Xanthogranulomatous Pyelonephritis: Case Report

BACKGROUND

In the emergency department (ED), pyelonephritis is a fairly common diagnosis, especially in patients with unilateral flank pain. Xanthogranulomatous pyelonephritis (XGP) is a rare type of pyelonephritis that is associated with unique features, which may lead to its diagnosis.

CASE REPORT

A 30-year-old male patient presented to the ED for evaluation of right-sided abdominal pain that has been ongoing for the past 24 hours. He noted the pain was located predominantly in the right flank and described it as sharp in nature. The pain was nonradiating and was associated with scant hematuria. He stated that he had similar pains approximately 1 month earlier that resolved after a few days. The patient underwent a bedside ultrasound and a subsequent computed tomography (CT) scan of the abdomen and pelvis, which showed an enlarged, multiloculated right kidney with dilated calyces and a large staghorn calculus, findings that represent XGP. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case report highlights an unusual variant of pyelonephritis, a relatively common ED diagnosis. XGP should be considered in patients with recurrent pyelonephritis, as treatment for XGP may require surgical intervention in addition to traditional antibiotic management.

Ovarian torsion masquerading as a ureteral stone

BACKGROUND

Abdominal pain is the most common complaint within the emergency department (ED) and has many varied etiologies. Some of these conditions can be medical emergencies, including ovarian torsion. While representing just 3% of gynecologic emergencies, ovarian torsion should be considered in all females presenting to the ED with abdominal or pelvic complaints.

CASE

A 38-year-old G5P5 female with a past medical history significant for ureterolithiasis presented to a freestanding ED with abdominal pain, nausea, and vomiting. She developed sudden onset of right sided abdominal pain radiating to her right flank upon awakening. The initial differential diagnosis was for ureterolithiasis or appendicitis. Her complete blood count (CBC) was normal, and testing for pregnancy, infection, and hematuria was negative. Computed topography (CT) imaging of the abdomen and pelvis revealed a 9 cm adnexal mass, consistent with a possible dermoid cyst. A pelvic ultrasound was ordered which showed a possible ovarian torsion. She was transferred to a tertiary care hospital where she had a laparoscopy with right-sided oophorectomy and salpingectomy performed.

DISCUSSION

This patient presented with abdominal pain, nausea, and vomiting and was first suspected to have ureterolithiasis or appendicitis. She was found to have an ovarian torsion with a dermoid cyst, which resulted in the loss of her ovary and fallopian tube. This case demonstrates the importance of including gynecologic emergencies in the differential on all female patients presenting with abdominal pain.

How I treat nutcracker syndrome

Anatomic compression of the left renal vein in the angle between the aorta and superior mesenteric artery may be asymptomatic or may result in symptoms, including flank pain, hematuria, or pelvic pain and/or congestion. Patients can be referred to a vascular surgeon due to symptoms and/or radiologic findings. Because symptoms of nutcracker syndrome can be vague and/or nondiagnostic, careful evaluation, assessment, and counseling with patients are required before undertaking intervention, which is often an open surgical procedure. The definitive diagnosis is ideally confirmed with diagnostic venography, including pressure measurements from the left renal vein and inferior vena cava. The optimal treatment includes open decompression of the left renal vein with renal vein transposition or gonadal vein transposition, with or without concomitant management of pelvic varicosities if symptomatic. Because most patients with nutcracker syndrome are young, long-term follow-up with scheduled ultrasound examinations should be maintained.

Massive renal infarction due to spontaneous renal artery thrombosis-a rare case report

Spontaneous renal artery thrombosis is a rare medical emergency. The signs and symptoms of the disease are variable and non specific making it difficult to diagnose on time and easily missed for other more common pathologies. Proper evaluation and timely intervention can prevent the loss of renal function. We present a case of 45 year old male with no comorbidity who presented with complaints of right flank pain, fever and vomiting for one day. With physical examination within normal limits, evaluation revealed right renal artery thrombosis.

Earlier point-of-care ultrasound, shorter length of stay in patients with acute flank pain

Background

The effects of early integration of point-of-care ultrasound (PoCUS) into patient care are uncertain. This study aims to investigate the effects of early PoCUS on patients with acute flank pain.

Methods

Adult non-traumatic patients with acute flank pain receiving PoCUS were enrolled. Expert physicians reviewed the medical records and made the “final diagnosis” for the cause of acute flank pain. The primary outcome was the relationship between the door to ultrasound (US) time and length of stay (LOS). The secondary outcomes included the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the sonographic diagnosis, compared with the final diagnosis.

Results

Eight hundred and eighty-eight patients were included in the analysis. Patients receiving early PoCUS (≤120 min) had a shorter LOS (128 vs. 217 min, p < 0.0001). Patients in the late POCUS group (> 120 min) had a trend to receive more CT scans. The disease distribution, sensitivity, specificity, PPV, and NPV were similar in patients receiving early or late PoCUS for target diagnoses. After adjusting for the confounders, early PoCUS (OR, 2.77, 95% CIs, 1.93–3.98) had a positive impact on shorter LOS. In addition, the effect of early PoCUS became more prominent (OR, 4.91, 95% CIs, 3.39–7.13) on LOS in less than 3 h.

Conclusions

Early integration of PoCUS is significantly related to shorter LOS in patients with acute flank pain without increasing morbidity and mortality. Our results suggested “PoCUS early” in these patients to possibly alleviate emergency department crowding.

Trial registration NCT04149041 at the ClinicalTrial.gov.

[Trampolining-induced gross hematuria : Unmasking the nutcracker syndrome]

The case of a 12-year-old boy with sports-induced recurrent macrohematuria and left-sided flank pain is reported. After extensive laboratory and imaging diagnostics, the diagnosis of nutcracker syndrome is made based on the characteristic clinical manifestation. Under a conservative approach and abstention from the triggering sport, a clinical as well as image-morphologically confirmed maturation occurred.

Presepsin as a predictor of septic shock in patients with urinary tract infection

Background

Recently, presepsin has been reported to be a useful biomarker for early diagnosis of sepsis and evaluation of prognosis in septic patients. However, few reports have evaluated its usefulness in patients with urinary tract infections (UTI). This study aimed to evaluate whether presepsin could be a valuable marker for detecting severe sepsis, and whether it could predict the therapeutic course in patients with UTI compared with markers already used: procalcitonin (PCT) and C-reactive protein (CRP).

Methods

From April 2014 to December 2016, a total of 50 patients with urinary tract infections admitted to Gunma university hospital were enrolled in this study. Vital signs, presepsin, PCT, CRP, white blood cell (WBC) count, causative agents of urinary-tract infections, and other data were evaluated on the enrollment, third, and fifth days. The patients were divided into two groups: with (n = 11) or without (n = 39) septic shock on the enrollment day, and with (n = 7) or without (n = 43) sepsis on the fifth day, respectively. Presepsin was evaluated as a biomarker for systemic inflammatory response syndrome (SIRS) or septic shock.

Results

Regarding the enrollment day, there was no significant difference of presepsin between the SIRS and non-SIRS groups (p = 0.276). The median value of presepsin (pg/mL) was significantly higher in the septic shock group (p < 0.001). Multivariate logistic regression analysis showed that presepsin (≥ 500 pg/ml) was an independent risk factor for septic shock (p = 0.007). ROC curve for diagnosing septic shock indicated an area under the curve (AUC) of 0.881 for presepsin (vs. 0.690, 0.583, and 0.527 for PCT, CRP and WBC, respectively). Regarding the 5th day after admission, the median presepsin value on the enrollment day was significantly higher in the SIRS groups than in the non-SIRS groups (p = 0.006). On the other hand, PCT (≥ 2 ng/ml) on the enrollment day was an independent risk factor for SIRS. ROC curve for diagnosing sepsis on the fifth day indicated an AUC of 0.837 for PCT (vs. 0.817, 0.811, and 0.802 for presepsin, CRP, and WBC, respectively).

Conclusions

This study showed that presepsin may be a good marker for diagnosing septic shock based on admission data in patients with UTI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-021-00906-4.

Comparison of Conservative and Surgical Treatments in Symptomatic Pregnancy Hydronephrosis

OBJECTIVES

This study aimed to evaluate the factors affecting the treatment choice in pregnant women with symptomatic hydronephrosis.

METHODS

Hospital records of pregnant women who visited our clinic due to symptomatic hydronephrosis between December 2010 and December 2020 were analysed retrospectively. Patients were divided into 2 groups: conservative and surgical (JJ stent) treatment groups. Age, gestational week, primipara, trimester, visual analogue scale (VAS), and preterm birth rates as well as clinical, laboratory, and ultrasonography findings were compared between the groups.

RESULTS

The study included 227 pregnant women (conservative treatment group, 133; JJ stent group, 94). Age, gestational week, primipara, trimester, hydronephrosis side, fever, pyelonephritis, pyuria, preterm labour and abortion, as well as blood urea nitrogen, creatinine, C-reactive protein, and white blood cell levels did not differ significantly between the groups (p > 0.05). In the JJ stent group, VAS, creatinine value, culture positivity rate, degree of hydronephrosis, and renal pelvis anterior-posterior (AP) diameter were significantly higher than those in the conservative treatment group (p < 0.05). The cut-off value for renal pelvis AP diameter was 16.5 mm in the first 2 trimesters and 27.5 mm in the third trimester.

CONCLUSIONS

Surgical treatment should not be delayed in pregnant women who do not respond to conservative treatment and have impaired renal function and grade 3-4 hydronephrosis. Early surgical intervention is necessary in patients with a renal pelvis AP diameter of >16.5 mm in the first 2 trimesters and >27.5 in the third trimester.

COVID-19 presenting as right flank pain in a postpartum woman: A case report

Introduction

Patients with COVID-19 infection may present a wide range of symptoms that make its diagnosis challenging, especially in patients with underlying conditions.

Presentation of case

A 30-year-old postpartum woman presented to the Emergency Department (ED) of Arash Women Hospital with right flank pain. Physical examination revealed tachycardia and decreased sounds in the base of the lung. Chest CT scan demonstrated patchy consolidations in bases of the lungs in favor of COVID-19 infection. The patient underwent pharmacotherapy with Remdesivir, steroid, and interferon beta-1a for eight days and was discharged in a good condition.

Discussion

This study suggests that involvement of lungs' bases may be associated with gastrointestinal symptoms such as abdominal or flank pain in the COVID-19 patients. It makes the diagnosis difficult in a scenario such as the described patient in our study where there may be other differential diagnoses correlating with the patient's clinical course.

Conclusion

COVID-19 should be in the differential diagnosis of any patient presenting to ED with relevant complaints. Correct and immediate diagnosis is critical for proper treatment and isolation of patients with COVID-19.

[Clinical ultrasound in nephrology]

When used correctly, modern ultrasound diagnostics are helpful for the nephrologist especially in emergency situations on the ward, in dialysis and in the emergency admission to quickly make the correct diagnosis or as a diagnostic gatekeeper to initiate the correct next diagnostic and therapeutic steps in a time-saving manner. In addition to conventional B‑mode/gray scale sonography and Doppler sonography, new ultrasound transducers with higher spatial resolution and above all contrast agent sonography have significantly expanded the technical possibilities and help nephrologists and internists to answer diagnostic and clinical questions. This particularly applies to the kidneys, which up to now could only be clarified by means of contrast-enhanced computed tomography or magnetic resonance imaging. This will allow the nephrologist in 2021 to amalgamate the clinical symptoms, imaging results and pathophysiological knowledge in an ideal, time-saving manner for the benefit of the patient.

Evaluation of the patients with flank pain in the emergency department by modified STONE score

BACKGROUND/AIM

Computed tomography (CT) is generally used for ureteral stone diagnosis. Unnecessary imaging use should be reduced to prevent increased radiation exposure and lower costs. For this reason, scoring systems that evaluate the risk of ureteral stones have been developed. In this study, we aimed to investigate the diagnostic accuracy of the modified STONE score (MSS) and its ability to predict ureteral stones.

MATERIALS AND METHODS

The research was conducted as a multi-center, prospective and observational study. Patients aged 18 and over who presented to EDs with complaints of flank pain and who received a CT were included. Patients were divided into two groups based on the presence or absence of stones, and the categories of the MSS were determined. The ability of the MSS to predict the ureteral stone and its diagnostic accuracy were calculated.

RESULTS

The median age (min/max) of the 367 study patients was 37 (18/91), and 244 (66.5%) were male. A ureteral stone was present in 228 (73.0%) patients. Male gender, previous stone history, duration of pain less than 6 h, presence of hematuria, and CRP value below 0.5 mg/dL were significantly more common in the group with stones. The prevalence of ureter stones in the MSS high-risk group was 96.0%. The area under the receiver operating characteristic curve and sensitivity of the MSS was 0.903 and 0.81, respectively.

CONCLUSION

The modified STONE score has high diagnostic performance in suspected urinary stone cases. This scoring system can assist clinicians with radiation reducing decision-making.

Can obstructive urolithiasis be safely excluded on contrast CT? A retrospective analysis of contrast-enhanced and noncontrast CT

PURPOSE

The aim of this study was to determine if contrast-enhanced CT can safely exclude obstructive urolithiasis in patients with flank plain. We performed a retrospective cohort analysis to compare the negative predictive values of contrast-enhanced and non-contrast CTs for the detection of obstructing urolithiasis.

METHODS

Through report analysis, we identified all non-contrast and contrast-enhanced CT examinations of the abdomen and pelvis performed on adult patients in the emergency department at a single, multi-site academic medical institution in 2017 with an indication of flank pain. The prevalence of obstructive urolithiasis in each group was calculated. We subsequently analyzed 200 consecutive studies from each of these groups (reported negative for obstructive urolithiasis) for negative predictive value calculation. Follow up abdominal imaging within 7 days from original presentation was used as a reference standard for analysis.

RESULTS

In the noncontrast group, 1 study out of 200 was false negative (negative predictive value = 99.5%). In the contrast-enhanced group, there were no false negatives (negative predictive value = 100%). The prevalence of obstructive urolithiasis was 44.0% (351/797) in the noncontrast group and 18.7% (86/459) in the contrast-enhanced group.

CONCLUSION

Our results suggest that contrast-enhanced CT can safely exclude obstructing ureteral calculi in the setting of acute flank pain. This finding is of clinical relevance given the inherent benefit of IV contrast in diagnosing abdominopelvic pathology.

Treatment and Management of Loin Pain Hematuria Syndrome

PURPOSE OF REVIEW

Loin pain hematuria syndrome (LPHS) is rare and seldom diagnosed, yet it has a particularly significant impact on those affected. This is a review of the latest and seminal evidence of the pathophysiology and diagnosis of LPHS and presents the typical clinical presentation and treatment options available.

RECENT FINDINGS

LPHS is typically found in young women with characteristic symptoms, including severe recurrent flank pain and gross or microscopic hematuria. The majority of patients will experience crippling pain for many years without effective therapy, often requiring frequent use of narcotic medication. However, the lack of conclusive pathophysiology, in conjunction with the rarity of LPHS, has prohibited the development and trial of definitive treatment options. Nevertheless, in order to combat this rare but severe disease, management strategies have continued to evolve, ranging from conservative measures to invasive procedures. This review presents an overview of the current hypotheses on the pathophysiology of LPHS in addition to summarizing the management strategies that have been utilized. Only 30% of LPHS patients will experience spontaneous resolution, whereas the majority will continue to face chronic, crippling pain. Several methods of treatment, including invasive and non-invasive, may provide an improved outcome to these patients. Treatment should be individually tailored and multi-disciplinary in nature. Further research is required to further elucidate the pathophysiology and develop new, specific, treatment options.

Thoracolumbar Junction Syndrome Accompanying Renal Artery Stenosis: A Case Report

Flank pain is a common reason for visits to the emergency room. The most common reason warranting hospital visits are urology-related problems. However, there are many other causes, such as musculoskeletal lesions, that difficult to achieve a correct diagnosis. Here, we describe a rare case of flank pain caused by thoracolumbar junction syndrome, accompanying renal artery stenosis. A 54-year-old male with hypertension presented with severe left flank pain for 1 week. Initially, he was diagnosed with left renal artery stenosis by computed tomography and decreased renal function on renal scan (Tc-99m DTPA). Although a stent was inserted into the left renal artery, flank pain persisted with only minor improvement. Through detailed physical examination, he was finally diagnosed with thoracolumbar junction syndrome. After three injections in the left deep paravertebral muscles at the T10–T12 levels, flank pain completely ceased. Clinicians must consider thoracolumbar junction syndrome, when treating patients with flank pain.

Clinical progression of renal vein leiomyoma: A case report

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Vascular smooth muscle tumours are rare entities. Majority of these are malignant.

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Differentiation between a vascular – leiomyoma and a leiomyosarcoma is chiefly upon histopathological examination. Imaging alone is non-contributory.

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The rarity of the tumour makes predicting the prognosis a challenging prospect.

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Renal Leiomyomas do not show aggressive behaviour and excellent prognosis is predicted post nephrectomy.

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An eight-year long charting of progress of leiomyoma in our case has demonstrated the non-malignant potential of such tumours.

Introduction

Vascular leiomyoma originating in the renal vein is a rare entity. Our case allowed us charting of progression of renal vein leiomyoma for 8-years’ duration. Apart from intraluminous growth causing displacement of viscera, the leiomyoma did not show any aggressive behaviour. Eventually, removal of the tumour through nephrectomy provided complete symptomatic relief to our patient.

Case presentation

A 75-year old female presented with an eight-year long history of severe pain in right flank. CT imaging revealed a mass arising from the right renal vein and a few hepatic tumours. The differentials included leiomyosarcoma, in view of hepatic lesions. Excision of the tumour was performed with radical nephrectomy. Immunohistopathological examination confirmed it to be a case of leiomyoma. Three months post-op, the patient reported complete pain relief and no adverse events, and there were no signs of recurrence.

Discussion and conclusion

Vascular leiomyomas do not show any aggressive behaviour. However, their growth tends to displace the normal viscera, causing pressure effects that may give rise to intractable pain. Vascular obstruction affects GFR and renal function. In our patient, despite a long period of growth, the tumour did not show any malignant changes. Tumour excision through radical nephrectomy resulted in symptomatic improvement in our patient. Since imaging alone does not distinguish a leiomyoma from its malignant counterpart with certainty, surgical excision may be warranted in all the cases.

Ureteral Ewing’s sarcoma in an elderly woman: A case report

BACKGROUND

Ewing’s sarcoma (ES) is regarded as a skeletal tumor, with few instances of extra-skeletal ES. A primary ES in the ureter is extremely rare.

CASE SUMMARY

We report the case of a 69-year-old woman who presented with intermittent flank pain and hematuria and was found to have a mass in the left ureter. Pathology of the excised mass indicated ES. The clinical treatment and pathologic characteristics in this case, and a review of the literature describing ES in the urinary system, are presented.

CONCLUSION

Due to the rarity and malignancy of ES in ureter, early diagnosis and prompt surgical treatment are critical.

Epidural analgesia for the treatment of colic attack with retrocaval ureter in late pregnancy complicated with marginal placenta previa: a case report

Background

Retrocaval ureter was diagnosed in a woman complaining of ureteric pain in the last trimester of pregnancy. We describe the rationale behind the administration of epidural analgesia for her colic attack.

Case presentation

A 41-year-old pregnant woman was hospitalized with a diagnosis of a marginal placenta previa at 34 weeks and 5 days of pregnancy. Her right ureter encircled the dorsal aspect of the inferior vena cava (IVC) and was compressed by a growing fetus, causing hydronephrosis. Her right lower back pain was exacerbated every day, till an epidural catheter was inserted. Her estimated glomerular filtration rate (eGFR) and hematocrit worsened, and an elective cesarean section was performed.

Conclusion

Epidural analgesia only provided pain relief for a few days. When a pregnant woman presents with a retrocaval ureter and severe pain, short-term epidural analgesia should be considered after evaluating the complex medical condition and size of the fetus.

Surgical Treatment of a Patient With Nutcracker Syndrome via Transposition of the Left Renal Vein

Introduction

Nutcracker syndrome (NCS) is caused by compression of the left renal vein (LRV) between the aorta and the superior mesenteric artery (SMA) where it passes in the fork formed at the bifurcation of these arteries. NCS leads to LRV hypertension, resulting in left flank and abdominal pain, with or without haematuria and pelvic ureteral varices.

Report

The patient was a young female with diagnostic criteria of NCS, with severe clinical manifestations. The patient underwent transposition of the LRV approximately 3.0 cm below the original anatomic site and was anastomosed to the inferior vena cava (IVC) outside the meso-aortic compression zone.

Conclusion

Although NCS is not as common as other clinical scenarios, it may be encountered by physicians in a variety of disciplines, and can cause substantial morbidity and mortality rates. This report addresses the surgical approach used in a particular case, as well as the possible complications and outcomes if not treated in due time.

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A young female patient with diagnostic criteria of NCS, with severe clinical manifestations.

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The patient underwent transposition of the LRV approximately 3.5 cm below the original anatomic site.

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She was then anastomosed to the inferior vena cava (IVC) outside the meso-aortic compression zone.

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The symptoms were masked for an extended period of time, while the patient deteriorated at a rapid pace.

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At 36 months of follow-up the patient remained symptom free.

The diagnostic yield of computed tomography in the management of acute flank pain and the emergency intervention rate for a proven acute ureteric stone

INTRODUCTION

The diagnostic and management pathways for patients presenting with acute flank pain are complex. Although computed tomography (CT) of the kidneys, ureters and bladder (KUB) is the gold standard investigation for urolithiasis, the multitude of differential diagnoses must also be considered in the context of long-term risk from ionising radiation. This study investigated the integrated role and diagnostic yield of non-contrast CT in cases of acute flank pain.

METHODS

A retrospective cohort study was undertaken of 1,442 consecutive patients investigated with CT KUB between March 2013 and February 2015. The primary outcome was diagnostic yield of CT with secondary outcomes being predictors of need for urological intervention.

RESULTS

A cause for acute flank pain was identified in 717 patients (50%), there was an incidental finding in 389 patients (27%) and normal imaging was reported in 336 patients (23%). A diagnosis was more commonly made in male than in female patients (70% vs 40%) and with increasing age (46% in patients aged <30 years, 56% in those aged 30-49 years and 63% in those aged ≥50 years). The overall rate for an ipsilateral urinary tract stone was 41%. Factors strongly associated with emergency intervention included stone size >10mm (odds ratio [OR]: 11.7, 95% confidence interval [CI]: 3.3-42.7), stones located at the pelviureteric junction (OR: 7.8, 95% CI: 2.6-22.9), C-reactive protein >50mg/l and ≤100mg/l (OR: 15.2, 95% CI: 5.1-45.3), and estimated glomerular filtration rate ≤30ml/min (OR: 5.8, 95% CI: 1.5-21.8).

CONCLUSIONS

This contemporary study identifies age and sex as independent variables affecting the diagnostic yield of CT KUB in cases of acute flank pain, and highlights factors associated with a need for emergency intervention in proven ureteric stones.

Vitamin D deficiency: an unrecognized cause of flank pain

Loin pain is frequently not associated with any urinary abnormality. Musculoskeletal abnormalities are not uncommon as alternative cause of flank pain. Osteomalacia of the ribs was infrequently encountered as the cause of flank pain. Vitamin D deficiency has been reported as a common problem worldwide with special predilection to the Middle East area. In this study, we looked for vitamin D deficiency in patients with flank pain associated with tenderness over the tips of the lowermost ribs. Out of 783 patients presenting with unilateral or bilateral flank pain to a single center over a period of 3 years, 316 did not have a definite urologic cause (group B). One hundred and eighty-seven of these patients had distinct tenderness over the costal margin (group B1) that could not be explained by history and radiology. All patients of group B were tested for serum levels of 25(OH) vitamin D. Very low serum levels of 25(OH) vitamin D was detected in all cases of group B1 and in only in only 26.4% of the remaining cases of group B (group B2). Relief of flank pain was noticed within 2 months in 55.1% of vitamin D deficient cases. In patients presenting with flank pain, the existence of tenderness of the last ribs instead of the renal angle proper should alert to a possible cause in the rib cage. Estimation of serum vitamin D level should be performed in these cases.

Case Report: 52-Year-Old Male with Right Upper Quadrant Abdominal Pain

Renal artery dissections (RADs) are lesions that disrupt vessels that primarily occur in patients with a known history of hypertension and caused by stenosis or enlargement of the renal artery typically due to underlying connective tissue disorders. However, RADs may occur spontaneously from trauma and no previous history of hypertension. Here, we report a rare case of bilateral isolated spontaneous RADs that characteristically occurs in healthy males. A 52-year-old male presented with left lower quadrant abdominal pain and renal insufficiency. Two years prior, he had experienced a similar episode of pain on the contralateral side, which was due to an infarct of the right kidney. On this admission, a computed tomography angiogram confirmed a new infarct of the left kidney, with dissection of a branch of the renal artery supplying the upper lobe. Work-up for cardiovascular, hematologic, radiographic or connective tissue causes was negative. We postulate that both RADs were potentially associated with the rapid twisting and turning of the abdominal area on a daily basis required for his occupation as an air traffic controller. The patient was treated with a renin angiotensin system inhibitor. After one year, both RADs had significantly improved and his renal function increased by ~23%. Isolated RAD may be associated with consistent or long-term activities that require rapid twisting and turning of the abdominal area. If left untreated, this may result in malignant hypertension, bilateral dissections, or renal ischemia. To avoid misdiagnosis; we provide a comprehensive review of the typical presentation and necessary assessment and management.

Amyloidosis of the renal pelvis presenting as flank pain

Amyloidosis is a rare disease defined by accumulation of extracellular amyloid systemically or within a specific organ. Localized amyloidosis of the genitourinary system is extremely rare, with the predominate location being the bladder. The imaging findings are often nonspecific and mimic urothelial carcinoma. We present a 49-year-old woman with a chief complaint of flank pain. A filling defect was discovered on radiological imaging. The defect was subsequently biopsied and proven to be a primary amyloidosis of the renal pelvis. We then review the radiological findings of amyloidosis of the genitourinary system.

The diagnostic value of magnetic resonance urography using a balanced turbo field echo sequence

OBJECTIVES

The aim of the study was to compare the inter-observer variability and the accuracy of magnetic resonance urography (MRU) using a thin sectional balanced-turbo field echo (B-TFE) sequence for detecting ureteral calculi and to determine the effect of additional factors (size, density and location of the calculus) on the sensitivity and specificity of the MRU.

MATERIALS & METHODS

MRU and CT images were evaluated independently by two radiologists according to presence, density and localization of calculi. The degrees of inter-rater agreement for categorical items were evaluated by the Kappa coefficient.

RESULTS

According to the 1st and 2nd observers, the sensitivity of MRU was 65.9 %, 71.8 % and the specificity of MRU was 95.9 %, 100 %, respectively. Inter-observer agreement was 84.6 % for stone detection. The larger size had a better effect on detectability (p < 0.05). Also, the higher density had a better impact on detectability (p < 0.05).

CONCLUSION

Our study has shown that B-TFE MRU was useful to detect ureteral calculi. However, B-TFE MRU has low sensitivity and high specificity in comparison with CT images. MRU is a reasonable alternative imaging technique for follow-up periods of selective groups like patients with large urinary stones, children or pregnant patients when ionizing radiation is undesirable.

KEY POINTS

• According to 1st and 2nd observers, sensitivity of MRU was 65.9 %, 71.8 %, respectively. • According to 1st and 2nd observers, MRU specificity was 95.9 %, 100 %, respectively. • Interobserver agreement was found to be over 84 % for stone detection. • B-TFE sequence provides calculus follow-up without radiation. • Larger calculi and more dense calculi individually have the better effect on detectability.

Acute Urinary Tract Disorders

Acute urinary tract disorders often manifest as flank pain and are a common complaint of patients who present to the emergency department. The pain is often a vague, poorly localized sensation that may have a variety of causes. Laboratory and clinical findings, such as hematuria, are neither sensitive nor specific for determining the cause of the flank pain. Accordingly, imaging is an important tool in determining a diagnosis and management plan. Patients with acute urinary tract disorders who present with pain include those with calculi as well as renal infection, vascular disorders, and hemorrhage.

Flank pain after minor trauma as the initial manifestation of malignant pheochromocytoma; a case report

Pheochromocytoma is a tumor which originates from chromaffin cells of the adrenal medulla or the sympathetic ganglia. This tumor secrets a high amount of catecholamine and metabolites, causing hypertension crisis with headache, tachycardia, sweating and flushing (classic triad of pheochromocytoma). However, in some cases the disease may cause atypical symptoms or may be asymptomatic. The presented patient is a 34-year-old man who referred to our clinic with left flank pain. He had a history of falling from height. In the primary physical examination, a large mass in the abdominal left upper quadrant was palpated. After diagnostic evaluation malignant pheochromocytoma was detected. The patient was discharged on the fourth day after surgery. Malignant pheochromocytoma can presented with atypical symptoms or can be asymptomatic.

Retrocaval ureter: an innocent bystander

Retrocaval ureter is a rare congenital anomaly, with the ureter passing posterior to the inferior vena cava. Though it is a congenital anomaly, patients do not normally present with symptoms until the 3(rd) and 4(th) decades of life, which result from a hydronephrosis. We are presenting a case of 45-year-old lady who had right flank pain and dysuria, which were associated with right hydroureteronephrosis. Diagnosis was confirmed by doing Intravenous Pyelogram (IVP) and patient underwent an open surgical repair of the anomaly.

Renal vein thrombosis associated with oral contraception and smoking: a case report from Japan, with literature review

Renal vein thrombosis, one of the common thrombotic complications of nephrotic syndrome or renal cell carcinoma, is reportedly a rare complication of hormonal contraception. Solitary renal vein thrombosis in the Japanese population is thought to be very rare because the incidence of venous thromboembolism is comparatively very low in Asian populations. We report a 38-year-old Japanese female with left renal vein thrombosis associated with oral contraception and concurrent smoking as the first Japanese case of solitary renal vein thrombosis associated with oral contraceptives, with a review of the literature. Seven cases were previously reported. The results revealed that all patients complained of acute onset of pain around the involved kidney without urinary symptoms or fever, and were effectively treated with anticoagulants. Other remarkable facts include that nausea and vomiting were frequently seen, and that the renal outcome was benign, despite various initial urine abnormalities. This report may alert clinicians to the importance of these risk factors as an etiology of renal vein thrombosis even in Asian populations. Clinicians should regard renal vein thrombosis as one of the differential diagnoses for acute flank pain in patients using oral contraceptives. A detailed history taking that reveals oral contraception, smoking, and other thrombophilic predispositions as well as timely computed tomographic scans would be the keys to diagnosis. Smoking cessation should be strongly recommended to oral contraceptive users, especially women over 35 years of age, regardless of dosage.

Comparison of Non-contrast-Enhanced Computed Tomography and Intravenous Pyelogram for Detection of Patients With Urinary Calculi

Purpose

The aim of this study was to investigate the changing pattern in the use of intravenous pyelogram (IVP), conventional computed tomography (CT), and non-contrast-enhanced computed tomography (NECT) for evaluation of patients with acute flank pain.

Materials and Methods

We retrospectively reviewed the medical records of 2,180 patients with acute flank pain who had visited Bundang Jesaeng General Hospital between January 2008 and December 2012 and analyzed the use of IVP, conventional CT, and NECT for these patients.

Results

During the study period there was a significant increase in NECT use (p<0.001) and a significant decrease in IVP use (p<0.001). Conventional CT use was also increased significantly (p=0.001). During this time the proportion of patients with acute flank pain who were diagnosed with urinary calculi did not change significantly (p=0.971).

Conclusions

There was a great shift in the use of imaging study from IVP to NECT between 2008 and 2012 for patients with acute flank pain.

Atypical Presentations of Epiploic Appendagitis: Early Diagnosis and Non-Operative Management is the Optimal Therapy

Epiploic appendagitis is a benign self-limiting inflammation of the appendices epiplocae of the colon. It often presents as abdominal pain rarely accompanied by fever, nausea, or vomiting or any other abdominal symptoms. It can mimick acute diverticulitis or appendicitis on clinical exam. The diagnosis of epiploic appendagitis primarily relies on imaging modalities such as CT. The treatment is analgesia and non-steroidal anti-inflammatory drugs are usually sufficient to control pain and no surgical intervention is needed. This report illustrates two cases with epiploic appendagitis who presented with atypical symptoms, clinical and radiological findings and management of this condition.

A case of renal artery thrombosis with renal infarction

Renal artery thrombosis is a rare, but serious and often misdiagnosed, condition. Emergency physicians and other physicians need to consider this diagnosis in unexplained flank pain, especially in patients with risk factors for this disease. In this case report, the authors review a case of renal infarction caused by renal artery thrombosis in a patient with risk factors for thrombosis but no previous history of thromboembolism. A review of scholarly articles was performed and the case is discussed in the context of the current knowledge of this condition. Common presenting symptoms, features of the history and risk factors will all be discussed herein. Diagnostic evaluation of flank pain in the setting of the suspicion of renal infarction will be discussed, including the modalities of high-resolution computed tomography, renal angiography, scintography and ultrasound. Acute management and prognosis will also be discussed.