Recurrent massive haemorrhage from an endoscopically inevident isolated rectal varix.

Anorectal varices are identified endoscopically in up to 40% of patients with liver cirrhosis [Misra SP, Dwivedi M, Misra V. Prevalence and factors influencing haemorrhoids, anorectal varices, and colopathy in patients with portal hypertension. Endoscopy 1996;28:340-5] but are an infrequent cause of bleeding and their management remains controversial. We present a patient with chronic hepatitis C virus infection who developed recurrent haemorrhage from an isolated, endoscopically inevident rectal varix in the absence of clinical or endoscopic evidence of portal hypertension. The difficulties in diagnosis and management of anorectal varices are highlighted.

Stripping of failing haemodialysis catheters using the Ampltaz gooseneck snare.

The development of a fibrin sheath at the tip of a long-term haemodialysis catheter may lead to deteriorating blood flow rates, resulting in inadequate haemodialysis. Restoration of functional patency has been described using the technique of percutaneous fibrin sheath stripping (PFSS) using a wire snare device. Our purpose was to assess this technique within an established renal vascular access service. All catheters referred for the assessment of low blood flow rates on dialysis were considered for the procedure. Initial fluoroscopic assessment of the catheter was followed by stripping of the tip of the catheter using a gooseneck snare. Seventeen of 22 well-positioned catheters undergoing a single PFSS attempt were restored to function with a median prolongation of patency of 4.25 months. Two catheters underwent a second PFSS procedure providing additional patency. Nineteen of a total of 24 (79%) PFSS procedures successfully restored catheter function. Seven catheters with poorly positioned tips or a kink were not restored to functional patency using PFSS. Two patients developed a puncture site haematoma. No patient developed symptoms of pulmonary emoblism. In conclusion, PFSS restored function in 79% of attempts in well positioned catheters. The method is technically straightforward, with a low complication rate and has become a routine part of the renal vascular access service.

Haematuria.

Many serious and potentially treatable diseases of the urinary tract may have haematuria as their only manifestation. However, asymptomatic microscopic haematuria detected by dipstick testing may be seen in up to 16% of screening populations. The great majority of such cases will have no sinister underlying cause, particularly in those under 40 years of age, and so the schedule of further investigations, some of which may be invasive, time-consuming and expensive, needs to be rationalised. In addition, the increasing popularity of 'fast track' clinics for the investigation of haematuria enhances the need for a clear strategy of investigation. Analysis of the epidemiology of asymptomatic haematuria and its causes combined with a consideration of the risk-benefit profile of the available investigations, makes it possible to set out an algorithm for the initial management of this common finding. Careful clinical assessment and basic laboratory tests for renal function, analysis of the urinary sediment and cytological examination of the urine are followed by ultrasound and plain radiography of the urinary tract. Flexible cystoscopy under local anaesthetic is central to the algorithm in patients of all ages. The importance of a nephrological opinion and consideration of renal biopsy, especially in younger patients with other evidence of glomerular disease, is stressed. The role of intravenous urography in excluding pathology of the upper urinary tract, especially in patients over the age of 40, is also considered.

The use of expandable metal stents in transplant renal artery stenosis.

The management of resistant transplant renal artery stenosis (TRAS) poses difficult problems. There is no consensus on the most appropriate course of action if severe stenosis recurs despite repeated percutaneous transluminal balloon angioplasty (PTA). Expandable metallic vascular stents have been increasingly successful as an adjunct to PTA in the coronary and peripheral circulation and more recently in the management of resistant native renal artery stenosis. We report four cases in which such stents were successfully used to treat resistant stenosis in transplant renal arteries. The cases illustrate the range of problems that may be caused by TRAS, from resistant hypertension to impending graft failure. The stents were successfully deployed in all four patients. One patient had an acute stent thrombosis successfully treated with immediate thrombolysis and two patients required repeat stenting. In all the cases there was arrest or slowing of previously aggressive recurrent TRAS and at the close of follow-up (4-24 months) all patients had adequate stable allograft function, and satisfactory blood pressure control including the one patient with a significant residual stenosis.

Retroperitoneal fibrosis in Marfan's syndrome.

To our knowledge, an association between Marfan's syndrome and retroperitoneal fibrosis (RPF) has never been described. We describe two cases who presented acutely with aortic disease and were later found to have changes of undiagnosed retroperitoneal fibrosis causing hydronephrosis on computed tomography (CT). An association is readily understandable based on the current hypotheses for the aortic disease in Marfan's syndrome and the etiology of RPF. We suggest why this has not been noted previously. CT has an established role in the diagnosis and follow up of RPF as well as in the assessment of the aortic complications of Marfan's syndrome. Awareness of the possibility of RPF and it's demonstration on CT may allow early diagnosis and help prevent significant renal impairment.