Clinical Profile and Renal Ultrasound Characteristics of Children With Nutcracker Syndrome in Turkey

Objective: We aimed to evaluate the clinical profile and radiological findings of children with nutcracker syndrome (NCS) and to assess the association between the parameters. Methods: A retrospective analysis of the clinical, laboratory and radiological parameters of children diagnosed with NCS between January, 2011 and October, 2017 was done. Results: Of a total of 29 patients [19 girls, 65.5%] with NCS, having a mean (SD) age of 10.8 years, 72.4% had BMI <-2SD. Approximately half of the patients (51.7%) were asymptomatic. Left flank pain was commonest (9/29; 31%) symptom, followed by macroscopic hematuria (4/29; 13.8%). Isolated proteinuria was seen in 9 children. There was no significant difference between the symptomatic and asymptomatic patients in terms of Doppler ultrasonography findings. All patients were followed up conservatively, 5 received enalapril therapy for moderate proteinuria. Conclusion: NCS should be considered in children, especially with low BMI, presenting with orthostatic proteinuria and hematuria, with or without left flank pain after ruling out the common causes.

Infarto renal: revisión sistemática sobre síntomas de sospecha clínica y repercusión sobre función renal / Renal infarction: systematic review of symptoms of clinical suspicion and repercussion on renal function / Infarto renal: revisão sistemática dos sintomas de suspeita clínica e repercussão na função renal

Resumen: Introducción: El infarto renal es una entidad poco frecuente y está sub-diagnosticada por lo que para su diagnóstico se necesita un alto índice de sospecha clínica. Objetivo: Determinar las características clínicas y paraclínicas más frecuentes en el infarto renal, destacando la repercusión en la función renal. Metodología: Se realizó una revisión sistemática de serie de casos en PUBMED y SciELO con los términos: "renal infarction" y "renal infarct". Se estudiaron variables: demográficas, clínicas y paraclínicas. En el caso de las variables paraclínicas se analizó el porcentaje de pacientes con valores elevados de cada una de las mismas. El análisis estadístico fue realizado con EPI INFO 7. 2. Resultados: Los síntomas y signos más frecuentes fueron oliguria, dolor en flanco y abdominal, nauseas, fiebre y vómitos. Los parámetros paraclínicos alterados fueron: LDH, PCR y glóbulos blancos. Se constató injuria renal aguda en 30.8% de los pacientes, la progresión a enfermedad renal crónica se observó en 17.3% y la progresión a enfermedad renal terminal se observó en 5.2% de los pacientes. Discusión y conclusiones: La determinación de las características clínicas y paraclínicas más frecuentes del infarto renal, se pueden utilizar para disminuir el retraso diagnóstico, lo que tiene consecuencias terapéuticas.

Abstract: Introduction: Renal infarction is a rare entity and is under-diagnosed, so a high index of clinical suspicion is needed for its diagnosis. Objective: To determine the most frequent clinical and paraclinical characteristics in renal infarction, highlighting the impact on renal function. Methodology: A systematic review of a series of cases was carried out in PUBMED and SciELO with the terms: "renal infarction" and "renal infarct". Variables were studied: demographic, clinical and paraclinical. In the case of paraclinical variables, the percentage of patients with high values ​​of each of them was analyzed. The statistical analysis was performed with EPI INFO 7. 2. Results: The most frequent symptoms and signs were oliguria, flank and abdominal pain, nausea, fever and vomiting. Paraclinical parameters altered were: LDH, CRP and white blood cells. Acute renal injury was found in 30.8% of patients, progression to chronic kidney disease was observed in 17.3% and progression to end-stage renal disease was observed in 5.2% of patients. Discussion and conclusions: The determination of the most frequent clinical and paraclinical characteristics of renal infarction can be used to reduce the diagnostic delay, which has therapeutic consequences.

Resumo: Introdução: O infarto renal é uma entidade rara e é subdiagnosticada, portanto, um alto índice de suspeita clínica é necessário para o seu diagnóstico. Objetivo: Determinar as características clínicas e paraclínicas mais frequentes no infarto renal, destacando o impacto na função renal. Metodologia: Uma revisão sistemática de uma série de casos foi realizada em PUBMED e SciELO com os termos: "infarto renal" e "infarto renal". As variáveis ​​foram estudadas: demográficas, clínicas e paraclinicais. No caso de variáveis ​​paraclínicas, foi analisada a porcentagem de pacientes com valores altos de cada um deles. A análise estatística foi realizada com o EPI INFO 7. 2. Resultados: Os sintomas e sinais mais frequentes foram oligúria, dor no flanco e abdominal, náusea, febre e vômitos. Parâmetros clínicos alterados foram: LDH, PCR e glóbulos brancos. A lesão renal aguda foi encontrada em 30,8% dos pacientes, a progressão para doença renal crônica foi observada em 17,3% e a progressão para doença renal terminal em 5,2% dos pacientes. Discussão e conclusões: A determinação das características clínicas e paraclínicas mais frequentes do infarto renal pode ser utilizada para reduzir o retardo no diagnóstico, o que tem consequências terapêuticas.

Retrocaval Ureter with Proximal Hydroureteronephrosis Presenting as Flank Pain in a Child: A Rare Case Report with Review of Literature

Retrocaval ureter also referred to as pre-ureteral vena cava or circumcaval ureter is a rare congenital anomaly with the ureterpassing posterior to the inferior vena cava. Although it is a congenital anomaly, patients do not normally present with symptomsuntil the 3rd and 4th decades of life after a resulting hydronephrosis. We present the report of a 12-year-old male child with ahistory of right flank pain and associated right proximal hydroureteronephrosis. Diagnosis was confirmed with computerizedtomography urography, and an open surgical repair was done for the anomaly. The case is discussed here along with reviewof recent literature.

Bilateral primary Non-Obstructive and Non-Refluxing Megaureter in Child: Diagnosis by Non-Radiation Imaging Modalities.

Bilateral megaureters can present as asymptomatic or symptomatic pathology in the form of flank pain or urinary tract infection. The entity can also be diagnosed in antenatal ultrasound scan. We present 12-year old male child who presented with both flank vague pain and was subjected to ultrasonography (US) and Magnetic Resonance Urography (MRU). There was no evidence of any reflux or obstruction noticed as uretero-vasical junctions were normal on both sides. He was diagnosed as a case of bilateral primary non obstructive megaureters. Base line study was carried out by non radiation modalities in our institute for further follow up.

A propósito de dos casos de síndrome de cascanueces / A propos of two nutcracker syndrome cases

Se presentan 2 pacientes con síndrome de cascanueces de sexo masculino de 7 y 12 años. El primero asiste a consulta por hematuria y dolor en el flanco izquierdo; y el segundo, por crisis de dolor intenso recurrente en flanco izquierdo y proteinuria ortostática. En ambos pacientes el estudio ultrasonográfico renal permitió sospechar la entidad por la dilatación de la vena renal izquierda, y la emergencia anómala de la arteria mesentérica superior. En ambos casos la tomografía (angiotac) demostró la anomalía vascular y permitió seguir un tratamiento sintomático expectante. Los 2 pacientes se consultaron por los síntomas más frecuentes del síndrome: dolor en el flanco en ambos, hematuria macroscópica en uno, y proteinuria ortostática en el otro; ambos presentaban las alteraciones de un cascanueces anterior. El ultrasonido renal buscando la dilatación de la vena renal izquierda y el trayecto de la arteria mesentérica, permite establecer el diagnóstico que se confirma con otros estudios de imágenes.

Two male patients, who presented with nutcracker syndrome, were reported in this article. A seven years-old patient went to the doctor´s on account of hematuria and pain in his left flank whereas a 12 years-old patient suffered recurrent intense pain in his left flank and orthostatic proteinuria. The renal ultrasonography performed in both patients showed dilated left renal vein and anomaly of the upper mesenteric artery, all of which allowed suspecting of this disease. The tomography (angiotac) proved the vascular anomaly and allowed indicating an expecting symptomatic treatment. These two patients were seen at the medical service because both presented with the most frequent symptoms of the syndrome, that is, pain at flanks, macroscopic hematuria in one and orthostatic proteinuria in the other. Both of them also showed alterations from a previous nutcracker event. The renal ultrasound to look for dilation of the left renal vein and the path of the mesenteric artery allows making the final diagnosis that is further confirmed with other imaging studies.

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.

Decision Factors in Performance of Intravenous Contrast-enhanced Computed Tomography for Patients with Acute Flank Pain in an Emergency Department

PURPOSE: The aim of this study is to determine decision factors for performance of intravenous (IV) contrast-enhanced computed tomography (CT) for patients with acute flank pain in an emergency department. METHODS: We evaluated patients who presented with acute flank pain and underwent IV contrast-enhanced CT from January 2010 to June 2011. The IV contrast-enhanced CT useful group was defined as patients whose CT findings were equal to the final diagnosis. But urolithiasis was an exception, because enhanced CT is not useful in making the final diagnosis. We conducted a comparison of clinical characteristics and laboratory findings between the IV contrast-enhanced CT useful group and the not useful group. We then performed logistic regression analysis for analysis of independent predictors. RESULTS: A total of 166 patients were enrolled in this study. The IV contrast-enhanced CT useful group included 41 (24.7%) patients. Results of logistic regression analysis demonstrated that right upper quadrant tenderness (p=0.023), right lower quadrant tenderness (p=0.037), and negative hematuria (p=0.007) were independent predictors for the IV contrast-enhanced CT useful group. CONCLUSION: In patients with acute flank pain, performance of IV contrast-enhanced CT is useful for detection of alternative findings in the presence of right upper quadrant tenderness, right lower quadrant tenderness, and negative hematuria.

Spinal Schwannoma in a Patient with Chronic Right Flank Pain Presenting at an Emergency Department

Many patients with flank pain present to an emergency department (ED). The differential diagnosis of flank pain is difficult, especially in the case of women. Spinal schwannoma (SS) is one of the most common intraduralextramedullary spinal tumors. SS can present as symmetrical pain in the back or pain that radiates to both the lower extremities, which is commonly observed in clinical practice. We report the case of a 47-year-old woman with pain in her right flank area that began 2 months before she presented to our ED. Abdominal contrast computed tomography was performed to identify an intra-abdominal cause for the pain. Incidentally, we found a schwannoma, a spinal cord tumor, at the 10th thoracic vertebrae level. The pain disappeared after the tumor was surgically resected. On the basis of our findings, we conclude that the pain in her right flank pain area was caused by the SS.

A Case of the Nutcracker Syndrome Presenting as Left Flank Pain

The nutcracker syndrome does not occur frequently. The condition usually results from compression of the left renal vein between the superior mesenteric artery and the abdominal aorta, and leads to varicocele, flank pain and lateralizing hematuria. With a full review of the literature, we now report and discuss a case of nutcracker syndrome in which a 30-year-old female visited the emergency center for left flank pain. She experienced complete recovery after conservative treatment.

Left Paraduodenal Hernia Presenting with Atypical Symptoms

Paraduodenal hernias are a rare congenital malformation, but they are the most common internal hernias. They develop secondary to a failure in midgut rotation, which may lead to small bowel obstruction or other clinical manifestations. The authors recently experienced a case of a left paraduodenal hernia presenting with unusual symptoms of left flank pain and vomiting.

Comparison between ultrasound and noncontrast helical computed tomography for identification of acute ureterolithiasis in a teaching hospital setting

CONTEXT AND OBJECTIVE: Recent studies have shown noncontrast computed tomography (NCT) to be more effective than ultrasound (US) for imaging acute ureterolithiasis. However, to our knowledge, there are few studies directly comparing these techniques in an emergency teaching hospital setting. The objectives of this study were to compare the diagnostic accuracy of US and NCT performed by senior radiology residents for diagnosing acute ureterolithiasis; and to assess interobserver agreement on tomography interpretations by residents and experienced abdominal radiologists. DESIGN AND SETTING: Prospective study of 52 consecutive patients, who underwent both US and NCT within an interval of eight hours, at Hospital São Paulo. METHODS: US scans were performed by senior residents and read by experienced radiologists. NCT scan images were read by senior residents, and subsequently by three abdominal radiologists. The interobserver variability was assessed using the kappa statistic. RESULTS: Ureteral calculi were found in 40 out of 52 patients (77 percent). US presented sensitivity of 22 percent and specificity of 100 percent. When collecting system dilatation was associated, US demonstrated 73 percent sensitivity, 82 percent specificity. The interobserver agreement in NCT analysis was very high with regard to identification of calculi, collecting system dilatation and stranding of perinephric fat. CONCLUSIONS: US has limited value for identifying ureteral calculi in comparison with NCT, even when collecting system dilatation is present. Residents and abdominal radiologists demonstrated excellent agreement rates for ureteral calculi, identification of collecting system dilatation and stranding of perinephric fat on NCT.

CONTEXTO E OBJETIVO: Estudos atuais demonstram que a tomografia computadorizada helicoidal sem contraste (TC) apresenta maior acurácia do que a ultra-sonografia (US) no diagnóstico da ureterolitíase aguda, porém, poucos estudos a esse respeito foram realizados em atendimento radiológico de urgência de hospital universitário. Nossos objetivos foram comparar a sensibilidade diagnóstica da US com a TC realizadas por residentes no diagnóstico de ureterolitíase aguda e comparar a análise da TC interpretada por residentes e radiologistas experientes. TIPO DE ESTUDO E LOCAL: Estudo prospectivo de 52 pacientes com cólica renal aguda, que foram submetidos a exame de US seguido de TC em período máximo de oito horas no Hospital São Paulo. MÉTODOS: Os exames de US foram realizados por médicos residentes e conferidos pelos preceptores, já os de TC foram analisados por outro residente e posteriormente analisados por três radiologistas independentes. RESULTADOS: Nos 52 pacientes analisados foram encontrados 40 cálculos ureterais na TC (77 por cento). A US apresentou uma sensibilidade de 22 por cento e especificidade de 100 por cento, que aumentou para 73 por cento e 82 por cento respectivamente, quando se associou a identificação da dilatação do sistema coletor. A TC analisada pelo residente e pelos radiologistas apresentou uma excelente correlação para identificação do cálculo ureteral, para heterogeneidade da gordura peri-renal e para dilatação do sistema coletor. CONCLUSÕES: A US realizada pelos residentes tem menor sensibilidade no diagnóstico da litíase ureteral, quando comparada à TC, mesmo quando associada à presença de dilatação do sistema coletor. Residentes e radiologistas especialistas apresentaram excelente concordância no diagnóstico de litíase ureteral.

A Case of Pelvic Congestion Syndrome Presenting with Chronic Left Flank Pain in an Adolescent Girl

Flank Pain is a leading indicator of renal and upper urinary tract disease or trauma, and rarely results from pelvic congestion syndrome. Although pelvic congestion syndrome occurs commonly in multi-parous women, pelvic congestion syndrome should also be considered as the cause of flank pain in an adolescent girl. We report the first case of pelvic congestion syndrome presenting with chronic left flank pain in an adolescent girl.

Usefulness of Ultrasonography as a Disposition Tool for Patients with Acute Flank Pain and Microscopic Hematuria in an Emergency Department

PURPOSE: To evaluate the usefulness of ultrasonography (US) as a disposition tool in emergency care centers for categorizing urolithiasis patients who present with acute flank pain and microscopic hematuria. METHODS: We enrolled patients who presented with acute flank pain and microscopic hematuria from January to August 2006 in the Emergency Care Center of Chungnam National University Hospital. We categorized patients into four groups according to their hydronephrosis and urinary complications, respectively, and retrospectively reviewed their charts relative to patients' disposition. RESULTS: One hundred eighty-two patients met the criteria and were enrolled in the study. Patients who were classified as group D (without complication or hydronephrosis) had 100% negative predictive value for invasive procedures (ureteroscopy or double J catheterization), hospital admission, extracoporeal shock wave lithotripsy (ESWL), and prescription of antibiotics. CONCLUSION: It is reasonable for emergency department residents to route patients without complication or hydronephrosis to the outpatient department after pain control and simple therapeutic education.

A Case of Fraley's Syndrome with Benign Hematuria

Fraley's syndrome is a disorder of vascular impression on the renal infundibulum which is associated with unexplained disabling flank pain, painless microscopic hematuria, and urinary tract infection. We experienced one case of Fraley's syndrome in a 12-year-old girl whose chief complaint was persistent microscopic hematuria. We report this case with a brief review of related literatures.

Idiopathic Spontaneous Renal Rupture

Spontaneous renal rupture is a rare, but important, clinical problem that heralds a variety of kidney abnormalities. Tumors are the most common cause, followed by vascular disease, infection, nephritis and blood dyscrasia. In some cases, no underlying abnormality of the kidney can be found. The patients usually present with an acute onset of flank pain, a tender mass, and common symptoms and signs of shock. In most cases rapid surgical intervention is necessary and nephrectomy remains the treatment of choice in cases of a ruptured tumor. A 47 year-old female, who had been in good health previously, was hospitalized because of a sudden onset of left flank pain for one day. There was no history of trauma. Physical examination revealed marked tenderness and guarding over the left flank abdomen. A perirenal hematoma on the left side was seen with abdominal sonography. Computerized tomography demonstrated a large perirenal hematoma and a kidney rupture caudally. Selective renal angiography demonstrated an active bleeding over the lower pole, so a coil embolization and nephrectomy were performed. The histological examination of the kidney revealed no underlying abnormality. We report a case of idiopathic spontaneous renal rupture, along with a literature review.