Arthur T. Rosenfield

THE VALUE OF UNENHANCED HELICAL COMPUTERIZED TOMOGRAPHY IN THE MANAGEMENT OF ACUTE FLANK PAIN

PURPOSE We developed an algorithm using unenhanced computerized tomography (CT) for the management of acute flank pain and suspected ureteral obstruction. MATERIALS AND METHODS During a 25-month interval 417 patients with acute flank pain underwent unenhanced helical CT. The final diagnosis was confirmed by additional imaging or clinical followup. For all patients who underwent additional imaging studies the official dictated radiology reports were used to determine whether the studies were recommended based on CT findings. Cases requiring intervention were evaluated to determine whether additional imaging was performed before the procedure. Medical records were reviewed and/or patients were interviewed to document the course of therapy and long-term outcome. RESULTS Unenhanced helical CT diagnosed ureteral stone disease with 95% sensitivity, 98% specificity and 97% accuracy. Of the 38 patients requiring intervention, including nephrostomy catheters in 18, lithotripsy in 3 and ureteroscopic stone extraction in 7, additional imaging (excretory urography) was performed in only 1. Additional imaging studies generated by CT were done in 3 cases in which the dictated reports were indeterminate for ureteral stones, including negative excretory urography in 2 and retrograde urography in 1. In 1 patient in whom CT misdiagnosed a ureteral stone unnecessary retrograde urography revealed the calcification to be a gonadal vein phlebolith. Seven patients with false-negative examinations reported spontaneous stone passage with no complications. CONCLUSIONS Unenhanced helical CT accurately determines the presence or absence of ureterolithiasis in patients with acute flank pain. CT precisely identifies stone size and location. When ureterolithiasis is absent, other causes of acute flank pain can be identified. In most cases additional imaging is not required.

Acute Focal Bacterial Nephritis (Acute Lobar Nephronia)

Acute lobar nephronia (ALN) refers to a renal mass caused by acute focal infection without liquefaction. The radiological findings in 12 patients with 13 episodes of ALN are described. A characteristic combination of uroradiological findings is (a) a relatively sonolucent mass which disrupts corticomedullary definition on ultrasonography; (b) a solid-appearing mass on other uroradiological studies; and (c) a positive gallium image in the region of the mass, which may be associated with increased activity elsewhere in the same or opposite kidney. The angiographic finding of significant venous narrowing within the mass associated with only minor arteriographic abnormalities is characteristic of ALN as well.

High Resolution Real-Time Ultrasonography in the Localization of the Undescended Testis

In a prospective study ultrasound was compared to palpation in 41 instances in which a testis was not present in the scrotum. A testis was palpable in 20 of these instances and not palpated in 21. Of 20 palpable undescended testes 14 (70 per cent) were identified by ultrasound. Of the 21 instances in which a testis was not palpated 3 intra-abdominal and 5 inguinal testes were identified at exploration. One of these organs (an inguinal testis) was identified by ultrasound. Two false positive sonograms in which a gubernacular structure mimicked an undescended testis occurred. Sonography cannot satisfactorily stand alone as a screening modality in the management of the undescended testis.

REEXAMINING THE VALUE OF HEMATURIA TESTING IN PATIENTS WITH ACUTE FLANK PAIN

PURPOSE Hematuria testing is routinely performed in patients with acute flank pain to screen for ureterolithiasis and to help determine the need for excretory urography. Unenhanced helical computerized tomography (CT) has recently been shown to be superior to excretory urography in diagnosing ureteral obstruction and can evaluate many other causes of flank pain. Given the speed, accuracy and safety of CT the value of hematuria testing for acute flank pain should be reexamined. MATERIALS AND METHODS We reviewed the medical records of 267 consecutive patients with acute flank pain referred for unenhanced helical CT. Microscopic and dipstick urinalysis data were obtained in 195 patients. Using helical CT as the gold standard, we calculated the sensitivity, specificity, predictive value and accuracy of hematuria for diagnosing ureterolithiasis. RESULTS Of the patients with ureterolithiasis 33% had 5 or less, 19% had 1 or less and 11% had no red blood cells (RBCs) per high power field. Of the patients without ureterolithiasis 24% had greater than 5 and 51% had greater than 1 RBC per high power field. Of the patients with ureterolithiasis 14% had a negative dipstick test and 1 RBC or less per high power field. There were 25 patients without ureterolithiasis who had CT abnormalities unrelated to the urinary tract, of whom 8 had greater than 1 RBC per high power field. CONCLUSIONS Absence of hematuria in the setting of acute flank pain cannot exclude a diagnosis of ureterolithiasis and should not obviate other diagnostic testing. Even when strongly positive on microscopy, hematuria has insufficient positive predictive value for diagnosing ureterolithiasis and may be misleading as other serious conditions resulting in acute flank pain may yield a positive test.

Gray-scale ultrasound in 204 proved gynecologic masses: accuracy and specific diagnostic criteria.

Gray-scale ultrasound results are evaluated in 182 women with 204 histologically proved gynecologic masses. Ultrasound provided information leading to the correct diagnosis in 56% of cases, contributory data in 23%, and nonspecific information in 14%. Errors occurred in 6%. A specific histologic diagnosis was possible in selected patients with simple ovarian cysts, cystadenomas, cystadenocarcinomas, dermoids, uterine fibroids, ectopic and molar pregnancies, missed abortions, and endometriosis. A characteristic but nondiagnostic ultrasound pattern was associated with carcinoma of the uterus, recurrent carcinoma of the ovary, and pelvic abscesses. A nonspecific pattern was common in tubo-ovarian abscesses.

Acute flank pain : A modern approach to diagnosis and management

Acute flank pain is a common and complex clinical problem. In addition to flank pain caused by ureterolithiasis, other urinary and extraurinary abnormalities can result in a similar clinical picture. Unenhanced CT can rapidly, accurately, and safely determine the presence or absence of ureteral obstruction. When obstruction is caused by ureterolithiasis, CT allows precise determination of stone size and location. These are the two most important factors used for patient management. In addition to direct stone visualization, there are many secondary CT signs of ureteral obstruction that are direct manifestations of the underlying pathophysiology. On the other hand, when obstruction is absent, CT can diagnose or exclude most other abnormalities that result in flank pain. As a result of its many advantages, unenhanced helical CT should become the dominant imaging modality for evaluation of all patients with acute flank pain in whom a clinical diagnosis is uncertain.

Comparison of Computerized Tomography, Ultrasound and Angiography in Staging Renal Cell Carcinoma

AbstractRenal cell carcinoma was staged prospectively with computerized tomography, ultrasonography and angiography in 23 cases. Staging was correct with computerized tomography in 91 per cent of the lesions (21 of 23), with ultrasound in 70 per cent (16 of 23) and with angiography in 61 per cent (14 of 23). Computerized tomography of the abdomen is the optimal technique to stage renal cell carcinoma and to determine adjacent organ invasion, lymph node metastases and venous extension. When computerized tomography is not available ultrasonography provides a useful alternative to angiography in preoperative tumor assessment in many cases.

ADVANCES IN THE IMAGING OF RENAL INFECTION: Helical CT and Modern Coordinated Imaging

Traditionally, imaging of renal infections was largely through a multimodality approach. Excretory urography, ultrasonography, nuclear scintigraphy, and CT all played major roles; however, in recent years, CT has increased in prominence in the imaging and evaluation of renal infection. Part of the reason for this trend includes improvements in the availability of CT scanners and more timely access to them. Helical scanning technology has also greatly increased the quality and usefulness of the information CT provides. Most uncomplicated cases of acute renal infection in adults do not require imaging for diagnosis and treatment. When imaging is indicated, however, contrast-enhanced CT almost always is the study of choice. For cases in which renal calculi may be present, the study should also include noncontrast images through the kidneys.

Resuscitation of pulmonary contusion: effects of a red cell substitute.

OBJECTIVE To determine the impact of a vasoactive red cell substitute, diaspirin cross-linked hemoglobin, on respiratory derangements after traumatic lung injury. DESIGN Randomized, controlled animal experiment. SETTING Large-animal laboratory. SUBJECTS Mechanically ventilated, anesthetized young Yorkshire male swine (15 to 20 kg). INTERVENTIONS Pigs (n = 6/group) received two pneumatic blasts to the right thoracic cage at baseline, were hemorrhaged 30 mL/kg from t = 0 to 20 mins, resuscitated with 0.9% saline (group 1, 90 mL/ kg) or diaspirin cross-linked hemoglobin (group 2, 15 mL/kg) from t = 20 to 40 mins, and then observed to t = 240 mins. MEASUREMENTS AND MAIN RESULTS Serial pulmonary and systemic hemodynamic measurements, total thoracic compliance assessment, spiral three-dimensional computed tomography scan, and lung weights (n = 3/group) were used to assess lesion size and lung water. Mean arterial pressure was restored in both animal groups. Mean pulmonary arterial pressure was significantly higher after resuscitation in animals receiving the red cell substitute. Oxygenation worsened mildly in both groups. Compliance diminished in both groups but was significantly worse at the end of the experiment in animals infused with diaspirin cross-linked hemoglobin. Right lung weights and right thoracic computed tomography scan volume were higher with diaspirin cross-linked hemoglobin than with saline. CONCLUSIONS After pulmonary contusion, resuscitation with diaspirin cross-linked hemoglobin led to pulmonary hypertension, greater pulmonary contusion lesion size, and stiffer lungs in this porcine model.

Evaluation of bronchospasm during excretory urography.

Mean pulmonary function was significantly decreased in 57 patients during excretory urography. Patients with a history of allergy had significantly greater mean decreases in flow rates than those without. Twelve did not have significant decreases in pulmonary function after needle puncture and intravenous injection of 5% dextrose in water. Eight healthy subjects did not have significant mean decreases after intravenous injection of 5% saline. Most patients undergoing excretory urography have bronchospasm that is greater in magnitude in those with a history of allergy.