Costovertebral Angle Tenderness Research Articles

A case of Perforated Retroperitoneal Appendicitis Mimicking Pyelonephritis

Introduction: Appendicitis is one of the most commonly diagnosed surgical diseases in childhood with emergency abdominal pain. Retrocecal retroperitoneal appendicitis is uncommon and potentially difficult to diagnose. This condition might present with atypical clinical, and radiological signs. Here, we present a patient with perforated retrocecal appendicitis in whom the clinical findings mimicked acute pyelonephritis. Case Report: A 3-year-old boy presented with right flank pain, fever, and vomiting since a two days. The abdomen was soft but right costovertebral angle tenderness positive. There was pyuria. The clinical impression was pyelonephritis. Ultrasonography showed perirenal fluid collection but did not show any collections pericecal area. In the Multi-detector CT (MDCT) MDCT a long inflamed retrocecal retroperitoneal appendix was seen with surrounding inflammation that extended to anterior pararenal space, and retroperitoneal air. At surgery, there was retrocecal retroperitoneal appendicitis with perforation and retroperitoneal collection. Appendectomy and drainage were performed. Conclusions: Patients with retroperitoneal appendicitis is that these patients often present with atypical and less severe abdominal complaints. In this situation, MDCT could be a rapid and efficient tool for localizing the appendix and for the differential diagnosis.

Urinary tract infection in pediatric patients – Recent updates

In children, urinary tract infection (UTI) is a common condition. Prompt identification and treatment are critical for reducing morbidity associated with this illness. Throughout infancy, the symptoms and indications remain nonspecific. During the first 2 years of life, the most prevalent sign of UTI is unexplained fever. Symptoms and indicators of pyelonephritis after the 2nd year of life include fever, chills, rigor, flank discomfort, and costovertebral angle tenderness. Suprapubic pain, dysuria, urinary frequency, urgency, murky urine, malodourous urine, and suprapubic tenderness are examples of the lower tract symptoms and indicators. When UTI is suspected, a urinalysis and urine culture should be conducted. In the treatment of acute uncomplicated UTI, second or third-generation cephalosporin and amoxicillin-clavulanate are currently the medications of choice. Parenteral antibiotic therapy is advised for infants under 2 months of age and any child who seems toxic is hemodynamically unstable, is immunocompromised, is unable to tolerate, or is not responding to oral medication. This study focuses on the most recent updates about UTIs in children and provides a comprehensive overview of the subject.

FRI229 Bilateral Adrenal Hemorrhage Following Deep Tissue Body Massage

Abstract Disclosure: M. Antony: None. S. Gundlapally: None. P. Russell: None. S. Storm: None. S. Patel: None. V. Verma: None. R. Kant: None. Introduction: Adrenal hemorrhages have been reported in patients undergoing ACTH stimulation test using bovine- source ACTH. It can also be seen in severe stressful situations such as septicemia and extensive thermal burns due to sudden and profound adrenocortical stimulation by endogenous ACTH. Idiopathic spontaneous adrenal hemorrhage and motor vehicle accident induced adrenal hemorrhage have also been rarely reported. Coagulopathy, thromboembolic disease, and postoperative state are 3 major risk factors associated with bilateral adrenal hemorrhage. We present a unique case of a patient who presented with bilateral adrenal hemorrhage following deep tissue body massage. Clinical Case: A 44-year-old male with a past medical history of recurrent pulmonary embolism (PE) and deep venous thrombosis (DVT) due to lupus anticoagulant disorder status-post inferior vena cava (IVC) filter and recent change from Coumadin to Xarelto presented to the ED with a chief complaint of right upper quadrant (RUQ) pain extending to the right flank. Patient experienced unrelenting pain after a deep-tissue massage one week prior to presentation. Patient was seen two days prior to admission for similar complaints, but was discharged after reassuring CT abdomen/pelvis, ultrasound, and labs. He returned after pain worsened, and a repeat CT showed right adrenal hemorrhage and enlargement. Patient denied all other symptoms except pain. Vitals included BP of 144/84 mmhg, RR 20/min, HR 89/min, temp of 98.1°F, and SpO2 of 99%. Physical exam was notable only for RUQ pain and right CVA tenderness. Initial labs showed normal CBC including HGB 13.6g/dL (13-17 g/dL), HCT 37.5% (38.5-52%), and PLT 181K/microL (150-450 K/microL). Glucose 120mg/dL (70-99mg/dL), Na 129mmol/L (135-146 mmol/L), K 3.3mmol/L (3.5-5.2 mmol/L), Cl 87mmol/L (98-107 mmol/L), anion gap 17mmol/L (4-15mmol/L). LFT, serum lipase and CPK were non-contributory. PT was elevated at 24.7s (10-13s) and INR was 2.1 (0.9-1.2). Anticoagulation was stopped for three to four weeks, and nonsurgical management was recommended. Potassium supplementation was given, and the patient was continued on his hypertension medications. On further investigation, origin of the hemorrhage was determined to be traumatic secondary to the massage during which the masseuse walked on the patient. The patient was discharged after three days but was readmitted after continued abdominal pain and hyponatremia. He was diagnosed with a left-sided adrenal hemorrhage on repeat CT scan twelve days after identification of the first. Medical management was successful. Conclusion: Adrenal hemorrhage is a potentially life-threatening condition often caused by trauma, severe burns, or septicemia. Anticoagulant therapy and thromboembolic disease, as seen in our patient, are also risk factors. The atypical trauma induced by the patient's massage likely initiated the hemorrhagic event. Presentation: Friday, June 16, 2023

Comprehensive prediction of urolithiasis based on clinical factors, blood chemistry and urinalysis: UROLITHIASIS score

Comprehensive prediction of urolithiasis using available factors obtained in the emergency department may aid in patient-centered diagnostic imaging decisions. This retrospective study analyzed the clinical factors, blood chemistry and urine parameters of patients who underwent nonenhanced urinary computed tomography for suspected urolithiasis. A scoring system was developed from a logistic regression model and was tested using the area under the curve (AUC). The prevalence of urolithiasis and important possible causes in the three risk subgroups were determined. Finally, the scoring model was validated. In the derivation cohort (n = 673), 566 patients were diagnosed with urolithiasis. Age > 35 years, history of urolithiasis, pain duration < 8 h, nausea/vomiting, costovertebral angle tenderness, serum creatinine ≥ 0.92 mg/dL, erythrocytes ≥ 10/high power field, no leukocytes ≤ + , and any crystalluria were retained in the final multivariable model and became part of the score. This scoring model demonstrated good discrimination (AUC 0.808 [95% CI, 0.776–0.837]). In the validation cohort (n = 336), the performance was similar (AUC 0.803 [95% CI, 0.756–0.844]), surpassing that of the STONE score (AUC 0.654 [95% CI, 0.601–0.705], P < 0.001). This scoring model successfully stratified patients according to the probability of urolithiasis. Further validation in various settings is needed.

Clinical factors distinguishing renal infarction from acute pyelonephritis: A randomly matched retrospective case-control study

IntroductionRenal infarction (RI) is rare but clinically important because the appropriate treatment depends on the time of diagnosis. RI is often misdiagnosed as acute pyelonephritis (APN) because both diseases have nonspecific symptoms such as flank pain and abdominal pain. We identified predictors for distinguishing RI from APN. MethodsThe data of patients visited the emergency department and diagnosed with RI or APN from March 2016 to May 2020 were prospectively collected and retrospectively analyzed. Patients aged under 18 years, with a history of trauma, or incomplete medical records were excluded. Using a matching ratio of 1:5, RI patients were randomly matched to APN patients. Multivariable logistic regression analysis was performed to identify factors that could distinguish RI from APN. In addition, we constructed a decision tree to identify patterns of risk factors and develop prediction algorithms. ResultsThe RI and APN groups included 55 and 275 patients, respectively. Multivariable logistic regression analysis showed that male sex (OR, 6.161; p = 0.009), atrial fibrillation (AF) (OR, 14.303; p = 0.021), costovertebral angle tenderness (CVAT) (OR, 0.106; p < 0.001), aspartate transaminase (AST) level > 21.50 U/L (OR, 19.820; p < 0.001), C-reactive protein (CRP) level < 19.75 mg/L (OR, 10.167; p < 0.001), and pyuria (OR, 0.037; p < 0.001) were significantly associated with RI distinguishing from APN. ConclusionMale sex, AF, no CVAT, AST level > 21.50 U/L, CRP level < 19.75 mg/L, and no pyuria were significant factors that could distinguish RI from APN.

Clinical factors and diagnoses associated with inappropriate urine-culture ordering in primary care

Background: Inappropriate urine-culture ordering is associated with increased antibiotic prescribing in myriad care environments, including acute and long-term care. In primary care, where urinary tract infections (UTIs) are commonly encountered, the appropriateness of urine-culture ordering has not been well described. We examined the appropriateness of urine-culture ordering and factors associated with inappropriate urine-culture ordering in primary care. Methods: We conducted a secondary analysis of data from a previous prospective study that included patients aged ≥18 years presenting with provider-suspected UTI with an accompanying urine culture at 2 safety-net, primary-care clinics in Houston, Texas, between November 2018 and March 2020. Patients with complicated or uncomplicated UTI were included, but those with a urinary catheter and pregnant females were excluded. Urine cultures were considered appropriate if the patient had an evidence-based symptom of UTI (ie, dysuria, frequency, urgency, hematuria, fever, chills, costovertebral angle tenderness, suprapubic, pelvic, or flank pain, or nephrolithiasis) as a diagnostic code or listed in providers’ free-text documentation. Diagnostic codes for symptoms that were not evidence based were grouped into categories based on body system, visit type (eg, routine visit), or sign or symptom clusters. We evaluated the relationships among demographic and clinical factors, the clinic visited, and non–evidence-based diagnostic codes with inappropriately ordered cultures. Results: We examined 870 cultures from 807 patients. Overall, 61.5% of patients were Hispanic (61.5%) and 23% were African American or Black. Also, 70.6% were women; the mean age was 49.2 years (SD, 14.6); and the mean Elixhauser score was 1.9 (SD, 5.4). Among the 870 cultures, 210 (24%) were ordered inappropriately. Dysuria (n = 289), frequency (n = 129), and UTI or cystitis (n = 117) were the most common, evidence-based codes among appropriate cultures. In the adjusted model, the nonteaching clinic (aOR, 6.33) and diagnostic codes comprising the following categories were associated with inappropriate culturing: acute lower back pain (aOR, 5.42), cardiac-related visits (aOR, 2.41), urinary incontinence (aOR, 4.46), routine health visits (aOR, 3.66), urine characteristics (aOR, 14.32), voiding difficulties (aOR, 3.88), and well-woman visits with a gynecological exam or family planning aspect (aOR, 12.27) (all P &lt; .05). Conclusions: This research highlights potential gaps or miscues in provider behavior related to urine culture ordering, and unveiled problematic culturing related to urine characteristics and to routine visits, especially of a gynecological nature. This information can be incorporated into diagnostic stewardship interventions to address misconceptions, and to further explore the reasoning or processes wherein urine cultures are ordered for routine visits.Financial support: NIAID UM1AI104681Disclosure: None

Robot-Assisted Laparoscopic Ureteroureterostomy of an Obstructive Retrocaval Ureter

Clinical History: A 32-year-old woman without significant medical history presented with incidentally found right severe hydronephrosis from a computed tomography scan after car accident. Her symptoms include only intermittent right flank pain. She has no dysuria or hematuria. Physical Examination: Examination was notable for right-sided costovertebral angle tenderness. Diagnosis: A computed tomography urogram scan was performed, which revealed severe right hydronephrosis with abrupt transition point at proximal ureter. The transition point was located posterior to the inferior vena cava, consistent with retrocaval ureter anatomy. Renal nucleotide scan showed 40% right kidney split function as well as a t1/2 of 35 minutes in right kidney, suggesting obstruction. Intervention: Given symptomatic pain, radiologic evidence of ureteral obstruction, good residual right renal function, and performance status, decision was made to perform a right robot-assisted laparoscopic ureteroureterostomy. Follow-up/Outcomes: Patient tolerated the procedure well and was discharged home the morning after surgery with drain removed. She had prompt return of daily activities and complete resolution of flank pain. Her ureteral stent was removed in clinic 6 weeks after the surgery. Repeat renal nucleotide scan 3 months after the surgery demonstrated resolution of obstruction with new t1/2 of 8.7 minutes. Patient Consent Statement: The author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure. The authors have no conflicts of interest that may alter the results of this study. Runtime of video: 4 mins 28 secs

Skin-to-Renal Pelvis Distance Predicts Costovertebral Angle Tenderness in Adult Patients with Acute Focal Bacterial Nephritis

The aim of this study was to examine whether the distance between the skin and the renal pelvis affects the detection of costovertebral angle (CVA) tenderness in patients with acute focal bacterial nephritis (AFBN). We retrospectively reviewed the charts of our patients between April 2013 and June 2019 who were diagnosed as having AFBN. Diagnosis was based on ultrasound or computed tomography with contrast, revealing at least one wedge-shaped area of decreased vascularity and confirmation of fever not attributable to another condition. We extracted 23 cases, all Japanese (mean age 60.0 years old [range 45-81 years], 7 males, 16 females). CVA tenderness was present in 8 of these 23 patients. Receiver operating characteristic curves were drawn to evaluate the ability to differentiate skin-to-renal pelvis distance (SPD), body mass index, and age. Only SPD was a useful predictor of CVA tenderness, and 66 mm was determined as the optimal cutoff point (area under the receiver operating characteristic curve 0.858, 95% confidence interval 0.70-1.00). Logistic regression analysis was performed with CVA tenderness as a dependent variable, and SPD, body mass index, and age as explanatory variables. SPD was an independent predictive variable of CVA tenderness (P = 0.038, odds ratio 0.76, 95% confidence interval 0.590-0.986). CVA tenderness showed low yield in the diagnosis of AFBN in patients with longer SPD. Its use for diagnosis in obese patients may therefore be limited.

Predictors for Distinguishing Renal Infarction From Urolithiasis in the Emergency Department: A Randomly Matched Retrospective Case-Control Study

BackgroundEmergency department (ED) clinicians may misdiagnose renal infarction (RI) as urolithiasis because RI is a rare disease with presenting symptoms similar to the symptoms of urolithiasis. However, earlier diagnosis of RI can improve patient prognosis. ObjectivesWe investigated potential predictors for distinguishing RI from urolithiasis based on clinical findings and laboratory results. MethodsThis randomly matched retrospective case-control study included patients who had been diagnosed with acute RI or acute urolithiasis between January 2016 and March 2020. Patients were excluded if they were aged under 18 years, had a history of trauma, or had incomplete medical records. Using a matching ratio of 1:4, RI patients were randomly matched to urolithiasis patients. Multivariable logistic regression was performed to identify factors that could distinguish RI from urolithiasis. ResultsIn total, 48 patients were included in the RI group and 192 patients were included in the urolithiasis group. Multivariable logistic regression showed that age ≥ 65 years (odds ratio [OR] 6.155; p = 0.022), atrial fibrillation (OR 18.472; p = 0.045), current smoking (OR 17.070; p = 0.001), costovertebral angle tenderness (OR 0.179; p = 0.037), aspartate aminotransferase level ≥ 27.5 U/L (OR 6.932; p = 0.009), sodium level ≥ 138.5 mEq/L (OR 0.079; p = 0.004), and hematuria (OR 0.042; p = 0.001) were significant predictors that could distinguish RI from urolithiasis. Based on these results, a nomogram was constructed. ConclusionAge ≥ 65 years, atrial fibrillation, current smoking, absence of costovertebral angle tenderness, aspartate aminotransferase level ≥ 27.5 U/L, sodium level < 138.5 mEq/L, and absence of hematuria were predictors that can distinguish between RI and urolithiasis.

2245. Urinary tract infections in the elderly population in Japan; long hospital stay, high medical costs, and decline in the activities of daily living scores

Abstract Background Japan has one of the most aging societies in the world. Urinary tract infection (UTI) is a common disease in the elderly, and the incidence of hospitalization owing to UTI is increasing with the aging population. Here, we examined the length of hospital stay, differences in the Barthel index (BI), activities of daily living score (ADLs) at admission and discharge, and medical costs of UTI in elderly patients. Methods We retrospectively included hospitalized UTI patients in our center between January 1, 2013 and March 31, 2019. The inclusion criteria were as follows: (1) urine culture positive for Escherichia coli (over 104 colony forming units/mL) within 48 h of admission, and (2) the presence of at least one of the following: fever ≥ 38°C, costovertebral angle tenderness, suprapubic tenderness, and dysuria at the time of admission. We classified the enrolled patients into four groups according to age: young adults (20–64 years), pre-old (65–74 years), old (75–84 years), and super-old (≥ 85 years). Patient characteristics were compared across groups using the Mann–Whitney U test, Fisher’s exact test, and Kruskal-Wallis test. The Bonferroni corrected P &amp;lt; 0.05 was considered statistically significant. Results This study enrolled 393 cases, including 112 (28.4%) young adults, 72 (18.3%) pre-old, 130 (33.2%) old, and 79 (20.1%) super-old. The lengths of hospital stay were 10.8, 17.9, 17.2, and 21.6 days in young adults, pre-old, old, and super-old, respectively (P &amp;lt; 0.05). Differences in the BI were 1.2, 4.2, 5.2, and 5.2 in young adults, pre-old, old, and super-old, respectively (P &amp;lt; 0.05). However, no significant differences in these values were noted among the pre-old, old, and super-old groups. The medical costs were 6,054, 8,310, 10,129, and 12,577-USD (1USD = 128 yen) in young adults, pre-old, old, and super-old, respectively (P &amp;lt; 0.05). Nevertheless, a comparison of the medical costs per day showed no significant differences among the groups. Conclusion UTI in elderly patients were associated with ADLs decline, longer hospital stays, and higher medical costs than those in younger patients; however, no significant differences were found among those aged ≥ 65 years. Disclosures Sho Saito, MD, PhD, DAIICHI SANKYO: Grant/Research Support|EVEC: Grant/Research Support|EVEC: Patents obtained through collaborative research|SHIONOGI: Grant/Research Support|Takeda: Advisor/Consultant.

Screening for Referral of Serious Pathology by Physical Examination Tests in Patients with Back or Chest Pain: A Systematic Review.

To investigate the most common physical examination tests (PET) for the screening for referral of patients with back or chest pain caused by serious pathology. A systematic review was conducted. Searches were performed on seven electronic databases between June 2020 and December 2021. Only studies evaluating patients with back and/or chest pain with clear reporting of PETs and prompt patient referrals were included. 316 full texts were included, and these studies had a total of 474/492 patients affected by a serious disease. Only 26 studies of them described suspicion of serious disease due to at least one positive PET. Cardiac/pulmonary auscultation and heartbeats/blood pressure measurements were the most frequently reported tests. None of the reported studies included physiotherapists and chiropractors who reported the use of various tests, such as: cardiac and pulmonary auscultation, lung percussion, costovertebral angle tenderness, and lymph node palpation, highlighting a lack of attention in measuring vital parameters. On the contrary, doctors and nurses reported the assessment of the range of motion of the thoracolumbar spine and hip less frequently. Appropriate reporting of PETs is sparse, and their utilization is heterogeneous among different healthcare professionals. Further primary studies are needed to describe PETs results in patients suffering from back and/or chest pain.

November 2022 Medical Image of the Month: COVID-19 Infection Presenting as Spontaneous Subcapsular Hematoma of the Kidney

No abstract available. Manuscript truncated after 150 words. A 57-year-old woman with pertinent medical history of hypertension presented to the emergency department with 3 days of right sided lower abdominal pain radiating to the flank, associated with nausea and nonbloody, nonbilious emesis. She reported recent travel to Florida where she visited amusement parks, but only rode small children’s rides with no experienced physical trauma. She experienced fatigue and chills 5 days prior to presentation and tested positive for SARS-CoV2 virus on admission. She had been vaccinated for COVID-19 x3 (Moderna). No other significant history nor medications were noted, and review of systems was otherwise unremarkable. Urinalysis demonstrated mild ketonuria (20), proteinuria (100) and moderate hematuria on urinalysis while BUN and creatinine remained stable at baseline throughout. Physical examination confirmed costovertebral angle tenderness to the right side. CT abdomen revealed an American Association for the Surgery of Trauma (AAST) grade 3 right renal subcapsular hematoma with 2.1 cm laceration …

S3238 A Case of Concurrent Cholecystitis and Stauffer Syndrome

Introduction: Stauffer syndrome (SS) is a paraneoplastic syndrome seen in some malignancies, most commonly 4-15% of primary renal cell carcinomas, resulting in nephrogenic hepatic dysfunction. SS commonly results in elevated alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and prothrombin time (PT) as well as decreased albumin in the absence of liver metastasis. The etiology of SS is unknown, although three have been suggested: elevated interleukin-6, elevated colony stimulating factor or, least likely, autoimmune. We describe a case of a woman presenting with right upper quadrant (RUQ) pain who was found to have indirect predominant hyperbilirubinemia and acute cholecystitis and renal mass on ultrasound. Case Description/Methods: An 81-year-old female presented to an outside hospital for RUQ and epigastric pain that worsened after fatty meals. Imaging showed acute cholecystitis as well as a right renal mass. Physical exam at the time was remarkable only for diffuse tenderness to abdominal palpation, most notably in the RUQ. There was no scleral icterus or costovertebral angle tenderness on exam. Labs on presentation can be seen in Table 1. Given the elevated indirect bilirubin, gastroenterology was consulted and suggested Gilbert syndrome (GS) or SS given their concern for renal cell carcinoma (RCC). The next day the patient underwent a laparoscopic cholecystectomy notable for acute gangrenous cholecystitis with cholelithiasis, and had rapid normalization of bilirubin over 48 hours. The patient followed with outpatient urology for renal biopsy, which was positive for clear cell RCC. Follow up imaging revealed scattered pulmonary nodules up to 1.1cm, with concern for metastasis. Surgery was deemed inappropriate and the patient was conservatively managed, given her wishes to prioritize quality of life and not undergo chemotherapy. (Figure) Discussion: This case illustrates an interesting clinical picture where a patient with confirmed cholecystitis also has a new renal mass, with elevated indirect bilirubin and PT, consistent with SS. The diagnosis of SS is made clinically, with hopeful resolution of abnormal lab values upon RCC resection. In this case, surgery was not indicated, hemolysis was ruled out with stable hemoglobin and normal peripheral smear, and the diagnoses of acute cholecystitis and RCC causing SS was made. In addition to hemolysis, GS, and Criggler-Najjar when working up indirect hyperbilirubinemia, it is imperative to include SS on the differential diagnosis.Figure 1.: CT abdomen with right renal mass. Table 1. - Patient labs on presentation and 2 days post-cholecystectomy Lab Admission Post-Op Day 2 Normal WBC Count (103 cells/uL) 17 14 4.1-9.3 Platelet (103/uL) 246 248 130-350 Hemoglobin (g/dL) 10.6 9.8 11-14.7 Albumin (g/dL) 3.3 2.7 3.5-5.2 Total Bilirubin (mg/dL) 2.8 0.9 0.1-1.2 Indirect Bilirubin (mg/dL) 2.4 0-0.9 Alkaline Phosphatase (IU/L) 96 102 30-115 AST (IU/L) 23 20 5-45 ALT (IU/L) 12 16 5-60 Lipase (U/L) 12 11-82 Prothrombin Time (s) 14.3 9.4-12.9 INR 1.2 0.83-1.14 AST = aspartate transaminase, ALT = alanine transaminase.

Hydronephrosis and free fluid identified by point-of-care ultrasound leads to diagnosis.

A 64-year-old man with a history of hypertension presented for evaluation of sudden-onset, right lower quadrant abdominal pain radiating to the right flank with associated non-bloody, non-bilious emesis. He denied dysuria, hematuria, fevers, chills, history of similar symptoms, or previous abdominal surgeries. On physical examination, he was afebrile and hypertensive to 189/113, with vitals otherwise within normal limits. He appeared uncomfortable, with moderate right upper and right lower quadrant tenderness with mild guarding but no costovertebral angle tenderness. Point-of-care ultrasound was performed, which identified moderate hydronephrosis with associated free fluid surrounding the right kidney, concerning for obstruction and collecting system rupture (Figure 1). A contrasted computed tomography of the abdomen and pelvis confirmed high-grade obstruction attributed to 5-mm calculus within the proximal ureter causing dilatation of the ureter with hydronephrosis and perinephric fluid (Figure 2). Findings were consistent with calyceal rupture, resulting in urology consult. The urology team took the patient to the operating room for ureteral stenting, antibiotics, and staged ureteroscopy and lithotripsy. Spontaneous rupture of the renal pelvis is a rare but critical diagnosis in patients with acute abdomen.1 A retrospective review found that 74% of cases were attributed to ureteric stones; less common causes included benign or malignant extrinsic ureteric compression, pelvic–ureteric junction and vesico–ureteric junction obstruction, bladder outlet obstruction, and iatrogenic disease.2 Treatment is tailored to the cause and is often managed conservatively with antibiotics but may require urologic intervention.3 Ultrasound is a helpful tool in identifying abnormalities consistent with calyceal rupture, which include hydronephrosis and perinephric free fluid.

Evaluation of the usefulness of costovertebral angle tenderness in patients with suspected ureteral stone.

The usefulness of costovertebral angle (CVA) tenderness for the diagnosis of a suspected ureteral stone remains controversial. This single-center, retrospective, observational study included patients aged 16-64 years with acute-onset unilateral lower back pain or abdominal pain. The diagnostic accuracy of CVA tenderness was investigated. In total, 132 patients met the criteria; 80 were diagnosed with ureteral stones. The sensitivity and specificity of CVA tenderness were 0.65 and 0.50, respectively; positive and negative likelihood ratios were 1.3 and 0.7, respectively. CVA tenderness cannot be used as a single diagnostic indicator to confirm or exclude ureteral stone diagnosis.

Man With Right Flank Pain

A 41-year-old man presented to the emergency department (ED) with right flank pain, without dysuria, hematuria, or fever. The patient had right costovertebral angle and lower quadrant tenderness. Computed tomography (CT) of the abdomen/pelvis revealed an obstructing 4-mm stone in the proximal right ureter, with hydronephrosis and delayed excretion (Figure 1, Appendix E1, available online at http://www.annemergmed.com). An abdominal X-Ray was obtained for urology follow-up that revealed contrast extravasation in the right abdomen concerning for calyceal rupture (Figure 2).

Point-of-Care Ultrasound in Diagnosing Emphysematous Pyelonephritis

A 57-year-old woman with no known systemic disease presented to the emergency department with abdominal pain and vomiting for 3 days. She was well-oriented, with a body temperature of 36.5°C, blood pressure of 133/80 mm Hg, and tachycardia of 118 beats/min. On abdominal palpation, she had tenderness, with no signs of peritoneal irritation. Right-sided costovertebral angle tenderness was elicited. Laboratory data revealed neutrophil-predominant leukocytosis (13,140/μL), thrombocytopenia (10,000/μL), and hyperglycemia (460 mg/dL), representing a new diagnosis of diabetes at the emergency department.

Evaluation of the natural medical-table hydrocarbonate mineral water application effectiveness in rehabilitation therapy of patients with urolithiasis

Background. Urolithiasis can be considered as a socially significant disease not only because it affects mostly people of working age, but also because it often turns into a chronic form, leading to an increase in the level of disability. This dictates the need to search for effective methods of treatment and prevention of disease recurrence, among which an important role is given to the use of non-pharmacological treatment methods balneological therapeutic factors.&#x0D; Aim. Evaluation of the effectiveness of the natural low-mineralized mineral water Tarkhanskaya-3 use in the rehabilitation therapy of urolithiasis in working-age patients.&#x0D; Material and methods. The study program involved 33 patients with urolithiasis. The patients of the main group (22 people), who did not have concomitant somatic acute or chronic pathology, took mineral water for 28 days 6 times a day, at home under the supervision of a polyclinic doctor and a nurse , at the rate of 4 ml/kg, degassed, heated to 2226 C. The control group (11 people) did not receive mineral water as a non-pharmacological therapy. The history of the disease, changes in the general analysis of urine and well-being (quality of life according to the Wisconsin questionnaire) were studied. The significance of differences was considered according to the generally accepted values of the Student's criterion and 2.&#x0D; Results. Comparative assessment of complaints and quality of life showed an improvement in the condition of patients who took mineral water: discomfort during urination disappeared, the number of patients with a positive costovertebral angle tenderness decreased, while no changes were recorded in the control group. In patients of the main group, a tendency towards a decrease in the level of uric acid from 326 to 256 mol/L (t=0.96; p 0.05) was revealed. Reliable data were obtained on the effect of mineral water intake on inorganic urinary sediment a decrease in the level of crystalluria (oxalaturia) in 70% of cases (2=3.9, p=0.048). Spontaneous discharge of salt crystals was registered in 2/3 of patients, an increase in daily urine output in all patients who took mineral water. The assessment of the quality of life of the main group patients showed a significant improvement in the state of health according to the scale impact on health (t=2.13; p 0.05). Evaluation of clinical and laboratory parameters did not reveal a significant effect on the electrolyte metabolism and concentration function of the kidneys.&#x0D; Conclusion. The intake of Tarkhanskaya-3 mineral water for the purpose of secondary prevention in the rehabilitation therapy of urolithiasis has a positive effect on the course of the disease.

Woman With Dysuria

A healthy 20-year-old nonpregnant woman presented to the emergency department with one day of fever and dysuria. Her temperature was 38.4 °C (101 °F), and she had right costovertebral angle tenderness. Laboratory investigations showed an increased C-reactive protein level (5.8 mg/dL), leukocytosis (WBC count 13,760/μl), and pyuria. Point-of-care ultrasonography (Figures 1 and 2) and abdominal computed tomography with contrast (Figure 3) were performed.

Duplex Collecting System of Right Kidney in 3-Year-Old Child: A Case Report

<i>Background: </i>The duplex collecting system is one of the congenital anomalies of kidney and urinary tract. It occurs in 0.2-2% of the general population. It can remain asymptomatic or become symptomatic. Affected children may present with urinary tract infections. Treatment options include pharmacological and surgical approaches. <i>Case:</i> We reported a 3-year-old male child, who was referred to Sanglah Hospital with recurrent fever. From the physical examination, we found positive costovertebral angle tenderness. Urinalysis showed high leukocyte sediments (1655/field of view), positive urine culture (<i>Enterococcus gallinarum</i>), and decreased glomerular filtration rate (68.75 ml/minute/1.73 m²). Ultrasonography of the right kidney showed two pelvicalyceal systems with severe hydronephrosis of upper moiety. The intravenous pyelography showed the drooping lily sign in the right kidney. We diagnosed the patient with a complicated urinary tract infection caused by <i>Enterococcus gallinarum</i>, duplex collecting system of right kidney, chronic kidney disease stage II. Antibiotics were administered due to complicated UTI. Open heminephrectomy was done. The patient was discharged in stable condition. <i>Conclusion: </i>The duplex collecting system may cause recurrent urinary tract infection. It can be a risk factor for renal scarring and cause chronic kidney disease. Comprehensive diagnostic workup and multidisciplinary management are needed to promote a good clinical outcome.