In principle, what you tell us does not fit with a nephritic colic. The urine is normal (without hematuria, caused by the lithiasis as it progresses), the Creat is normal (it can rise up to 1.9 in nephritic colic). The increase in LDH is non-specific and can be found in hepatic parenchymal lesions, AMI or pulmonary embolism, as well as in many other less frequent cases (tumors, myopathies, etc.). In this case, we have an important risk factor for embolism, which is atrial fibrillation, which, in addition, being a 45-year-old male, with no previous history, does not seem to respond to an underlying structural heart disease together with right lumbar pain, which could correspond to irritation of the pleura at the level of the right lumbar spine. Spiral CT with contrast has acquired great value in the diagnosis of PTE, due to its rapidity and good sensitivity, higher than 83-92% in most studies, and according to some it can reach 100% for central thrombi, located in main, lobar or segmental pulmonary arteries. Its specificity is greater than 90%. Nodes can produce false positives. It can also provide an alternative diagnosis in case PTE is not confirmed, so it would be a very useful test. Doppler ultrasound would be the most useful test to diagnose the source of the emboli, so it could also be a valid answer depending on what they mean by "useful". It is a noninvasive technique that has demonstrated its good sensitivity and specificity in the diagnosis of DVT compared to phlebography. It also allows the diagnosis of other pathologies that could justify the patient's symptoms. Its limitations are the assessment of infrapopliteal thrombi and, in many cases, in patients who are not thin, of the iliac and cava veins.

A 45-year-old male patient with a history of uric lithiasis and repeated expulsive nephritic colic for the past 25 years comes to the emergency room reporting palpitations and severe right lumbar pain for the past 2 hours. Urinalysis shows a pH of 5.5 and leukocyturia without proteinuria. The electrocardiogram confirms a previously unknown AF. Blood biochemistry shows a Creat of 0.9, Ca of 11 and LDH of 950. What is the most useful diagnostic maneuver to perform?

ANESTHESIOLOGY, CRITICAL CARE AND EMERGENCY MEDICINE

Intravenous urography revisited in the age of ultrasound and computerized tomography: diagnostic yield in cases of renal colic, suspected pelvic and abdominal malignancies, suspected renal mass, and acute pyelonephritis.

The aim of our study was to assess the diagnostic yield of intravenous urography (IVU) compared to ultrasound (US) and computerized tomography (CT) in cases of renal colic, suspected pelvic and abdominal malignancies, suspected renal mass, and acute pyelonephritis. We retrospectively analyzed the case charts of 216 consecutive patients. The patients had been referred to the Department of Radiology by different hospital departments and local general practitioners. All had undergone clinical examination, US and IVU, in that order. When deemed necessary, conventional tomography was performed. Patients with renal masses also underwent CT. In cases without renal colic and normal US examination, the subsequent IVU failed to detect any further important pathology. Hydronephrosis was equally well detected using US and IVU, however, the level of obstruction was better determined using delayed X-ray films. In 24% of cases of renal colics the initial US was normal, however, the IVU revealed ureteric obstruction. Repeat US 8-12 h later always showed hydronephrosis. In 6 of 34 solid renal masses, IVU and conventional tomography failed to make the correct diagnosis, but never could the patient be spared a subsequent CT. IVU is only indicated if US shows hydronephrosis. In cases of renal colic, repeat US is necessary to diagnose the possibly developing hydronephrosis. Clinical history, US and a plain abdominal image will suffice to make the diagnosis. Renal masses always require CT. In these cases, IVU is not necessary. There is no indication left for conventional renal tomographies.

Heightened suspicion and rapid evaluation with CT for early diagnosis of partial renal infarction.

Although renal infarction has been well studied and clearly defined, it remains greatly underdiagnosed, resulting in significant morbidity. Acute segmental renal infarction is a diagnosis even more problematic, as the problem can appear insidiously and masquerade as other entities including stone, infection, and even tumor. The clinical manifestations and evaluation of partial renal infarction in our patients were reviewed. Seven patients presenting to the emergency department who were subsequently found to have partial renal infarction were identified from the 5-year records of a single institution. Patients were evaluated for presenting complaints, physical findings, temperature, and blood pressure. Laboratory analysis consisted of a complete blood count (CBC); measurements of creatinine, lactate dehydrogenase (LDH), aspartate transaminase/alanine transaminase (AST/ALT), and alkaline phosphatase; and urinalysis. The sequence of the work-up was recorded, as well as time to diagnosis. The etiology of infarction was identified for all patients. All seven patients were eventually discovered to have partial renal infarction as a result of dysrhythmia (N = 4), mural thrombus (N = 2), or septic emboli (N = 1). The average time to diagnosis was 65.2 hours with a range of 9.5 to 168 hours. The chief complaint was flank pain (N = 3), nonspecific abdominal pain (N = 2), left lower-quadrant pain (N = 1), and mental status change (N = 1). The presenting signs and symptoms included abdominal tenderness (N = 4), nausea and vomiting (N = 4), temperature >100.5 degrees F (N = 3), and hypertension (N = 3). Laboratory studies revealed a white cell count >11,000/microL in six, microhematuria in four, proteinuria in four, elevated LDH in all patients, elevated AST/ALT in two, and elevated alkaline phosphatase in one. The work-up varied by presentation, but definitive diagnosis was made by CT in all five patients scanned and by angiography in two. Angiography confirmed the CT findings in four of the five patients. In evaluating partial renal infarction, a strong clinical suspicion is necessary. We found a history of dysrhythmia or other cardiac disease, the presence of abdominal or flank pain, fever with an elevated white cell count, and an elevated LDH to be clinically significant, and their presence should alert the clinician to the possibility of renal infarction. Once a degree of suspicion exists, early evaluation with CT should speed the diagnosis and effect decreased morbidity.

[The meaning and usefulness of spiral CT for radiolucent ureteric stones diagnosis: our experience].

The aim of this work was to report some case histories on the usefulness of spiral TC, used for several years both to diagnose renal colic and urinary lithiasis and to study radio lucent stones that are often difficult to be detected with traditional radiology. 13 patients, aged between 31 and 76 (average age: 54.2), were therefore examined. Eight of them had a ureteral colic when examined, while five patients had shown symptoms some days before being hospitalised in our ward. In all cases, ultrasonography showed a significant hydronephrosis, while direct radiography of the urinary tract could not detect any images that could be associated with radio-opaque lithiasis. All patients therefore underwent an abdominal spiral TC with no contrast medium within 24 hours after hospitalisation. The confrontation between the results obtained by ultrasonography and those obtained by spiral TC, showed the usefulness of the former method to detect stones located in the proximal ureter or in its intramural tract, while the latter could detect the lithiasis of the proximal ureter in 3 cases (23%), of the mid ureter in 2 cases (15.3%), and of the distal ureter in 8 cases (61%). The stones had, approximately, a 5 mm diameter in 5 cases. In 6 cases the diameter was between 6 and 10 mm, and more than 1 cm in 2 cases. Both methods proved to be equally accurate in the assessment of the hydronephrosis degree and of the thickness of the renal parenchyma. The therapy was medical in 2 cases and open surgery in 3 cases, while 8 patients were treated with ureterolitholapaxy with a ballistic searcher. The usefulness of TC in the study of urolithiasis nowadays is supported by a large literature which clearly supplies with documentary evidence the high sensitivity and specificity of such a method in diagnosing the presence of urolithiasis in general and above all of ureteric stones. Such a method not only makes an accurate evaluation of the stones location possible, but it can also assess the calculi dimensions and the indirect signs of the functionality of the kidney affected, without having to use the contrast medium. This method needs very limited execution times and allows a diagnostic of possible collateral pathologies. The main disadvantage of spiral TC, if compared to conventional radiology, is that the patient is exposed to a larger quantity of ionizing radiations, although such an inconvenience will be overcome by the new and more technologically advanced machines. According to our experience, though based on a limited number of cases, spiral TC allowed us to get a quick diagnosis of radio-lucent lithiasis, to see the seat and dimensions of the calculi and finally to chose the most effective treatment. We can therefore think of a diagnostic protocol, for ureteral colics with hydronephrosis or complicated by hyperpyrexia or sepsis, with spiral TC in order to have a quick diagnosis and start the most effective therapy in case an ultrasonographic research should not result diriment.

Role of the plain radiograph and urinalysis in acute ureteric colic.

(1) To determine the accuracy of accident and emergency (A&E) doctors' diagnosis of radio-opaque ureteric calculi on plain abdominal radiographs; (2) to study the predictive value of haematuria with a history suggestive of ureteric colic. A prospective study of all patients seen in a three month period with a provisional diagnosis of ureteric colic. Intravenous urography (IVU) was used as the gold standard for diagnosis of ureteric calculi. The accident and emergency department and medical unit of a large teaching hospital. 60 patients who were admitted with an initial diagnosis of ureteric colic, 51 subsequently undergoing intravenous urography. A&E doctors achieved a calculated sensitivity of 29% (95% confidence intervals 13% to 49%) and a specificity of 73% (52% to 90%) for identification of renal calculi on plain abdominal radiograph, compared with figures of 68% (48% to 84%) and 96% (78% to 100%) respectively for consultant radiologists. The difference between these results was highly significant (P = 0.0011). No patient with a definitive diagnosis of ureteric colic had a negative result for haematuria on urinary dipstick analysis. A&E doctors are poor at identifying radio-opaque ureteric calculi on plain abdominal radiographs. If haematuria is absent on urinalysis then ureteric colic is an unlikely diagnosis.

Present-day imaging of patients with renal colic.

In the past decade alternatives to urography have been proposed for the study of patients with renal colic. In 1992 it was suggested to replace urography with KUB and ultrasonography. In 1993 the combination of KUB and ultrasonography followed by urography in unresolved cases was proposed and, in 1995, it was suggested to replace urography with unenhanced helical CT (UHCT). This article illustrates the contribution of UHCT to the study of patients with renal colic and analyses advantages and shortcomings of the technique compared with other diagnostic approaches. Diagnostics of the patient with renal colic is based on the detection of direct and indirect signs which allow identification of not only the calculus, with a sensitivity of 94-100% and accuracy of 93-98% according different authors, but also other signs that can serve to guide patient management and evaluate long-term prognosis. Unenhanced helical CT has the capability to detect extraurinary abnormalities which present with flank pain and mimic renal colic. The examination technique affects the quality of the images and therefore diagnostic accuracy as well as the dose to the patient. With regard to setting parameters, the choice of thickness and table feed should be guided by numerous factors. Multiplanar reconstruction is indicated in the study of the entire ureter course to identify the exact site of the calcification for the urologist to perform an evaluation similar to that obtained by urography. Many authors consider UHCT to be a valuable tool for suggesting the best therapeutic approach. Among these there are also urologists. The evaluation is based on the stone detection, its size and level in the urinary tract. Cost analysis shows that the cost of UHCT is equal to or inferior to the cost of urography. With regard to the dose, different data are reported in the literature. A high pitch (more than 1.5) and a thin collimation (3-mm thickness) are good compromise between quality and dose which can be compared to the dose of normal urography. What is to be done if helical CT is not available? If helical CT is not available, plain film plus ultrasonography should be considered. This approach does not solve all the cases; in unresolved cases urography is indicated. It should also be noted that US has a good sensitivity in detecting other conditions such as biliary lithiasis, acute pancreatitis, acute appendicitis and abdomino-pelvic masses which are responsible for pain that mimics renal colic. In conclusion, IVU should not have any more the priority in investigating the patients with renal colic. Helical CT should be the first choice in imaging a patient with renal colic. If this technique is not available, plain film and ultrasonography should be considered adding urography in unresolved cases.

[Spiral computerized tomography without perfusion of contrast media as first line investigation in patients with renal colic].

We investigated the diagnostic accuracy of unenhanced helical CT in the detection of stones in patients with suspected renal colic from ureteral stones and compared CT findings with the results of plain abdominal film and US. We reviewed the findings relative to 80 patients (age range 24-75) who came to our observation to the Emergency Department with acute flank pain. All patients had been examined with plain abdominal radiography, US and unenhanced helical CT. While abdominal radiography showed the presence of radiopaque stones in 38 patients only (47.5%), US demonstrated ureter dilatation in 72 patients and detected stones in 36 of them (45%). Helical CT performed best, depicting a stone in 72 patients (90%), with high sensitivity and specificity. Mean stone size was 3 mm, with 7 mm-1 mm range. The biggest stones were seen in 3 cases and the smallest ones in 34. In 8 patients with no signs of stones we found other extraurinary conditions, namely pancreatitis, diverticula, renal cancer. We also found a case of urinary tract infection. Thanks to its short execution time and accuracy, helical CT makes the examination of choice in patients with acute flank pain due to renal colic. It is also a most valuable tool in the differential diagnosis of other pathological causes of pain such as abdominal or pelvic masses and inflammatory conditions.

Abdominal aortic aneurysm

Classification Abdominal aortic aneurysms are commonly divided according to their size and symptomatology. An aneurysm is usually defined as an outer aortic diameter over 3 cm (normal diameter of the aorta is around 2 cm), or more than 50% of normal diameter. If the outer diameter exceeds 5.5 cm, the aneurysm is considered to be large. Ruptured AAA should be suspected in any older (age >60) person with collapse, unexplained low blood pressure, or sudden-onset back or abdominal pain. Abdominal pain, shock, and a pulsatile mass is only present in a minority of cases. Although an unstable person with a known aneurysm may undergo surgery without further imaging, the diagnosis will usually be confirmed using CT or ultrasound scanning. The suprarenal aorta normally measures about 0.5 cm larger than the infrarenal aorta. Differential diagnosis Aortic aneurysm rupture may be mistaken for the pain of kidney stones, or muscle related back pain.

InternalMed_Harrison

The diagnosis is often made on the basis of the history, physical examination, and urinalysis. Thus, it may not be necessary to wait for radiographic confirmation before treating the symptoms. The diagnosis is confirmed by an appropriate imaging study—preferably helical CT, which is highly sensitive, allows visualization of uric acid stones (traditionally considered “radiolucent”), and is able to avoid radiocontrast (Fig. 342-2). Helical CT detects stones as small as 1 mm that may be missed by other imaging modalities. Typically, helical CT reveals a ureteral stone or evidence of recent passage (e.g., perinephric stranding or hydronephrosis), whereas a plain abdominal radiograph (kidney/ureter/bladder, or KUB) can miss a stone in the ureter or kidney, even if it is radiopaque, and does not provide information on obstruction. Abdominal ultrasound offers the advantage of avoiding radiation and provides

Kawasaki disease

Other optional tests include: Electrocardiogram may show evidence of ventricular dysfunction or, occasionally, arrhythmia due to myocarditis. Echocardiogram may show subtle coronary artery changes or, later, true aneurysms. Ultrasound or computerized tomography may show hydrops (enlargement) of the gallbladder. Urinalysis may show white blood cells and protein in the urine (pyuria and proteinuria) without evidence of bacterial growth. Lumbar puncture may show evidence of aseptic meningitis. Angiography was historically used to detect coronary artery aneurysms, and remains the gold standard for their detection, but is rarely used today unless coronary artery aneurysms have already been detected by echocardiography. Biopsy is rarely performed, as it is not necessary for diagnosis.

Relative merits of ultrasound and intravenous urography in the investigation of the urinary tract.

Three hundred and fifty adult patients referred for intravenous urography were entered into a prospective double blind trial comparing intravenous urography with real time ultrasound. The study was performed to clarify the relative merits of the two techniques. Our results show that ultrasound and a plain abdominal radiograph should be the examination of first choice in most circumstances. This is particularly so in vague abdominal pain and in recurrent urinary tract infections where intravenous urography can usually be omitted or used only as a secondary investigation for further evaluation of abnormal ultrasound findings. In acute renal colic, intravenous urography should be the primary investigation. In macroscopic haematuria, initial examination by ultrasound would reliably diagnose mass lesions, show whether the lesion is cystic or solid and assess possible spread. Normal ultrasound does not exclude haematuria due to ureteric lesions or bladder lesions and intravenous urography is recommended.

Page kidney

Diagnosis Techniques for the diagnosis of Page kidney are all imaging based, including abdominal x-ray, intravenous pyelography, angiography, renal doppler ultrasound, CT scan, and Magnetic resonance imaging (MRI). X-ray and pyelography may add in diagnosis, but are non-diagnostic when used alone. Additionally, pyelograms use potentially nephrotoxic contrast agents, further limiting their utility. Diagnosis is primarily made using ultrasound and CT. CT and MRI imaging can show the space occupying lesions but doppler ultrasound is needed to display the hemodynamic changes occurring in the kidney. Ultrasound is often the initial diagnostic test of choice but due to its low resolution further imaging may be necessary. Treatment

Brodifacoum

In another case reported in 2013, a 48-year-old female patient reported 4 days of mild dyspnea, dry cough, bilateral popliteal fossae pain, and diffuse upper abdominal pain. She had no history of liver disease or alcohol or illicit substance abuse. Initial physical examination was remarkable only for mildly pale conjunctivae and mild abdominal tenderness and pain in the left popliteal fossa. A complete blood count and complete metabolic panel were normal. Prothrombin time (PT) was above 100 s, partial thromboplastin time (PTT) was above 200 s and international normalized ratio (INR) was reported as above 12.0. Urinalysis revealed hematuria (blood in the urine). Venous Doppler ultrasound of lower extremities demonstrated left popliteal vein thrombosis. Computed tomography scan of the abdomen demonstrated transmural hematoma, and a fecal occult blood test was positive. A full anticoagulant work-up showed critical reduction of vitamin K-dependent factors II, VII, IX, and X. PT and PTT

Abdominal trauma

Diagnosis Ten percent of people with polytrauma who had no signs of abdominal injury did have evidence of such injuries using radiological imaging. Diagnostic techniques used include CT scanning, ultrasound, and X-ray. X-ray can help determine the path of a penetrating object and locate any foreign matter left in the wound, but may not be helpful in blunt trauma. Diagnostic laparoscopy or exploratory laparotomy may also be performed if other diagnostic methods do not yield conclusive results. Ultrasound Ultrasound can detect fluid such as blood or gastrointestinal contents in the abdominal cavity, and it is a noninvasive procedure and relatively safe. CT scanning is the preferred technique for people who are not at immediate risk of shock, but since ultrasound can be performed right in an emergency room, the latter is recommended for people who are not stable enough to move to CT scanning. A normal ultrasound does not rule out all injuries.

Asymptomatic nephrolithiasis detected by ultrasound.

Data from several countries suggest a recent world-wide increase in the prevalence of stone disease. However, these studies have not analyzed the effect that increases in utilization of imaging modalities have had on detection of asymptomatic stones. A retrospective chart review of all patients who had an abdominal or retroperitoneal ultrasound in 2005 at a Department of Veterans' Affairs Medical Center was conducted. The charts of patients who had ultrasounds demonstrating kidney stones were further reviewed. Patients were classified into symptomatic and asymptomatic groups on the basis of their clinical history. Age and sex for all patients were recorded. For those patients with stones, additional data were recorded. Of all patients in the study, the percentage of those with asymptomatic stones was calculated. Taking into account uncertainty about symptomaticity in some patients, a sensitivity analysis for the presence or absence of gross and microhematuria was performed to determine a range for the percent of asymptomatic stones. Appropriate statistical tests were used to determine significance. The prevalence of all kidney stones in the study group was 8.6 %. Using the sensitivity analysis, 29.8 to 45.7% of all stones were asymptomatic. Of stones found on abdominal ultrasounds, 71.4% were asymptomatic, whereas 36.8% of stones found on retroperitoneal ultrasound were asymptomatic. Asymptomatic stones have a relatively high prevalence on ultrasound. Epidemiologic estimates of prevalence of nephrolithiasis need to account for increases in utilization of imaging modalities and the resulting detection bias.

Imaging characteristics of indinavir calculi.

Indinavir sulfate is an effective protease inhibitor of the human immunodeficiency virus type 1. Use is associated with a significant incidence of crystallization and stone formation in the urinary tract, and these calculi are not visible on plain radiographs. Previously all urinary stones, including uric acid and matrix, were believed to be radiodense on computerized tomography (CT). We conducted a retrospective study to evaluate the radiographic appearance of indinavir calculi. Retrospective chart review of 36 patients taking indinavir sulfate and presenting with renal colic was performed with attention to presentation, urinalysis, radiographic evaluation and management. Specifically, imaging characteristics on CT were addressed. All patients complained of ipsilateral flank pain and 35 had nausea and/or vomiting. Of 30 patients with dysuria or urgency the majority had hematuria, and most had pyuria and/or proteinuria. No stones were visualized on abdominal radiography. Diagnosis was confirmed on 1 of 13 excretory urograms and 4 of 11 renal ultrasounds. None of 12 CT scans was diagnostic of renal lithiasis. Indinavir sulfate is a protease inhibitor with poor solubility and significant urinary excretion. Crystallization and stone formation are demonstrated in as many as 20% of patients taking the medication. Most patients present with flank pain, nausea or vomiting and hematuria. Previously CT was thought to identify all urinary calculi with clarity but it cannot reliably confirm the presence of indinavir calculi.

[The local lysis therapy of spontaneous renal artery dissection with arterial thrombosis].

A 33-year-old previously completely healthy man developed severe, at first colicky then persisting, pain in the left flank. The blood pressure was 190/110 mm Hg and he had pain over the left kidney on percussion. There was a mild leucocytosis (10,300/microliters), serum creatinine of 1.5 mg/dl and a rise in lactate dehydrogenase level to 395 U/l, while the urine was unremarkable. The pyelogram demonstrated on the left the upper calyceal system only and this very weakly. Colour Doppler ultrasound showed a massively reduced blood flow in the left renal vein while the artery was not visible. Digital subtraction angiography demonstrated eccentric narrowing of the left renal artery by an intravascular thrombus, providing the diagnosis of spontaneous renal artery dissection with thrombosis. Complete recanalization occurred after local thrombolysis with 500,000 IU urokinase over 7 hours, and subsequent administration of four times 40 mg tissue plasminogen activator over 4 hours. But the scintigram still demonstrated impaired renal function with decrease in clearance to 10% of total. The patient was still symptom-free on re-examination 16 months later, serum creatinine concentration was stable at 1.3 mg/dl and the blood pressure was normal.

Bilateral Renal Hypoperfusion Following Motor Vehicle Accident.

Renal hypoperfusion noted on abdominal computed tomography (CT) scan without any underlying comorbid condition is a rare finding. Most reported cases of renal hypoperfusion have an association with an underlying cardioembolic problem, such as atrial fibrillation, endocarditis, cardiomyopathies, or artificial valve thrombi. We present a case of transient renal hypoperfusion evident on abdominal CT scan following blunt trauma. An 18-year-old male without any significant past medical history presented to the emergency department with the complaint of abdominal pain. The patient reported history of motor vehicle accident 1 week prior to his presentation. He was a front seat passenger wearing a seatbelt when the car went into a ditch. Airbags were deployed and the patient briefly lost consciousness. He presented 1 week later with complaints of generalized abdominal pain, more on the left side that started a few days after his accident, nonradiating, constant, 4/10 intensity. He denied dysuria, hematuria, groin pain, fever, chills, nausea, vomiting, abdominal pain, diarrhea, constipation, decreased oral intake, joint pain, leg swelling, or redness. He denied any medication use or any history of intravenous drug abuse. There was no reported family history of kidney disease or blood clots. Initial laboratory tests, including complete blood count, basic metabolic panel, erythrocyte sedimentation rate, and urinalysis were unremarkable except trace protein on the urinalysis. Contrast-enhanced CT of the abdomen showed multiple, confluent, focal areas of hypoperfusion of the renal parenchyma bilaterally. Given the CT findings of bilateral renal hypoperfusion, the patient was admitted to the hospital and an extensive workup was performed to rule out cardioembolic etiology. Echocardiogram, renal ultrasound, magnetic resonance angiogram of the abdomen, vasculitis panel, and hypercoagulable workup was unremarkable. The CT findings of renal hypoperfusion were considered secondary to transient hypoperfusion from blunt trauma. Abdominal pain resolved with nonsteroidal anti-inflammatory drugs and he was discharged to home. Follow-up abdominal CT scan with contrast obtained a few months later showed normal kidneys with resolution of previously noted renal hypoperfusion. Our case highlights a benign incidental finding of bilateral renal hypoperfusion following motor vehicle accident (with airbag injury), which resolved on follow-up imaging. On literature search, such CT scan findings of transient renal hypoperfusion of unclear significance have not been previously reported. Even though our patient underwent extensive workup to rule out cardioembolic etiology, it may be reasonable to forego such workup following blunt abdominal trauma.

[Ultrasound diagnosis of an abdominal aortic aneurysm in a 52 year old woman].

The abdominal aortic aneurysm (AAA) is defined as increasing the diameter of the aorta in more than 50 % of its original size and the infra-renal location is the most common (90 %). AAA disease mainly affects older men and white smokers, and has a male: female ratio of 4:1, as well the diagnosis is rare in women under age 55. Aneurysm rupture is the most common complication and cause of death in the general population, its etiology is unclear, but is commonly associated with atherosclerosis. The AAA do not exhibit rupture and  it is usually asymptomatic diagnosed incidentally, however, as the aneurysm grows, appears symptoms such as back pain, abdominal or groin pain, well as palpation of a pulse mass on umbilical and supra-umbilical region. Imaging study such as ultrasound and CT scan are the mainstay of diagnosis. We present a case of 52 years old patient with no history related to the diagnosis, who presented sudden and severe abdominal pain. She was admitted to the emergency room with a diagnosis of acute cholecystitis vs. acute pancreatitis. After ultrasound and CT studies, the diagnosis was a complicated abdominal aortic aneurysm.

[Lithiasis of soft appearance within a calyceal diverticulum in the right kidney. Report of one case and therapeutic management].

To report the case of a 28-year-old female patient carrying a lithiasis of soft appearance located within a calyceal diverticulum in the right kidney which presented clinically during pregnancy, and to comment on therapeutic management, as well as the outcome one year after conservative treatment. 28-year-old female patient with history of renal colic during pregnancy, who presents at our clinics in the postpartum period with a recurrent abdominal and lumbar pain. Kidney-ureter-bladder (KUB) x-ray and intravenous urography (IVP) detected a lithiasis of soft appearance within a calyceal diverticulum in the right kidney. Treatment was conservative with potassium citrate/citric acid and follow-up controls with urine culture (every 3 months) and ultrasounds (every 8 months). Currently she is asymptomatic but the lithiasis persists on KUB and urine culture is positive (Escherichia coli) and receives treatment with cefuroxime 250 mg every 12 hours for 6 days and nitrofurantoin 100 mg every night for three months. Most urinary stones located within calyceal diverticula have an asymptomatic course, treatment not being necessary. The most frequent clinical presentations of these stones are flank pain, urinary infection demonstrated by positive urine culture, and incidental finding. IVU is an effective method for diagnosis. ESWL is not an effective treatment for them, being percutaneous techniques the most suitable for a single-surgical procedure resolution of both lithiasis and pyelocalyceal diverticulum.

[Significance of simple radiography of the abdomen in nephritic colic].

The utility of the abdominal plain film in the emergency department to evaluate urolithiasis is questionable. Between another things, there are influence of the different formation of distinct examinators. A retrospective study in 65 patients referrals to urology in 1997 and 1998 by suspicion of renal colic was carried out. The radiography of abdomen took in the emergency room the day of the income is reviewed with a protocol, by a resident of Familiar and Community Medicine and by the urologist, separately and without information of the medical records. We have excluded three patients. At last, we diagnose 49 patients as renal colic with certainty, 6 patients with doubtful diagnosis and 7 patients with distinct diagnosis. The urologist achieved the most adequate reading in 11 cases; in 7 was best the resident, to equal in 31, and in 13 the differences were not important. The resident obtained of radiography a sensitivity of the 67% and a specificity of the 42% and the urologist 71% and 57% respectively. There are few differences of reading, at least when the resident dispose a protocol of interpretation. Despite to the almost null diagnostic utility of the radiography, supply additional ation, and permit to value the evolution with a few aggressive technique.

Infected renal hematoma in a healthy adolescent with no renal structural anomaly.

Renal abscesses are uncommon in otherwise healthy children and adolescents who have no underlying renal structural anomalies. A previously healthy, immunocompetent, 14-year-old male without a history of abdominal trauma or urinary tract infection (UTI) was found to have a renal hematoma that became infected and developed into a renal abscess. He presented with a 2-day history of nausea, vomiting, fever and 1-day history of abdominal pain that radiated to the right flank. Clinical examination, blood work, and initial imaging indicated likely infection; however, findings were normal on urinalysis and urine culture had no growth. Complete blood count (CBC) showed a leukocytosis with a left shift. Renal ultrasound showed a 4-cm mass-like area of liquefaction in the upper pole of the right kidney, confirmed by abdominal computed tomography (CT) scan with and without contrast. Intravenous ceftriaxone was started and the patient continued to improve. He was discharged on hospital day 6 after remaining afebrile for over 20 hours and inflammatory markers continued to decrease. Intravenous ceftriaxone was continued, and oral clindamycin was added. Both antibiotics were discontinued on day 24 since onset of illness.

[Early and systematic use of ultrasonography in emergency patients with renal colic: analysis of the actual diagnostic efficacy].

In this study, the diagnostic yield of ultrasonography (US) in the early phase of acute urinary obstruction was retrospectively assessed and compared with that of clinical examination. 351 patients were admitted to our emergency department because of suspected renal colic over an 11 months' period: urinary obstruction was subsequently confirmed with other examinations in 76 of them, who were all submitted to renal US within 2 hours of the onset of symptoms. Emergency US results were then retrospectively compared with clinical and laboratory data and the cost of each US exam was calculated. Thirty-nine of 76 patients had negative US findings (51.3%). In the extant 37 patients, US showed hydronephrosis (which was mild in 13 patients and moderate in 6) and renal stones (in 18 patients). Hydronephrosis was associated with renal stones or increased parenchymal echogenicity in 5 and 6 patients, respectively. Pain, which was always severe, was not a useful sign for diagnostic purposes. In contrast, all the 37 patients with abnormal US findings (hydronephrosis, renal stones and increased parenchymal echogenicity) exhibited specific clinical and laboratory abnormalities such as hematuria, ketonuria and marked blood pressure increase (diastolic pressure > 100 mmHg). The same abnormalities, although less severe (mild hematuria and ketonuria and increased diastolic pressure not exceeding 100 mmHg) were nevertheless present in all the 39 patients with negative US findings and yet having a renal colic. The cost of each emergency US exam (calculated on the basis of literature tables and reference cost) was approximately It. L. 104,000. The corresponding total cost for submitting to US all the 76 patients with renal colic was approximately It. L. 7,900,000. In the early phase of urinary obstruction, the association of hematuria, ketonuria and increased blood pressure was more reliable than US findings-the latter method yielding a 51.3% false-negative rate. The presence and severity of the above clinical and laboratory abnormalities might thus represent a criterion to select the patients who are less likely to have positive US findings. This should allow the cost of medical and non-medical staff, equipment and materials to be reduced. As for our personal series, It. L. 28,000,000 was the estimated additional cost of performing US routinely in all the remaining (275) patients with suspected renal colic.

Ultrasonography compared with intravenous urography in the investigation of adults with haematuria.

To compare ultrasonography with intravenous urography in the investigation of adults with haematuria. Prospective study entailing the examination of all patients with both investigations concurrently. The investigations were performed independently on routine lists by different duty radiologists. Each was aware of the details of the request form but not of the findings of the other investigation. Radiology department of a teaching hospital. 155 Consecutive adult patients (aged 18-93) referred from general practitioners and hospital outpatient clinics with a history of haematuria. When results of both examinations proved normal no clinical or radiological follow up was sought. All abnormal findings of either investigation were correlated with results of subsequent imaging studies or operative findings. 81 Patients (52%) had normal findings on urography and ultrasonography. Overall, the findings of ultrasonography concurred with those of urography in 144 cases (93%). Among the discrepant findings of the two investigations ultrasonography missed two ureteric calculi; one was in a non-dilated ureter, and in the other case ultrasonography detected the secondary ureteric dilatation. Ultrasound examination alone detected four bladder tumours not visible on urography with sizes ranging from 5 to 21 mm, representing one fifth of the 20 cystoscopically proved bladder tumours detected in the series. Ultrasonography detected all the 22 neoplastic lesions discovered in the study (20 bladder, two renal). Ultrasonography clarified the nature of renal masses evident in three urograms (simple cysts). Ultrasonography is a safe and accurate method of investigating the urinary tract in adults with haematuria. When combined with a single plain abdominal radiograph it proved to be superior to urography as the primary imaging study in this series. Ultrasonography should certainly be preferred to urography if cystoscopy is not planned. No urothelial tumours of the upper urinary tract were found in the series, reflecting their rarity. For those patients in whom ultrasonography and plain radiography have shown no abnormality and in whom cystoscopic appearances are normal urography would be advisable to exclude urothelial tumours of the upper urinary tract.

Ischemic colitis

Diagnostic tests There is a recent optical test, but it requires endoscopy (see Diagnosis). There are no specific blood tests for ischemic colitis. The sensitivity of tests among 73 patients were: The white blood cell count was more than 15,000/mm3 in 20 patients (27%) The serum bicarbonate level was less than 24 mmol/L in 26 patients (36%) Plain X-rays are often normal or show non-specific findings. In a series of 73 patients, plain abdominal radiography (56%) showing colic distension in 53% or a pneumoperitoneum in 3%. CT scans are often used in the evaluation of abdominal pain and rectal bleeding, and may suggest the diagnosis of ischemic colitis, pick up complications, or suggest an alternate diagnosis.

[Diagnosis of "severe" renal insufficiency of unknown origin: value and respective roles of ultrasonography and intravenous urography (author's transl)].

A retrospective study in 46 patients hospitalised with severe renal insufficiency of unknown origin, and investigated by means of a straight x-ray of the urinary system followed by bilateral renal ultrasonography, emphasises the importance of the latter examination for establishing the medical or surgical origin of the affection. Intravenous urography, which carries certain risks and does not supply supplementary information, can sometimes be avoided, but it is essential when dilated cavities are seen on ultrasonography. In the absence of the latter sign it should be performed when there is clinical evidence of an obstruction, or when the kidneys are of normal size of enlarged, depending on the results of biological tests or the clinical history. The only contraindication to its use is when ultrasonography has shown two small kidneys with thin cavities resulting from an acute episode of a pre-existing chronic nephropathy.

[Right ectopic hydronephrotic kidney with pelvic lithiasis. Report of a case].

To report a case of hydronephrotic ectopic kidney with lithiasis and pelvic localization, its diagnostic aspects and surgical treatment. A 39-year-old male consulted at the emergency services for low abdominal pain. Physical examination disclosed a hypogastric mass. Patient evaluation by ultrasound, intravenous urography and pyelography revealed a right hydronephrotic ectopic kidney with lithiasis and pelvic localization. Nephrectomy via a right infraumbilical incision was performed. Pelvic renal ectopy is uncommon, but not rare in our area. This anomaly is associated with a higher than normal incidence of hydronephrosis and lithiasis. The diagnostic techniques most frequently used to evaluate these patients are ultrasound, intravenous urography, cystography and pyelography. When a surgical procedure is performed, the anatomical features of this anomalous condition should be considered, such as abnormal vascularization, pyelourethral anomalies, kidney rotation and absence of perirenal fat tissue.

One year's clinical experience with unenhanced spiral computed tomography for the assessment of acute loin pain suggestive of renal colic.

To assess the use of unenhanced spiral computed tomography (CT) as the primary investigation of choice for suspected acute renal colic in clinical urological practice. Patients and Methods Between 1 August 1997 and 31 July 1998, all patients attending a hospital accident and emergency department with acute loin pain suggestive of renal colic underwent a physical examination, urine analysis, plain abdominal radiography (if clinically indicated) and unenhanced spiral CT. The effective radiation dose and financial cost of unenhanced spiral CT and standard three-film emergency intravenous urography (IVU) were calculated. In all, 116 patients were assessed, 63 of whom had calculi and related secondary phenomena of obstruction identified on unenhanced spiral CT. There were two false-positive and one false-negative result. An alternative urinary tract diagnosis was made in four patients, including two with renal cell carcinoma and one ureteric transitional cell carcinoma. Causes other than in the urinary tract were diagnosed in three patients, i.e. two with ovarian cyst and one with sigmoid diverticulitis. The effective radiation dose of unenhanced spiral CT was 4.7 mSv and that for three-film IVU was 1.5 mSv. The costs of both IVU and unenhanced spiral CT were identical. Unenhanced spiral CT allows a rapid, contrast-medium-free, anatomically accurate diagnosis of urinary tract calculi and in the present series had a sensitivity of 98% and a specificity of 97%. CT provided an alternative diagnosis in 6% of patients. These advantages must be weighed against the threefold greater radiation dose of unenhanced spiral CT than with three-film IVU, and in practice the requirement for a radiologist to interpret routine axial scans.

Suspected ureteral colic: plain film and sonography vs unenhanced helical CT. A prospective study in 66 patients.

The aim of this study was to compare the sensitivity and specificity of plain abdominal films plus ultrasound, vs nonenhanced CT for the diagnosis of ureteral colic in patients with acute flank pain. During a 4-month period, 66 patients (mean age 48 years) with acute flank pain were prospectively studied by means of plain abdominal film, US, and unenhanced CT. The presence of lithiasis and of obstructive uropathy signs were determined. The plain film was only used as a guide for the US exam. Clinical follow-up of all patients was obtained. Ureteral lithiasis was confirmed in 56 patients. The CT had a greater sensitivity (93 vs 79%) and negative predictive value (71 vs 46%) for the detection of lithiasis. The combination of lithiasis plus obstructive signs showed a sensitivity and a specificity of 100% for CT and of 100 and 90%, respectively, for US. The 11 lithiasis not detected by US were passed spontaneously (10 were <5 mm). Both techniques showed similar extraurinary pathology. Computed tomography is the most accurate technique for the detection of ureteral lithiasis; however, the combination of plain film and US is an alternative to nonenhanced CT with a lower sensitivity and radiation dose that has a good practical value.

[Value of ultrasound in early diagnosis of renal cell carcinoma].

The importance of ultrasonography in early detection of renal cell carcinoma was analyzed for 1854 patients, who were operated from 1975 to 1997. The 5-year survival rate of all patients amounts to 75%, the 10- and 20-year survival rate was 68% and 64%. While from 1975 to 1986 tumor symptoms like hematuria (30%), abdominal pain (19%) and palpable mass (3%) lead to diagnosis of renal cell carcinoma in 56% of all cases, there were only 26% from 1987 to 1997. 83% of asymptomatical tumors from 1987 to 1997 were accidentally detected by means of ultrasonography in a kidney independent examination. These tumors are significantly smaller (5.5 cm) than the tumors of symptomatical patients (7.8 cm) and show often a significantly lower local tumor stage, a better tumor grade, frequently lymph nodes, which are free of tumor infiltration and more rarely distant metastasis. The 5-year survival rate of patients with incidental tumors, detected by ultrasonography (82%) was significantly better (log rank < 0.001) in comparison with the symptomatical patients (72%). These results verify 1. The effectivity of ultrasonography in early diagnosis of renal cell carcinoma and 2. The advantage of survival on patients with early tumor detection. That's why asymptomatic patients, who selected under risk factors should be examinated by ultrasonography consistently too.

[Laparoscopic cholecystectomy in a patient with situs inversus totalis].

To report a case with situs inversus totalis (SIT) and chronic cholelithiasis solved by laparoscopic surgery, outlining the utility of minimal invasive surgery and specific considerations in patients with anatomic variations. A case of a 46 year-old female who presented with a six-month history of abdominal colic pain at the left hypochondrium, accompanied with nausea and vomiting, is presented. On examination she had epigastric tenderness. Blood tests, including liver function tests, were normal. Electrocardiogram showed right axis deviation and right ventricular hypertrophy, in keeping with dextrocardia. Chest-X-Ray confirmed the diagnosis of dextrocardia. An ultrasound scan of the upper abdomen identified the gallbladder containing stones in the left upper quadrant. A CT scan visualized the spleen and the gastric camera in the right upper quadrant. Barium gastrointestinal transit, barium enema and abdominal-X-Ray were used as complementary diagnostic studies. A magnetic resonance cholangiography was not performed because the patient suffered from claustrophobia. Cholecystectomy and transcystic cholangiography were performed by laparoscopic route, taking care to set-up the operating theatre in the mirror image of the normal set-up for cholecystectomy. The patient completed a successful procedure without complications and was discharged 48 hours after the procedure. Histological exam diagnosed a chronic lithiasic cholecystitis. Laparoscopic cholecystectomy is an adequate surgical procedure for patients with total situs inversus and cholelithiasis, having a high security range. Detailed clinical examination is important for the diagnosis of previously unknown anatomic variations. Transcystic cholangiography is mandatory when a magnetic resonance cholangiography can not be performed. Furthermore, perhaps in this situation a left-handed surgeon is better prepared than a right-handed one to comfortably carry out the procedure.

The diagnostic yield of intravenous urography: a demographic study.

To examine the impact of intravenous urography (IVU) on patient management in unselected patients in an effort to identify groups in which the use of urography could be reduced. The results of IVU in 235 consecutive unselected patients were assessed prospectively to establish the value of IVU in patient management. Patients were divided into subgroups on the basis of age, sex, presenting symptoms and source of referral. The percentage of examinations with findings affecting patient management was taken as the 'positive diagnostic yield.' Differences between the positive diagnostic yields of IVU in the various groups were examined using the chi 2 test. For all patients the diagnostic yield was 37.4%. In patients over 50 years of age the yield was 46% while below that age the yield fell to 20%. This difference was significant (chi 2 = 13.88, P < 0.001). There were no significant differences between the other defined groups. Specifically, patients referred by general practitioners were as likely to have an IVU abnormality as were patients referred by a hospital practitioner. Patients with painless microscopic haematuria had a lower diagnostic yield (20%) than the other groups examined but this was not significant. IVU has a high diagnostic yield in an unselected population. Although the yield is lower in younger patients IVU offers advantages over other techniques in the investigation of urolithiasis--the commonest positive diagnosis in this study. We argue that it should retain its position as the primary investigation for the majority of patients with urological disease, particularly those suffering loin pain or haematuria.

[Retroperitoneal fibrosarcoma. Apropos of a case].

To report one case of retroperitoneal fibrosarcoma in a 45 year-old caucasian patient cared for at the Public Health System hospitals in Republic of Cuba. Blood analysis showed increased erythrocyte sedimentation rate and moderate anemia. Intravenous urography showed that left kidney was displaced towards midline but presented a good contrast uptake and excretion. Renal ultrasound discovered a large hyperechogenic mass with internal calcifications. CT scan confirmed a left flank tumor with internal necrosis which displaced the kidney. Complete tumour resection was performed confirmatory of the histological diagnosis of retroperitoneal fibrosarcoma. Postoperative chemotherapy was administered. Four months after surgery patient presented with severe lumbar-abdominal pain; abdominal ultrasound showed retroperitoneal and intraperitoneal recurrences; patient have a sudden death after a dyspnea episode one month later. Necropsy revealed right pulmonary thromboembolism, abdominal ganglionar metastases and retroperitoneal tumour extension. Our experience confirms the aggressiveness of this tumours and their tendency to local recurrence.