case report 1-5/uroradiology

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case report

 1What is this study? What does it show in this man with a long history of ankylosing
?spondylitis and recurrent bilateral loin pain
 2How do appearances vary according to disease stage
3Describe the appearance of the specimen from an autopsy of an elderly man in
4What are the causes of this condition




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Answers to Case
 1Figure -1a is a 5-min post-contrast image from an IVU showing irregular
calyces with contrast tracking out from the fornices into the papillae, producing
an ‘egg in cup’ appearance. Figure -1b is a close-up image of the left upper
pole with the tracking contrast arrowed. Appearances are consistent with papillary
necrosis, and in this case it was secondary to analgesic use.
2Early on, normal appearances or subtle papillary swelling. Later, contrast tracks
into the papillae as shown above. The necrotic papillae then cavitate and slough
off from the medulla. If they remain in the calyx they give a ‘egg in cup’ appearance
on IVU. Detached papillae may cause fi lling defects within the pelvis or
ureteric obstruction. Subsequently necrotic papillae may calcify. In the sites from
which papillae have been lost calyces appear clubbed and the medulla overlying
the damaged papillae becomes scarred causing an irregular cortical outline.
3Figure -2 shows the upper pole of a bisected kidney removed from an elderly
man who had untreated bilateral urinary tract obstruction and pyelonephritis.
The papillae are yellow and necrotic and show early central cavitation. The
sloughed papillae may also calcify due to Proteus colonisation. The renal outline
may become wavy due to focal atrophy.
 4A mnemonic for the causes of papillary necrosis: POSTCARDS
P – pyelonephritis
O – obstruction
S – sickle cell
T – TB
C – cirrhosis
A – analgesic abuse
R – renal vein thrombosis
D – diabetes mellitus
S – systemic vasculitis
Of all these, sickle cell disease and diabetes mellitus are the most common causes
in contemporary practice.

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