Perinephric Fluid Research Articles

Right Flank Pain: A Case Report of an Interesting Sonographic Finding

BackgroundFocused bedside ultrasound is a screening tool frequently used by emergency physicians to evaluate hepatobiliary and renal pathology in patients presenting with abdominal complaints in the emergency department (ED). ObjectiveThis case report describes a sonographic finding that was interpreted as free fluid in the right upper quadrant. Computed tomography (CT) was used to confirm the diagnosis. Case ReportA 44-year-old man presented to the ED with the sudden onset of right-sided abdominal pain and exhibited right costovertebral angle tenderness on physical examination. Focused bedside ultrasound of the right upper quadrant revealed severe hydronephrosis of the right kidney and free fluid of either subcapsular, perinephric, or peritoneal location represented by an anechoic stripe in Morison’s pouch. On CT evaluation, this patient was found to have perinephric fluid accumulation from a presumed ruptured renal calyx in the setting of chronic ureteropelvic junction obstruction with severe hydronephrosis. ConclusionThe exact location of anechoic fluid in the abdomen is not always apparent on bedside ultrasound. To minimize misinterpreting focused bedside ultrasound examination findings, we recommend a number of sonographic techniques to identify possible mimics of free fluid. Suspected free fluid findings on bedside ultrasound should always be evaluated within the clinical context of the patient’s presentation.

Non-contrast Computed Tomography After Percutaneous Nephrolithotomy: Findings and Clinical Significance

To describe the post-percutaneous nephrolithotomy (PNL) non-contrast-enhanced computed tomography (NCCT) findings and assessed their clinical significance. NCCT evaluates stone clearance after PNL and also reveals procedure-related changes. One hundred consecutive patients who underwent PNL were evaluated by NCCT one day post-procedure. Two radiologists analyzed the type and severity of the NCCT findings, which were then statistically analyzed in relation to the patient's clinical course. The patients' mean age was 54 years (range 18-82) and the mean maximal stone diameter was 37 mm (range 15-70). The median operative time was 110 minutes for an immediate stone-free rate of 83%, changing to 94% (P = .073) after a second-look PNL in 11 patients. The post-PNL NCCT findings were hydronephrosis (70%), atelectasis (54%), ipsilateral pleural effusion (52%), paracolic gutter fluid (44%), perinephric hematoma (40%), perinephric fluid (32%), ureteronephrosis (31%), renal swelling (23%), contralateral pleural effusion (22%), residual fragments (RFs) (17%), subcapsular hematoma (10%), and flank hematoma (6%). Univariate analysis revealed a significant association with clinical variables for all NCCT findings except for atelectasis, ureteronephrosis, contralateral pleural effusion, RFs, and flank hematoma. In multivariate analysis, only perinephric fluid (P = .007) and ipsilateral pleural effusion (P = .034) were associated with longer hospitalization, and perinephric fluid with longer recovery (P = .004). The complication rate was 12%, but none were linked with the radiological findings. This work describes the post-PNL NCCT findings and their clinical significance. Perinephric fluid and ipsilateral pleural effusion were found to independently predict longer hospitalization and recovery time.

The TEMPI Syndrome: Telangiectasias, Elevated Erythropoietin and Erythrocytosis, Monoclonal Gammopathy, Perinephric Fluid Collections, and Intrapulmonary Shunting

Abstract 1037▪▪This icon denotes a clinically relevant abstractWe report a rare and novel syndrome which we have termed TEMPI: telangiectasias, elevated erythropoietin and erythrocytosis, monoclonal gammopathy, perinephric fluid collections, and intrapulmonary shunting. In 2010, the index case of a man with unexplained erythrocytosis and perinephric fluid collections was published in the Case Records of the Massachusetts General Hospital in the New England Journal of Medicine. In the case report, we appealed to readers to share insights and similar cases. As a result, two strikingly similar cases were identified: a woman in Antwerp, Belgium and a woman in Los Angeles, California. The patients share five characteristics constituting the TEMPI syndrome.The three patients had all been healthy until their 3rd or 4th decades when they began to manifest symptoms. Telangiectasias developed spontaneously and were most prominent over the trunk, arms, hands, face, and oropharynx; there was no evidence of liver dysfunction. Erythrocytosis was present, with the presenting hematocrit ranging between 58–64% (hemoglobin 19–22 g/dL). The serum erythropoietin level was elevated at diagnosis, and gradually rose to values greater than 5000 mU/ml. Extensive imaging did not reveal a source of erythropoietin production, and evaluations incluing hemoglobin electrophoresis, hemoglobin oxygen affinity, and gene sequencing were negative. An IgG-kappa monoclonal gammopathy was identified, at similar concentrations of approximately 0.7g/dL, without hypercalcemia or lytic bone lesions, and the bone marrow biopsies revealed fewer than 10% plasma cells, consistent with a diagnosis of monoclonal gammopathy of undetermined significance (MGUS). The progressive accumulation of bilateral perinephric fluid collections is a striking and unique feature of the syndrome. There were no intraparenchymal renal cysts; the fluid was localized between the kidney and the renal capsule. Sampling of the fluid revealed a clear, aseptic, serous fluid with low protein, few leukocytes, and no cholesterol or triglycerides. Microscopic intrapulmonary shunting was identified, and slowly progressed with worsening hypoxia and shortness of breath. There was no evidence of pulmonary hypertension on echocardiogram or right heart catheterization. All three patients have suffered spontaneous venous thromboses, and two of the patients suffered spontaneous intracranial hemorrhages without identifiable arterio-venous malformations on MRI/MRA or cerebral angiography.The pathophysiology underlying the TEMPI syndrome is unknown. The similar characteristics shared by patients of different ages, genders, and geographies suggest an acquired rather than an inherited disorder. The presence of an IgG-kappa paraprotein in all three patients is suggests that the paraprotein might be involved in the pathophysiology of this disease. One of the patients underwent empiric treatment with the proteasome inhibitor bortezomib, with dramatic improvement in her symptoms after six cycles of therapy. The telangiectasias resolved, the level of serum erythropoietin normalized, the monoclonal gammopathy disappeared, the perinephric fluid collections resolved, and the degree of intrapulmonary shunting decreased to the point that she was able to discontinue her supplemental oxygen. Based on her clinical improvement, the decision was made to treat the other patients similarly. We will report in detail the characteristics of this novel syndrome as well as the treatment results. The response of one patient to the treatment of her MGUS suggests that the monoclonal gammopathy is involved in this syndrome by a mechanism that remains to be defined. Disclosures:Off Label Use: In this presentation, the authors used bortezomib as an empiric treatment for an undiagnosed medical condition.

The role of hypoxia-inducible factor-1 alpha in TEMPI syndrome.

Sir, Two recent reports in The New England Journal of Medicine on a newly described syndrome, namely TEMPI syndrome (telangiectasia, erythrocytosis, monoclonal paraprotein, paranephric fluid collections, intrapulmonary shunting) are fascinating [1, 2], considering the number of cases where the radiological finding of perinephric fluid collections are not investigated further [3] or the concomitant laboratory finding of a paraprotein is dismissed as another case of monoclonal gammopathy of undetermined significance (MGUS). Sykes et al. [2] hypothesize that the IgG paraprotein in TEMPI syndrome may be pathogenic due to the resolution of most clinical features after a trial with the proteasome inhibitor, bortezomib. But, as bortezomib also affects the function of hypoxia-inducible factor-1 alpha (Hif-1α) and down-stream transcription of vascular endothelial growth factor (VEGF) [4], inhibition of Hif-1α would also explain the resolution of the symptoms seen in the patient described by Sykes et al. Expression of Hif-1α and Hif-1α messenger RNA has been detected in all human tissues [5]. Intratumoral hypoxia is known to induce Hif-1α expression that increases VEGF and angiogenesis, but growth factors and loss-of-function mutations in von Hippel Lindau gene and p53 also induce Hif-1α expression (and possibly development of telangiectasias and erythrocytosis) [6]. Zhang et al. [7] showed that even under normoxic conditions, the oncogenic c-Myc/Hif-1α pathway modulates multiple myeloma cell production and mediates production and secretion of VEGF. Bortezomib was also shown to decrease both c-Myc and Hif-1α levels. Specific inhibitors of Hif-1α may therefore reverse most of the pathological manifestations of TEMPI syndrome.

The TEMPI Syndrome — A Novel Multisystem Disease

To the Editor: The description of a man with erythrocytosis and perinephric fluid collections recently appeared in the Case Records of the Massachusetts General Hospital1 (Patient 1 in Table 1), and the authors of that article appealed to readers to share similar cases. Two additional patients were identified (Patients 2 and 3), and a review of the literature identified three more patients with similar findings2–4 (Patients 4, 5, and 6). These six patients shared five characteristics — telangiectasias, elevated erythropoietin level and erythrocytosis, monoclonal gammopathy, perinephric-fluid collections, and intrapulmonary shunting — defining a syndrome that we have termed the TEMPI . . .

Perinephric Fluid Collections Due to Renal Lymphangiectasia

Fluid collections around the kidneys on cross-sectional imaging may be caused by urine, blood, pus, lymph, or plasma. Ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) can not only show and characterize the fluid, but also may help determine the underlying cause of the perinephric fluid collection, such as ureteric obstruction, kidney injury, infection, or renal lymphangiectasia. Renal lymphangiectasia is characterized by abnormal and ectatic lymphatic vessels within and around the kidneys. Dilated lymphatics may result in peripelvic cysts (intrarenal lymphangiectasia) and perinephric fluid collections (extrarenal lymphangiectasia), which can be visualized using US, CT, and MRI. Proper diagnosis on imaging helps in planning a conservative management approach to this benign condition, which requires intervention for only significant symptoms or complications. We describe a 60-year-old man with normal kidney function and bilateral perinephric fluid collections in whom renal lymphangiectasia was diagnosed noninvasively on the basis of characteristic findings on US, CT, and MRI.

2147 EVALUATION OF ACUTE RENAL COLIC: A COMPARISON OF NON-CONTRAST CT VERSUS 3-TESLA NONCONTRAST HASTE MR UROGRAPHY

With the introduction of a 3-T scanner, magnetic resonance urography (MRU) may be an alternative imaging modality for evaluation of acute renal colic. We performed a prospective study to compare the performance of computed tomography (CT) with half-Fourier single shot turbo spin-echo (HASTE) MRU in the evaluation of patients with suspected renal colic. Patients presenting to the emergency department with acute renal colic were eligible for inclusion. Following a standard CT stone evaluation, patients underwent a non-contrast HASTE MRU study with a 3-T scanner. The presence of perinephric fluid, hydronephrosis, ureteral obstruction, and calculus was assessed. A total of 22 patients completed the study. Twenty (91 %) were diagnosed with an upper tract stone by radiographic findings. MRU detected a discrete stone in 50 % of the patients with stones detected by CT. Perinephric fluid was noted in 12 MRUs, compared to 7 CTs. Using CT as the reference standard, the combination of stone or perinephric fluid and ureteral dilation gave MRU a sensitivity of 84 %, specificity of 100 %, and accuracy of 86 % (95 % CI 0.72–1.0). HASTE MRU with a 3-T MR scanner can reliably detect the presence of upper urinary tract obstruction. Although CT imaging remains the superior modality with which to detect calculi, MRU detects a greater number of secondary signs of upper tract obstruction. For situations in which the use of ionizing radiation is undesirable, MRU is a reasonable imaging alternative.

Spontaneous rupture of the renal pelvis due to an obstructing ureteral calculus diagnosed by point-of-care ultrasound

Abstract A 37-year-old man presented to the emergency department with left flank pain and vomiting. Bedside ultrasound performed by the treating emergency physician revealed left-sided hydronephrosis and perinephric fluid, suggesting a rupture of the renal pelvis. Urinary sonography revealed an absent left ureteral jet, suggesting left ureteral obstruction. Treatment was initiated and a non-contrast computed tomography scan confirmed the initial ultrasound findings.

Perinephric abscess caused by ruptured retrocecal appendix: MDCT demonstration

Acute appendicitis may occasionally become extraordinarily complicated and life threatening yet difficult to diagnose. One such presentation is described in a 60-year-old man who was brought to the hospital due to right lumbar pain and fever for the last 15 days. Ultrasonography showed a right perinephric gas and fluid collection. Abdominal computed tomography with multidetector-row CT (MDCT) revealed gas-containing abscess in the right retroperitoneal region involving the perinephric space, extending from the lower pole of the right kidney up to the bare area of the liver. Inflamed retrocecal appendix was seen on thick multiplanar reformat images with its tip at the lower extent of the abscess. Laparotomy and retroperitoneal exploration were performed immediately and a large volume of foul smelling pus was drained. A ruptured retrocecal appendix was confirmed as the cause of the abscess.

Renal lymphangiectasia presented by pleural effusion and ascites

A young male patient complaining of vague abdominal pain, dyspnea, generalized weakness and abdominal distension for 6 months was referred for abdominal ultrasound. Ultrasound showed enlarged echogenic kidneys, perinephric and renal sinus cystic fluid collections bilaterally with ascites and right pleural effusion. The ultrasound findings were confirmed by abdomen CT scan. Renal function test was within normal. Laboratory analysis of aspirated perinephric fluid revealed abundant lymphocytes. The radiological findings and perinephric fluid aspiration analysis are consistent with renal lymphangiectasia. Pleural effusion, in addition to ascites and perinephric fluid collections, is a new presentation of the disease. Ascites and pleural effusion were improved by diuretics.

An Overview of Renal Transplantation: Current Practice and Use of Ultrasound

Imaging has played a major role in monitoring the well-being of the renal graft. Ultrasound, in particular, has been extremely helpful for the detection of postoperative complications related to the transplant kidney. From an imaging perspective, the complications of renal transplantation can be categorized into vascular complications, complications related to the collecting systems (urological complications), perinephric fluid collections, and parenchymal complications. Additionally, there are some complications that may occur, secondary to a transplant renal biopsy. To be able to correctly identify the complications associated with renal transplants, one should have a comprehensive understanding of various aspects of the transplant procedure and be familiar with the normal or expected findings after a transplant. This article provides an overview of renal transplantation and discusses the use of various imaging modalities in its evaluation. The various complications associated with renal transplant as well as renal biopsy are elaborated in this article with special emphasis on the use of ultrasound.

Iatrogenic ureteral injury secondary to a thoracolumbar lateral revision instrumentation and fusion

Background context Urologic, gynecologic, and colorectal surgical procedures account for most of the iatrogenic ureteral injuries; however, iatrogenic injury secondary to thoracolumbar spinal surgery remains a rare complication. Purpose To report a case of iatrogenic ureteral injury secondary to a thoracolumbar lateral revision instrumentation and fusion managed by percutaneous nephrostomy, ureteroureterostomy, and ureteral stent placement. Study design Case report. Methods A 24-year old female underwent surgical removal of a lumbar plate and broken screw with placement of a unirod spanning L1–L3 through a thoracolumbar exposure with resection of the twelfth rib. Results On postoperative day 14 she developed left flank pain. Computed tomography scan of the abdomen and pelvis demonstrated a left perinephric fluid collection. After placement of a nephrostomy tube, a retrograde pyelogram with a concomitant antegrade nephrostogram confirmed the diagnosis of ureteral entrapment in the lumbar instrumentation. A spatulated end to end ureteral anastomosis (ureteroureterostomy) was performed over a double J ureteral stent. Conclusions Although an iatrogenic ureteral injury secondary to thoracolumbar surgery is rare, it should be included in the differential diagnosis for a patient presenting with flank pain after undergoing lateral thoracolumbar fusion. A urinoma, also an uncommon occurrence, may be a presenting sign. Prompt diagnosis and institution of appropriate corrective surgical procedures may result in successful outcome.

The use of preoperative chemotherapy in Wilms' tumor with contained retroperitoneal rupture

Abstract Purpose The National Wilms Tumor Study currently describes 3 indications for the use of preoperative chemotherapy: extensive caval involvement, bilateral tumors, and patients who only have a single kidney. However, the management of patients who present with a contained retroperitoneal rupture is not specifically addressed. This is relevant because of the strong possibility of peritoneal contamination when performing a primary resection and the resultant requirement for total abdominal radiation. The use of neoadjuvant chemotherapy in this subgroup of patients may be warranted. Methods We retrospectively reviewed our experience with Wilms' tumor and identified 3 cases with contained rupture at presentation. Details of their initial evaluation and therapy, resection and pathologic findings, and follow-up constitute this report. Institutional review board waiver was obtained for the purposes of this review. Results Two male patients, aged 2.9 years, and 1 female patient, aged 9.3 years, were identified. All patients received preoperative chemotherapy with vincristine and dactinomycin (n = 1) plus doxorubicin (n = 2) for 4 to 6 weeks before surgical resection. One patient underwent pretreatment computed tomography–guided biopsy of the kidney mass for diagnostic purposes. Presurgical computed tomographic scans showed resolution of perinephric blood and fluid with tumor shrinkage. Histopathologic analyses showed all tumors were resected with negative margins, and there was no intraoperative tumor spillage. All patients received 1050 to 1080 cGy of flank radiation postoperatively. All patients are currently alive at follow-up without evidence of local recurrence or distant disease. Conclusions Neoadjuvant chemotherapy allowed for complete resection and avoidance of total abdominal radiation in 3 patients with ruptured Wilms' tumor and hematoma within the retroperitoneum. These data support the use of initial chemotherapy in children with retroperitoneal rupture and hematoma of Wilms' tumor at diagnosis.

Reply to Letter to the Editor #D-07-00415 regarding "The use of preoperative chemotherapy in Wilms' tumor with contained retroperitoneal rupture"

We appreciate the thoughtful response to our article on the management of contained preoperative rupture of Wilms' tumors (J Pediatr Surg. 2007 Sep;42[9]:1595-1599) by the Renal Tumor Committee of the Children's Oncology Group. We agree that sweeping conclusions regarding therapy for childhood malignancies should not be made based on single institutional series or case reports and that the Renal Tumor Committee and its predecessor, the National Wilms' Tumor Study Group, have made great progress in Wilms' tumor management. We are very familiar with the articles cited in this letter. However, most therapeutic interventions evaluated by large cooperative group trials are based on small pilot experiences. Neither the Renal Tumor Committee nor the previous National Wilms' Tumor Study Group has ever specifically addressed the problem of a patient who presents with a large, loculated, perinephric fluid collection around a renal tumor that by all imaging criteria is contained within the Gerota fascia. It is rightly pointed out that spill is a significant predictor of outcome in these children, and we strongly agree with this. Our therapeutic approach was based on avoiding diffuse peritoneal contamination. With a sizeable fluid collection around the involved kidney, this would be unavoidable with immediate surgery and result in massive peritoneal contamination.

Maternal urinoma during pregnancy

Urinoma is peripelvic extravasation of urine seen as the squeal of urinary trauma or stones. Little is known about maternal urinoma during pregnancy. A 27-year-old primigravida presented with gradual worsening right flank pain at 21(5/7) weeks of gestation. She denied any past medicosurgical history. Initial work-up revealed cost-vertebral angle tenderness and mild hydronephrosis by ultrasonography. Her symptom worsened and follow-up ultrasonography was performed 48 h later, which showed worsened hydronephrosis with large perinephric fluid collection. A Double-J stent was placed under cystoscopy. After the placement, the patient's symptoms improved quickly. The stent was removed three weeks later. The patient delivered vaginally at 39 weeks of gestation without complication. Maternal urinoma during pregnancy developed in the right side of the kidney in five of six reported cases (83.3%), and all were seen in the second half of pregnancy. All showed flank pain as the initial presentation. Ultrasonography for diagnosis was used in half of the patients. Fifty percent underwent Double-J stent before delivery and 16.7% after delivery. All cases delivered at term and 33.3% underwent cesarean delivery. Maternal urinoma is an important differential diagnosis for flank pain during pregnancy. Double-J stent placement was the main management. Close monitoring of the symptom with serial ultrasonography may be the key for diagnosis.

The use of preoperative chemotherapy in Wilms' tumor with contained retroperitoneal rupture

Purpose The National Wilms Tumor Study currently describes 3 indications for the use of preoperative chemotherapy: extensive caval involvement, bilateral tumors, and patients who only have a single kidney. However, the management of patients who present with a contained retroperitoneal rupture is not specifically addressed. This is relevant because of the strong possibility of peritoneal contamination when performing a primary resection and the resultant requirement for total abdominal radiation. The use of neoadjuvant chemotherapy in this subgroup of patients may be warranted. Methods We retrospectively reviewed our experience with Wilms' tumor and identified 3 cases with contained rupture at presentation. Details of their initial evaluation and therapy, resection and pathologic findings, and follow-up constitute this report. Institutional review board waiver was obtained for the purposes of this review. Results Two male patients, aged 2.9 years, and 1 female patient, aged 9.3 years, were identified. All patients received preoperative chemotherapy with vincristine and dactinomycin (n = 1) plus doxorubicin (n = 2) for 4 to 6 weeks before surgical resection. One patient underwent pretreatment computed tomography–guided biopsy of the kidney mass for diagnostic purposes. Presurgical computed tomographic scans showed resolution of perinephric blood and fluid with tumor shrinkage. Histopathologic analyses showed all tumors were resected with negative margins, and there was no intraoperative tumor spillage. All patients received 1050 to 1080 cGy of flank radiation postoperatively. All patients are currently alive at follow-up without evidence of local recurrence or distant disease. Conclusions Neoadjuvant chemotherapy allowed for complete resection and avoidance of total abdominal radiation in 3 patients with ruptured Wilms' tumor and hematoma within the retroperitoneum. These data support the use of initial chemotherapy in children with retroperitoneal rupture and hematoma of Wilms' tumor at diagnosis.

Resolution of page kidney-related hypertension with medical therapy: A case report

A 24-year-old man developed systolic hypertension as a result of renal contusion, perinephric fluid collection, and renal compression (Page kidney) after blunt renal trauma. The patient was treated with an angiotensin-converting enzyme inhibitor for 30 days, after which his blood pressure normalized and the medications were discontinued. Follow-up clinical and laboratory examinations at 3, 6, and 12 months showed normal results. Transient hypertension may develop in patients after blunt renal injury as a result of Page phenomenon. Appropriate medical therapy is warranted and may be successful because spontaneous resolution may be delayed or not occur at all.

Lymphocele and kidney transplantation

Lymphocele is a special complication following kidney transplantation. The authors examined the factors associated with an increased occurrence of clinically significant perinephric fluid collections and/or lymphoceles among sirolimus-treated renal transplant recipients. From the point of view of the lymphocele a comparison was made for the risks and benefits of the conventional and a newer immunosuppressive combination. At the University of Texas in Houston in a retrospective study the incidence, predisposing factors, and consequences of these fluid collections among patients treated with sirolimus-cyclosporine-prednisone ( n = 354, Group I) versus cyclosporine-prednisone-azathioprine ( n = 136, Group II) were compared. More Group I patients (135/354; 38.1%) displayed perinephric fluid collections than Group II patients (24/136; 17.6%; p < 0.001). In both subgroups the serum creatinine levels were elevated at the time of diagnosis from a nadir of 179.5 +/- 141.7 to 359.9 +/- 259.6 mmol/l (Group III, sirolimus treated) and from 222.6 +/- 205.9 to 383.7 +/- 255.2 mmol/l (Group IV, sirolimus free). A significantly greater number of patients required treatment for lymphoceles among Group I (15.8%; 56/354) versus Group II recipients (4.4%; 6/136; p < 0.001). Single or repeated percutaneous drainage procedures successfully treated 35 Group I patients versus all 6 Group IV patients ( p = 0.033). No patients in Group II versus 21 patients in Group I underwent surgical procedures ( p < 0.001). A significantly higher rate and higher histologic grade of acute rejection episodes, particularly proximate to the onset of the lymphocele, occurred among Group IV patients, namely 54.2% (13/24) versus 21.4% (29/135) Group III patients ( p < 0.001). Additionally we report the case of a 29-year-old patient who underwent a lymphocele fenestration with omentoplasty 8 years after his transplantation. Despite an Influenza A + Chlamydia pneumonia and acute rejection which was followed by a GI bleeding and stomach resection he fully recovered and is doing well with an excellent kidney function a year after. Addition of sirolimus to a cyclosporine-prednisone regimen resulted in both a higher incidence and a requirement for more aggressive treatment of perinephric fluid collections and/or lymphoceles with a much lower acute rejection frequency.

Renal lymphangiectasia

Renal lymphangiectasia is a benign disorder of renal lymphatics. Seldom observed, the pathophysiology is unclear. The clinical course may vary, and management alternatives range from percutaneous drainage in symptomatic cases to pharmacological substitutes in the form of anti-hypertensives and diuretics. We present a case of bilateral perinephric collections on imaging, which presented with gross ascites, abdominal pain and reversible hypertension. Ultrasound examination indicated ascites. Computerized tomography revealed bilateral symmetrical large perinephric collections. This is consistent with the appearance of renal lymphangiectasis (enlarged kidneys with fluid collections seen to be abutting the surrounding structures) reported in the literature. Needle aspiration of the perinephric fluid was undertaken, and laboratory analysis was carried out, which revealed a protein level of 643 mg dl(-1) and a total leucocyte count of 50, of which 80% were lymphocytes. Thereafter, a diagnosis of renal lymphangiectasia was made, and conservative treatment with diuretics and anti-hypertensives was initiated. Reassessment at subsequent follow up visits showed improvement in the patient's clinical condition.

Perinephric fluid collection: An unusual presentation of bowel perforation

Perinephric fluid collection: An unusual presentation of bowel perforation