1991, The British Journal of Radiology, 64,
All-All
Case reports
Glynn et al (1989) reported a case of diffuse retroperitoneal amyloidosis and recorded the CT features. Takebayashi et al (1984) documented the discrete echopoor sonographic appearance of amyloidosis involving retroperitoneal nodes. In this patient, both ultrasound and CT showed diffuse amyloid infiltration of the retroperitoneum which also involved the perinephric fat, hitherto not described. The differential diagnosis of a solid infiltrative retroperitoneal echo pattern includes haemorrhage, lymphoma, desmoplastic tumours and retroperitoneal fibrosis (Barneth & Morley, 1985).
References ALLEN III, H. A., VICK, C. W.,
MESSMER, J. M. & PARKER,
G. A., 1985. Diffuse mesenteric amyloidosis: CT, sonographic and pathologic findings. Journal of Computer Assisted Tomography, 9, 196-198. BARNETH,
E.
&
MORLEY,
P.,
1985.
Abdomen,
GIT
and
peritoneum (Chapter 20). In Clinical Diagnostic Ultrasound (Blackwell Scientific Publications, London), pp. 297-344. GLYNN JR, T.
P.,
KREIPKE, D.
L. &
IRONS, M.
J.,
1989.
Amyloidosis: diffuse involvement of the retroperitoneum. Radiology, 170, 726. KIMBALL, K. G., 1961. Amyloidosis in association with neoplastic disease. Annals of Internal Medicine, 55, 958-974. SCOTT, P.
P.,
SCOTT, W.
W.
&
SIEGELMAN, S.
S.,
1986.
Amyloidosis: an overview. Seminars in Roentgenology, XXI, 103-112. TAKEBAYASHI, S., ONO, Y., SAKAI, F., TAMURA, S. & UNAYAMA,
Acknowledgment The authors express their appreciation to Professor Albert Solomon for his encouragement and review of the manuscript.
S., 1984. Computed tomography of amyloidosis involving retroperitoneal lymph nodes mimicking lymphoma. Journal of Computer Assisted Tomography, 8, 1025-1027.
Percutaneous nephrostomy to relieve renal tract obstruction in pregnancy By * M . Trewhella, FRCR, t B . Reid, M B BS, t A . Gillespie, FRCOG and §D. Jones, FRCS Department of 'Radiology, tObstetrics and Gynaecology, and §Surgery, The Princess of Wales Royal Air Force Hospital, Ely, Cambridgeshire, UK
{Received May 1990 and in revised form October 1990)
Keywords: Percutaneous nephrostomy, Renal tract obstruction, Pregnancy
Dilatation of the renal tract in pregnancy is a common event (Peake et al, 1983). Whilst frequently asymptomatic, the distension can be associated with considerable pain, the acute presentation of which may be attributed to other surgical or obstetric emergencies such as appendicitis or placental separation (Anteby et al, 1975). Renal tract obstruction may also occur in pregnancy, and failure to recognize it may lead to rupture of the urinary tract and loss of the kidney (Meyers et al, 1985). We present a case in which such a renal tract obstruction was relieved percutaneously. Whilst percutaneous nephrostomy is a commonly practised technique, its use in pregnancy has not been reported previously.
normal. No evidence of placental separation or fetal abnormality was seen. A I31I hippuran probe renogram showed reduced right renal function (37%) and a rising right excretion curve (Fig. 1). In view of the right renal obstruction and decreased function, a percutaneous nephrostomy was per-
Case report A 27-year-old multigravida who was 25 weeks pregnant was referred with a 2-day history of right loin pain and frequency. Urinary analysis showed microscopic haematuria and proteinuria. A previous pregnancy had been uneventful, and her uterine ultrasound scan at 16 weeks' gestation was normal. On admission, she was apyrexial with a normal pulse rate and blood pressure. On examination, there was tenderness in the right iliac fossa. Cardiotochography was normal. Biochemical and haematological indices were normal: urea 2.9 mmol/1, creatinine 85 mmol/1. An ultrasound scan showed a right hydronephrosis and hydroureter. The left renal tract was
Vol. 64, No. 761
10 Figure 1. Excretion curves of I3II hippuran isotope study at 25 weeks gestation (corrected for background).
471
Case reports case by the combination of hydronephrosis and ipsilateral loin pain. It was confirmed by a probe 13II hippuran isotope study, chosen in this instance rather than the more widely available 99mTc DTPA because the fetal radiation dose is much lower: 0.016 mGy for 1 MBq 13II hippuran; 1.5 mGy for 200 MBq 99mTc DTPA. Retrograde catheterization for the relief of renal tract obstruction has been described in such cases (Nielsen & Rasmussen, 1988), but it was felt that the percutaneous approach had the advantage of avoiding the need for a general anaesthetic and the potentially hazardous attempted bypass of an obstructed ureter with a stent. To be successful, however, this technique does require that the patient can satisfactorily manage a nephrostomy as an outpatient. 18 Figure 2. Excretion curves of """Tc DTPA isotope study, 6 weeks after delivery (corrected for background).
Acknowledgments We would like to thank Dr E. P. Wraight of the Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge for formed with a pigtail catheter being inserted into one of the performing the isotope studies and discussing the results with lower pole calyces. This led to immediate relief of the pain. The us. We would like to thank the Director General of Medical patient learned nephrostomy care and was discharged a week later on prophylactic trimethoprim 100 mg daily. She was Services (RAF) for his permission to present this case report. reviewed weekly, and on three occasions reduced urine output from the catheter was restored by gentle flushing with normal saline. A coliform infection at 37 weeks' gestation was treated References with ampicillin. At 38 weeks, labour commenced, and a healthy ANTEBY, S. D., RON, M. & DIAMANT, Y. Z., 1975. Hydroureter 3125 g girl was delivered vaginally. An antegrade study via the and hydronephrosis of pregnancy presenting as acute nephrostomy and a renal ultrasound scan performed 2 days obstetric or surgical emergencies. International Surgery, 60, after delivery showed less dilatation than during pregnancy and (2) 93-95. no evidence of ureteric obstruction. The nephrostomy catheter MEYERS, S. J., LEE, R. V. & MUNSCHAUER, R. W., 1985. was clamped for 24 hours and no problems arose. It was then Dilatation and nontraumatic rupture of the urinary tract removed, and mother and baby were discharged on the sixth during pregnancy: a review. Obstetrics and Gynecology, 66, post-natal day. Six weeks after delivery, the patient remained (6) 809-815. asymptomatic, and a ""Tc DTPA renogram showed equal renal function on both sides with no evidence of renal obstruc- NIELSEN, F. R. & RASMUSSEN, P. E., 1988. Hydronephrosis during pregnancy: four cases of hydronephrosis causing tion (Fig. 2). symptoms during pregnancy. European Journal of Obstetrics, Gynecology and Reproductive Biology, 27, 245-248. Discussion PEAKE, S. L., ROXBURGH, H. B. & LANGLOIS, S. LE P., 1983. The possibility of obstruction rather than physioUltrasonic assessment of hydronephrosis of pregnancy. Radiology, 146, 167-170. logical ureteric dilatation of pregnancy was raised in this
472
The British Journal of Radiology, May 1991
All-All
Case reports
Glynn et al (1989) reported a case of diffuse retroperitoneal amyloidosis and recorded the CT features. Takebayashi et al (1984) documented the discrete echopoor sonographic appearance of amyloidosis involving retroperitoneal nodes. In this patient, both ultrasound and CT showed diffuse amyloid infiltration of the retroperitoneum which also involved the perinephric fat, hitherto not described. The differential diagnosis of a solid infiltrative retroperitoneal echo pattern includes haemorrhage, lymphoma, desmoplastic tumours and retroperitoneal fibrosis (Barneth & Morley, 1985).
References ALLEN III, H. A., VICK, C. W.,
MESSMER, J. M. & PARKER,
G. A., 1985. Diffuse mesenteric amyloidosis: CT, sonographic and pathologic findings. Journal of Computer Assisted Tomography, 9, 196-198. BARNETH,
E.
&
MORLEY,
P.,
1985.
Abdomen,
GIT
and
peritoneum (Chapter 20). In Clinical Diagnostic Ultrasound (Blackwell Scientific Publications, London), pp. 297-344. GLYNN JR, T.
P.,
KREIPKE, D.
L. &
IRONS, M.
J.,
1989.
Amyloidosis: diffuse involvement of the retroperitoneum. Radiology, 170, 726. KIMBALL, K. G., 1961. Amyloidosis in association with neoplastic disease. Annals of Internal Medicine, 55, 958-974. SCOTT, P.
P.,
SCOTT, W.
W.
&
SIEGELMAN, S.
S.,
1986.
Amyloidosis: an overview. Seminars in Roentgenology, XXI, 103-112. TAKEBAYASHI, S., ONO, Y., SAKAI, F., TAMURA, S. & UNAYAMA,
Acknowledgment The authors express their appreciation to Professor Albert Solomon for his encouragement and review of the manuscript.
S., 1984. Computed tomography of amyloidosis involving retroperitoneal lymph nodes mimicking lymphoma. Journal of Computer Assisted Tomography, 8, 1025-1027.
Percutaneous nephrostomy to relieve renal tract obstruction in pregnancy By * M . Trewhella, FRCR, t B . Reid, M B BS, t A . Gillespie, FRCOG and §D. Jones, FRCS Department of 'Radiology, tObstetrics and Gynaecology, and §Surgery, The Princess of Wales Royal Air Force Hospital, Ely, Cambridgeshire, UK
{Received May 1990 and in revised form October 1990)
Keywords: Percutaneous nephrostomy, Renal tract obstruction, Pregnancy
Dilatation of the renal tract in pregnancy is a common event (Peake et al, 1983). Whilst frequently asymptomatic, the distension can be associated with considerable pain, the acute presentation of which may be attributed to other surgical or obstetric emergencies such as appendicitis or placental separation (Anteby et al, 1975). Renal tract obstruction may also occur in pregnancy, and failure to recognize it may lead to rupture of the urinary tract and loss of the kidney (Meyers et al, 1985). We present a case in which such a renal tract obstruction was relieved percutaneously. Whilst percutaneous nephrostomy is a commonly practised technique, its use in pregnancy has not been reported previously.
normal. No evidence of placental separation or fetal abnormality was seen. A I31I hippuran probe renogram showed reduced right renal function (37%) and a rising right excretion curve (Fig. 1). In view of the right renal obstruction and decreased function, a percutaneous nephrostomy was per-
Case report A 27-year-old multigravida who was 25 weeks pregnant was referred with a 2-day history of right loin pain and frequency. Urinary analysis showed microscopic haematuria and proteinuria. A previous pregnancy had been uneventful, and her uterine ultrasound scan at 16 weeks' gestation was normal. On admission, she was apyrexial with a normal pulse rate and blood pressure. On examination, there was tenderness in the right iliac fossa. Cardiotochography was normal. Biochemical and haematological indices were normal: urea 2.9 mmol/1, creatinine 85 mmol/1. An ultrasound scan showed a right hydronephrosis and hydroureter. The left renal tract was
Vol. 64, No. 761
10 Figure 1. Excretion curves of I3II hippuran isotope study at 25 weeks gestation (corrected for background).
471
Case reports case by the combination of hydronephrosis and ipsilateral loin pain. It was confirmed by a probe 13II hippuran isotope study, chosen in this instance rather than the more widely available 99mTc DTPA because the fetal radiation dose is much lower: 0.016 mGy for 1 MBq 13II hippuran; 1.5 mGy for 200 MBq 99mTc DTPA. Retrograde catheterization for the relief of renal tract obstruction has been described in such cases (Nielsen & Rasmussen, 1988), but it was felt that the percutaneous approach had the advantage of avoiding the need for a general anaesthetic and the potentially hazardous attempted bypass of an obstructed ureter with a stent. To be successful, however, this technique does require that the patient can satisfactorily manage a nephrostomy as an outpatient. 18 Figure 2. Excretion curves of """Tc DTPA isotope study, 6 weeks after delivery (corrected for background).
Acknowledgments We would like to thank Dr E. P. Wraight of the Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge for formed with a pigtail catheter being inserted into one of the performing the isotope studies and discussing the results with lower pole calyces. This led to immediate relief of the pain. The us. We would like to thank the Director General of Medical patient learned nephrostomy care and was discharged a week later on prophylactic trimethoprim 100 mg daily. She was Services (RAF) for his permission to present this case report. reviewed weekly, and on three occasions reduced urine output from the catheter was restored by gentle flushing with normal saline. A coliform infection at 37 weeks' gestation was treated References with ampicillin. At 38 weeks, labour commenced, and a healthy ANTEBY, S. D., RON, M. & DIAMANT, Y. Z., 1975. Hydroureter 3125 g girl was delivered vaginally. An antegrade study via the and hydronephrosis of pregnancy presenting as acute nephrostomy and a renal ultrasound scan performed 2 days obstetric or surgical emergencies. International Surgery, 60, after delivery showed less dilatation than during pregnancy and (2) 93-95. no evidence of ureteric obstruction. The nephrostomy catheter MEYERS, S. J., LEE, R. V. & MUNSCHAUER, R. W., 1985. was clamped for 24 hours and no problems arose. It was then Dilatation and nontraumatic rupture of the urinary tract removed, and mother and baby were discharged on the sixth during pregnancy: a review. Obstetrics and Gynecology, 66, post-natal day. Six weeks after delivery, the patient remained (6) 809-815. asymptomatic, and a ""Tc DTPA renogram showed equal renal function on both sides with no evidence of renal obstruc- NIELSEN, F. R. & RASMUSSEN, P. E., 1988. Hydronephrosis during pregnancy: four cases of hydronephrosis causing tion (Fig. 2). symptoms during pregnancy. European Journal of Obstetrics, Gynecology and Reproductive Biology, 27, 245-248. Discussion PEAKE, S. L., ROXBURGH, H. B. & LANGLOIS, S. LE P., 1983. The possibility of obstruction rather than physioUltrasonic assessment of hydronephrosis of pregnancy. Radiology, 146, 167-170. logical ureteric dilatation of pregnancy was raised in this
472
The British Journal of Radiology, May 1991
