X ray conference 2011.10.12

1. 報告者：fellow 1 陳筱惠 X ray conference2011.10.12

2. Case 01

3. Patient Profile • Name: 游O琴 • Sex: female • Age: 56-year-old • Occupation: 餐飲業 • Chart number: 8970369 • Date of admission: 2011/09/25

4. Chief Complaint • Right flank pain and black urine for 1 week

5. Present Illness • Small kidney with kidney stones was told at亞東hospital 2~3 years ago. She received URS + SM then. • Right flank/low abdominal pain and black urine for 1 week; associated symptoms: dysuria, frequency, and urgency; no fever or hematuria • LMD visit twice, but no improvement under analgesic + oral antibiotic • At ER, foley was inserted for urine retention

6. Past History • Small kidney with kidney stones was told at 亞東hospital 2~3 years ago. She received URS + SM then. • Urinary tract infection or chronic kidney diseases: denied • No hypertension, diabetes mellutis, heart, liver, or other significant systemic diseases • Current medicine: nil

7. Personal History • Allergy: no known allergy • Alcohol: denied; betel-nut: denied; cigarette: denied • Over-the-counter medication or chinese herb: nil

8. Family History • No family history of diabetes mellutis, malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

9. Physical Examination • Vital signs: blood pressure: 142/81mmHg; temperature: 36‘C; pulse rate: 90/min; respiratory rate: 17/min • General apperance: acute ill looking • Eye: conjunctiva: not pale, sclera: no icteric • Neck: supple, no lymphadenopathy or jugular vein engorgement • Chest: symmetric expansion breathing sound: bilateral clear heart sound: regular heart beats, no S3 or S4, no murmurs • Abdomen: soft, flat, diffuse tenderness, no muscle guarding or rebounding liver/spleen: impalpable bowel sound: normoactive • Back: right flank knocking pain • Extremities: no lower limb pitting edema • Skin: intact, no rash

10. Laboratory data – 9/24

11. Urinalysis – 9/24 • 9/24 urine culture: Viridans streptococcus (> 100,000) • 9/25 blood culture: negative

12. KUB – 9/24

13. Kidney and bladder echo – 9/26

15. Left kidney Length: 11.2 cm • Mild dilatation of the pelvocalcyeal systems • A peri-pelvic echo-free lesion (2.0cm) in the lower pole • Right kidney Length: 14.4 cm • Irregular in contour, increased cortical echogenicity and decreased thickness • Severe dilatation of the pelvocalcyeal systems and ureter; multiple tiny hyperechoic lesions without acoustic shadow kidney and soft tissue-like density

16. Bladder: distended • foley within it. • A protruding mass (4.9x2.7cm) with connection of a peri-bladder lumen near right vesicle-ureter junction, a iso-echoic lesion (1.2cm)

17. Abdominal CT – 9/25

20. Right hydronpehrosis and hydroureter, due to ureterocele; complicated with infection and probably pyonephrosis and pyoyreter • Multiple tiny stones inside • Left minimal hydronephrosis • Urinary bladder mucosal thickening and enhancement, suggesting chronic cystitis

21. Discussion -- Pyonephrosis • Infected purulent urine in an obstructed collecting system • S/S: typically associated with fever, chills, and flank pain, although may be asymptomatic, too • Etiologies: • Ascending infection of the urinary tract • Hematogenous spread of a bacterial pathogen

22. Incidence: relatively uncommon • The risk of pyonephrosis is increased in patients with upper urinary tract obstructionsecondary to various causes (eg,stones, tumors, ureteropelvic junction [UPJ] obstruction • Pathogen: • Escherichia coli, Enterococcusspecies, Candidaspecies, Enterobacterspecies, Acteroidesspecies, Staphylococcusspecies, Salmonellaspecies, Tuberculosis

23. Complications: • Sepsis and septic shock • Irreversible damage to the kidneys • Treatment: surgical emergency for decompression • Disadvantages of retrograde decompression: • General anesthesia, contraindicated in unstable patients • Smaller-caliber urinary drainage catheter than with percutaneous access

24. Increased irritative urinary symptoms • Lack of antegrade access for radiologic studies or inability to administer medications such as antibiotics via nephrostomy tube • Bypassing the obstruction may not be possiblein some patients. • Pyelovenous, pyelolymphatic, and pyelosinus backflow of infected urine into the systemic circulatory system

25. Ultrasonographic features of pyonephrosis: • Dilated collecting system • Echogenic debris in the in dependent areas of collecting system • Strong echoes with acoustic shadowing • Change position when patient moves • Air can be seen in these infections. Ultrasonographic Evaluation of Renal Infections Radiol Clin N Am 44 (2006) 763–775

27. CT: depicts both hydronephrosis and often the underlying cause • Contrast-enhanced imaging is more desirable as in infection parenchymal and functional changes can be assessed. • Pelvic and ureteral wall thickness • Renal enlargement • Perinephric fat stranding • Fluid–fluid levels and gas within the collecting system Imaging of urinary tract infection in the adult Eur Radiol (2004) 14:E168–E183

28. Case 02

29. Patient Profile • Name: 徐O華 • Sex: female • Age: 63-year-old • Occupation: nil • Chart number: 6425429 • Date of admission: 2011/09/05

30. Chief Complaint • Low abdominal pain for 4 days

31. Present Illness • Underlying diseases: rheumatoid arthritis, diabetes mellitus, and history of infectious spondylitis with left anterior epidural abscess post operation in 2011/03 (stool/urine incontinence under foley use and bedridden status since then) • Turbid urine, suprapubic and right flank pain for 4 days; associated symptoms: poor appetite, nausea/vomiting; no fever

32. Past History • Underlying diseases: • Rheumatoid arthritis • Hypertension • Diabetes mellitus • Osteoporosis • Iatrogenic adrenal insufficiency • History of infectious spondylitis with left anterior epidural abscess post operation operation at 802 hospital in 2011/03 • No heart, liver, or other significant systemic diseases • Current medicine: from our Rheuma OPD

33. Personal History • Allergy: no known allergy • Alcohol: denied; betel-nut: denied; cigarette: denied • Over-the-counter medication or chinese herb: nil

34. Family History • No family history of diabetes mellutis, malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases

35. Physical Examination • Vital signs: blood pressure: 124/92mmHg; temperature: 36.6‘C; pulse rate: 110/min; respiratory rate: 18/min • General apperance: acute ill looking • Eye: conjunctiva: mild pale, sclera: no icteric • Neck: supple, no lymphadenopathy or jugular vein engorgement • Chest: symmetric expansion breathing sound: bilateral clear heart sound: regular heart beats, no S3 or S4, no murmurs • Abdomen: soft, flat, low abdominal tenderness, no muscle guarding or rebounding liver/spleen: impalpable bowel sound: normoactive • Back: right flank knocking pain • Extremities: no lower limb pitting edema • Skin: intact, no rash

36. Laboratory data – 9/3

37. Urinalysis – 9/3 • 9/3 urine culture: Proteus mirabilis (>100,000) • 9/3 blood culture: negative

38. KUB – 9/3

39. Kidney echo – 9/5

40. Left Kidney Length: 10.2 cm • One isoechoic band extending from the cortex to central sinus • Right Kidney Length: 10.4 cm • One mass-like lesion (7.0x3.5cm) over middle portion • The both kidneys are normal in size and contour. The cortical echogenicity and thickness are normal. • No evidence of renal stone or cyst exists.

41. Abdominal CT – 9/7

43. Multifocal ill-defined low denity of bilateral renal parenchyma, C/W acute pylonepheritis Dilatation of bilateral renal pelvis and ureters to right middle ureter and left upper ureter level No definite dilatation of bilateral renal calyces No definite ureteral stones or tumor could be identified. DDx: extrarenal pelvis, retroperitoneal fibrosis/ adhesion, or ureteral stricture

44. Retrograde pyelography – 9/13

45. Ureteral catheter passing up to the left upper ureter at L4 level and right middle ureter at S3 level Mild bilateral hydronephrosis. No obvious filling defect in the collecting system. The right upper ureter and right renal collecting system are not well opacified. No definite radiopaque stone in the urinary tract

46. Discussion -- Extrarenal calyces/pelvis • The presence of extrarenal calyces is a very rare anomaly of the upper urinary tract. • First described in 1925 • The total number of cases reported so far is only 20. • Kidney with extrarenal calycesis usually associated with other anomalies like bifid kidney, renal ectopia, horseshoe kidney and renal dysplasia. Extrarenal calyces: A rare anomaly of the renal collecting system Indian J Pathol Microbiol. 2009 Jul-Sep;52(3):368-9.

47. The calyces were long and extrarenal in position. They drained into a cystic structure which represented either a grossly dilated pelvis (pelviureteric junction) or a ureteral cyst. • The exact cause of extrarenal calyces is not very clear. • Hypothesis: a disparity resulting from slow development of the metanephric tissue or to a relatively rapid development of the ureteric bud

48. Many cases of collecting system anomalies including extrarenal calyces are detected incidentally or may be diagnosed because of its complications. • Excretory urography often provides good anatomic information. • A false impression of hydronephrosis or chronic pyelonephritis

49. Discussion -- retroperitoneal fibrosis • Rare disease, incidence of idiopathic form about 0.1~1.3 per 100,000 person-years • Etiology: • Idiopathic form: 70%, 40 ~ 60 years of age, 2 to 3:1 male-to-female predominance • Secondary form • Drugs: ergot-derivatives, methysergide, bromocriptine, beta blockers, methyldopa, hydralazine, analgesics • Malignancy: carcinoid, Hodgkin's and non-Hodgkin lymphoma, sarcomas

50. Infections: tuberculosis, histoplasmosis, actinomycosis • Radiation therapy for testicular seminoma, colon, pancreatic cancer • Surgery: lymphadenectomy, colectomy, aortic aneurysmectomy