Parametric - inflammatory process in perinephral tissue. Parametric can be primary or occur after injury lumbar region and secondary when the infection gets into okolopochechnuyu fibre hematogenous or lymphogenous by means of any nidus of infection in the body. The causative agent is often aureus.
The inflammatory process starts in the lymph nodes, which are located on the rear and front surface of the kidney. On this basis, there are front, rear, top and bottom parametric. Purulent parametric can cause cellulitis perinephral fiber, spreading down the iliopsoas muscle. Pus when paranemia thick, greenish, without smell. There are two forms of chronic paranemia - fibrous sclerosis and fibro-lipomatous that occur most often when tuberculosis and calculous janefrose (see).
Over and symptoms. The disease begins gradually or suddenly appear chills, fever, pain in the lower back. As a result of inflammation on the iliopsoas muscle occurs psoas-symptom - patients tighten the thigh to the stomach. In advanced cases in the lumbar region swelling occurs; the skin of the lower back is getting tense, hyperemic. When palpation of the lumbar region determine the pain in costovertebral corner, muscle tension, positive symptom of Pasternatskogo. Urine is usually unchanged.
The number of leukocytes in the blood increased to 15 000-25 000. Especially indicative of the so-called local leukocytosis - increase in the number of cells on the side of defeat: to compare the blood taken from the finger and the lumbar region on both sides. With the rapid development of the disease have symptoms of intoxication: prostration, yellowness of the skin, nausea, dryness of the language.
The diagnosis. Sometimes the disease is mistaken for flu, pneumonia, typhus. If there is swelling or pain in the lumbar region diagnosis is not difficult. Review on an x-ray when paranemia you can determine the curvature of the spine with a bulge in the healthy side, smoothness outlines the iliopsoas muscle, changing the position and sharp restriction of mobility of kidney at the time of inhalation and exhalation. A lumbar puncture may aid in the diagnosis. If timely treatment the prognosis is favorable.
Treatment of paranemia. Antibacterial therapy. When formed the abscess shown operation (lumbotomy) with the drainage of purulent cavities. When Pioneros and paranemia - nephrostomy (see), and after acute nephritis phenomena - nephrectomy (see).
Prevention: rehabilitation of all foci of inflammation.

Parametric (paranephritis; from the Greek. para - and about nephros - kidney - inflammatory process in perinephral the tissue, in the second fat layer retroperitoneal space (paranephron), located between the front and rear fascias buds (Fig.). The inflammatory process in the first fat layer retroperitoneal space (textus cellulosus retroperito-nealis), adjacent to the muscles of the back wall of the abdomen, called a retroperitoneal abscess, or retroperitoneum. Inflammation positionschocolate fatty tissue third of the fat layer retroperitoneal space (paracolon) called parabolica.
The etiology and pathogenesis. Parametric can be primary arising after injuries to the lumbar region, and secondary, when the infection gets into okolopochechnuyu fibre hematogenous or lymphogenous way. More common secondary P. Often, the disease occurs in the soil of pyelonephritis. In this case the infection of the kidney penetrates into parametri the specified path or damage, or pelvis and fibrous capsules kidneys (epistemology jade, carbuncle kidneys, Pioneros). Source of paranemia can be retroperitoneal, parasitic, parametritis, parabolic, abstemiously inferior pneumonia, pleurisy, etc. more Often P. occurs hematogenous of such purulent foci, as a boil, felon, osteomyelitis, and in a generalized infection, flu, sore throat, fever and other Pathogen P. often is aureus.
Pathological anatomy. The inflammatory process begins
in the lymph nodes, which in Parametrii three: two on the back and one on the front surface of the kidney. According distinguish between front, rear, top and bottom P. Front is rare due to the weak development ahead kidney fat (sometimes mixed with parabolica). Purulent parametric can cause cellulitis perinephral tissue or in the form of limited hearth with a tendency to necrosis of the tissue, which can be leakages outside of paranemia distributed via m. iliopsoas under pobertova ligament and to the pelvis. Top P. may be complicated subphrenic abscess (see). Pus when paranemia often thick, greenish-yellow, odourless. When the pus has the smell of urine or feces, this indicates a message ulcer with kidney or intestines. Acute parametric can take a chronic or disease from the very beginning, is chronically. There are two forms of chronic P.: fibrous sclerosis and fibro-lipomatous, which are observed frequently in chronic inflammatory processes in the kidney tuberculosis or calculous janefrose (see). In case of sclerotic paranemia adhesions formed from the surrounding tissues and organs (the peritoneum, the inferior Vena cava, the intestines, the diaphragm), which creates great difficulties for the operation, in particular by nephrectomy.

Retroperitoneal fiber, the area of the left kidney (front-cut, Stromberg): 1 - pancreas; 2 - flexura coli sin.; 3 - paranephron (capsula adiposa renis); 4 - paracolon; 5 - textus cellulosus retroperitonealis; 6 - colon descendens; 7 - ureter et paraureterium; 8 - colon sigmoideum; 9 - mesosigmoideum.

Over and symptoms. The disease can begin either gradually or abruptly: there chills, fever, pain in the lower back. Pain radiating to the front and down in iliac region, thigh, bladder or perineum. Often patients tighten the thigh to the stomach (psoas-symptom) and I can not lie on the sick side. In the lumbar region often there is more or less severe swelling. Leather waist at the beginning of the disease is not changed, but subsequently becomes swollen, hard, waist smoother. Palpation of the lower back pain is defined in costovertebral corner, muscles tense and painful, a symptom of Pasternatskogo positive. Analysis of urine when paranemia often normal; sometimes it is possible to detect microorganisms. The common symptoms frequently happens increase of temperature up to 40 degrees in 2-3 days, then the fever takes remitting, intermittently or hectic nature. The patient is dry, coated tongue, appear thirst, nausea, bloating and bowel paresis. The blood - leukocytosis with neutrophilic shift to the left, acceleration ROHE. If timely treatment of acute P. may be a reverse development of the inflammatory process; if belated treatment of Parametrii occurs ulcer. In chronic P. above the symptoms are mild, and some of them are missing.
Diagnosis of paranemia is sometimes very difficult. The disease is mistaken for typhoid, pneumonia, malaria, influenza, etc. To diagnostic errors can lead the transition process of paranemia to adjacent organs. Hasty inappropriate prescription of antibiotics is also difficult diagnosis. The differential diagnosis FWD P. from parabolica should be taken into account indications bowel disease in history. Pus when Paraclete has fecal odor. Back P. characterized by swelling of the skin, swelling at the lumbar region, psoas-symptom. At the top paranemia reported symptoms of jet pleurisy, limited mobility of the dome of the diaphragm, shoulder pain from the defeat, offset kidney down, making it available to palpation. At the bottom P. determined located low infiltration. Great value for the diagnosis of the disease is an x-ray examination. On the overview picture of the urinary tract in a patient P. defined: the curvature of the lumbar spine with a bulge in the healthy side, smoothness contours m. iliopsoas, the changed position of the kidneys, the outlines of which can be reinforced or deformed surrounding infiltrate. For the same reason, on the excretory programme and the retrograde pyelogram may be a deformation of the pelvis and cups. The upper section of the ureter shifted laterally. The mobility of kidney at the time of inhalation and exhalation are severely limited. When determining comparative leukocytosis (in the blood taken from skin lumbar regions and fingers) - increase in the number of cells on the affected side. A lumbar puncture may be helpful in the diagnosis, but the application of this manipulation should be limited because of the potential distribution of pus in other departments of the retroperitoneal space or kidney.
Treatment of paranemia improved significantly with the advent of antibiotics, especially when used in the early stage of the disease. In combination with antibiotics prescribed sulfanilamida, nitrofurans, urotropine, and so on, restorative, and physical therapy. When formed the abscess shown operation - lumbotomy with drainage of the oral ulcer. A. I. Pytel and I. P. Pogorelko believe that this is enough to push the muscles in the lumbar region of the diamond, allowing to drain an abscess in any of its location, and, if necessary, to make decapsulation kidney or nephrostomy. Such access also provides the least amount of postoperative hernias. In cases of paranemia arise out of Pioneros shown removal of the kidney (if it allows the patient) with split on two points: 1) nephrostomy and drainage retroperitoneal space and 2) nephrectomy after acute nephritis phenomena (see Kidneys, surgery).

Inflammation perinephral fiber (parametric)

The causative agent of paranemia in most cases is Staphylococcus, rarely Diplo - or Streptococcus. The infection is logged in parametri hematogenous route from primary purulent (a boil, felon, osteomyelitis) or lymphogenous way from the source of sepsis in the adjacent organs (appendiceal infiltrate, parametritis). The emergence of paranemia may be due to General infection (fever, sore throat, pneumonia) or by bleeding in okolopochechnuyu fibre with fractures of the lumbar. In these cases, parametric has vnepochechny origin.
Renal parametric occurs due to the spread purulent-inflammatory focus from primarily diseased kidneys in parametri, for example when calculous and tuberculosis Pioneros, carbuncle kidney or aposematism nephritis. Often parametric, clinically flowing as vnepochechny, is the result of a breakthrough in okolopochechnuyu fibre asymptomatic abscess in the cortical layer of the kidney.
Local changes when paranemia expressed in hyperemia, edema, and round-cell infiltration perinephral fiber. Infiltration may be reverse or purulent melt with the formation of one or more of abscesses in fat capsule kidneys, often behind or at the lower pole of her, rarely in front of or near the upper pole of the kidney, therefore, distinguish back, front, bottom and top paranefrit. Ulcers or encapsulated, being surrounded by extremely dense infiltrate or destroy fascial jumper penetrating okolopochechnuyu fibre, and distributed under the retroperitoneal fat type phlegmon.
In the form of chronic inflammatory process proceeds by type sclerosing (brigandine) or fiber-lipomassage of paranemia. Kidney immured in the infiltration woody density thickness up to 3-4 cm, it is extremely difficult to access during the operation.
Parametric develops sharply or gradually. In the first case, sudden fever, accompanied by spectacular chills, in the second, the temperature rises gradually.
Pain in the back side of the disease may long be absent or occur immediately. Movement, voltage abdominals intensify pain. The hip on the patient side shows medially and anteriorly, straightening it causes a sharp pain in Ilium (spastic reduction m. psoatis).
When viewed often found smoothness or bulging of the contours of the lower back side of the disease (with the rear paranemia) and the curvature of the lumbar and nizhnegnutov spine, facing bulge in the healthy side. In some cases, there is an edema and hyperemia skin.
Palpation kidney painful. Symptom of Pasternatskogo strongly positive, there is a high leukocytosis blood, accelerated ROHE. When paranemia renal origin urine contains pus and bacteria. When vnepochechny paranemia urine free of pus, and the results of functional kidney samples normal.
Pain and infiltration in the back, forced bringing of the thighs help to make a correct diagnosis. When vnepochechny paranemia in history often an indication transferred purulent infection (sore throat, felon, boils, and so on). When parametrico renal origin in history marked a long-term or recurrent urinary tract infection. The absence on the overview image contours kidneys, contours m. psoatis, curvature of the spine, high standing and immobility of the diaphragm under fluoroscopy, pleural effusion sinus indicate parametric.
Bilateral retrograde pyelography made without delay of breath, finds a clear outline of the pelvis and cups on the side of the disease (fixed, motionless kidney, Fig. 74) and blurry contours pelvis on the healthy side.

bilateral pyelogram in right bottom paranemia
Fig. 74. Bilateral pyelogram without delay of breath) at the lower right-hand paranemia.

Treatment. In the early stages (stage infiltration) parametric treated with antibiotics. Thus more than half of the cases it is possible to achieve cure. To ease pain and relieve muscle spasms locally applied heat, UHF. When the abscess (a heave zublena) shown surgery - lumbotomy and drainage. Oblique lumbar section naked retroperitoneal space and open ulcer. After opening the main ulcer stupidly destroy fascial jumpers, among which can accommodate small ulcers. In the retroperitoneal space enter drains and gauze tampons. When paranemia due aposematism nephritis, it is necessary, in addition to drainage of paranemia, to make decapsulation kidney, and the carbuncle - dissection. When paranemia caused by pyonephrosis, the operation falls into two stages:
1) draining the kidney and retroperitoneal space and
2) nephrectomy (usually in 2-3 months). In the postoperative period (if any interference) needs to continue therapy with antibiotics.