550
BRITISH JOURNAL OF UROLOGY
Obstructive Jaundice due to Arteriovenous Fistula after Right Neph rectomy S. R. ALVAREZ, A. G. RUIZ, R. P. SANCHEZ and R. 0. DE DIEGO, Department of Surgery and Department of Medicine, GastroenterologyDivision, Section Red Cross Hospital, Torrelavega,and National Hospital Valdecilla, Santander, Spain
Case Report
Fig. 2 Retrograde ureterogram confirms a large intraluminal filling defect.
Comment Xanthogranulomatous pyelonephritis (XPN) is a chronic renal parenchymal infection characterised by tissue necrosis and phagocytosis of liberated cholesterol and other lipids by macrophages (xanthoma cells). Recognised aetiological factors include calculus disease, obstructive uropathy, recurrent urinary tract infections and prolonged paralysis (Tolia et al., 1980). Fistula and sinus formation, while rare in XPN, are well documented and total nephrectomy with primary excision of the fistula or sinus (if practicable) is the treatment of choice (Parsons et al., 1986). XPN in association with ureterocutaneous fistula has not previously been described in the English literature. Chronic infections commonly result in amyloid deposition, although the patient had no evidence of secondary systemic amyloidosis.
A 69-year-old woman presented as an emergency with colicky abdominal pain. She had undergone right nephrectomy due to renal tuberculosis 30 years previously. For the last 3 years she had suffered from repeated attacks of biliary colic, some of which were accompanied by transient jaundice and bilirubinuria. On examination her blood pressure was 160/90mmHg ; she was slightly icteric and tender in the right hypochondrium. Biochemical analysis revealed normal SGOT, SGPT and alkaline phosphatase, gamma GT 204u/l, with a total bilirubin of 2.4mg/100ml and a direct bilirubin of 1.9 mg/100 ml. Plain abdominal X-ray (Fig. 1) showed a calcified nodular mass in the right hypochondrium. Ultrasonography revealed multiple stones in the gallbladder. The common bile duct measured 10mm in diameter and contained a defect, possibly caused by a stone.
References Parsons, M. A., Harris, S. C., Grainger, R. G. et al. (1986). Fistula and sinus formation in xanthogranulomatous pyelonephritis. Br. J . Urol., 58,488493. Tolia, B.M.,Iloreta, A., Freed, S. Z.e t d (1980). Xanthogranulomatous pyelonephritis: detailed analysis of 29 cases and a brief discussion of atypical presentation. J . Urol., 126, 437442.
Requests for reprints to: K. J . OFlynn, Department of Urology, Lodge Moor Hospital, Redmires Road, Sheffield S10 4LH.
Fig. 1 Calcified nodular mass in the right hipochrondrium (Arrows).
55 1
CASE REPORTS
Her symptoms disappeared on conservative treatment and blood pressure fell to 130/90 mm Hg. At elective surgery on the seventh day the gallbladder was found to be atrophied and no stones were felt within it. The common bile duct appeared swollen and displaced towards the midline. An aneurysmal swelling was observed at the apex of the vascular stump of the previous right nephrectomy with calcification of its walls. Cholecystectorny and per-operative transcystic cholangiography showed a dilated biliary tract with displacement towards the midline and a filling defect at the level of the middle third (Fig. 2). This proved to be an arteriovenous fistula of the vascular stump of the right nephrectomy. The origin of the renal artery was clamped and the renal vein was clamped at its entry to the cava. The fistula and aneurysmal zone were reresected with closure of the new stumps with a continuous monofilament suture. Further cholangiography showed the disappearance of both the defects within the bile duct and the extrinsic compression. The post-operative course was uneventful. Histological examination showed chronic cholecystitis and an arteriovenous fistula. In the arterial zone of the fistula there were lipoid deposits with calcific encrustations and proliferation of the intima.
by aneurysmal enlargement of the vascular stumps of the right renal pedicle due to formation of an arteriovenous fistula (Morin et al., 1986), although nephrectomy with mass ligature of the pedicle is a recognised cause of arteriovenous fistula (Joyex et al., 1984; Feldman et al., 1985). Abdominal auscultation was not carried out prior to surgery and this might have revealed an abdominal murmur since a murmur was audible when the abdomen was opened. The diagnosis was also made difficult by calcification inside the aneurysm which confused it echographically with the gallbladder.
References Feldman, S. L., Presman, D. and Kandel, G . L. (1985). Renal arterio-venous fistula following nephrectomy. Br. J . Surg., 57, 592-593. Joyex, A., Saint-Aubert, B. and C a m p s , A. C. (1984). Fistule artkrioveineusedu pkdicule rknal gauche dkpistke 30 ans apres une ntphrectomie. J . Chir.,121,487490. Morin, R. P., DUM, E. J. and Wright, C. B. (1986). Renal arteriovenous fistulas : a review of etiology, diagnosis, and management. Surgery, 99,114-1 18. Requests for reprints to: S. Revuelta Alvarez, Avda de Valdecilla, 27-2"-7" F, 3901 1 Santander, Cantabria, Spain.
Comment This is the first report of a patient with obstructive jaundice secondary to compression of the bile duct
Bilateral Ureteric Strictures Secondary to Candidiasis W.C. LYE, E. J. C. LEE, Department of Medicine, K. H. TUNG, Department of Urology, and R. SINNIAH, Department of Pathology, National University Hospital, Singapore
Case Report
Fig. 2 Cholangiography: dilated biliary tract with displacement towards the midline and a filling defect on the middle third (Arrow).
A 42-year-old housewife with diabetes mellitus presented with a 1-week history of fever and loin pain. Ultrasonography revealed bilateral hydronephrosis and hydroureters. A right antegrade nephrostogram disclosed a dilated pelvicaliceal and ureteric system down to the level of the sacroiliac joint. A left antegrade nephrostogram showed a dilated collecting system with 2 ureteric narrowings, 1 at the junction of the upper and middle third and the other near the vesicoureteric junction. Cystoscopy was performed and a double pigtail stent inserted in the left ureter. There was difficulty in manipulating the double pigtail stent into the right ureter and this was complicated by a ureteric perforation.
BRITISH JOURNAL OF UROLOGY
Obstructive Jaundice due to Arteriovenous Fistula after Right Neph rectomy S. R. ALVAREZ, A. G. RUIZ, R. P. SANCHEZ and R. 0. DE DIEGO, Department of Surgery and Department of Medicine, GastroenterologyDivision, Section Red Cross Hospital, Torrelavega,and National Hospital Valdecilla, Santander, Spain
Case Report
Fig. 2 Retrograde ureterogram confirms a large intraluminal filling defect.
Comment Xanthogranulomatous pyelonephritis (XPN) is a chronic renal parenchymal infection characterised by tissue necrosis and phagocytosis of liberated cholesterol and other lipids by macrophages (xanthoma cells). Recognised aetiological factors include calculus disease, obstructive uropathy, recurrent urinary tract infections and prolonged paralysis (Tolia et al., 1980). Fistula and sinus formation, while rare in XPN, are well documented and total nephrectomy with primary excision of the fistula or sinus (if practicable) is the treatment of choice (Parsons et al., 1986). XPN in association with ureterocutaneous fistula has not previously been described in the English literature. Chronic infections commonly result in amyloid deposition, although the patient had no evidence of secondary systemic amyloidosis.
A 69-year-old woman presented as an emergency with colicky abdominal pain. She had undergone right nephrectomy due to renal tuberculosis 30 years previously. For the last 3 years she had suffered from repeated attacks of biliary colic, some of which were accompanied by transient jaundice and bilirubinuria. On examination her blood pressure was 160/90mmHg ; she was slightly icteric and tender in the right hypochondrium. Biochemical analysis revealed normal SGOT, SGPT and alkaline phosphatase, gamma GT 204u/l, with a total bilirubin of 2.4mg/100ml and a direct bilirubin of 1.9 mg/100 ml. Plain abdominal X-ray (Fig. 1) showed a calcified nodular mass in the right hypochondrium. Ultrasonography revealed multiple stones in the gallbladder. The common bile duct measured 10mm in diameter and contained a defect, possibly caused by a stone.
References Parsons, M. A., Harris, S. C., Grainger, R. G. et al. (1986). Fistula and sinus formation in xanthogranulomatous pyelonephritis. Br. J . Urol., 58,488493. Tolia, B.M.,Iloreta, A., Freed, S. Z.e t d (1980). Xanthogranulomatous pyelonephritis: detailed analysis of 29 cases and a brief discussion of atypical presentation. J . Urol., 126, 437442.
Requests for reprints to: K. J . OFlynn, Department of Urology, Lodge Moor Hospital, Redmires Road, Sheffield S10 4LH.
Fig. 1 Calcified nodular mass in the right hipochrondrium (Arrows).
55 1
CASE REPORTS
Her symptoms disappeared on conservative treatment and blood pressure fell to 130/90 mm Hg. At elective surgery on the seventh day the gallbladder was found to be atrophied and no stones were felt within it. The common bile duct appeared swollen and displaced towards the midline. An aneurysmal swelling was observed at the apex of the vascular stump of the previous right nephrectomy with calcification of its walls. Cholecystectorny and per-operative transcystic cholangiography showed a dilated biliary tract with displacement towards the midline and a filling defect at the level of the middle third (Fig. 2). This proved to be an arteriovenous fistula of the vascular stump of the right nephrectomy. The origin of the renal artery was clamped and the renal vein was clamped at its entry to the cava. The fistula and aneurysmal zone were reresected with closure of the new stumps with a continuous monofilament suture. Further cholangiography showed the disappearance of both the defects within the bile duct and the extrinsic compression. The post-operative course was uneventful. Histological examination showed chronic cholecystitis and an arteriovenous fistula. In the arterial zone of the fistula there were lipoid deposits with calcific encrustations and proliferation of the intima.
by aneurysmal enlargement of the vascular stumps of the right renal pedicle due to formation of an arteriovenous fistula (Morin et al., 1986), although nephrectomy with mass ligature of the pedicle is a recognised cause of arteriovenous fistula (Joyex et al., 1984; Feldman et al., 1985). Abdominal auscultation was not carried out prior to surgery and this might have revealed an abdominal murmur since a murmur was audible when the abdomen was opened. The diagnosis was also made difficult by calcification inside the aneurysm which confused it echographically with the gallbladder.
References Feldman, S. L., Presman, D. and Kandel, G . L. (1985). Renal arterio-venous fistula following nephrectomy. Br. J . Surg., 57, 592-593. Joyex, A., Saint-Aubert, B. and C a m p s , A. C. (1984). Fistule artkrioveineusedu pkdicule rknal gauche dkpistke 30 ans apres une ntphrectomie. J . Chir.,121,487490. Morin, R. P., DUM, E. J. and Wright, C. B. (1986). Renal arteriovenous fistulas : a review of etiology, diagnosis, and management. Surgery, 99,114-1 18. Requests for reprints to: S. Revuelta Alvarez, Avda de Valdecilla, 27-2"-7" F, 3901 1 Santander, Cantabria, Spain.
Comment This is the first report of a patient with obstructive jaundice secondary to compression of the bile duct
Bilateral Ureteric Strictures Secondary to Candidiasis W.C. LYE, E. J. C. LEE, Department of Medicine, K. H. TUNG, Department of Urology, and R. SINNIAH, Department of Pathology, National University Hospital, Singapore
Case Report
Fig. 2 Cholangiography: dilated biliary tract with displacement towards the midline and a filling defect on the middle third (Arrow).
A 42-year-old housewife with diabetes mellitus presented with a 1-week history of fever and loin pain. Ultrasonography revealed bilateral hydronephrosis and hydroureters. A right antegrade nephrostogram disclosed a dilated pelvicaliceal and ureteric system down to the level of the sacroiliac joint. A left antegrade nephrostogram showed a dilated collecting system with 2 ureteric narrowings, 1 at the junction of the upper and middle third and the other near the vesicoureteric junction. Cystoscopy was performed and a double pigtail stent inserted in the left ureter. There was difficulty in manipulating the double pigtail stent into the right ureter and this was complicated by a ureteric perforation.
