Renal artery thrombosis secondary to sepsis-induced disseminated intravascular coagulation in acute pyelonephritis

There are some reports of renal vein thrombosis associated with acute pyelonephritis, but a case of renal artery thrombosis in acute pyelonephritis has not been reported yet. Here we report a case of renal artery thrombosis which developed in a patient with acute pyelonephritis complicated with sepsis-induced disseminated intravascular coagulation (DIC). A 65-year-old woman with diabetes was diagnosed with acute pyelonephritis complicated with sepsis. Escherichia coli was isolated from both blood and urine cultures. When treated with antibiotics, her condition gradually improved. She suddenly complained of severe right flank pain without fever in the recovery phase. A computed tomography scan revealed right renal artery thrombosis with concomitant renal infarction. Prophylactic anticoagulation therapy was not suggested because of sustained thrombocytopenia and increased risk of bleeding. Flank pain resolved with conservative treatment and perfusion of infarcted kidney improved at the time of discharge. To our knowledge, this is the first case of renal artery thrombosis related to acute pyelonephritis with sepsis-induced DIC.

The Impact of Donor and Recipient Age in the Outcome of Kindney Transplatation / 대한이식학회지

PURPOSE: As general population survival has improved in the last few decades, the age of patients participating in renal transplantation also has increased. This study aimed to investigate the impact of donor and recipient age as predictor of long-term graft survival in renal transplantation. METHODS: We analyzed the transplantation outcome in 598 patients, who received renal transplantation from 1978 to 2003 at Hanyang Universitiy. Patients were divided into four groups according to the age at renal transplantation. Group A (donor age> or =50, recipient age> or =50, n=19/3.2%), group B (donor age> or =50, recipient age or =50, n=69/11.6%), group D (donor age<50, recipient age<50, n=357/59.8%). Univariate analysis was used to assess the effect of donor and recipient age as predictor factors of graft outcome. We used Kaplan Meier log-rank method for graft survival and P values less than 0.05 were considered significant. RESULTS: In elderly donor group, graft survival was 89.8% at 1 year, 76.4% at 3 years and younger donor group was 92.8 at 1year, 84.0% at 3 years and the differences showed statistic significance (P=0.009). Univariate analysis of age factor showed a significant reduction of graft survival in recipients transplanted with kidneys coming from donors older than 50 years, however recipient age greater than 50 years was not found as an independent risk factor. The incidence of rejection was 24.6% in elderly donor group and 23.5% in younger donor group (P=NS). Among the four groups, the most valuable result was group D and the 1 year and 3 years graft survival were 93.1%, 84.5% respectively but it was not significant statistically (P=0.50). CONCLUSION: This result is important for the design of allocation and transplantation strategies for kidneys procured in elderly donors and recipients.

Characteristic Sonographic Appearance of Normal Appendix in Children: Inner Hypoechoic Band without Folding

PURPOSE: To identify the characteristic ultrasonographic findings of the normal appendix in children in order to detect it more easily and so to exclude acute appendicitis from a diagnosis with more confidence. MATERIALS AND METHODS: Among 64 patients presenting with right lower quadrant pain, 44 patients, excluding 15 patients diagnosed as acute appendicitis and 5 patients with non-visualization of the appendix due to severe ileus and obesity, were evaluated for the point of incidence, the thickness and the presence of folding of the inner hypoechoic band of the normal appendix. The age of the patients ranged from 3 to 15 years with a mean age of 6.5 years. Two patients were operated on and we correlated the preoperative ultrasonographic findings with the histologic findings. RESULTS: In all the cases of the 44 patients with normal appendix, the inner hypoechoic band was discovered, which was seen as a linear structure without folding along the whole length of appendix. This measured as 0.75 mm (0.3-1.5 mm) for the mean thickness. The inner hypoechoic band corresponded to the mucosal layer that had abundant lymphoid tissue on the histologic examination. CONCLUSION:For the pediatric normal appendix, the inner hypoechoic band without folding is present, and this corresponds to the mucosal layer with abundant lymphoid tissue.

Radiologic Findings of the Anthrax: Focus on Alimentary Anthrax

PURPOSE: To evaluate the radiologic findings of alimentary anthrax. MATERIALS AND METHODS: 19 patients with alimentary anthrax, which was caused by ingestion of contaminated beef, were included in this study. The diagnosis was made .b.y demonstration of Bacillus anthracis in smear and culture of the contaminated meat. We evaluated the clinical manifestations and the findings of thoracic, abdominal radiographs, cervical, abdominal ultrasonograms and abdominal CT scans. RESULTS: Out of the 19 patients with the alimentary infection, 9 had oropharyngeal form, 18 had abdominal form and 8 had combination of oropharyngeal and abdominal form. The patients had general symptoms and signs such as fever, chill, myalgia. Clinical symptoms and signs were sore throat, throat injection, throat ulcer and patch in oropharyngeal form, and nausea, vomiting, abdominal pain, diarrhea, and gross GI bleeding in abdominal form. Radiologic findings included enlarged cervical lymph nodes(36%) in oropharyngeal form, and paralytic ileus(26%), ascites(26%), hepatomegaly(21%), enlarged mesenteric lymph nodes(26%), small bowel wall thickening(5%) in abdominal form. In two patients, late complications occurred as intestinal obstruction due to ileal stricture with perforation, and inflammatory changes of pelvic cavity due to ileovesical fistula. CONCLUSION: Radiologic findings of alimentary anthrax are difficult in differentiation from those of other inflammatory bowel disease, but those radiologic findings with clinical manifestations may be helpful in diagnosis and evaluation of disease process in patients with alimentary anthrax.

Treatment of Malignant Biliar Obstruction with Wallstent Endoprosthesis

PURPOSE: The purpose of this study was to evaluate the patency, procedure related complications and effectiveness of Wallstent application to the malignant biliary obstruction as a palliative treatment. MATERIALS AND METHODS: We retrospectively reviewed the clinical results, duration of survival, patency rate and complication of the Wallstent application on 33 patients who had had obstructive jaundice by the malignant lesion in recent 3 years. One or two step procedures. were mainly taken with 10mm diameter Wallstents. Grouping according to place the stent at the hilum or not, and grouping according to place the stent through the ampulla or not were done to evaluate the difference of the patency and survival rate between the groups. RESULTS: Biliary endoprosthesis with Wallstent were successfully placed in all patients without difficulty. Procedure related short-term complication rate was about 18.1% (n=6/33). Complications were fever(n=4), cholecystitis(n=1) and sepsis(n=l). Long-term complications were mainly obstruction(n=9/31) of the Wallstent during the follow-up period. Also cholecystitis occurred in one patient 3 months later. Mean survival duration was 139.72 (46-237)days ormong those who expired. Mean patency duration of stents was 139.67 (26-310) days. Survival rates were 93.5% at the second month, 68.8% at the third month, 61.2% at the 4th month, 53.5% at the 5th month, 49.1% at the 7th month and 35.7% at the 9th month. Patency rates were 93.7% at the second month, 84.2% at the 4th month, 66.9% at the 5th month, 59.5% at the 7th month and 39.6% at the 10th month. The application was repeated in the 6 patients with stent occlusion. Significant statistical difference could not be found between the groups according to placing the stent at the hilum and according to placing the stent through the ampulla. Patency rates were higher than survival rates in the follow-up period. CONCLUSION: Wallstent application provides good palliation with little discomfort and few complications in the patients with malignant obstructive jaundice.

CT Appearance of Internal Hernia:Whorling Sign of Mesentery and Mesenteric Vessels

PURPOSE: To evaluate CT findings of internal hernia. MATERIALS AND METHODS: Three patients with internal hernia had abdominal CT scans and two of them had small bowel follow through examinations. The CT features of two patients with retroanastomotic and one patient with left paraduodenal hernia were evaluated and correlated with small bowel follow through examinations, and surgical findings. Two patients with retroanastomotic hernia had a history of subtotal gastrectomy with antecolic gastrojejunostomy. The diagnosis of internal hernia was made on the basis of surgical find ings in two patients of retroanastomotic hernia, and characteristic barium study findings in one patient of left paraduodenal hernia. RESULTS: The small bowel follow through examination showed small bowel loops gathered in a circumscribed mass in the left mid abdomen, and delay in passage through these loops. In case of left paraduodenal hernia, abrupt narrowing of the distal duodenum could be identified. The characteristic CT findings of all three patients were whorling of the mesentery and mesenteric vessels in the left mid-abdomen. In the patient with left paraduodenal hernia, after resolution of the gastrointestinal symptoms, a follow-up CT scan showed spontaneous disappearance of whorling of the mesentery and mesenteric vessels suggesting spontaneous resolution of the hernia. In the other two cases, upon exploration of the abdomen, dilatation of afferent duodenum caused by adhesion between ligament of Treitz and adjacent bowel walls, and retro- anastomotic herniation of the efferent loops were found. CONCLUSION: The usual diagnosis of internal hernia is based on the appearance of the small bowel follow through examination. However, we consider that the whorling appearance(we call it whorling sign) of the mesentery and mesenteric vessels on CT scan is also suggestive of internal hernia in patients under clinical suspicion.