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Emergency treatment of life-threatening haemorrhage after renal biopsy by selective arterial embolization
ABSTRACTS was also of high attenuation (263 + / - 21 HU) but did not give rise to any decrease in image quality. The attenuation values for Kaltostat (91 + / - 6.1 HU) and TAC (74.9 + / - 49 HU) fell within the attenuation range of soft tissue and fat respectively. On MR images BIPP and Kaltostat showed similar signal characteristics to muscle whilst the signal intensities of aqueous Betadine and TAC were indistinguishable from bone marrow and fat respectively on both T1 and T2 weighted images. Radiologists should be aware of the potential pitfalls of mistaking surgical packing materials for organic material on both CT and M R images.
IMAGING OF DISSECTING NEUROPATHIC JOINTS W. C. G. PEH, J. BROCKWELL, M. T. C H A U and M. M. T. N G
Departments of Diagnostic Radiology, Orthopaedic Surgery and Medicine, The University of Hong Kong and Queen Mary Hospital, Hong Kong Introduction: Unlike the Charcot-like joint seen in the diabetic foot, true neuropathic joints are rarely encountered in modern clinical practice. The imaging features of three cases of dissecting neuropathic joints are described. Subjects and Materials: Three patients, none of whom were previously known to have nenropathic arthropathy, were seen over a six month period. Two patients had chronic renal failure while the third was found to have classical syphilitic neuroarthropathy. They presented with painful swellings o f the thigh, shoulder and forearm respectively, mimicking either thrombophlebitis or soft tissue tumours. All were investigated prospectively. Results: Radiographs and computed tomography (CT) demonstrated destructive changes of the hip, shoulder and elbow joints respectively, with soft tissue bony debris located adjacent to and remote from the joints. All patients had arthrography and post-arthrographic CT which showed tracking of joint contents into the surrounding muscles and fascial planes, with communication to the dissected bony debris. One patient underwent magnetic resonance imaging of the shoulder, confirming CT arthrographic findings. Conclusion: The diagnosis of dissecting neuropathic joint should be considered in patients presenting with painful soft tissue swelling and having radiographic features of neuroarthropathy. CT arthrography is probably the most useful imaging modality for confirmation of this diagnosis.
EMERGENCY TREATMENT OF LIFE-THREATENING H A E M O R R H A G E AFTER RENAL BIOPSY BY SELECTIVE ARTERIAL EMBOLIZATION H. SANSOM and J. MclVOR
Charing Cross Hospital, London The only serious complication of percutaneous renal biopsy is massive haemorrhage, which has an incidence of less than 1%. The treatment of persistent massive haemorrhage by selective renal arterial embolisation is well described, but we have found only one report of this procedure being used in the emergency situation. We report three patients with life threatening haemorrhage post renal biopsy who were successfully treated by selective arterial embolisation on the same day as the biopsy. The three patients had developed severe haemorrhage into the renal tract immediately post biopsy. All required urgent blood transfusion and were being considered for surgery. Selective arterial embolisation, performed within 6 hours of the biopsy controlled the bleeding in all three cases. The catheters and particulate embolisation material used for these cases would be available in most Radiology Departments. Our conclusion is that selective arterial embolisation can be used as an emergency procedure to treat life threatening haemorrhage resulting from percutaneous renal biopsy and that this procedure can be performed by an experienced vascular radiologist without special equipment.
ACQUIRED POSTERIOR URETHRAL DIVERTICULA: A COMPLICATION O F SURGERY FOR HIGH ANORECTAL MALFORMATIONS S. J. VINNICOMBE, C. D. GOOD, C. M. HALL and A. K I N G
Great Ormond Street Hospitalfor Children NHS Trust, London Introduction: Children with high anorectal malformations (ARM's) are prone to urinary problems because of: a) the accompanying
771
rectourethral fistula b) associated urinary tract anomalies c) associated neural problems (sacral agensis) d) complications of surgery. The purpose of this study was to highlight the clinical and radiological features of a particular complication of surgery, the posterior urethral diverticulum. Method: We have retrospectively reviewed a series of 5 children with this complication. Results: Recurrent urinary tract infection occurred in all 5; 3 developed enuresis dribbling incontinence; 1 had urinary retention. Ultrasound showed cystic masses behind the bladder in all cases. In 2, this was mistaken for bowel. In another, calculi within the diverticulum were misinterpreted as normal rectal contents. Micturating cystourethrography simultaneously demonstrated the bladder and diverticulum in only 2 cases. In 2, only the diverticulum filled and in 1, only the bladder filled, through the posterior urethra was abnormal. In 1 patient excretory urography was required to identify the bladder. Conclusion: since symptoms are cured by excision of the diverticulum, this diagnosis should be considered in any child with a previous A R M who has a suggestive history. Awareness of the potential pitfalls of imaging will allow prompt diagnosis.
CONGENITAL ANOMALIES OF THE PORTAL VENOUS SYSTEM - C T APPEARANCES WITH EMBRYOLOGICAL CONSIDERATION G. WALSH and M. P. WILLIAMS
Department of Radiology, Derriford Hospital, Plymouth The portal vein is formed by the union of the splenic and superior mesenteric veins behind the neck of the pancreas. This system is derived from the vitelline veins. We present three cases each of which illustrates a congenital variant of the portal venous system, describe their CT appearances and consider the embryological processes accounting for these anomalies. I A 65 year old female with Ca of bronchus was referred for tumour staging. A preduodenal portal view (PPV) was noted. No other anomalies were evident. II A 36 year female with a history of recurrent episodes of acute pancreatitits presented for CT of abdomen. A PPV was noted. In addition SMV rotation, a vertically orientated pancreas and polysplenia were present. I I I A 40 year old male with a family history of Von Hippel-Lindau syndrome presented for screening CT of abdomen. A right sided paraduodenal hernia together with SMV rotation were found Developmental anomalies of the portal venous system are occasional incidental findings in adults. SMV rotation should alert the radiologist to the presence of midgut malrotation and/or internal herniae. A PPV is essential to recognise especially on pre-operative imaging as undetected it represents a significant surgical hazard.
URETERIC PSEUDODIVERTICULA G. WALSH, P. HUGHES, N. RING and M. P. WILLIAMS
Derriford Hospital, Plymouth Ureteric pseudodiverticula (UPD) are outpouchings measuring less than 5 mm in diameter which are occasionally seen as an incidental finding on retrograde/excretory urography. They were first described by Holly and Sumcad in 1957 and since then approximately 100 cases have been reported. U P D have most frequently been found in the elderly male with a history of chronic urinary tract sepsis. Histologically, U P D represent invaginations of hyperplastic transitional epithelium into the lamina propria. The underlying muscularis propria may be effaced but remains intact. Continuity with the ureteric lumen is maintained though U P D may co-exist with both ureteritis cystica and ureteritis glandularis. An increased prevalance of uroepithelial malignancy has been suggested in patients with UPD, one series indicating that the association may be as high as 46%. We wish to illustrate the appearances of this rare condition and present a brief review of its possible aetiology and significance. We describe the findings in two elderly males one of whom had a co-existing transitional cell carcinoma. In conclusion, U P D are an occasional incidental finding on urographic studies. This hyperplastic proliferative change may indicate a degree of uroepithelial instability. This makes recognition of the appearance and possible significance of U P D important as periodic patient review may be indicated.
IMAGING OF DISSECTING NEUROPATHIC JOINTS W. C. G. PEH, J. BROCKWELL, M. T. C H A U and M. M. T. N G
Departments of Diagnostic Radiology, Orthopaedic Surgery and Medicine, The University of Hong Kong and Queen Mary Hospital, Hong Kong Introduction: Unlike the Charcot-like joint seen in the diabetic foot, true neuropathic joints are rarely encountered in modern clinical practice. The imaging features of three cases of dissecting neuropathic joints are described. Subjects and Materials: Three patients, none of whom were previously known to have nenropathic arthropathy, were seen over a six month period. Two patients had chronic renal failure while the third was found to have classical syphilitic neuroarthropathy. They presented with painful swellings o f the thigh, shoulder and forearm respectively, mimicking either thrombophlebitis or soft tissue tumours. All were investigated prospectively. Results: Radiographs and computed tomography (CT) demonstrated destructive changes of the hip, shoulder and elbow joints respectively, with soft tissue bony debris located adjacent to and remote from the joints. All patients had arthrography and post-arthrographic CT which showed tracking of joint contents into the surrounding muscles and fascial planes, with communication to the dissected bony debris. One patient underwent magnetic resonance imaging of the shoulder, confirming CT arthrographic findings. Conclusion: The diagnosis of dissecting neuropathic joint should be considered in patients presenting with painful soft tissue swelling and having radiographic features of neuroarthropathy. CT arthrography is probably the most useful imaging modality for confirmation of this diagnosis.
EMERGENCY TREATMENT OF LIFE-THREATENING H A E M O R R H A G E AFTER RENAL BIOPSY BY SELECTIVE ARTERIAL EMBOLIZATION H. SANSOM and J. MclVOR
Charing Cross Hospital, London The only serious complication of percutaneous renal biopsy is massive haemorrhage, which has an incidence of less than 1%. The treatment of persistent massive haemorrhage by selective renal arterial embolisation is well described, but we have found only one report of this procedure being used in the emergency situation. We report three patients with life threatening haemorrhage post renal biopsy who were successfully treated by selective arterial embolisation on the same day as the biopsy. The three patients had developed severe haemorrhage into the renal tract immediately post biopsy. All required urgent blood transfusion and were being considered for surgery. Selective arterial embolisation, performed within 6 hours of the biopsy controlled the bleeding in all three cases. The catheters and particulate embolisation material used for these cases would be available in most Radiology Departments. Our conclusion is that selective arterial embolisation can be used as an emergency procedure to treat life threatening haemorrhage resulting from percutaneous renal biopsy and that this procedure can be performed by an experienced vascular radiologist without special equipment.
ACQUIRED POSTERIOR URETHRAL DIVERTICULA: A COMPLICATION O F SURGERY FOR HIGH ANORECTAL MALFORMATIONS S. J. VINNICOMBE, C. D. GOOD, C. M. HALL and A. K I N G
Great Ormond Street Hospitalfor Children NHS Trust, London Introduction: Children with high anorectal malformations (ARM's) are prone to urinary problems because of: a) the accompanying
771
rectourethral fistula b) associated urinary tract anomalies c) associated neural problems (sacral agensis) d) complications of surgery. The purpose of this study was to highlight the clinical and radiological features of a particular complication of surgery, the posterior urethral diverticulum. Method: We have retrospectively reviewed a series of 5 children with this complication. Results: Recurrent urinary tract infection occurred in all 5; 3 developed enuresis dribbling incontinence; 1 had urinary retention. Ultrasound showed cystic masses behind the bladder in all cases. In 2, this was mistaken for bowel. In another, calculi within the diverticulum were misinterpreted as normal rectal contents. Micturating cystourethrography simultaneously demonstrated the bladder and diverticulum in only 2 cases. In 2, only the diverticulum filled and in 1, only the bladder filled, through the posterior urethra was abnormal. In 1 patient excretory urography was required to identify the bladder. Conclusion: since symptoms are cured by excision of the diverticulum, this diagnosis should be considered in any child with a previous A R M who has a suggestive history. Awareness of the potential pitfalls of imaging will allow prompt diagnosis.
CONGENITAL ANOMALIES OF THE PORTAL VENOUS SYSTEM - C T APPEARANCES WITH EMBRYOLOGICAL CONSIDERATION G. WALSH and M. P. WILLIAMS
Department of Radiology, Derriford Hospital, Plymouth The portal vein is formed by the union of the splenic and superior mesenteric veins behind the neck of the pancreas. This system is derived from the vitelline veins. We present three cases each of which illustrates a congenital variant of the portal venous system, describe their CT appearances and consider the embryological processes accounting for these anomalies. I A 65 year old female with Ca of bronchus was referred for tumour staging. A preduodenal portal view (PPV) was noted. No other anomalies were evident. II A 36 year female with a history of recurrent episodes of acute pancreatitits presented for CT of abdomen. A PPV was noted. In addition SMV rotation, a vertically orientated pancreas and polysplenia were present. I I I A 40 year old male with a family history of Von Hippel-Lindau syndrome presented for screening CT of abdomen. A right sided paraduodenal hernia together with SMV rotation were found Developmental anomalies of the portal venous system are occasional incidental findings in adults. SMV rotation should alert the radiologist to the presence of midgut malrotation and/or internal herniae. A PPV is essential to recognise especially on pre-operative imaging as undetected it represents a significant surgical hazard.
URETERIC PSEUDODIVERTICULA G. WALSH, P. HUGHES, N. RING and M. P. WILLIAMS
Derriford Hospital, Plymouth Ureteric pseudodiverticula (UPD) are outpouchings measuring less than 5 mm in diameter which are occasionally seen as an incidental finding on retrograde/excretory urography. They were first described by Holly and Sumcad in 1957 and since then approximately 100 cases have been reported. U P D have most frequently been found in the elderly male with a history of chronic urinary tract sepsis. Histologically, U P D represent invaginations of hyperplastic transitional epithelium into the lamina propria. The underlying muscularis propria may be effaced but remains intact. Continuity with the ureteric lumen is maintained though U P D may co-exist with both ureteritis cystica and ureteritis glandularis. An increased prevalance of uroepithelial malignancy has been suggested in patients with UPD, one series indicating that the association may be as high as 46%. We wish to illustrate the appearances of this rare condition and present a brief review of its possible aetiology and significance. We describe the findings in two elderly males one of whom had a co-existing transitional cell carcinoma. In conclusion, U P D are an occasional incidental finding on urographic studies. This hyperplastic proliferative change may indicate a degree of uroepithelial instability. This makes recognition of the appearance and possible significance of U P D important as periodic patient review may be indicated.