Cost-effective emergency diagnosis plan for urinary stone patients presenting with ureteric colic.

OBJECTIVE: To develop a cost-effective plan for the accurate diagnosis of urinary stone patients presenting with ureteric colic based on an assortment of investigations which are less invasive and more economical than intravenous urography (IVU). PATIENTS AND METHODS: 143 consecutive emergency patients presenting with ureteric colic were admitted to hospital and prospectively studied by history recording, physical examination, laboratory tests and imaging procedures according to a preset format. Significant association of the final diagnosis of urinary stones (which was made by actual stone retrieval) with various diagnosis variables obtained from the results of investigation (including IVU) was statistically studied using bivariate correlation and multivariate logistic regression analysis. Algorithms for reaching an accurate diagnosis of urinary tract stones were formulated using the most significant diagnostic variables and the accuracy of each of those plans was compared with that of emergency IVU. RESULTS: 18 patients were excluded for various reasons. Of the remaining 125 patients 82 (66%) were confirmed as having urinary stones. A positive IVU had the strongest correlation with the final diagnosis of urinary tract stones. Other findings associated with eventual stone retrieval in a descending order of significance were: calcular sonographic features; radio-opacities on a plain abdominal film of the kidney, ureter and bladder (KUB), and microhaematuria. Based on these findings two algorithms could be formulated to reach as accurate a diagnosis as possible. Algorithm A in which an initial ultrasound is mandatory had a sensitivity of 89%, a specificity of 88% and an overall accuracy of 88% for urinary stone detection compared with 91, 77, and 86%, respectively, for algorithm B in which ultrasonography was employed selectively after initial KUB and urinalysis for microhaematuria. This compares with 94, 79, and 89%, respectively, for IVU. CONCLUSION: Both plans are viable alternatives which could replace routine emergency IVU.

Bochdalek hernia in adulthood: a case report and review of recent literature.

A 37-year-old Filipino woman presented with a post road-traffic accident fracture of dorsal spine 12. Chest radiograph revealed evidence of loops of small bowel in the left lung field. She admitted to symptoms of respiratory insufficiency since birth and treatment for tuberculosis in childhood. A pre-operative diagnosis of left traumatic diaphragmatic hernia was not confirmed at laparotomy which revealed typical left congenital Bochdalek hernia with smooth edges and herniation of small bowel and spleen into the left pleural cavity. Following reduction and repair of the hernia, the patient made an uneventful recovery. Chest radiograph remains normal till now, eight years post-operatively.

Bronchiectasis due to lipid aspiration in childhood: clinical and pathological correlates.

We report the clinical and pathological features in six Arab children with bronchiectasis caused by ghee lipid aspiration. They all had a history of ghee administration followed by a history of chronic cough dating from early childhood. Chest radiographs showed consolidation/collapse of the right middle and left lower lobes in the majority, and bronchography and chest CT scan confirmed bronchiectasis. The children were treated medically, without any improvement, and five required surgery. The histology of the lung revealed dilated bronchi filled with vacuolated granular eosinophilic material and the peripheral lung tissue was mostly atelectatic with patchy lymphocytic bronchiolitis. Frozen sections of the lung tissue showed scattered lipogranulomas with fat-laden macrophages and fat droplets within peripheral and perivascular lymphatics. In communities where the traditional practice of force-feeding infants and children with ghee exists, it may be an important predisposing cause of bronchiectasis.

Paterson-Brown Kelly syndrome.

Over a five-year period (September 1987 to August 1992), eight patients, one male and seven females, with a characteristics history of dysphagia due to cervical esophageal webs (Paterson-Brown Kelly syndrome) were encountered. The patients, all Arabs, comprised six Saudi females, one Yemeni female and an Eygptian male. All the patients, except two, were in middle age. The webs, single in five patients and multiple in three, and present at the levels of the 5th, 6th and 7th cervical vertebrae, were located in the anterior wall of the esophagus in four patients, circumferential-producing stenosis in three patients, while one patient with multiple webs had both types of location. Associated iron-deficiency anemia was present in all patients, three of them with evident koilonychia. One patient had associated nodular goiter and rheumatoid arthritis while another had a fatal complicating postcricoid carcinoma. The only male patient had associated ulcerative protocolitis. All seven patients without malignant complication of their webs had marked or total resolution of their dysphagia with iron therapy, pharyngoscopy/esophagoscopy, and dilatation. The Paterson-Brown Kelly syndrome of postcricoid dysphagia is discussed briefly.

Staphylococcal vertebral osteomyelitis: case report.

A 65-year old male Saudi patient presented with rapidly progressive quadriparesis. Lower cervical myelopathy was associated with radiological features of bone destruction, inflammatory disease of the spine and a paravertebral mass. Although tuberculosis and brucellosis are more commonly responsible for this clinical picture in our practice, Staphylococcus aureus was isolated from tissue recovered at surgery. He has been followed up for 12 months and has made an almost complete recovery after surgical decompression of spinal cord and a 2-month course of intravenous flucloxacillin. This case underscores the need for tissue diagnosis in patients presenting with inflammatory paravertebral swellings even in areas endemic for tuberculosis and brucellosis.

Specific investigations in chronic urinary bilharziasis.

Seventy-two patients with histologically confirmed chronic urinary bilharziasis were studied for the reliability of some specific investigative tools in diagnosing this disease, namely urinalysis, serology, urography, and cystoscopy. Of the 72 patients 36 (50%) had hematuria and only 3 (4%) had ova of Schistosoma haematobium on urinalysis. Sixty-two patients (86%) had features of bilharziasis on intravenous urography (IVU). Of the remaining 10 patients with negative urography 6 underwent serology and all had positive results. Of the total patients 52 underwent serology and 49 had significant bilharzial antibody titer (94.2%). At cystoscopy all patients (100%) had features of bilharziasis. It is concluded that the most reliable diagnostic tools in chronic urinary bilharziasis are cystoscopy, serology, and to a lesser extent urography. Unlike early bilharziasis, chronic bilharziasis can be missed if total reliance is placed on urinalysis for screening a population at risk.

Hydatid disease of the liver: evaluation of ultrasound and computed tomography.

We have evaluated computed tomography (CT) and ultrasonography (US) in 41 patients with hepatic hydatid disease. CT was diagnostic in all patients, while US performed on 36 patients was diagnostic in 34. In the remaining two cases, heavy calcification in one and a large amount of intracavitary air in the other prevented accurate diagnosis. The US findings in the liver regarding cyst form (multilocular or unilocular), size and location were comparable to those of CT. CT detected associated extrahepatic cysts in the abdomen and pelvis in 11 patients while US performed on the same group of patients detected such cysts in seven patients. It is suggested that the entire abdomen and pelvis should be scanned in patients suspected of hydatid disease and when a hepatic lesion is suggestive of the disease.

Bilharzial vesicoureteric reflux and bladder neck stenosis: fact or fiction?

A group of 47 patients with histologically confirmed chronic urinary bilharziasis underwent micturating cystourethrography to look for vesicoureteric reflux (VUR) and bladder neck stenosis (BNS); 13 patients were found to have VUR of varying grades (8 unilateral and 5 bilateral). None had evidence of BNS. Urinary tract infection (UTI), loin pain, hydroureter and renal failure were compared in patients with and without VUR. Of the 13 patients with reflux, 3 had UTI, loin pain was present in 8, 11 had an ipsilateral hydroureter and 2 presented with renal failure. In the 34 patients without reflux, 8 had UTI, loin pain was present in 22, 30 had hydroureter and 3 presented with renal failure. It was concluded that the incidence of UTI, loin pain, hydroureter and renal deterioration associated with bilharzial VUR was not significantly different from that found in bilharzial patients without VUR. Thus the clinical significance and the need for surgical correction of isolated VUR in bilharziasis are questionable.