An unusual ureteral dynamic obstruction in a kidney transplant patient.

INTRODUCTION: Ureteral complications are common in kidney transplanted patients; approximately 2.6-15% of patients develop ureteral obstruction/stenosis at some time after surgery, which is one of the most frequent urologic complications. Inguinal herniation of the neoureter is a rare complication but it must be taken into account. CLINICAL REPORT: We describe the case of a 78-years old male kidney transplanted patient (2004), who was admitted at the emergency room due to abdominal pain and with evidence of acute kidney injury. The ultrasound showed hydronephrosis (grade III) along with ureteral dilatation which ended with an image compatible with a kinking, that was confirmed at the TC and showed that the kneeling was in the right inguinal canal. It was possible, with a manual hernia reduction manoeuvre, to readjust the kneeling of the neoureter resolving the condition temporarily. The patient underwent underwent surgical hernia repair with no complication and complete recovery of renal function. CONCLUSIONS: When ureter obstruction of the transplanted kidney occurs, it is crucial to resolve the obstruction as soon as possible in order to preserve kidney function. Hernioplastic is an effective way to treat ureter obstruction when it is caused by its herniation.

A rare case of acute scrotum in a 12-year old boy: torsion of a paradidymal cystic appendage (organ of Giraldes).

Acute scrotum from testicular and epididymal cyst is relatively uncommon, whereas torsion of a cystic paradidymis is exceedingly rare. In this paper, we present the case of a healthy 12-year-old male patient admitted in our emergency room for acute scrotum, in whom diagnosis of torsion of a cystic paradidymis was suggested at color-Doppler US. Surgical exploration after ultrasound examination revealed a cystic paradidymis (Giraldes' organ) (PC) torsion. Immunohistochemical investigations were also performed after cyst excision to confirm the diagnosis. In our experience this is a very rare condition and appears to be only the third case reported in literature and the only one with pre-operative ultrasound (US) images demonstrating the presence of the cyst and its twisted pedicle.

Recommendations for early diagnosis of Developmental Dysplasia of the Hip (DDH): working group intersociety consensus document.

This consensus document has been prepared by a multidisciplinary group of experts (Paediatricians, Radiologists, Paediatric Orthopaedics) and it is mainly aimed at paediatricians, hospitals and primary care providers. We provide recommendations for the early diagnosis and treatment of Developmental Dysplasia of the Hip (DDH) and indications on its management.

Ultrasound findings in paediatric cholestasis: how to image the patient and what to look for.

Paediatric biliary tract and gallbladder diseases include a variety of entities with a wide range of clinical presentations. Cholestasis represents an impaired secretion of bilirubin by hepatocytes, manifesting with high blood levels of conjugated bilirubin and jaundice. Various causes may be involved, which can be recognised analysing blood tests and hepatobiliary imaging, while sometimes liver biopsy or surgery may be necessary. High-resolution real-time ultrasonography is an important tool for differentiation of obstructive and non-obstructive causes of jaundice in infants and children. In this paper, we briefly review the normal anatomy and the ultrasound aspects of main pathologies affecting gallbladder and biliary tree in neonatal and paediatric age.

Ultrasonographic and multimodal imaging of pediatric genital female diseases.

Ultrasonography is the first-line imaging modality in the evaluation of the female pelvis in childhood and adolescence, because it is easy to perform, non-invasive and it does not require sedation. The transabdominal approach is preferred in children and adolescents, after filling the bladder to move away the bowel loops from the pelvis. The probe frequency must be adapted to age, thickness of tissues and depth of the structures under examination. High-frequency (4-12 MHz) linear or convex probes are used in newborns; high-frequency linear probes (4-12 MHz) in toddler, convex 5-7.5 MHz probes in girls and convex 3.5-5 MHz probes in teenagers. In this article, the main pathological conditions of the genital female tract in pediatric age are examined, such as congenital anomalies, disorders of sex development, ovarian cysts, ovarian tumors, adnexal torsion, primary amenorrhea, precocious puberty and pelvic inflammatory disease.

Pediatric cystic diseases of the kidney.

Pediatric renal cystic diseases include a variety of hereditary or non-hereditary conditions. Numerous classifications exist and new data are continuously published. Ultrasound is the primary technique for evaluating kidneys in children: conventional and high-resolution US allows a detailed visualization of renal parenchyma and of number, size and location of the cysts, hence representing the most important diagnostic imaging technique for the first diagnosis and follow-up of these young patients. The purpose of this pictorial essay is to review the spectrum of renal cystic lesions in children from simple, complex or malignant single cysts to the several poly/multicystic kidney diseases.

Paediatric neck ultrasonography: a pictorial essay.

The neck structures are located very superficially and are therefore easy to explore by ultrasound examination. Ultrasonography is crucial for the detection of neck pathologies in children. High-frequency probes (10-15 MHz) are used for the ultrasound examination on the patient lying in supine decubitus and with their neck stretched out. The outcome of the exam depends mainly on the child's cooperation-hence the need for warm sonographic gel and a comfortable cushion to place under the patient's shoulders. The complete scan of the neck includes the evaluation of the thyroid and salivary glands and the vascular structures as well as the lymph node analysis. In children and adolescents, the thymus is often visualised in the supraclavicular and jugular scans. It appears as a structure, usually hypoechoic, with thin hyperechoic straps, though echogenicity increases with age. In this pictorial essay, the main pathological conditions of the neck in paediatric age will be examined, such as thyroid dysgenesis, thyroiditis, thyroid nodules, lymphadenopathies, cystic lesions, haemangiomas and vascular malformation, cervical thymus, fibromatosis colli and pilomatrixoma.

Classification and ultrasound findings of vascular anomalies in pediatric age: the essential.

Proper nomenclature is a major obstacle in understanding and managing vascular anomalies. Often the same term is used for totally different types of lesions or, conversely, the same lesion may be labeled with different terms. Although in recent times there has been a greater understanding of the problems concerning vascular anomalies, episodes of improper use of terminology still remain. The aim of this article, starting from the most recent classification of vascular anomalies, is to provide a clinical and instrumental approach to identifying these lesions and to converge towards a clear and unambiguous terminology that must become univocal among the various operators to avoid diagnostic misunderstandings and therapeutic errors.

Pediatric musculoskeletal ultrasound: a pictorial essay.

Ultrasound (US) is the main imaging modality for the evaluation of pediatric patients with musculoskeletal diseases; particularly, it is an appropriate and reliable tool for diagnosis, follow-up and treatment of several musculoskeletal pathologies affecting the pediatric age. High-frequency (10-15 MHz) and high-resolution probes provide very lofty quality images, allowing a detailed study of the pediatric musculoskeletal system. Among the well-known advantages of this technique-such as the absence of ionizing radiations, its low cost and wide availability-US can as well rely on some intrinsic characteristics of the pediatric musculoskeletal system that can improve its diagnostic capability. The unossified portions of the pediatric skeleton and the absence of a thickened adipose tissue allow US to be highly effective and reliable in the study of muscles, tendons and cartilage. Lower-frequency sectoral transducers can be required in the study of some joints such as the shoulder or the hip, as well as in the examination of deep soft-tissue lesions. Furthermore, both color and spectral Doppler play an important role in the examination of soft-tissue lesions and synovial phlogosis. In this pictorial essay the main pathological conditions of pediatric musculoskeletal system will be examined, such as painful hip, evolutionary hip dysplasia, osteochondrosis, trauma-related pathologies and juvenile idiopathic arthritis.

Ultrasonography of the pediatric spleen: a pictorial essay.

In infants and children, the spleen is involved in many pathological processes, whether those processes are isolated or related to systemic diseases. Pathology of the pediatric spleen includes congenital anomalies, splenomegaly, trauma, focal lesions, infarction, and tumors. Ultrasonography (US) is a widely available, fast, noninvasive imaging technique to assess the size, shape, and position of the spleen, as well as to define splenic echotexture. US is capable of screening for splenic disorders without the risk of ionizing radiation; it is the initial imaging examination performed to evaluate suspected splenic pathology, providing clinicians with helpful decisional support. US plays an important role in the detection of even very small amounts of hemoperitoneum, a herald of significant abdominal organ injury, in pediatric blunt abdominal trauma. Moreover, contrast-enhanced US may allow early detection of splenic injuries, ideally minimizing children's risk from radiation exposure. This pictorial essay illustrates the normal ultrasound appearance of the pediatric spleen and the sonographic findings which may guide clinicians to a correct diagnosis of pathologic conditions.

4-Point ultrasonography to confirm the correct position of the nasogastric tube in 114 critically ill patients.

PURPOSE: Nasogastric feeding tube is routinely positioned in intensive care units. The complications of misplacement are rare but very dangerous for the patients. The aim of this study is to estimate the diagnostic accuracy of this new technique, 4-point ultrasonography to confirm nasogastric tube placement in intensive care. METHODS: One hundred fourteen critical ill patients monitored in ICU were included. The intensivist provided in real time to perform the exam in four steps: sonography from either the right or left side of the patient's neck to visualize the esophagus, sonography of epigastrium to confirm the passage through the esophagogastric junction and the positioning in antrum, sonography of the fundus. Finally, gastric placement of the nasogastric feeding tube was confirmed with thorax radiograph. RESULTS: One hundred fourteen of the gastric tubes were visualized by sonography in the digestive tract and all were confirmed by radiography (sensitivity 100%). The entire sonographic procedure, including the longitudinal and transversal scan of the esophagus, the esophagogastric junction, the antrum and the fundus, took 10 min. CONCLUSIONS: Our pilot study demonstrated that not weighted-tip gastric tube routinely used in Intensive Care is visible with the sonography. The pilot study confirmed the high sensitivity of the sonography in the verify correct positioning of gastric tube in the adult ICU patients. The ultrasound examination seems to be easy and rapid even when performed by a intensivist whit a sonographic training of only 40 h. The sonographic exam at the bedside was performed in a shorter time than the acquisition and reporting of the X-ray.

Gallbladder adenomyomatosis: imaging findings, tricks and pitfalls.

Gallbladder adenomyomatosis (GA) is a benign alteration of the gallbladder wall that can be found in up to 9% of patients. GA is characterized by a gallbladder wall thickening containing small bile-filled cystic spaces (i.e., the Rokitansky-Aschoff sinuses, RAS). The bile contained in RAS may undergo a progressive concentration process leading to crystal precipitation and calcification development. A correct characterization of GA is fundamental in order to avoid unnecessary cholecystectomies. Ultrasound (US) is the imaging modality of choice for diagnosing GA; the use of high-frequency probes and a precise focal depth adjustment enable correct identification and characterization of GA in the majority of cases. Contrast-enhanced ultrasound (CEUS) can be performed if RAS cannot be clearly identified at baseline US: RAS appear avascular at CEUS, independently from their content. Magnetic resonance imaging (MRI) should be reserved for cases that are unclear on US and CEUS. At MRI, RAS can be identified with extremely high sensitivity, but their signal intensity varies widely according to their content. Positron emission tomography (PET) may be helpful for excluding malignancy in selected cases. Computed tomography (CT) and cholangiography are not routinely indicated in the suspicion of GA. TEACHING POINTS: 1. Gallbladder adenomyomatosis is a common benign lesion (1-9% of the patients). 2. Identification of Rokitansky-Aschoff sinuses is crucial for diagnosing gallbladder adenomyomatosis. 3. Sonography is the imaging modality of choice for diagnosing gallbladder adenomyomatosis. 4. Intravenous contrast material administration increases ultrasound accuracy in diagnosing gallbladder adenomyomatosis. 5. Magnetic resonance is a problem-solving technique for unclear cases.

Incisional Hernia Following Ventriculoperitoneal Shunt Positioning.

Incisional hernia represents a rare complication after ventriculoperitoneal shunt positioning due to failure of the fascial suture in the site of abdominal entrance of ventriculoperitoneal catheter. Clinical presentation can be extremely variable, according to patient's performance status, herniated material constitution (i.e. mesenteric fat, bowel loops or both) and complication occurrence (e.g. strangulation or intestinal obstruction). Early diagnosis is fundamental in order to surgically repair the defect and prevent further complications. We present the case of a paucisymptomatic incisional hernia following ventriculoperitoneal shunt positioning. Diagnosis was made by means of ultrasound and confirmed by means of computed tomography. The patient was successfully managed by means of surgical repositioning of herniated loop and re-suture.

Ovarian hyperstimulation syndrome in systemic amyloidosis.

We report on the case of a young woman with a diagnosis of amyloidosis who developed severe portal and splenic venous thrombosis shortly after hormonal follicle stimulation therapy for oocyte preservation. The clinical implications are discussed.

[Liver resection after downstaging with neoadjuvant chemotherapy for "unresectable" colorectal metastases]. / Resezione epatica dopo downstaging con chemioterapia neoadiuvante per metastasi colo-rettali "irresecabili".

Hepatic resection is the only treatment that offers a chance of long-term survival in patients with metastases from colorectal cancer. Nevertheless, a curative resection can be performed in only 10-20 per cent of patients: multiple bilobar metastases or "unresectable" disease are the greatest obstacles to surgical radicality. Techniques such as preoperative portal embolisation, preoperative portal ligation, two-stage hepatectomy, and neoadjuvant chemotherapy, have extended the possibility of liver surgery to patients with advanced metastatic colorectal cancer. The outcomes of two patients treated successfully with neoadjuvant chemotherapy (one case with FOL-F-OX, and one with FOL-F-IRI) followed by liver resection were analyzed. In both patients neoadjuvant chemotherapy enabled a curative liver resection to be performed without significant complications. In some patients, neoadjuvant chemotherapy permits the "downsizing" of metastatic disease to such an extent that a surgical approach proves feasible. This advance can dramatically improve the prognosis of patients with multiple or unresectable liver metastases from colorectal cancer.