1979, British Journal of Radiology, 52, 913-916


Case reports Alternatively it is possible in this particular patient that air in the cervical oesophageal loculus was prevented from being displaced downwards by extrinsic compression from the azygos vein stretched across its lower border. Whatever the explanation it is apparent that very rarely a chronically dilated oesophagus, distended with air but empty of food, may produce serious symptoms and signs of proximal airways obstruction by compressing the trachea at or above the thoracic inlet. ACKNOWLEDGMENT

We wish to thank Mr. Charles Drew, F.R.C.S., Senior Thoracic Surgeon to Westminster Hospital, under whose care this patient was admitted, for permission to publish this case. REFERENCES D'ABREU, A. L., COLLIS, J. L. and CLARKE, D. B., 1971. A

Practice of Thoracic Surgery, 3rd edition, pp. 496 (E. Arnold, London). BELLO, C. T., LEWIN, J. R., NORRIS, C. M. and FARRAR,

7. Barium outlines the dilated air filled oesophagus. Note the size of the upper part of the oesophagus.

G. E., JR., 1950. Achalasia (cardiospasm); report of a case with extreme and unusual manifestations. Annals of Internal Medicine, 32, 1184.


by a pinch-cock valve formed artificially by the dilated, redundant section folding over on itself.

GIUSTRA, P. E., KILLORAN, P. J. and WASGATT, W. N., 1973.

Acute stridor in achalasia of the oesophagus (cardiospasm). American Journal of Gastroenterology, 60, 160-164. MCLEAN, R. D. W., STEWART, C. J. and WHYTE, D. G. C ,

1976. Acute thoracic inlet obstruction in achalasia of the oesophagus. Thorax, 31, 456-459.

Fibroepithelial ureteric polyps By D. B. Crawford, M.B., F.R.C.R., E. D. Levinson, M.D., E. M. Henken, M.D. Department of Radiology, John Dempsey Hospital, University of Connecticut Health Center, Farmington, Connecticut 06032, USA and G. Klauber, M.B., F.R.C.S.(C) Department of Surgery (Pediatrics), John Dempsey Hospital, University of Connecticut Health Center, Farmington, Connecticut 06032, USA {Received February 1979) Benign polyps of the ureter are rare. Most frequently they are composed of fibroepithelial tissue. They may present radiologically as ureteric obstructions, most commonly at the uretero-pelvic junction, or may be seen incidentally as smooth filling defects in the ureter on contrast examination.


Case 1 A 15-year-old white male presented with left abdominal pain and a feeling of pressure in the left flank area. He had no relevant previous history. On examination the left kidney was palpably enlarged. Urinalysis revealed 1 + protein, 100-150 red blood cells per

high powered field and calcium oxalate crystals. The serum creatinine was 0.8% and corrected creatinine clearance was 97 ml per minute. Intravenous urography suggested left uretero-pelvic junction obstruction. This was confirmed by a frusemide urogram. The ureter distal to the uretero-pelvic junction obstruction was poorly visualized due to low flow of contrast. Neither antegrade nor retrograde pyelography was performed. At surgery the obstruction was found to be due to five finger-like polyps extending 1.5 cm from the wall of the ureter (Fig. 1). Frozen section revealed these to be benign, and a local resection and pyeloplasty were performed. Histologically the polypoid tumour was composed of large amounts of loose, oedematous fibrovascular stalks harbouring smooth muscle which communicated with the muscle of the ureteric wall. The polyps were covered by normal transitional epithelium.



52, No. 623 Case reports

Case 2 A 22-year-old white female presented with symptoms typical of left renal colic. Previous medical history was negative. An intravenous urogram demonstrated a calculus in the distal portion of the left ureter causing partial obstruction. Moderate caliectasis was noted on the right and a thin linear polypoid defect in the proximal ureter was seen and confirmed on subsequent follow-up urogram and retrograde pyelogram (Fig. 2). At surgery a long stalked polyp was locally resected. Histologically this was lined with regular transitional epithelium overlying a fibrovascular stroma containing connective tissue and blood vessels (Fig. 3). DISCUSSION

The differential diagnosis of uretero-pelvic junction obstruction and radiolucent ureteric filling defects should include benign and malignant neoplasms. Both are rare, especially the benign variety, the most common being the fibroepithelial polyp. These arise from mesodermal tissue and are also known as fibrous polyps, fibromyxomas and myxomas. They are reported with greater frequency than other polyps possibly because of their propensity to


Gross specimen of the resected five finger polyp arising from the proximal ureter.

become large and mobile enough to cause symptoms. Approximately 50 cases of fibrous polyps were discovered on review of the literature (Banner et ah, 1979; Davides and King, 1976; Stuppler and Kandzari, 1975). These polyps can occur in all ages, the youngest patient being four years and the oldest 72 years, with the greatest number in the 20-40 age group (Stuppler and Kandzari, 1975). They are most commonly found in the proximal ureter and frequently cause uretero-pelvic junction obstruction. The most common presenting symptoms are flank pain and haematuria. The diagnosis can be suggested preoperatively if a well demarcated, pedunculated filling defect is found during intravenous urography. Malignant ureteric tumours are more likely to cause a shorter filling defect with an irregular, shaggy outline, and occur more commonly in older patients. The latter are also more apt to completely obstruct the ureter and cause severe hydronephrosis (Crum et al., 1969). Local excision and ureteric reconstruction rather than nephroureterectomy has been recommended as the treatment of choice in view of the benignancy of

FIG. 2. Intravenous urogram, right kidney. There is moderate, generalized caliectasis. There is a long polypoid radiolucent defect in the proximal ureter just distal to the ureteropelvic junction (•

Fibroepithelial ureteric polyps.

1979, British Journal of Radiology, 52, 913-916 NOVEMBER 1979 Case reports Alternatively it is possible in this particular patient that air in the c...
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