1/34. Left-sided omental torsion: CT appearance. A 34-year-old male presented with exquisite left flank pain. Computed tomography showed a hyperdense vascular structure surrounded by whirling linear streaks situated in the greater omentum under the splenic flexure of the colon. Omental stranding extended caudally into the pelvis where part of the inflamed omentum entered a left inguinal hernia sac. Surgery revealed left-sided torsion of the greater omentum. Left-sided omental torsion is infrequent and pre-operative diagnosis is rarely established. The CT findings of an omental fatty mass with a whirling pattern is characteristic of omental torsion. Preoperative diagnosis is important because conservative management has been suggested. ( info) |
2/34. Rib pain in a 23-year-old woman with severe asthma. This case illustrates the importance of considering a wide range of diagnoses in patients complaining of rib, flank, and pleuritic pain. Further, additional evaluation is warranted when "pneumonia" does not respond to conventional treatment. ( info) |
3/34. Thrombotic thrombocytopenic purpura presenting as bilateral flank pain and hematuria: a case report. Thrombotic thrombocytopenic purpura (TTP) is a rare disease whose incidence is now increasing. We present a case of a 37-year-old man who presented with bilateral flank pain and hematuria, subsequently diagnosed with TTP. Thrombotic thrombocytopenic purpura has classically been characterized by the pentad of fever, microangiopathic hemolytic anemia, neurologic symptoms, renal dysfunction, and thrombocytopenia. The pathogenesis of the disease has been a mystery until recently. We review the current literature regarding the pathophysiology and management of this disorder. Our discussion focuses on the importance of understanding this disease while considering the differential diagnosis of a patient presenting with anemia and thrombocytopenia because the common pitfall of rapidly administering platelets to a patient with TTP may lead to a disastrous outcome. ( info) |
4/34. Recurrent abdominal and flank pain in children with idiopathic hypercalciuria. OBJECTIVE: To evaluate the role of idiopathic hypercalciuria (IH) as a cause of recurrent abdominal pain (RAP) in children. patients AND methods: We retrospectively reviewed the medical records of 124 children referred for various complaints who had 24-h urine calcium excretion greater than 2 mg/kg/d or random urine calcium-creatinine ratio greater than 0.18 mg/mg. RESULTS: Fifty-two children with various clinical complaints had RAP or flank pain. These comprised of 22 males and 30 females, 9 mo to 15.9 y of age, mean 6.7 /- 3.5 y. A family history of urolithiasis was present in 50% of all the children. Only 6 of the 52 children with abdominal pain had renal stones. In addition to abdominal pain, 27 children had hematuria and 10 had urinary incontinence. Mild metabolic acidosis was present in three children, parathyroid hormone activity elevated in two and serum vitamin d activity was increased in nine. All children were treated with increased fluid intake and a reduction in dietary sodium and oxalate and some required treatment with thiazide and antispasmodics. Forty-five cases responded to treatment, 5 failed to improve from therapy, and 2, which were not followed up as patients, were not available. CONCLUSION: We describe 52 children with RAP or back pain due to IH and recommend that IH be considered in the differential diagnosis of RAP in childhood. ( info) |
5/34. Primary renal carcinoid natural history of the disease for ten years: case report. BACKGROUND: Primary renal carcinoid is extremely rare and there are few reports on the natural history of the disease. CASE PRESENTATION: A 68-year-old male with a right renal mass who lost to follow-up for ten years has been presented. His only complaint was a mild flank pain. Upon admission to the hospital for his renal mass, he underwent a right radical nephrectomy and pathological examination revealed the diagnosis of primary renal carcinoid. CONCLUSIONS: In light of the presented case, primary renal carcinoma may have a prolonged natural history with no distant metastasis and any change in the quality of life of the patient. ( info) |
6/34. Nonoperative management of acute spontaneous renal artery dissection. Isolated spontaneous renal artery dissection is a rare condition that can result in renal parenchymal loss and severe hypertension. Although several risk factors have been identified in association with renal artery dissection, the natural history is not well defined. The rarity and nonspecific presentation of the disease often lead to diagnostic delay. That, coupled with the anatomic limitations imposed by dissection into small branch arteries, frequently precludes successful revascularization. Over a 12-month period, four cases of spontaneous renal artery dissection (SRAD) were treated at a single institution. The patients (ages 44-58 years) presented with acute onset of abdominal/flank pain, fever, and hematuria. Diagnostic work-up included an abdominal CT scan revealing segmental renal infarction. Angiographic evaluation was diagnostic for renal artery dissection in all cases. In one case there was evidence of fibromuscular dysplasia (FMD), and in a second there was acute dissection superimposed upon atherosclerotic disease. diagnosis was made within 12-72 hr of the onset of symptoms. All patients were managed expectantly with anticoagulation. Two patients were known to have a history of hypertension prior to admission. All four patients have required antihypertensive treatment following dissection, but the condition has been easily controlled. Renal function has remained stable in all cases. None of the four cases required exploration. Two of the four patients underwent repeat angiographic evaluation for recurrent symptoms of pain. In the case of the patient with FMD, a new dissection was seen in the contralateral renal artery, and in the second, repeat angiogram revealed proximal remodeling of the dissected artery. Management strategies for SRAD include surgical revascularization, endovascular intervention, and observation with or without anticoagulation. The available literature does not demonstrate a clear benefit of treatment with any of these modalities. In the short term, the combination of anticoagulation and expectant management appears to produce satisfactory outcomes for this difficult problem. ( info) |
| The incidence of tuberculosis has been increasing in recent years, and its treatment has also become challenging. The diagnosis of renal tuberculosis is often difficult and delayed. Early and correct diagnosis of tuberculosis with different organ system involvement is very important and can be easier with ultrasonography, computed tomography and/or magnetic resonance imaging. Although renal tuberculosis is the result of hematogenous spread more commonly from the lungs, less than 5%, of patients with urinary tract tuberculosis have active pulmonary disease. Renal tuberculosis may show variable radiological findings depending on the stage of the infection. Although an end-stage "autonephrectomized" kidey in tuberculosis is classically defined to be small in size, enlargement may on rare occasions be observed, which is the case in our patient. This form greatly mimics diffuse xanthogronulomatous pyelonephritis. Both diseases show thickening of the perirenal fasciae and spread of inflammation into the adjacent organs. Computed tomography and magnetic resonance imaging may show some specific features to differentiate these two entities. ( info) |
8/34. Posterior "Nutcracker" phenomenon in a patient with abdominal aortic aneurysm. We report on a posterior "nutcracker" phenomenon due to an abdominal aortic aneurysm in a patient with a retro-aortic left renal vein. A 71-year-old man with a known abdominal aortic aneurysm presented in the emergency room with mild hematuria and flank pain. Computed tomography angiography revealed an aortic aneurysm, which compressed the left renal vein between the aorta and the vertebral column. Compression of the left renal vein, due to the aorta with consecutive congestion and hematuria as well as flank pain, was previously described as nutcracker phenomenon. In case of a retro-aortic left renal vein, increase of the aortic diameter can lead to compression of the renal vein and furthermore to the classical signs and symptoms of the "nutcracker" phenomenon, even though the aneurysm is not ruptured or there are no aorto-caval or aorto-left renal vein fistulas. ( info) |
| We present a 65-year-old woman who was found to have a spontaneous rupture of an aneurysmal intrarenal arteriovenous fistula. To our knowledge, the present case is only the 3rd reported in the literature. The preferred method of treatment of ruptures of arteriovenous fistulae is embolization. However, the process of choosing among embolization, surgery, or a combination of both procedures must be individualized for each patient based on vital signs and symptoms. ( info) |
| Ureteropelvic junction obstruction is usually intrinsic and is most common in children. Aberrant renal arteries are present in about 30% of individuals. Aberrant renal arteries to the inferior pole cross anteriorly to the ureter and may cause hydronephrosis. To the best of our knowledge, although there are some papers about aberrant renal arteries producing ureteropelvic junction obstruction, there is no report of a case which is diagnosed by the new modalities, such as computed tomography angiogram (CTA) or magnetic resonance angiogram (MRA). We describe a 36-year-old woman with right hydronephrosis. kidney ultrasonogram and excretory urogram revealed right hydronephrosis. CTA and MRA clearly displayed an aberrant renal artery and hydronephrosis. The patient underwent surgical exploration. For the evaluation of hydronephrosis by an aberrant renal artery, use of CTA and MRA is advocated. ( info) |