Costovertebral Angle Research Articles

Nephrolithiasis with unusual initial symptoms

Objective: To describe a less common initial symptom of nephrolithiasis, its diagnostic pitfalls, risk factors, and mimicry of other conditions. Intervention and long-term management of nephrolithiasis is also discussed.Clinical Features: A Caucasian man aged 25 years had sudden bilateral inguinal and occasional periumbilical pain. The initial symptom suggested an abdominal pathologic condition; however, costovertebral angle pain followed 1 hour later with no radiation between the 2 anatomic sites. The initial urine dipstick result was negative for hematuria, but a kidney, ureter, and bladder radiograph revealed a smooth 2-mm × 3-mm stone lodged at the left vesico-ureteral junction.Intervention and Outcome: The patient was referred to a regional university medical center to receive extracorporal shock-wave lithotripsy several days after his initial visit. He was given pain medicine for the waiting period and received daily lumbar spine adjustments with a mild reduction in pain. He eventually received ureteroscopic laser lithotripsy because the shock-wave unit had malfunctioned before his appointment. The fragment analysis showed a calcium oxalate composition, and the patient was advised to lower his intake of oxalates. The patient had become a vegetarian approximately 3 months before this first stone episode.Conclusion: Nephrolithiasis is a condition commonly seen in chiropractic practice. Although it is usually easy to recognize, the diagnosis can be elusive if the typical historic factors and diagnostic results are absent or altered. The short-term management of nephrolithiasis is pain management, stone elimination, and the collection of a specimen to identify the composition and underlying metabolic abnormality. Long-term management is to prevent the recurrence of stones. Conservative comanagement by the chiropractic physician can be implemented through nutritional means.

Retroperitoneal mass and hydronephrosis

T 49-year-old man presented to the hospital with a 3-day history of left flank pain. His past urologic history is significant for several bouts of gross hematuria after participating in long-distance running. On physical examination, the patient was normotensive. There was mild costovertebral angle tenderness. The urinalysis showed trace blood. A film of the kidney, ureter, and bladder (KUB) showed a 9 3 9-cm calcific mass inferior to the left kidney margin (Fig. 1). A computed tomography scan of the abdomen demonstrated left hydronephrosis with an obstructing stone in the proximal left ureter. There was a complex left retroperitoneal mass corresponding to the large rim calcification seen on the KUB film (Fig. 2). The patient underwent cystoscopy, a retrograde ureteropyelogram, and placement of a left JJ stent. A large proximal ureteral stone was now seen having been hidden within the outline of the calcified mass (Fig. 3). A magnetic resonance image of the abdomen further characterized this mass as separate from the kidney and arising from the retroperitoneum/psoas muscle (Fig. 4). The patient underwent extracorporeal shock wave lithotripsy using a Dornier HM4 unit (2000 shocks at 29 kV) with successful fragmentation of the stone. No intervention is planned at this time for the retroperitoneal mass as the patient was asymptomatic prior to the colic episode. It is believed that the mass was related to the blunt trauma sustained in a motor vehicle accident 18 years before this hospitalization. The differential diagnosis for this mass would include an old retroperitoneal hematoma or urinoma. The mass was only brought to our attention because of the acute renal obstruction. One can hypothesize that the mass may have impeded urinary drainage, resulting in stasis and subsequent stone formation.

PEDIATRIC RETROPERITONEOSCOPIC NEPHRECTOMY USING 2 MM. INSTRUMENTATION

We describe several modifications of the retroperitoneoscopic approach to nephrectomy for benign renal disease, including the use of 2 mm. instrumentation and prone patient positioning. A total of 14 children underwent retroperitoneoscopic nephrectomy in the prone position. An inflatable dissecting device was inserted into the retroperitoneum after a small muscle splitting incision was made at the lateral border of the sacrospinalis muscle approximately 1 cm. below the costovertebral angle. After inflation the dissecting device was replaced with a 5 mm. cannula and pneumoretroperitoneum was maintained with carbon dioxide insufflation. Two 2 mm. trocars were then placed under endoscopic guidance. Dissection was performed using 2 mm. instrumentation and the specimen was retrieved through the largest port site. Nephrectomy was performed in 9 girls and 5 boys 3 months to 9.8 years old. The preoperative diagnosis included chronic pyelonephritis with minimal renal function, reflux with a nonfunctioning kidney, multicystic dysplastic kidney, an upper pole dysplastic moiety with an associated ureterocele and a dysplastic kidney with a vaginal ectopic ureter. Mean operative time for retroperitoneoscopic nephrectomy was 142 minutes with an estimated blood loss of less than 15 ml. Contralateral ureteral reimplantation was performed after retroperitoneoscopic dissection in 5 patients. Overall average hospital stay was 2 days and there were no complications. Several modifications of the retroperitoneal approach, including the use of prone patient positioning and 2 mm. instrumentation for visualization and dissection, may improve the safety and efficacy of this technique in children.

The Development of a Technique for Radiofrequency Lesioning of Splanchnic Nerves.

This article describes the development of a technique for radiofrequency lesioning of the splanchnic nerves. It features point neurolysis and improvement in safety from previously described techniques with the use of a curved, blunt needle. After extensive anatomic studies, the site of entry has been identified 4 cm lateral to the spinous process at the costovertebral angle of either the T11 or T12 vertebral body, and the placement of the needle tip at the junction of posterior two thirds to the anterior one third of the vertebral body. The use of a sharp, straight needle has been discouraged to prevent pneumothorax, and bowel, kidney, or nerve root injury. The radiofrequency lesion permits a point neurolysis, thus decreasing the rate of complications. Our experience of 22 patients treated with this technique has been complication-free, and the outcome was effective for all 10 patients with cancer. In the nonmalignancy group, some patients needed a second neurolysis (radiofrequency) procedure 4 months apart. There were also no secondary complications in these patients. We expect multicenter data accumulation in the coming years, which will determine the true efficacy of the radiofrequency of splanchnic nerves.

Operative Videothoracoscopy in the Surgical Treatment of Penetrating Firearms Wounds of the Chest

We prospectively analyzed our experience with operative videothoracoscopy (OVT) performed in a field military hospital in cases of penetrating firearms wounds of the thorax (PFAWT) sustained in Chechnya. From February to April 1996, we treated 206 wounded patients, of whom 37 (18.0%) had sustained chest injuries. PFAWT were present in 23 soldiers, accounting for 62.2% of all chest injuries. Twelve injuries were confined to the thorax, eight patients had associated injuries, and three soldiers had thoracoabdominal injuries. Nineteen patients had pleural drainage performed during medical evacuation. The thoracic injuries were right-sided (17), involved bullets or shell splinters (23); were through and through (16), represented solitary wounds (19), and were associated with internal organ injuries (21). Fifteen patients had indications for OVT when they were delivered from the battle-field 1.5 to 22 hours after injury. All patients manifested signs of hemorrhagic shock and hemodynamic instability. Indications for OVT were ongoing intrapleural bleeding (6), clotted hemothorax (6), or marked air leakage (3) preventing lung inflation with the OP-02 apparatus (field modification). OVT revealed 12 lung wounds, nine of which were multiple wounds, pleural bleeding in 6 patients, clotted hemothorax in 11 patients, and foreign bodies in 5 patients. Two patients underwent thoracotomy, one for suspicion of heart injury and the second because we could not adequately visualize and control bleeding revealed at OVT to be from the intercostal artery in the left costovertebral angle. Eight of 23 patients had no indication for operative videothoracoscopy and were managed with continued pleural aspiration and drug therapy. Wedge resection of the lung using an Endo-GIA-30 stapler was necessary in two patients because of parenchymal destruction and bleeding. Evacuation of clotted blood by fragmentation and aspiration was satisfactory in all cases. Satisfactory manual suturing of selected lung injuries was obtained largely with intracorporeal knot tying. The duration of the procedures ranged from 40 to 90 minutes. No morbidity nor mortality was encountered in patients undergoing OVT. Postoperative pain was minimized by using OVT placement of catheters in the chest wall soft tissue with local administration of 2% Trimecain. Patients were able to stand in 10 to 12 hours and to walk by the end of the first postoperative day. All patients who underwent OVT were evacuated without drains by the third or fourth postoperative day, all tolerating sitting and standing positions. We conclude that early OVT in the military field hospital for continued bleeding, clotted hemothorax, and continued major air leakage has several advantages in military patients with PFAWT: early definition and management of organ injury; identification and control of bleeding in most instances; earlier and more accurate assessment for thoracotomy; vigorous lavage and removal of projectiles such as bone fragments and evacuation of clotted hemothorax; early debridement with suture closure of the thoracic wall canal; and minimal postoperative pain with dramatically reduced suppurative sequelae and bronchopleural fistulae.

A randomized trial of three antibiotic regimens for the treatment of pyelonephritis in pregnancy

Objective: To compare the effectiveness of three antibiotic regimens for the treatment of acute pyelonephritis in pregnancy. Methods: One hundred seventy-nine pregnant women earlier than 24 weeks’ gestation who had acute pyelonephritis were randomized to 1) intravenous (IV) ampicillin and gentamicin, 2) IV cefazolin, or 3) intramuscular ceftriaxone. All participants then completed 10-day courses of oral cephalexin after primary treatment. A urine culture was performed on admission and 5–14 days after completion of therapy. Surveillance for persistent or recurrent infection and obstetric complications continued until delivery. On the basis of a two-sided hypothesis test and with α = .025, 60 subjects were needed in each group for statistical power greater than 80% to detect a difference between ceftriaxone and other antibiotics if hospital length of stay differed by 1 or more days. Results: The treatment groups were similar in age, parity, temperature, gestational age, and initial white blood cell count. There were no statistically significant differences in length of hospitalization, hours until becoming afebrile, days until resolution of costovertebral angle tenderness, or infecting organism. There were no statistically significant differences in birth outcomes between the three groups. The average (standard deviation) age at delivery was 38.8 ± 3.6 weeks. The average birth weight was 3274 ± 523 g. Eleven (6.9%) of 159 subjects delivered prematurely. Escherichia coli was the most common uropathogen isolated (137 of 179, 76.5%). Blood cultures were positive for organisms in 15 cases (8.4%). At follow-up examination within 2 weeks of initial therapy, eight (5.0%) of 159 subjects had urine cultures positive for organisms. Ten women (6.3%) had cultures positive for organisms later in their antepartum course, and 10 other participants (6.3%) developed recurrent pyelonephritis. Conclusion: There are no significant differences in clinical response to antimicrobial therapy or birth outcomes among subjects treated with ampicillin and gentamicin, cefazolin, or ceftriaxone for acute pyelonephritis in pregnancy before 24 weeks’ gestation.

RETROPERITONEAL FIBROSIS MIMICKING RECURRENT LEUKEMIA IN A 7-YEAR-OLD BOY

Retroperitoneal fibrosis is an extremely uncommon diagnosis in children. We report on a child with histologically confirmed retroperitoneal fibrosis that clinically mimicked recurrent leukemia. CASE REPORT A 7-year-old boy presented with acute lymphocytic leukemia in clinical remission 5 months aRer induction chemotherapy with methotrexate, vincristine and prednisone. Additional maintenance chemotherapy included doxorubicin and L-asparaginase. He did not receive radiation therapy. Persistent left flank pain and microhematuria prompted renal ultrasound that demonstrated left hydronephrosis. Physical examination revealed costovertebral angle tenderness without rebound. Excretory urography demonstrated delayed function with columnization of contrast material to the level of the common

Free Intraperitoneal Rupture of Hydronephrotic Kidney

Occult hydronephrosis may commonly manifest symptoms following even minor blunt trauma. The usual presentation is pain and gross hematuria. However pelvic or caliceal rupture can occur with extravasation into the retroperitoneum. Under extremely rare circumstances free intraperitoneal rupture occurs and may present as an acute abdomen. CASE REPORT A 64-year-old Asian woman fell on the right side. She was evaluated elsewhere and noted to be alert, oriented, hypertensive and hemodynamically stable. She had a history of hypertension but was taking no medications. She denied any other medical or surgical history. Examination was significant for abdominal tenderness and guarding. Abdominal computerized tomography (CT) (no contrast medium reported) demonstrated injuries consistent with traumatic renal fracture. At transfer to our institution the patient was in significant distress secondary to diffuse abdominal pain. Blood pressure was 190/100 mm. Hg with heart rate of 90 to 100 per minute. Mild contusions involved the right hand, forearm and flank. The abdomen was somewhat distended with marked diffuse tenderness, worse on the right than the leR side. Involuntary guarding was consistent with peritoneal irritation and the right costovertebral angle was moderately tender. Rectal examination revealed guaiac positive stool but the remainder of the cardiac, pulmonary, vascular and neurological examination was normal. Urine was grossly clear. Laboratory values included white blood count 20 x 103/pl. (normal 4.3 to 10.81, hematocrit 40% (normal 37 to 48), normal electrolytes, creatinine 1.2 mg./dl. (normal 0.6 to 1.51, and urinalysis 3 to 5 red and 0 to 2 white blood cells per high power field. Chest x-ray demonstrated clear lungs and mild cardiomegaly without pneumothorax or rib fracture. Review of the unenhanced CT demonstrated a heterogeneous fluid density filling a large multicystic structure in the right retroperitoneum. Normal kidney parenchyma was not identified. The examination was rzpeated with intravenous contrast medium using a standard helical CT trauma protocol. Findings were notable for a multicystic structure with thin peripheral enhancement and heterogeneous density in some areas suggestive of hemorrhage (part A of figure). In a lower cut a 1.5 cm. calcification was noted just inferior to the

Acute pyelonephritis focusing on perfusion defects on contrast enhanced computerized tomography(CT) scans and its clinical outcome.

ObjectivesMany cases of acute pyelonephritis show renal perfusion defects on contrast enhanced computerized tomography (CT) imaging studies. The purpose of this study is to show the frequency of renal perfusion defects in uncomplicated acute pyelonephritis and to compare the clinical responses of patients who had perfusion defects or not.MethodsWe studied patients who had symptoms and signs of acute pyelonephritis through CT examinations with contrast enhancement. We identified 21 cases who had perfusion defects among 35 patients who had undergone CT imaging studies and compared the clinical data in the two groups of patients who had perfusion defects on CT (group 1) and who had not (group 2).ResultsNearly all patients had typical symptoms and signs of acute pyelonephritis such as high fever and chill, flank pain and costovertebral angle tenderness. Combined clinical problems were septic shock (one case, 4.8%) and disseminated intravascular coagulation (DIC) (one case, 4.8%) in group 1. Laboratory findings were not different between the two groups. All patients were treated with antibiotics and had successful recoveries. The duration of recovery of pyuria in group 1 (5.2±9.6 days) was not longer than that in group 2(3.1±2.9 days) (p>0.05). The length of defeverscence in group 1 (7.0±4.6 days) was longer than in group 2 (3.5±2.7 days) (p<0.05). There were no differences between group 1 and group 2 in the rate of predisposing factors. Thirteen of 21 cases (61.9%) in group 1 and five of 14 cases (35.7%) in group 2 had positive urine culture results which are relatively low probably due to the administration of antibiotics prior to our emergency room visit. Perfusion defects on CT were very frequent findings (60.0% of the clinical acute pyelonephritis patients). We classified CT findings of group 1 as focal unilateral (2 cases, 9.5%), multifocal unilateral (14 cases, 66.7%) and multifocal bilateral (5 cases, 23.8%), and there were no differences between the subgroups of group 1 in the duration of defeverscence.ConclusionThose patients who had perfusion defects on CT showed relatively severe clinical courses but responses to early antibiotics were very good. Contrast enhanced CT scans may be very sensitive for the detection of acute renal parenchymal inflammatory disease and for defining the extent of disease, but it is clinically not essential to perform in the early uncomplicated acute pyelonephritis because CT diagnosis does not change management. Clinical use of contrast enhanced CT scan may be appropriate in case of persistence of fever and leukocytosis for more than seven days despite antibiotic treatment.

Case 9-1996

Presentation of CaseA 21-year-old woman was admitted to the hospital because of thoracolumbar pain.The patient had been well until 17 weeks earlier, when she began to have pain in the midline thoracolumbar region of the spine, with radiation to the right flank, accompanied by nocturnal fever. The pain was aggravated by coughing, sneezing, straining, and recumbency and was not relieved by acetaminophen.Fourteen weeks before admission she came to this hospital. Her temperature was 38°C. The physical examination was normal except for tenderness in the right costovertebral angle and a narrow introitus that prevented a digital examination. The . . .

Total vertebrectomy for en bloc resection of lung cancer invading the spine

We describe a technique of total vertebrectomy for en bloc resection of a non-small cell lung cancer with vertebral invasion through a combination of thoracic and enlarged posterior approaches, and present our entire experience of total and partial vertebrectomy for tumors invading vertebral bodies or the costovertebral angle.

Paraplegia after thoracotomy: Report of five cases and review of the literature

Paraplegia complicating thoracotomy is rare but catastrophic. This report comprises 40 cases: 5 of our cases and 35 reported cases. Our cases comprised a stab wound of the left chest (1), decortication (1), lobectomy for bronchogenic carcinoma (2), and segmental resection for tuberculosis (1). The reported cases included 25 cases following thoracotomy for thoracic pathology (bronchogenic carcinoma, 12; pulmonary tuberculosis, 7; thoracic trauma, 2; bronchiectasis, 1; peptic esophagitis, 1; neurogenic tumors, 2; and benign lung lesion, 1 and 10 cases following operation for malignant hypertension. The surgical procedures performed on the 25 patients with thoracic pathology were lobectomy (8), bilobectomy (1), pneumonectomy (7), decortication (1), thoracoplasty (1), excision of neurogenic tumors (2), drainage of tuberculous cavity (1), and Nissen procedure (1). The intraoperative factors contributing to the neurologic deficit were bleeding at the costovertebral angle (9), migration of oxidized cellulose into spinal canal (9), thrombosis of anterior spinal artery (4), epidural hematoma (2), epidural narcotic (2), metastatic carcinoma (1), and hypotension (1). This serious complication can be prevented by meticulous operation and careful hemostasis. The immediate use of tomographic scanning or magnetic resonance imaging followed by surgical decompression might avert this serious complication.

Unilateral Spontaneous Adrenal Hemorrhage During ACTH Treatment of Multiple Sclerosis

Unilateral Spontaneous Adrenal Hemorrhage During ACTH Treatment of Multiple Sclerosis

Masses of myeloadipose tissue: Radiological and clinical considerations

The records of 30 patients presenting radiological evidence of masses of extramedullary myeloadipose (hemopoietic) tissue, 25 patients suffering from thalassemia, one from sickle-cell anemia, and one from myelofibrosis were studied. Three patients presented with primary myelolipomas. Most of the patients with thalassemia presented with masses of hemopoiesis in the costovertebral angle and five patients presented with spinal cord compression. Magnetic resonance imaging is the best method for visualization and assessment of the extent of the masses in the thorax and spinal canal. Radiotherapy is the treatment of choice for spinal cord compression. One patient with thalassemia and one patient with myelofibrosis presented with masses of extramedullary hemopoiesis in the adrenals. All five patients with masses of myeloadipose tissue in the adrenals were treated surgically.

Monoclonal antibodies in the diagnosis of renal disease: A preliminary report

A 74-year-old, previously healthy woman sought medical advice because of multiple erythematous pustular skin lesions, which had started on her hands and had progressed to her arms, back, abdomen, chest, and legs. The patient had no history of renal dysfunction, renal stones, diabetes mellitus, hypertension, urinary tract infections, or analgesic abuse. She was taking no medications. She had no history of documented hypotension, fever, or chills. The patient denied sore throat, swollen glands, chest pain, shortness of breath, arthritis, and seizures. She had had rheumatic fever when she was a child. Physical examination on admission revealed a blood pressure of 140/ 70 mm Hg; pulse, 80 beats per minute and regular; temperature, 98.6F, and an estimated central venous pressure of 8 cm H20. Numerous pustular lesions, most of which were crusted, were noted on the hands, arms, trunk, buttocks, and soles. No adenopathy was present. The chest was clear. Cardiac examination disclosed an S4, with no S3 or pericardial friction rub. A grade TI/VI blowing diastolic murmur was present at the left sternal border. No opening snap was heard. The abdomen was soft and nontender without evidence of guarding or rebound. The kidneys, liver, and spleen were not palpable. Moderate left costovertebral angle tenderness was present. Rectal and pelvic examinations were unremarkable, The stool was guaiac negative. There was no peripheral edema and no evidence of active synovitis. The patient was alert, oriented, and had full range of motion in a11 extremities; she had no localizing neurologic abnormalities. All reflexes were equal and reactive throughout, with bilateral plantar responses. Laboratory data on admission showed a hematocrit of 39.4%, a white blood cell count of 17,300/mm3 with a normal thiferential, and a sedimentation rate of 90 mm/hr. Sodium was 138 mEq/liter; potassium,

Identification of viral infections in pregnancy by assay of (2'-5')-oligo-isoadenylate synthetase.

Interferons are produced in response to viral infections. Among the biochemical changes they cause in cells is the induction of the enzyme (2'-5')-oligo-isoadenylate synthetase. The activity of this enzyme can be measured and this can indicate exposure and response of cells to interferon. The efficacy of such an assay of peripheral blood of pregnant women may aid in establishing screening guidelines for potentially teratogenic viral infections. The blood of 44 primigravidas with complaints of fever, myalgia, cough, vaginal discharge and/or costovertebral angle tenderness was assayed for activity of the enzyme (2'-5')-oligo-isoadenylate synthetase and compared to assays of the enzyme activity in a group of 37 healthy primigravidas which served as a control group. It was found that the group with viral infections had an increase in enzyme activity from twice to 15 times the normal value, with characteristic rises of enzyme activity in several viruses known or suspected to cause human defects. Several general guidelines are proposed to assist the obstetrician in determining a viral etiology of acute illness in pregnancy, It is suggested that the assay of enzyme activity of (2'-5')-oligo-isoadenylate synthetase may provide a simple tool for rapid diagnosis of viral infections in pregnancy.

20 URINARY TRACT INFECTION CAUSED BY STAPHYLOCOCCUS SAPROPHYTICUS (SS)

In 492 college coeds, with acute, uncomplicated UTIs, documented by >105 colonies per ml. of the same bacteria in 2 or 3 consecutive urine cultures, E. coli and novobiocin resistant (SS) comprised 76.0% and 13.0% of the urinary pathogens, respectively, and other bacteria 11.0%. The in-vitro sensitivity testing revealed that SS were 100% sensitive to trimethoprim, trimethoprim/sulfamethoxozole, nitrofurantoin, and cephalexin; 91.0% to ampicillin; 93.0% to sulfasoxozole and 0.0% to nalidixic acid. Patients with either E. coli or SS organism presented with similar symptoms of an acute lower tract infection. Costovertebral angle tenderness was noted in 21.0% of the patients with SS and in 10.0% of those with E. coli. Fever >99.5C. was present in 15.0% of patients with SS and in 25.0% of those with E. coli. Clinical response to therapy was similar for both groups. Isolation of SS from the periurethral (52.0%), vaginal (31.0%), and rectal (11.5%) areas could only be accomplished in patients who had this organism as the primary urinary pathogen. SS was the second most common urinary pathogen isolated after E. coli in young women.

Peripelvic renal pseudocyst due to obstruction

A 70-year-old male was seen with a 5 week history of recurrent left flank pain. Excretory urography confirmed the presence of a nadiopaque left uneteral calculus about 5 mm in diameter bocated at the bevel of L5 causing mild obstruction. In addition a 5 cm mass in the left kidney distorted the pelvocalyceal system (fig. 1A). This mass was radiolucent on nephrotomography. The right kidney appeared normal at this time, except for a 2 mm calculus in the lower pole calyx (fig. 1D). Microhematunia and left costovertebral angle tenderness was present. Ultrasound evaluation of the mass performed 6 days later was ‘ ‘suggestive of a cyst.” The patient remained free of symptoms for 10 days; he then experienced sudden onset of right flank discomfort. Repeat excretory urography revealed that he had passed the left unetenal calculus and that the previously noted penipelvic mass was moderately smaller (fig. 1B). However, the right pelvocalyceab system now appeared similar to that seen on the left side, with a definite mass lesion distorting the night renal pelvis and infundibubum (fig. 1E). The rightureter was dilatedto the ureterovesical junction suggesting obstruction. The radiopaque calculus previously seen in the right kidney was no longer present. It was suspected that the calculus had recently passed and that there was residual edema at the night uretenovesical junction. The patient remained free of symptoms, and a follow-up excretory unogram 10 weeks later appeared honmal (figs. 1C and iF). There was no residual distortion of the pelvocalyceal system and no evidence of obstruction.

Ultrasound as an Aid in the Diagnosis of Hydrops of the Gallbladder

ACUTE cholecystitis and acute hydrops of the gallbladder present as a surgical emergency. Ultrasonography provides a simple, rapid, and noninvasive procedure, which is helpful in the evaluation and diagnosis of gallbladder disease. A case of acute hydrops of the gallbladder in which cholecystosonography was helpful in its management is presented. Report of a Case A 96-year-old woman was admitted for abdominal pain of one day's duration. The patient experienced crampy abdominal pain in the right upper quadrant but denied nausea or vomiting, alteration in bowel habits, or change in color of stool or urine. The patient had no jaundice, abdominal distention, or fever. She gave a history suggesting mild cholecystitis for 55 years. Tenderness was present in the right upper quadrant and the right costovertebral angle. A complete blood count showed leukocytosis with shift to the left. Hematocrit reading was 40%, and hemoglobin level was 10 gm/100 ml. The patient

Retroperitoneal Fibrosis and Avascular Necrosis of the Femoral Head

A REPORT of avascular necrosis of the head of the femur in a patient that ten years previously had had confirmed retroperitoneal fibrosis¹provoked interest in the possible association between the two entities when a patient with retroperitoneal fibrosis who had previously undergone surgery for avascular necrosis of the femoral head was encountered. <h3>Report of a Case</h3> A 44-year-old woman was admitted to Yale-New Haven Hospital with left costovertebral angle pain radiating to the lower abdomen, dysuria, intermittent hematuria and a history of previous pyelonephritis. She had the left femoral head replaced by an Austin-Moore prosthesis 18 months previously for confirmed avascular necrosis of the femoral head. The patient denied corticosteroid or methysergide maleate use, but admitted to heavy use of "over-the-counter" analgesics, alcohol, and cigarettes. The patient appeared cachectic and lethargic. Her temperature was 37 C, and she had moderate left costovertebral angle tenderness. A chest x-ray film