March 31, 2009

Blood in urine

URINE can be a very valuable diagnostic signs in order to make a clinical diagnosis. Changes in color of urine might suggest something is going wrong in your body. Before I proceed, take a look at the picture and can you describe the abnormality in picture A, B, and C

Answer and discussion

A) Dark color urine (Excess conjugated billirubinuria)

B) Black color urine (haemoglobinuria + Haemosiderrinuria)

C) Bloody color urine (post renal problem@ occult blood)

OK! Once you see the urine, you suppose to have these things in your mind

1) Is it blood?

2) Is there any chemical intake? (drugs,)

3) Any tissue injury? (strenuous exercise)

4) Any infection? (High grade fever, travelling history?)

5) Any genetic disease resulting in hemolytic

6) Any renal disease?

IF you suspect it as a blood or derivatives of blood. Another two question should arise in your mind

1) Is it intravascular or extravascular hemolysis?

2) Is it pre renal, renal or post renal causes?

IN order to confirm the idea of diagnosis floating in your mind, you may do few tests. But the common and CHEAPER one would be

1) Urinary FEME (look for RBC, cast)

2) Dipstick test (look for billirubin and urobilinogen)

OK. Next step would be how to interpret the cast and dipstick test for urobilinogen&bilirubbin. So what are they?

CAST is a cylindrical molds made of protein which forms in tubular of the kidney.

UROBILINOGEN is the final product of bilirubin synthesis. It is soluble in water and can be excreted in urine as it is being conjugated in intestine. Elevation in urobilinogen can be due to problem either pre hepatic or hepatic itself.

MEANWHILE, Bilirubin cannot being excreted in urine as it is not water soluble. However, if it is being conjugated, then it can be released in urine. The MOST COMMON cause for the presence of bilirubin is OBSTRUCTION of biliary duct system. Remember that bilirubin is being conjugated in liver. However, it cannot be excreted into intestine. Hence, back flow of conjugated bilirubbin into hepatic circulation occur and finally being excreted by kidney

THEN, the next step is to find what is the culprit behind the problem. So, you may proceed with doing other lab or radiological investigation. We may classify it as general and specific investigation. However, both of it should be perform base on history taking and other clinical manifestation.

GENERAL investigation


2) U&E

3) Clotting screen

4) CXR

5) KUB

SPECIFIC examination

1) PSA (prostate specific antigen to rule out prostate carcinoma)

2) Sickling test (for sickle cell anaemia)

3) IVU (Intravenous urography to look for stone, tumor)

4) US (to look for cystic vs solid lesion, stone, urinary obstruction)

5) CT scan

6) Cystoscopy

7) Uretroscopy

8) Selective renal angiography

9) Renal biopsy

10) Prostatic biopsy

FINALLY is Differential diagnosis of red urine (other than blood, haemoglobinuria and Billirubinuria)

1) Myoglobinuria

2) Rifampin

3) Phenytoin

4) Phenazopyridine

5) Phenolphthalein

6) Phenindione

7) Beetroot

8) Senna

9) Food color

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