsen.

 

Study of the pleural fluid

 

Pleurocentesis

Diagnosric pleurocentesis with closed system  and syrenge and with vacuum device

 

The amount of fluid contained in the pleural cavity of a healthy person is insignificant. Its composition is close to that of lymph. The fluid serves as a lubricant to decrease friction between the pleural membranes during respiration. The volume of pleural fluid may in­crease in disordered circulation of the blood and lymph in the lungs. This can be either transudate (of non-inflammatory origin) or effusion (occurr­ing in inflammatory affections in the pleura). Effusion can also be due to clinical causes such as primary infection of the pleura or it can be a symp­tom attending some general infections and some diseases of the lungs or mediastinum (rheumatism, infarction, cancer and tuberculosis of the lungs, lymphogranulomatosis, etc.). The pleural fluid is studied in order (1) to determine its character (transudate, effusion, pus, blood, chylous fluid); (2) to study the cell composition of the fluid in order to obtain information concerning the character of the pathology and sometimes its diagnosis (when cancer cells are detected); (3) to reveal the causative agent of an infectious disease and to determine its sensitivity to antibiotics. Analysis of the pleural fluid includes macroscopic, physicochemical, microscopic and sometimes microbiological and biological analysis.

The appearance of the pleural fluid depends mostly on its cell composi­tion and partly on the chemical composition. Fluids of the following character are differentiated: serous, serofibrinous, fibrinous, seropurulent, purulent, putrefactive, haemorrhagic, chylous, and chylous-like.

Transudate and serous effusion are clear and slightly opalescent. Tur­bidity of the fluid may be due to abundance of leucocytes (seropurulent and purulent effusion), erythrocytes (haemorrhagic effusion), fat drops (chylous effusion) or cell detritus (chylous-like effusion). The character of the cells can be determined by microscopy. The chylous character of the effusion is determined by an ether test (opacity disappears in the presence of ether). This fluid can be due to congestion of lymph or destruction of the thoracic duct by a tumour or an injury.

The colour of transudate may be pale yellow, serous effusion from pale yellow to golden, and in jaundice it may be deep yellow. Purulent effusion is greyish or greenish-yellow; in the presence of blood it becomes reddish or, more frequently, greyish-brown. The putrefactive effusion is of the same colour. Depending on the amount of the haemorrhage and also on the time of blood retention in the pleura, the haemorrhagic fluid can be pink to dark red or even brown. In haemolysis it may have the appearance of lacquer. Chylous effusion looks like thin milk.

The consistency of pleural effusion is usually liquid. Purulent fluid can be thick, cream-like, and sometimes it enters the puncture needle with dif­ficulty. Pus of the old encapsulated empyema can be of puree consistency, with grains, and fibrin flakes.

Only putrefactive effusion has offensive smell (gangrene of the lung). The smell depends on protein which is decomposed by anaerobic enzymes.

Physicochemical studies of the pleural fluid include determination of relative density of the fluid and protein; these are the main criteria for differentiation between the effusion and transudate. Relative density of the pleural fluid is determined by a hydrometer; a urometer is normally used for the purpose (see “Analysis of Urine”). Relative density of the transudate is about 1.015 g/cm³ (1.006-1.012), and of the effusion is slightly higher, i.e. 1.018-1.022.

Protein content is lower in transudate than in the pleural fluid, i.e. not higher than 3 per cent (usually 0.5—2.5 per cent). The pleural effusion con­tains from 3 to 8 per cent of protein. A refractometric method is more suitable for determining protein in the pleural fluid, but some other methods can also be used, such as biuretic, gravimetric, Roberts-Stolnikov method and others. The composition of protein fractions of the pleural fluid is about the same as of blood serum. Albumins prevail in transudate while fibrinogen is absent or almost absent for which reason transudate does not clot. The fibrinogen content of pleural effusion is lower than that of blood (0.05-0.1 per cent) but its quantity is sufficient to clot spontaneously most of them. The total protein content of transudate rarely reaches 4—5 per cent and additional tests are therefore used to differentiate it from the pleural effusion. Rivalta’s reaction: a cylinder is filled with water acidified with a few drops of acetic acid;

1 or 2 drops of the punctate are added; as effusion sinks to the bottom it leaves a cloudy trace (like cigarette smoke), while in case of transudate the reaction is negative. Lucaerini test: 2 ml of hydrogen peroxide (3 per cent solution) are placed on a watch glass (against a black background) and a drop of the punctate is added: opalescence appears in case of the positive reaction. Both reactions are used to detect the presence of seromucin in effusion. This is a mucopolysaccharide complex which is absent from transudates.

Microscopy is used to study the precipitate of the pleural fluid obtained by centrifuging. The fluid may clot before or during centrifuging, and the precipitate becomes unsuitable for examination because most of its cells will be captured in clots. To preclude clotting, sodium citrate or heparin is added to the test fluid. Precipitate cells are studied by several techniques. Studied are native preparations, dry smears stained after Romanovsky-Giemsa or Papanicolaou. Fluorescence microscopy, histological studies of the precipitate in paraffin, or cell culture are used to detect tumour cells.

An accurate calculation of leucocytes and erythrocytes is unimportant because their quantity in the preparation depends largely on the duration and speed of centrifugation. A small quantity of erythrocytes can be contained in any punctate because of puncturing of the tissues. Their number is high in haemorrhagic effusion in patients with tumours, injuries, and hemorrhagic diathesis. The leucocyte count is high in bacterial infections of the pleura. Leucocytes are scarce in transudates, which contain many mesothelium cells. Exudates sometimes contain cells suspected for :umour, but it is difficult to determine their nature iative preparation. Fhe precipitate containing minimum supernatant liquid is used to make a smear. The elements of the precipitate, i.e. neutrophils, lymphocytes, ‘osinophils, monocytes, macrophages, mesothelial cells and tumour cells, :an be differentiated by colour.

Transudates used for microbiological studies are as a rule sterile but they can be infected during repeated paracenteses. Effusion may be sterile (e.g. in rheumatic pneumonia or lung cancer). Mycobacteria are usually not found bacterioscopically in serous effusion of tuberculous aetiology, but inoculation of the nutrient medium of guinea pigs with the effusion gives sometimes positive results.

 

 

 

 

Study of bonchial washings.

 This is necessary to  reveal tuberculos mycobacteria in them (e.g. in patients who do not expectorate sputum), or to detect malignant tumour cells. The patient should lie on the affecte side, His pharynx and larynx should be anaesthetized with a dicaine solution and then 10-12 ml of warm isotonic sodium chloride solution are slowly  injected into the larynx and the trachea using a laryngeal syribge The solution irritates the bronchial mucosa to cause cough and expectoration  of mucus. The expectorated washings are collected in a sterile vesel.

Mycobacteria are detected in them by the flotation method or by inoculation of a nutrient medium. To prepare material for cytological studies, the washings are centrifuged and native preparations and smears are prepare from the  precipitate. Native preparations are inspected in a common phase-contrast  microscope,  or  in  a  fluorescence  microscope  (after fluorochrome treatment).  Smears are stained  after Romanovky-Giems (or by fluorochromes) for fluorescence microscopy.

 

Main Clinical Syndromes

   Syndrome of focal consolidation of pulmonary tissue. The syndrome of focal consolidation of lung tissue is caused by filling of the alveoli with the inflammatory fluid and fibrin (in pneumonia), blood (in lung infarction growing connective tissue in the lung (pneumosclerosis, calcification) in long-standing pneumonia, or developing tumour. The common complain of the patient is dyspnoea. Examination of the patient reveals thoracic lagging of the affected side during respiration; vocal fremitus is intensified in the consolidated area; the percussion sound  over the consolidation site is slightly or absolutely dull auscultation reveals broncial respiration exaggerated bronchophony and (in the presence of liquid secretion in fine brochi)  resonant (consonating)  rales. X-ray examination shows the  focus of consolidation as an area of increased density in the lung tissue, its size and contours depending on the character and stage of the disease, and some other factors.

   Cavity in the  lung. Cavity in the lung is formed in abscess or tuberculosis (cavern) or during degradation of the lung tumour. An empty large  cavity is communicated with the bronchus and surrounded by a ring of inflamed tissue. Examination of the chest reveals unilateral thoracic lagging  and intensified vocal fremitus. Percussion reveals dulled tympany or (if the  cavity is large and peripheral) tympany with a metallic tinkling.  Auscultation  reveals  amphoric breathing, intensified bronchophony, and often  medium and large resonant  vesicle rales. X-ray examination proves the  presence of the cavity in the lung.

   Fluid in the pleural cavity. The syndrome of accumulation of pleural  fluid occurs in hydrothorax (accumulation of non-inflammatory effusion,  i.e. transudate, for example in cardiac failure), or in pleurisy with effusion inflammation of the pleura). The syndrome is characterized by dyspnoea  due to respiratory insufficiency caused by lung compression and decreased  respiratory surface, asymmetry of the chest (enlargement of the side where  pleural effusion is accumulated) and  unilateral thoracic lagging during  respiration.  Vocal fremitus  is markedly weakened over the  area of the  pleural effusion, or it may be undeterminable; percussion reveals a dulled

 sound or absolute  dullness; in auscultation respiration and bronchophony  are markedly dakened or absent X-ray examination reveals an area of in-

 creased density in  the area of accumulation of the pleural fluid, which is  usually at  the bottom of the chest (often bilateral in hydrothorax). Its up-

 per border is quite distinct If transudate is accumulated in the pleural cavi ty its border is more horizontal,  while in the presence of pleural effusion,

 the border is  scant, to coincide with the Damoiseau’s curve as determined  by percussion (see “Pleurisy with Effusion”).

   Air accumulation in the pleural cavity. Air is accumulated in the pleural  cavity when  the bronchi are communicated with the pleural cavity (in  subpleural tuberculosis cavern or abscess), in injury to the chest, or in ar tificial pneumothorax (injection  of air  into the pleural cavity for medical  purposes in the presence of large caverns in the lungs). Asymmetry of the chest found in this syndrome is  due to the enlarged side where air is accumulated; the affected side of the chest cannot take part in the respiratory act. Vocal fremitus is markedly weaker or absent altogether over the site of air accumulation;  percussion reveals tympany. Breathing sounds and bronchophony are either weak or absent and are not conducted to the chest surface  to be detected  by auscultation. X-ray examination reveals a light pulmonary field without  pulmonary pattern;  a shadow of  the  collapsed lung  can be seen toward the root.

   External  respiratory  dysfunction.   The function  of  the  external respiratory apparatus is to supply the body with oxygen and to remove carbon dioxide formed by exchange reactions. This function is realized firstly by ventilation, i.e. gas exchange between the outer and alveolar air. This ensures the required oxygen and carbon dioxide pressure in the alveoli (an important  factor is intrapulmonary  distribution of the  inspired air).

Secondly, this function is realized by diffusion of carbon dioxide and oxygen through the walls of the alveoli and lung capillaries (oxygen is supplied from the alveoli to the blood and carbon dioxide is diffused from the blood to the alveoli). Many acute and chronic diseases of the bronchi and the lungs cause respiratory insufficiency. The degree of morphological changes  in the lungs does not always correspond to the degree of their dysfunction.    Respiratory insufficiency is now defined as the condition with abnormal gas composition of the blood, or this abnormality is compensated for by intense work of the external respiratory apparatus  and higher load on the heart. This decreases functional abilities of the body. It should be noted that the external respiratory function is closely connected with the blood circulatory  function:  the  heart work  is  intensified  during  external respiratory insufficiency, which is an important compensatory element of the heart function.

   Respiratory insufficiency is  manifested clinically by dyspnoea and cyanosis; at later stages, when cardiac failure joins the process, oedema occur.    The patient with respiratory insufficiency employs the same compensatory reserves as a healthy person does during heavy  exercise. But the compensatory mechanisms of a sick person are actuated much earlier and at loads under which  a healthy person  would feel no discomfort (e.g. dyspnoea and tachypnoea can develop in a patient with lung  emphysema even during slow walking).

   Among  the  first  signs of  respiratory insufficiency are  inadequate changes in ventilation  (rapid and deep breathing) at  comparatively light loads for a healthy individual; the minute volume increases. In certain cases (bronchial asthma, lung emphysema, etc.) respiratory insufficiency is compensated by intensified work of the respiratory muscles,  i.e. by the altered respiratory mechanics. In other words, in  patients with pathology of the respiratory system, the external respiratory function is maintained at the required level by mobilizing compensatory mechanisms (i.e. by efforts greater than  required  for  healthy persons), and  by  minimizing the

respiratory reserves: the maximum lung ventilation decreases, the coefficient of oxygen consumption drops, etc.

    Various mechanisms are  involved gradually to compensate for progressive  respiratory insufficiency depending on its degree. At the early stages of respiratory insufficiency the external respiratory function at rest is realized iormal way. The compensatory mechanisms are only actuated during exercise in a sick person. In other words, only reserves of the external respiratory apparatus are decreased at this stage. As insufficiency further progresses, tachypnoea, tachycardia, and signs of intensified work of the respiratory muscles (during both inspiration and expiration), with involvement of accessory muscles, develop during light exercise and even at rest. At the later stages of respiratory insufficiency, when the body compensatory  reserves  are  exhausted, arterial hypoxaemia and hypercapnia develop. In addition to the growing vivid arterial hypoxaemia, signs of latent oxygen deficit also develop; underoxidized products (lactic acid, etc.) are accumulated in the blood and tissues.

    Still at  later stages, right ventricular incompetence joins pulmonary insufficiency because of the developing hypertension in the lesser circulation, which is attended by increased load on the right ventricle, and also because of dystrophic changes in the myocardium occurring as a result of its constant overload and insufficient oxygen supply. Hypertension in the vessels of the  lesser circulation in diffuse affections of the  lungs arises by reflex mechanisms  in  response to insufficient lung  ventilation and  alveolar hypoxia the Euler-Liliestrand reflex (this reflex mechanism is an important adaptation means in focal lung affections; it limits blood supply to insufficiently ventilated alveoli).  Further, in chronic inflammatory diseases of the lungs due to cicatricial and sclerotic changes in the lungs (and due to affections  in the lung vessels) blood passage through the lesser circulation becomes even more difficult.  Increased load on the myocardium of  the right ventricle stimulates gradual development of its insufficiency to cause congestion in the greater circulation  (pulmonary heart).

    Depending on the cause and mechanism of developing respiratory insufficiency, three types of disordered  lung ventilation are distinguished: obstructive, restrictive and mixed (combined).

    The obstructive type is characterized by difficult passage of air through the bronchi (because of bronchitis,  bronchospasm,  contraction or  compression  of  the trachea or  large  bronchi, e.g.  by a tumour, etc.). Spirography shows marked decrease in  the MLV and PVC, the VC being decreased insignificantly. Obstruction of the air passage increases the load on the respiratory muscles. The ability of the respiratory apparatus to perform additional functional load decreases (fast inspiration, and especially expiration, and also rapid breathing  become impossible).

   The restrictive type of ventilation disorder occurs in limited ability of the lungs to expand and to collapse, i.e. in pneumosclerosis, hydro- and pneumothorax, massive pleural  adhesions, kyphoscoliosis, ossification of the costal cartilages, limited mobility of the ribs, etc. These conditions are in the first  instance attended by a limited depth of the maximum possible inspiration. In  other words,  the  vital capacity of the lungs decreases  (together with the maximum lung ventilation), but the dynamics of the  respiratory act is not affected: no obstacles to the rate of normal breathing  (and whenever necessary, to significant acceleration of respiration) are imposed.

    The mixed, or combined type includes  the signs of the two previous   disorders, often with prevalence of one of them; this type of disorder occurs in long-standing diseases of the lungs and the heart.

    External respiratory dysfunction occurs also when the anatomical dead  space increases (in the presence of large cavities inside the lung, cavern,  abscesses, and also in multiple large bronchiectases). Similar to this type   the respiratory insufficiency due to circulatory disorders  (e.g. in throm boembolism, etc.) during which part of the lung is excluded from gas exchange,  while its ventilation is to a  certain degree maintained. Finally  respiratory insufficiency  arises during uneven distribution of air in the lungs (distribution disorders), when a part of the lung is not ventilated (in  pneumonia, atelectasis), with preservation  of blood circulation. Part of  venous blood is not oxygenated before it enters pulmonary veins and the  left chambers of the heart. Similar to this type of respiratory insufficiency  (with regard to pathogenesis) is the so-called vascular bypass or shunting  (from right to left),  during which part  of the venous blood from  the  pulmonary artery system enters directly the pulmonary vein (bypassing the  capillaries) to mix with oxygenated arterial blood. Oxygenation of blood in  the lungs is thus upset but hypercapnia may be absent due to compensatory  intensification of ventilation in the intact  parts of the lung. This is partial  respiratory insufficiency (as distinct from  total insufficiency where hypoxaemia and hypercapnia are present).

    Respiratory  insufficiency  is  characterized  by  upset gas  exchange through the alveolar-capillary membrane of the lung. It occurs when this  membrane is thickened to interfere with normal gas  diffusion through it  (the so-called pneumonoses, alveolar-capillary block). It is not  accompanied by hypercapnia  either since the rate of C02 diffusion is 20 times  higher than that of oxygen. This form of respiratory insufficiency is, in thel  first instance, characterized by arterial hypoxaemia  and cyanosis. Lungs  ventilation is intensified.

   Respiratory  insufficiency  associated  with  toxic  inhibition  of the  respiratory centre, anaemia, or oxygen  deficit in the inhaled air, is not connected directly with the pathology of the lungs.

   Acute and  chronic  respiratory insufficiency  are differentiated.  The  former occurs in  attacks of bronchial asthma.

   Three degrees and three  stages of respiratory insufficiency are also distinguished. The degrees of respiratory insufficiency reflect the gravity of the disease at a given moment. The first degree of respiratory insufficiency dyspnoea, in the first  instance) becomes evident only  at moderate or  significant physical load. Dyspnoea develops during light exercise in the second degree of insufficiency; the compensatory mechanisms are involved  when the patient is at rest and functional diagnosis can reveal some deviations  from  the  normal indices. The  third degree  is characterized  by  dyspnoea at rest and cyanosis as a manifestation of arterial hypoxaemia;

 deviations from the normal indices during functional pulmonary tests are

 signficant.

    Stages  of respiratory insufficiency in chronic diseases of the lungs  reflect the changes occurring during the progress of the disease. Stages of  latent pulmonary, pronounced pulmonary, and cardiopulmonary  insuffi ciency are normally differentiated.

 

METHODS OF THE INVESTIGATIONS OF URINARY TRACT PATHOLOGY

URINALYSIS

The study of urine is important for establishing a diagnosis of and config on the course of the pathology. Various pathological processes oclg in the kidneys and the urinary tracts have their effect on the properif urine. Pathological metabolites may be released into the blood in us diseases. Excreted by the kidneys, these metabolites are also found e urine and their determination is therefore important diagnostically.i samples taken after night sleep are usually studied. The analysis is with the study of its phystcal properties:

he normal daily amount of urine (daily diuresis) excreted by an adult s from 1000 to 2000 ml, the ratio of the urine evacuated during the 😮 the nocturnal diuresis being 3:1 or 4:1. The daily amount of urine n 500 ml and over 2000 ml can be considered pathological under cer-conditions.

he colour of normal urine depends on its concentration and varies i straw-yellow to the colour of amber. Concentration of urochromes, ilinoids, uroerythrin and of some other substances accounts for the ur of urine. The most marked changes in the urine colour depend on presence of greenish-brown bilirubin, large quantity of erythrocytes earance of meat wastes), reddish-brown urobilin, and medicines tylsalicylic acid and amidopyrine give pink colour to the urine, lylene blue colours it blue, and rhubard greenish-yellow). Normal urine is clear. Cloudiness may be^due to salts, cell elements, mucus, fats, and bacteria.

The smell of urine is specific and not pungent. When decomposed by bacteria in- or outside the bladder, urine smells of ammonia. In the ‘presence of ketone bodies (in grave forms of diabetes mellitus), urine smells “fruity” (the odour of decomposing apples).

The specific gravity of the urine varies from 1.001 to 1.040. It is measured by an urometer (hydrometer) with the scale reading from 1.000 to 1.050. Determinationsf the specific gravity of the urine is of great clinical importance becauseMt gives information on the concentration of substances dissolved in it (urea, uric acid, salts) and characterizes the con­centrating and diluting capacity of the kidneys. It should be remembered that specific gravity depends not only on the amount of particles dissolved but mainly on their molecular weight. High-molecular substances (e.g. pro­teins) account for increased specific gravity of the urine without influenc­ing substantially the osmotic concentration of the urine. The osmotic con­centration of the urine depends mainly on the presence of electrolytes and urea. Osmotic concentration is expressed in mosm/1. The maximum osmotic concentration of urine in a healthy person is 910 mosm/1 ‘(max­imum sp. gravity, 1.025—1.028). The specific gravity of the urine may ex­ceed 1.030-1.040 in the presence of high quantity of glucose (glucosuria), because the concentration of 10 g/1 increases gravity of the urine by 0.004.

Chemical analysis of urine. Reaction of the urine. The kidneys are im­portant for maintaining acid-base equilibrium in the body. The kidneys are / capable of removing the.ions_af_hyikogen and hydrocarbonate from the – blood and this is a mechanism by whicbupH_Qf blood is maintained cons­tant. The concentration of the hydrogen ions is the true reaction of urine (active acidity or pH of the medium). The sum of dissociated and un-dissociated hydrogen ions is the titration (analytical) acidity. The true reac­tion of urine may vary from pH 4.5 to 8.4. The pH of urine can be deter­mined colorimetrically and electrometrically. Colorimetry includes methods employing litmus paper, bromthymol blue, and other indicators, by which the pH is determined only tentatively. More accurate determina­tion of pH is done by comparing colour intensity of test solutions with standard solutions (the Michaelis method).

Special indicator papers can also be used for sufficiently accurate deter­mination of the pH of urine in the range from 5.0 to 9.0. The mean pH value of the urine in healthy subjects (with normal nutrition) is about 6.0. The value of pH is affected by the use of medicinal preparations (diuretics, corticosteroids). Acidity of urine can increase in diabetes mellitus, renal in­sufficiency, tuberculosis of the kidneys, acidosis, and hypokaliaemic alkalosis. Urine reacts alkaline in vomiting and chronic infections of the urinary tracts due to bacterial-ammoniacal fermentation

Determination of protein in urine. Normal Wine does not practically contain protein. The small quantity of plasma proteins (to 150 mg/day), that is present in the urine, cannot be determined by qualitative tests used in practical medicine. The appearance of protein in the urine in concentra­tions determinable by qualitative methods is called proteinuria. It can be of renal and extrarenal origin. Organic renal proteinuria occurs in kidney af­fections due to increased permeability of glomeruli which is underlain by vascular inflammation (or structural disorganization of the basal mem­brane. Glomerular. permeability is upset by the “molecular sieve” mechanism, i.e. low-molecular proteins are lost in the first instance. This proteinuria is called selective. As the process progresses, high-molecular proteins are also lost (non-selective proteinuria). Selectivity of proteinuria is an important diagnostic and prognostic sign.

Functional renal proteinuria is connected with the permeability of membranes in the renal filter in the presence of strong stimulation, slowing of the blood flow in the glomeruli, etc. Functional proteinurias include emotional, athletic (effort), cold, and orthostatic (a condition characterize ed by the appearance of protein in the urine when the patient is in the erect posture; hence the name). In cases with extrarenal proteinuria, proteins enter the urine from the urinary and sex ducts (admixtures of inflammatory exudate); extrarenal proteinuria does not exceed 1 g/1. Tests intended to (, reveal protein in the urine are based on its thermal or acid coagulation (the urine sample should first be filtered).

Acetic-acid test. The test gives reliable results provided the pH of the medium is 5.6. If the urine contains much phosphates, a few drops of acetic acid, which is usually added in this test, do not decrease the pH qf the medium significantly and the proteins remain dissolved as alkalalbumins. In other cases it is enough to add a few drops of acetic acid to decrease the pH much below 5.6, and the proteins form acid albumins without giving cloudiness. The test should be better carried out with the Bang buffer (56.5 ml glacial acetic acid and 118 g of sodium acetate dissolved in 1 1 of water). To a 5-ml sample of urine added are 1-2 ml of the Bang buffer and the mixture is boiled for 30 s. The solution turns cloudly in the presence of even insignificant amount of protein.

Sulphosalicylic acid test. This is one of the most sensitive and popular tests. To 3-4 ml of filtered urine added are 6-8 drops of a 20 per cent solution of sulphosalicylic acid. Cloudiness develops if the test is positive.

Quantitative determination of albumin. A modified Heller’s test is no\y popular: a white ring appears at the interface between the test liquid con­taining albumin and nitric acid. A thin but distinct ring appears by the end of the third minute to indicate the presence of 0.033 g/1 of albumin in the test urine. Filtered urine is layered on 1-2 ml of a 50 per cent nitric acid and the time is marked. If the white ring forms earlier than in 2 minutes, the urine sample should be diluted with water so that the white ring shov be formed during the course of the second or third minute. The amount albumin contained in the urine is determined by multiplying 0.033 g/1 the dilution degree.

Turbidimetric tests are widely used for determining protein in the urii The sulphosalicylic acid is used for the purpose. Since turbidity is prop< tional to protein concentration in the urine, protein can be determir from the calibration curve after determining extinction (optical density) the solution.

Rapid-diagnosis methods are very popular now. They are used for p phylactic large-scale examination of the population (with special paper dicators). Protein error of some acid-base indicators is used as the work -principle. The paper is impregnated in bromphenol blue and citrate bul solution. As the”paper is wetted, the buffer dissolves to ensure the requi pH of the medium for the indicator reaction. Amino groups of prol react with the indicator at pH 3.0-3.5 to alter its initial yellow coloui greenish-blue. By comparing the new colour with a special scale of st dards, it is possible to assess tentatively protein concentration in the urine.

Protein concentration in urine expressed in grammes per litre does -express the absolute amount of protein lost. It is therefore recommende ( express it in grammes per day. The protein concentration in the urine lected during 24 hours should first be determined, diuresis measured, the amount of protein lost per day finally calculated.

Determining Bence-Jones proteins. Bence-Jones proteins occui myeloma and Waldenstrom’s macroglobulinaemia. These are light polypeptide chains, which pass an intact renal filter because of t relatively small molecular weight, and are determined by thermal precij tion and electrophoreiic study of urine.

Determining glucose in urine. The urine of a healthy person cont very small quantity of glucose (0.03—0.15 g/1) which cannot be detecte common qualitative tests. Glucose in the urine (glycosuria) can be 1 physiological and pathological. In the presence of normal renal fund glycosuria occurs only in increased concentration of sugar in the b (normal sugar content of blood is 4.6-6.6 mmol/1 or 0.8-1.2 g/1), i. the presence of hyperglycaemia. The so-called renal glucose thres (sugar concentration in the blood) does not usually exceed 9.9 mn (1.8 g/1); higher concentration of sugar indicates glycosuria.

Physiological glycosuria can be observed in persons whose diet is ri carbohydrates (alimentary glycosuria), following emotional stress, ant ministration of some medicines (caffeine, corticosteroids). Less frequf renal glycosuria associated with disturbed resorption of glucose ir es: glycosuria develops in the presence of normal amount of sugar in lood. As a primary disease, glycosuria occurs in he form of renal tes. Secondary renal glycosuria occurs in chronic nephritis, nephritic syndrome, and in glycogen-storage disease. Pathological glycosuria occurs frequently in diabetes mellitus, less frequentlyln thyrotoxicosis, in tary insufficiency (Itsenko-Cushing syndrome), and in livjer_cirrhosis. rv order to assess correctly glycosuria (especially in patients with etes mellitus), it is necessary to calculate the daily loss of sugar with e. Most qualitative tests used to detect glucose in urine are based on the cing power of glucose. 4 laities’ test for sugar in the urine is based on the property of glucose to ice copper hydroxide in an alkaline medium to yellow cuprous hydroxor red cuprous oxide. 

Nylander’s test. The reaction is based on reduction of bismuth nitrate ducose to bismuth metal. In the presence of sugar, the colour of solu- / 1 changes from brown to black. The test urine should be free from pro-_; . Extraneous reducing substances (antipyrin, benzoic acid, etc.) giving ilse reaction should be removed by adding 1 ml of 95 per cent alcohol I a small amount of animal carbon to 9 ml of urine. Glucose oxidase (notatin) test. This is a highly specific and very simple^ :yme test. Glucose oxidase (notatin) is /3-d-glucose dehydrogenase. At \{s it stage, the enzyme acts on glucose to liberate hydrogen peroxide.”At : second stage, the presence of hydrogen peroxide is established by a-lox indicator (like in the benzidine test).

The principle of the glucose oxidase test is used in the indicator paper :thod. A paper strip impregnated with glucose oxidase, peroxidase and a nzidine derivative is dipped in urine: if the urine contains glucose the per turns blue in 30-60 seconds.

Quantitative determination of glucose in urine. The amount of glucose mtained in a given sample of urine can be determined by the anglei>f itation of a polarized beam of light: glucose rotates the polarized light to

e right.

Althausen colorimetric method. The method is based on the colour :action occurring during heating a glucose solution with alkali. To 4 ml of rine added is 1 ml of 10 per cent solution and the mixture is boiled for a minute. The solution is allowed 3 stand lor ten minutes and its colour compared with this of colour stan-ards (either visually or photometrically).

Determining ketone (acetone) bodies. The presence of ketone bodies acetone, acetoacetic and (3-oxybutyric acid) in the urine is called .etonuria. Ketonuria is usually observed in severe diabetes mellitus but it ;an also develop due to carbohydrate deficit (in gliiveToxlcosis, longstanding gastroifnlestlfRil disorders, etc.); it may develop postoperatively. Ketone bodies in the urine occur simultaneously and their separate determination is therefore clinically impracticable. The Lange test is most commonly used for the etection of ketone bodies in the urine. The test urine sample is mixed with acetic acid and njtrqgjrusside, and then ammonia is layered: a violet ring is formed at the hn^rem£e~of the liquids if the test ispositive.

Determination of bilirubin. Normal urine is practically free from bilirubin. Increased amounts of bilirubin in the urine at which common qualitative bilirubin tests become positive (bilirubinuria) occur in hepatic and subhepatic jaundice at which the concentration of bound bilirubin (bilirubin glucuronide) in the blood increases. Most qualitative tests for bilirubin are based on its conversion into green biliverdin under the aciion of oxidizers.

Rosin’s test. Lugol (1 per cent iodine solution) is layered upon 4-5 ml of urine: a greenjing appears at the interface between the liquids if the test is positive.

Fouchet’s test. To 10—12 ml of urine added are 5—6 ml of a 15 per cent barium chloride solution; the mixture is stirred and filtered. Barium chloride precipitates bilirubin. The precipitate is separated on a filter and 2-3 drops of Fouchet’s reagent (100 ml of a 25 per cent trichloroacetic acid solution mixed with 10 ml of a 10 per cent ferric chloride solution) are added: green-bluish or light-blue spots appear on the filter if the test is positive. The Fouchet test is more sensitive.

Determining urobilinoids. Urobilinoids are urobilin (urobilinogens, urobilins) and stercobilin (stercobilinogens, stercobilins). Urobilin and stercobilin bodies are not deterrrrfned separately. Excretion of large Ly amounts of urobilinoids in the urine i called urobilinuria which occurs in diseases of the liver (hepatitis, cirrhosis), haemolytic anaemia, and in in­testinal diseases (ententes, etc.).

Neubauer’s test. The test is based on the reaction between urobilin bodies and the Ehrlich reagent (2 g of p-dimethylaminobenzaldehyde + + 100 ml of a 20 per cent hydrochloric asid solution). To a few millilitres of urine (freshly taken and cooled to roonji temperature) added are a few drops of the Ehrlich reagent: colouration of the liquid during the first 30 seconds indicates increased content of urobilin bodies (positive test), while development of colour at later period indicates either their absence or the presence of their normal quantity.

Florence‘ test. Urobilinoids are extracted from the urine acidified with sulphuric acid by ether (8-10 ml of urine and 3 ml of ether). The ether ex­tract is then layered ypon 2-3 ml of concentrated hydrochloric acid. The advantage of this test is that it is also positive in the presence of normal quantity of urobilinoids and can therefore be used to establish their com­plete absence.

Bogomolov’s test. To 10 ml of urine added are 2-3 ml of a saturated copper sulphate solution. Next, a few drops of\hydrochloric acid are added to clarify the solution. The mixture is allowed to stand for 5 minutes, 2—3 ml of chloroform are added, and the mixture is shaken: chloroform turns pink in the presence of urobilin bodies.

Quantitative determination of urobilinoids is based on their colour reaction (pink) with p-dimethylaminobenzaldehyde or with hydrochloric acid.

Rapid diagnosis (by[ indicator paper) of ketonuria, bilirubinuria, urobilinuria is based on trie employment of the same chemical reactions with subsequent colorimetry.

Microscopy of urine sediment. A urine specimen is stirred thoroughly and its 10 ml are transferred into a centrifugal test tube. After centrifug-ing, the supernatant is decanted while the precipitate transferred onto an object glass for microscopy,) The precipitate is first examined at small and then at large magnification to study the formed elements, cylinders, and salts.

 

Urine sediments and color of urine: 1 – relan bleeding (1 – erythrocites, 2 – leykocites), 2 variant (1 – epithelium of vagina, 2 –  leykocites), 3 – spermatorrhoea, 4 – urine sediments in kidney tumor1 – tumor cells, 2 – epithelial cells), 5 – urine sediments in honorrhoea (honococci inside of leykocites), 6 – urine sediments in echinococcosis.

7- normal color of urine,  8- urine in diabetes incipidus (light-yellow),  9 – brown transparent in heart failure, 10 – cloudy urine like meat wastes,  11- dark-brown urine in jaundice, 12 – uraturia (yellow sediment), 13 – dark urine in liver melanoma, 14 – cloudy urine with white sediment in phosphaturia.

 

Erythrocytes (red blood cells) can be altered and unaltered. Unaltered erythrocytes contain haemoglobin and appear as greenish-yellow discs. Altered erythrocytes are free from haemoglobin and are colourless one- or two-contour rings (Plate 21). These erythrocytes occur in the urine of low specific gravity; erythrocytes shrink in the urine of specific gravity. The urine of a healthy person can have single erythrocytes.

Erythrocytes may be liberated either from the kidneys or from the) urinary  tract. The presence of erythrocytes in the urine is called – haematuria. Haematuria that can only be established by microscopy is called microhaematuria, while haematuria revealed by macroscopy is called macrohaematuria. It is important practically to decide whether haematuria is of glomerular or nonglomerular origin. In the latter case blood is liberated into the urine from the urinary tract due to the presence of stones in the pelves, urinary bladder or ureters, and because of tuberculosis or malignant  newgrowths of the urinary bladder. In the presence of glomerular haematuria, the urine usually contains much protein. Proteinoerythrocytic dissociation (i.e. haematuria with insignificant proteinuria) usually suggests haematuria associated with pathology of the urinary tract. An intermittent character of haematuria (with strongly vary intensity) is another evidence of non-glomerular haematuria.

Three-glass test  is used for differential diagnosis of haematuria. The patient urinates into three vessels. If the blood originates in the urinary tract (urethra), the highest amount of blood is present in the first portion of the urine; if bleeding occurs in the urinary bladder, haematuria is t highest in the last portion. If the source of haemorrhage is located in otl parts of the urinary system, all three portions of the urine contain eq quantity of erythrocytes.

Leucocytes are found in the urine as small granular rounded cells. T swell in the urine of low specific gravity. Leucocytes in the urine of healthy person are usually neutrophils and their amount is insignifican 1-2 in the microscope’s vision field). Increased quantity of  leucocytf the urine (leucocyturia) indicates inflammation in the kidneys or urinary tract (urethritis, prostatitis, cystitis, pyelonephritis). Thompson’s test used for differential diagnosis of leucocyturia. The firts portion of an I morning urine specimen is collected in the first glass, the main bulk o „urine in the second glass, and only the residue in the third glass. If pring quantity of leucocytes is found in the first portion, it indicate presence of urethritis and prostatitis. If the main quantity of leukocyte found in the third portion, this suggests the disease of the urinary bladder Uniform distribution of leucocytes in all portions of the urine may be at affection of the kidneys. Cell structures are quickly destroyed in all urine; it is therefore difficult to judge about the degree of leucocytes. Eosinophils are sometimes found in the urine; they differ from leucocytes by ample uniform refracting granularity. The present eosinophils suggests an allergic character of the disease.

       In the absence of active inflamn process, the quantity of leucocytes in the urine may remaiormal method of supravital staining is widely used now. It was proposed ir     by Sternheimer and Malbin. Depending on their morphological prop leucocytes are coloured either red or pale-blue by a specia (water-alcohol mixture of 3 parts of Gentian violet and 97 pa safranine). Leucocytes that are coloured blue in the urine of low s) gravity are greater in size and contain vacuolized cytoplasm with gr that are set in Brownian movement. They are found in patient pyelonephritis. Leucocyte cells (Sternheimer-Malbin cells) can be to the urine of patients with iso- or hyposthenuria with any location source of inflammation in the urinary tract. These cells are more offered “active leucocytes”. They are determined by adding distilled with urine precipitate to create low osmotic pressure.

Increased number of “active leukocytes” suggest activation of infections  in the urinary tract or exacerbation of pyelonephritis.

Microscopy can reveal cells of squamous, transitional, and epithelium. Squamous epithelium cells are round polygonal; they are large, colourless, and contain a small nucleui he urine from the external genitalia and the urethra; their diagnostic tance is low. Cells of transitional epithelium line the mucosa of the y tract; their configuration is quite varied; they are smaller than ious epithelium cells; the nucleus is rounded. The presence-of large it of transitional epithelium in the urine indicates inflammatory pro-1 the pelves or the bladder. Cells of renal (cuboidal) epithelium of :s are rounded or polyhedral; they are small (slightly larger than cytes) and have a large, eccentrically located nucleus; their granularity rse. They are often found in hyaline cylinders. The presence of renal Hum in the urine is a specific sign of acute and chronic affections of kidneys, and also of fever, toxicosis, and infectious diseases. tests are proteinous or cell formations of tubular origin; they have Irical configurtion and variable size. Hyaline casts are pro-is formations of indistinct contour with smooth and slightly granulare; they are found in acute and chronic nephritis, nephrotic syndrome, and also in physiological transient albuminuria. Hyaline casts can find in the urine of practically healthy people when the pH of the urine is test sharply along with increasing specific gravity of the urine, which characteristic of dehydration. It is believed that hyaline casts are formed of protein secreted in the tubules; but there are no reliable data that 1 confirm this conjecture. Granular casts have distinct contours; they it of dense granular mass formed by degraded cells of renal Ilium. Their presence indicates dystrophic processes in the tubules. Feasts have distinct contours and a homogeneous yellow structure, presence is characteristic of chronic diseases of the kidneys. The can also contain epithelial, erythrocytary, haemoglobin and cyte casts, and cylindrical formations of amorphous salts, which are ostically unimportant.

Von-organized sediment” of the urine consists of salts that precipitate stals and amorphous substances. Their character depends on the color composition of the urine, its pH, and other properties. Acid urine is uric acid (yellow rhomboid-type crystals), urates (yellowish-i amorphous salt), oxalic lime, or oxalates (colourless octahedral ils that may also occur in alkaline urine). Alkaline urine ins ammonium urate, calcium carbonate, triple phosphates, amor-phosphates, and neutral calcium phosphate (Plate 26). The sediment gnostically insignificant but pathological urine can contain crystals, thyrosine, and leucine. The presence of thyrosine and leucine is usually characteristic of subacute dystrophy of the liver and of poisoning. The presence of lipoids in the urine is characteristic necrotic syndrome. In a polarizing microscope, lipoids give a dilation and appear as lustrous crosses.

 

Changes of urine sediments iorm and in some types of pathology: 1 – cellular elements (1  group  – cells of plain epitheliumfrom the lower parts of urinary ducts), 2 – cells with tails, polygonic cells of renal epithelium

2 – casts in urine sediments (1- hyaline casts with sediments of salts, leukocites erythrocites, 2-  granular cast,  3- hyaline cast with sediments of salts and detritis),  3– cast in uric sediment ( 1-granular cast, 2- blood cast, 3- wax cast, 4- epithelial cast), 4 – crystl sediments in urine: 1 –amphoric urates, 2- crystals of uric acids,  5– crystals of phyphates, 6– cristalic sediment in urine ( 1- leucin, 2- thyrosin, 3- cholesterol), 7– urine sediments in jaundice ( 1- crystals of bilirubin, 2- castsimpregnated with bile pigments, 3- renal epithelial cells),  8–  crystals of sulfa drugs in urine ( 1- streprocid, 2 – sulfosalasilum, 3- sulfothiasolum), 9– urine sediment in jaundice ( 1- cholesterol crystals, 2- casts with fat sediments).

 

Addis-Kakovsky test. The test is used for quantitative determination of the formed elements in the urinary sediment. Urine collected during ten hours is stirred thoroughly, its amount is measured and a 12-minute aliqudt (l/50th of the full volume) is placed in a graduated centrifugal test tube. ( After centrifuging for 5 minutes at 2000 rpm the supernatant is removed by a pipette, while the remaining 0.5 ml sediment is stirred and transferred into a cell for counting blood formed elements. Leucocytes, erythrocytes, and casts are counted separately. The quantity of cells counted in one microlitre is multiplied by 60 000 to find the quantity of the formed cells of the urine excreted during the day. The normal counts are 1 000 000 for erythrocytes, 2 000 000 for leucocytes, and 20 000 for casts.

Nechiporenko’s method is now widely used to count erythrocytes and leucocytes in 1 ml of urine. The main advantage of this method is that an average sample of urine is taken for analysis and the presence of pus from the sex organs is thus excluded. A disadvantage of the method is that it does not account for diuresis. The normal counts are 1000 erythrocytes, 4000 leucocytes, and 220 hyaline casts.

Bacterioscopic and bacteriological study of urine. Urine cultures are used to establish the infectious nature of a disease of the urinary system. Sterile glassware should be used for the purpose. Whenever necessary, the urine is studied bacterioscopically for the presence of tuberculosis mycobacteria. A smear is prepared frown the urinary sediment with Ziehl-, Nielsen staining. The urine is studied bacteriologically to determine qualitative and quantitative composition of its microbial flora. In the presence of bacteriuria, it is very important to determine its degree and microorganism sensitivity to various antibiotics.

FUNCTIONAL TESTS FOR KIDNEYS

Assessing the renal function by specific gravity and amount of the urine excreted. In conditions of water deficit, a normal person excretes a small amount of the urine with high specific gravity; and vice versa: if excess liquid is taken, the amount of the urine excreted increases while its specific gravity_s decreases. The kidneys thus maintain equilibrium in the bodily fluids, i.e. they maintain constancy of osmotic concentration and volumes of the fluids. If the body is dehydrated, osmotic concentration of ex­tracellular fluid increases and the amount of released antidiuretic hormone (ADH) increases to increase tubular resorption of water. If the amount of taken liquid increases, osmotic concentration of extracellular fluid decreases; this decreases secretion of ADH and water resorption to increase diuresis. In pathology, the kidneys are incapable of ensuring the required osmotic gradient in the medulla and the concentrating power of the kidneys is thus upset. The impaired power of the kidneys to resorb the osmoticafly active substances without water disturbs their diluting capacity.

Zimnitsky’s test. The main advantage of this method is that the renal function is tested without interfering with the normal life of the patient. The patient collects^his urine at 3-hour intervals (8 portions during 24 hours). The volume^of each portion and specific gravity of the urine are determined. The volumes of daily and night urine are compared and a con­ clusion is derived concerning daily and nocturnal diuresis. Fluctuations in specific gravity of the urine during the course of the day and its maximum value are thus determined. Normally the daily diuresis exceeds the nocturnal one; volumes of urine portions can vary from 50 to 250 ml, and their specific gravity from 1.005 to 1.028. Nocturnal diuresis (nycturia) prevails in renal insufficiency to indicate longer work of the kidneys because of their impaired functional capacity. If renal insufficiency is pronounced, decreased specific gravity becomes permanent (hyposthenuria). Combina-tion of polyuria with low specific gravity of the urine and nycturia is a specific sign of renal dysfunction.

Dilution test. The patient is given to drink 1-1.5 1 of water or thin tea within 30-45 minutes and then the urine is collected at.3 glass intervals during 4 hours. The portions are measured and their specific gravity determined. A normal individual would eliminate about 75 per cent of the taken liquid during four hours, while the specific gravity of the urine decreases to 1.003-1.001. The firit portions will be larger and their specific gravity lower. A more accurate method includes also calculations where the amount of liquid taken is referred to the body weight: 22 ml of liquid is given per kg body weight.

If the excretory function of the kidneys is decreased, the amount of urine excreted during 4 hours is markedly less than that of liquid taken; the / specific gravity in all portions is about the same, but not below 1.006-1.007. If the renal function is upset significantly, the specific gravity of the urine in all portions is 1.009-1.011, which corresponds to the specific gravity of the primary urine. The dilution test is contraindicated in oedema and hypertension.

Urine concentration test. The patient receives no fluids for 36 hours (nor food containing much liquid). Urine is collected at 3-hour intervals during 24 hours (8 specimens). The volume and specific gravity of each specimen is determined. The specific gravity of the urine of a healthy in­dividual will in these conditions be not lower than 1.028. If the specific gravity of thus obtained urine does not rise over 1.022, this indicates im­paired renal function.

The urine concentration test is valid when applied to cases where the daily diuresis does not exceed 400 ml. The test is contraindicated in acute inflammatory processes in the kidneys, in cardiovascular and renal ciency, and in essential hypertension.

The renal function can be assessed by studying glomerular fill renal plasma flow, tubular transport of certain substances (e.g. reabsorption), secretion of extraneous substances, urea and electro cretion in the urine. It is possible to reveal and assess the degree of r sufficiency by studying concentration of urea, indican, residual ni creatinine, potassium, sodium, calcium, magnesium and phosphate blood (see Tables 7 and 8 of the “Appendix”).

Renal insufficiency arises in cases where the mass of the active chyma is 20 per cent (and lower) of the normal weight. The detenr of the mass of the active nephrons is thus important to assess tl function. The measure of active nephrons is the maximum reabsor) glucose (normal 300-500 mg/min) and the glomerular filtration ra mal, 65-120ml/min).

Clearance tests are now widely used to study the renal function ing to Van Slyke. Glomerular filtration and tubular reabsorption c can be measured by clearance tests with substances that are not resc liberated in the tubules. This means that these substances enter uri by glomerular filtration. Once we assume that a given substance co in a minute volume of plasma passes entirely into a minute vol urine, i.e. the plasma is completely cleared of this substance, the amount is then equal to the amount passed with urine. The filtered ty of substance is equal to the product of glomerular filtration (F] concentration in plasma (P). The quantity excreted with urine is ( the product of the urine minute volume (V) and the concentratior substance in the urine ((/), i.e, FP – UV. Hence

The U, V, and P values can be found clinically and used for th mination of F that characterizes the volume of plasma which is cor cleared of the given substance during one minute. This volume i clearance.

If a substance that is filtered in the glomeruli but is not rcabsc liberated in the tubules is used for the assessment of renal functi clearance of this substance is actually equal to glomerular filtratior this phenomenon, Rehberg proposed a test for studying the am filtration by endogenic or exogenic creatinine.

If one assumes that creatinine content of plasma and glomerulai is the same, it is possible to determine the degree of concentratioi glomerular filtrate as it passes the tubules. In other words, not of filtration but also of reabsorption can thus be determined age of reabsorbed water):

(F/r-, V) X   100

F ( liealthy   individuals   the   amount   of  glomerular   filtration   is

ml. The percentage of reabsorbed water is 98.5-99.

Renberg test can be carried out with additional administration of xe and liquid, or without it. The second version is used more fre Blood is taken from the vein of the patient on a fasting stomach itinine concentration is determined.

 Diuresis is measured thoroughly and creatinine content determine , using the formula given above, the amount of glomerular filtra-i reabsorption percentage are calculated. Renal failure develops, glomerular filtration decreases gradually to  low values as 5-2-1 ml/min. Tubular reabsorption changes less y to decrease in cases of pronounced insufficiency to 80-60 per itances that are not only filtered in the glomeruli but also secreted tubules give a mixed clearance, e.g. filtration-reabsorption or n-secretion clearance. This clearance is used to assess the renal / i in general (rather than its separate function). Clearance of some — ;es (diodrast, phenol red, para-aminohippuric acid, etc.) is so high    _v ctically approaches the renal blood flow, i.e. the amount of blood sess the kidneys during one minute. The renal blood flow can thus mined by the clearance of these substances, determination   of  glomerular   filtration   is   of  great   clinical mce and is one of the most popular methods for quantitative study jnal function. The prognostic value of the method increases if it is Follow-up studies. Thus, persistent decrease in glomerular filtration — 50 mg/min during 18-24 months following acute ilonephritis suggests the conversion of the acute process into the disease.

X-RAY EXAMINATION

kidneys are normally not seen on X-ray pictures, except in thin in-s (oval silhouettes can frequently be seen by sides of the spinal col-:tween the 11th thoracic and 3rd lumbar vertebrae). Stones in the and the ureters are visualized by X-rays. Best seen are stones con-calcium salts (oxalates and phosphates); stones containing urates illy not seen. In suspected tumour, X-raying is done after placing

 

 

Emphysematous phyelonephritis (gas cysts of the right kidney)

 

 

Kidney stone on plain X-ray

 

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чо

від

 

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міхур

 

 

  Normal excretory urogram (kidneys are located in typical place, calices are well filled with contrast, ureters are visible) (1- renal calyx,  2 – contours of a kidney, 3- renal calices, 4 –ureter, 5 – bladder)

 

Dystopia of the right kidney (excretory urogram)

 

 

Excretory urography is carried out in hospitals: the patient is given in­travenously a jcooirast substance that is readily excreted by the kidneys (25-40 ml of a 30-50 per cent solution of iodjn^grerjaration verographin, urotrast, or the like) and then a series of pictures are taken by which deter­mined are the size, position and functional capacity of the kidneys (by the readiness with which they excrete the contrast substance), the’size and con-figuration of the_pgjves, position of the ureters, and the presence of con-crements (Fig. 104a and b). If the renal function is strongly upset, the con­trast substance is poorly excreted, and the procedure fails to give the wanted results. Drop-infusion urography is used for diagnosis of com­plicated cases. The patient is given 200-250 ml of a 25 per cent solution of a contrast substance by drop infusion during 10-15 minutes. The dose of the infused preparation may be increased with this method while the safety of the procedure is higher since the infusion can immediately, be discon­tinued if first signs of allergic response to the contrast substa’nce appear. The pictures of the kidneys and the ureters obtained by this technique are much better even in decreased renal function. The silhouettes of the kidneys are especially well seen on pictures taken immediately after ad­ministering the contrast substance. Retrograde pyelography is made for special indications. Liquid contrast substance (urotrast) or gaseous substance (oxygen, air) is administered into the renal pelvis through special ureteral catheter using a cystoscope. Retrograde pyelography is carried out in cases when findings of the excretory pyelography are not reliable or not sufficiently informative to establish correct diagnosis of pelvic affection. Renal angiography (nephroangiography) is used to diagnose disordered blood supply to the kidneys due to upset circulation in the renal artery (stenosis, atherosclerotic plaque, etc.). A special contrast substance (car-diotrast, and the like) is injected into the aorta (through the femoral artery using a special tube) at the level of branching of the renal arteries.

 

Stone of the right kidney (on the left side – plain X-ray picture, on the right one – excretory urogram (stone in renal calix).

Pyeloectasia of the lest kidney (excretory urogram)

 

 

 

Retrograde pyelography in urolithiasis (plain X–ray on the left side – stones are absent, left-side retrograde pyelography on the right side – multiple stones in renal calyx).

 

 

 

 

Computer tomography (normal kidneys)

Computer tomography: tumor of the right kidney

Computer tomography: stone of the right kidney

 

Normal transfemoral angiogram

Normal selective left-sided renal angiogram

Selective left-sided renal angiogram (kidney polycystosis)

 

 

 

Venocavography (on the left side – norm, on the right one there is defect of filling due to tumor of the right kidney

 

CATHETERIZATION OF THE URINARY BLADDER

The urinary bladder is catheterized for both diagnostic and therapeutic purposes (taking urine specimens for studies, evacuation of the accumulated urirfe from the bladder, in disordered urination, lavage of the bladder with disinfectant solutions, etc.). The urinary bladder is usually catheterized by a soft elastic tube which is sterilized and coated with vaseline oil before use.

CYSTOSCOPY

Cystoscopy Js the inspection of the urinary bladder by a cystoscope. The procedure is used to inspect the bladder mucosa, to reveal the presence of ulcers, papilloma, tumours, stones, and also to carry out some therapeutic manipulations. Using a special thin catheter, it is possible to take urine specimens from each kidney and to study the renal function (chromocystoscopy). In chromocystoscopy, the patient is given in­travenously 5 ml of a 0.4 per cent indigo carmine solution, and then the time of the appearance of coloured urine from the orifice of the ureter is noted by observation through a cystoscope. In a healthy individual, the urine coloured by indigo carmine begins passing from the ureters in 3-5 minutes following the stain administration. The appearance of the col­oured urine from the affected kidney will be delayed, or the urine will not be discharged at all.

KIDNEY BIOPSY

Transcutaneous biopsy of the kidneys is now practised at nephrological departments. A piece of the kidney tissue is taken for histological, histochemical or other examinations by a long needle provided with a syringe (for aspiration). The puncture is made on the side of the loin, ovei kidney. In order to reveal the causative agent of pyelonephritis, the obt ed sample is cultivated on a nutrient media and the microbial sensitivit antibiotics is determined. Transcutaneous nephrobiopsy is used to estat the character of the tumour, to diagnose chronic glomerulonephr amyloidosis, and in some other cases, but always only for special stric dications, because of the great danger of this procedure.

 

 

а

 The place of puncture biopsy of a kidney: а – the diatance from the lower pole of kidney to the span of the column; б – the distance from the lower pole of the kidney to the spina iliaca; в – lower edge of costal arch.

Kidney biopsy

RADIOGRAPHIC STUDIES

Radioisotope nephrography is used to study the kidney function, patient is given intravenously diodrast or hippuran labelled with ¹³¹I. Tl a multichannel unit is used to determine the rate of blood clearance fi the labelled preparation (to show the general secretory function of kidneys) and accumulation of the preparation in the urinary bladder show the general urodynamics in the upper urinary tract).

Nephrography is .used to study the renal function in chn glomerulonephritis, tuberculous affection of the kidneys, pyelonephr amyloidosis, to diagnose disordered urine outflow from one kidney, an facilitate differential diagnosis of hypertension (Fig. 105). — Scanning of the kidneys is sometimes used. In this case accumulatioi /the labelled radioactive preparation (e.g. ²⁰³Hg labelled neohydrin) in kidneys is determined by a special apparatus, gamma-topograph or a sc ner. Kidney silhouette is recorded on a paper. The renal function is assessed by the intensity of accumulation of the preparation (intensity of the silhouette). The presence of focal ac­cumulation defects indicates tumours, cysts, tuberculous affections of the kidneys, and other destructive processes. The shape and size of the kidneys can be determined from a scanogram.

 

 

Іsotope renogram of parenchimatous type  (decreased height of the curve, prolongation of time Тmax and Т_1/2 max).

 

 

Іsotope renogram of isosthenuric type  (the height of the curve is small, prolongation of time Тmax and Т_1/2 max).

 

Іsotope renogram of the left kidney (downward) of afuctional type  (absorption of isotope is absent). Isotope renogram iorm – upward.

 

 

Іsotope renogram of the right kidney (upward) of obturation type  (isotope is accumulated in kidney but nor excreted). Isotope renogram iorm – downward.

.

 

 Scintigram of kidneys (upward are normal kidnets, downward – sclerosed left kidney)

 

 

 

Echography. Echography (ultrasonography) is widely used iephrology to determine the size and position of the kidneys, the condition of the renal tissue, to reveal cysts, tumours of the parenchyma, stories in the pelves, etc.

Transverse and longitudinal scanograms on the right kidne iorm.

1

 Hydronephrosis of a kidney (ultrasound examination: calicies are deformed).

Stone of the left kidney

Acute left-sided pyelonephritis

 

Chronic pyelonephritis(blood flow velocity is decreased on Doppler-ultrasound).

 

Normal renal dopplerogram (on the right) and in chronic pyelonephritis (on the left side).