Costovertebral Angle Research Articles

Comparison Between Urine Dipstick and Microscopic Examination Urinalysis With Urine Culture to Evaluate the Sensitivity and Specificity for Each in Diagnosing Urinary Tract Infection in Qassim Region, Saudi Arabia.

Urinalysis is the most popular test for evaluating emergency room patients with possible urinary tract infections (UTIs). Due to their speed and inexpensive cost, urine dipsticks are frequently performed in the Emergency Room. Although a urine dipstick test may be less expensive and time-saving than a laboratory study, it may not be accurate. The study evaluated the sensitivity and specificity of urine dipstick and microscopic urinalysis with a urine culture. A prospective, observational study was conducted on adults who visited the Emergency Department at King Fahd Specialist Hospital in Buraydah and reported having dysuria, urine urgency, or frequency, as well as suprapubic or costovertebral angle soreness. Patients who could not give a trustworthy history, had symptoms of vaginal discharge, or had taken antibiotics within the previous 72 hours were excluded. One hundred fifty-three urine samples were collected and examined using urinalysis and dipstick. In addition, 113 (73.86%) of 153 urine samples exhibited no growth in urine culture. With a count of nine, Escherichia coli (E. coli) was the most often isolated organism among the positive cultures (5.88%). Klebsiella pneumoniae was the second most common in our sample with eight (5.23%). The urine dipstick was shown to have an overall sensitivity of 0.79, specificity of 0.39, positive productive value (PPV) of 0.30, and negative productive value (NPV) of 0.85. Urinalysis exhibited a high sensitivity of 0.95 and a poor specificity of 0.21. Our study showed that urine dipsticks may be more beneficial than urinalysis for ruling out urinary tract infections (UTIs), while urinalysis may be more helpful in verifying their presence.

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.

Incidence of catheter-associated urinary tract infections by Gram-negative bacilli and their ESBL and carbapenemase production in specialized hospitals of Bahir Dar, northwest Ethiopia

BackgroundCatheter-associated urinary tract infections (CAUTIs) due to multidrug-resistant Gram-negative bacilli (GNB) is a common concern globally. Investigating the incidence of CAUTI and associated antibiotic resistance has paramount importance from the health care associated infections perspective. This study therefore assessed the incidence of CAUTIs due to GNB and the production of extended-spectrum beta-lactamase (ESBL) and carbapenemase among inpatients in specialized hospitals of Northwest, Ethiopia.MethodsA total of 363 patients with indwelling urinary catheters who were admitted in the hospital for > 48 h were consecutively enrolled and followed from 3 to 18 days. Data were collected through interviewing and review of medical records. Patients who developed at least one of the following: fever (> 38 OC), suprapubic tenderness, or costovertebral angle pain, coupled with a GNB positive urine culture of ≥ 103 CFU/mL with no more than two bacterial species were defined as CAUTI. The ESBL and carbapenemase production were detected and identified by chromogenic medium. Logistic regression analysis was done to identify associated factors.ResultsFrom 363 patients followed, the incidence rate of CAUTI was 27.8 per 1000 catheter days. Catheterization for ≥ 8 days (AOR = 10.6, 95%CI:1.8–62.1) and hospitalization for > 10 days (AOR = 8.1, 95%CI: 2.4–27.2) were the factors significantly associated with CAUTIs. E. coli (n = 18, 34.6%), Proteus species (n = 7, 13.5%), and P. aeruginosa (n = 6, 11.5%) were the most frequent GNB. Isolates revealed high rates of resistance to amoxicillin-clavulanic acid (100%), cefazolin (n = 51, 98%), ceftazidime (n = 47, 90%) and cefotaxime (n = 46, 88%). Most of the GNB isolates (86.5%) were multidrug-resistant. Overall, 19.2% and 5.8% of GNB isolates were ESBL and carbapenemase producers, respectively.ConclusionsIncidence of CAUTI with Gram-negative bacilli is high. As most of the GNB isolates are MDR and showed a super high rate of resistance to amoxicillin-clavulanic and third-generation cephalosporins, empirical treatment with these substances is virtually ineffective in patients with suspected GNB infection in Ethiopia. The expression of ESBL and carbapenemase among GNB isolates is also a concern. Therefore, improved infection prevention and control measures, careful use of catheters and third generation of cephalosporins are needed to improve patient outcomes and reduce the burden of CAUTIs and the spreading of antimicrobial resistance.

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.

A rare case of a combination of ectopic kidney and medial arcuate ligament syndrome: a case report

BackgroundEctopic kidney and median arcuate ligament syndrome are both rare conditions. The clinical presentation and diagnosis of these conditions are not well studied. There are no reports on the combination of these two rare conditions.Case presentationWe report a 24-year-old woman with fever, dysuria, urinary frequency and left flank pain for two days. The primary diagnoses in the clinic were left acute pyelonephritis and left hydronephrosis due to throbbing pain in the left costovertebral angle and pyuria. However, further computed tomography showed right ectopic pelvic kidney, left renal pelvis dilatation without definite ureteral lesion, good bilateral renal contrast enhancement, and compression of the celiac axis due to obstruction by the median arcuate ligament. Chronic abdominal symptoms were reported by the patient after repeat history taking. The patient’s condition was fully explained and discussed with her and her family, but they refused further therapy. After the acute pyelonephritis began improving, the patient was discharged for follow-up at our outpatient clinic.ConclusionWe present an extremely rare case of a combination of two rare conditions: ectopic kidney and median arcuate ligament syndrome. No study to date has reported on the relationship between the two diseases. Given the rarity of the two conditions, no evidence or even a hypothesis exists to explain the possible etiology of their combination. More reports are required to enhance the understanding of these rare conditions.

Pheochromocytoma: Intricate Cardiovascular Manifestations

Abstract We present the case of a 60-year-old female patient, dyslipidemic, obese, diabetic and hypertensive, with a history of resected right adrenal pheochromocytoma (1999 - no subsequent surgical or endocrinological re-evaluation), presenting for increased blood pressure values and the recurrence of symptoms (headaches, palpitations, sweating), with progressive accentuation in the last months. The patient associates pain in the right costovertebral angle and weight loss. The clinical examination revealed facial erythrosis, excessive sweating, tachycardic heart sounds, increased blood pressure and orthostatic hypotension. Electrocardiography reveals sinus tachycardia, signs of left ventricular hypertrophy, with repolarization abnormalities, morphological aspect confirmed by the transthoracic echocardiography. An ultrasound of the abdomen and pelvis ultrasound objectified a large tumor formation at the level of the right adrenal gland and a liver nodule. In the context of the symptoms, the suspicion of recurrent pheochromocytoma was raised, confirmed biochemically by the increase in urinary normetanephrines and through imagistic methods (CT scan of the abdomen and pelvis), the patient having an indication for curative surgical treatment. After completing the preoperative assessment (ECG Holter monitor, ABPM), during the hospitalization period, the antihypertensive regimen was adjusted by combining 4 antihypertensive drugs, episodes of orthostatic hypotension being managed by administering glucocorticoids and colloidal solutions for volume repletion. The patient was referred to the general surgery clinic for resection of the tumor, following the antihypertensive preparation protocol. Although the post-procedural evolution was favorable, the patient presents a high risk of tumor recurrence, requiring annual evaluation for a period of 10 years. Also, due to the association of cardiovascular risk factors and target organ damage, the patient requires periodic cardiological evaluation.

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

WHO International Standard Terminologies on Traditional Chinese Medicine: Use in Context, Creatively

WHO International Standard Terminologies on Traditional Chinese Medicine: Use in Context, Creatively

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).