Bloody Diarrhea and Pain in a Potentially Deadly Abdominal Condition
Authors
Lanna Cheuck, DO
Director of Minimally Invasive Urological Surgery
Department of Surgery
South Nassau Communities Hospital
Freeport, New York
Disclosure: Lanna Cheuck, DO, has disclosed no relevant financial relationships.
Christopher Atalla, DO
Intern
Nassau University Medical Center
East Meadow, New York
Disclosure: Christopher Atalla, DO, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
House Staff
Department of Diagnostic Radiology
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Bradley Fields Schwartz, DO, FACS
Professor of Urology
Director, Center for Laparoscopy and Endourology
Department of Surgery
Southern Illinois University School of Medicine
Springfield, Illinois
Disclosure: Bradley Fields Schwartz, DO, FACS, has disclosed no relevant financial relationships.
A 35-year old woman presented to the emergency department with gross hematuria and intermittent left abdominal pain that was moderate in intensity. The patient never experienced these symptoms before. She denied any alleviating or exacerbating factors. The patient’s medical and surgical histories were negative. She was not on any medications nor did she have any allergies to medications. A review of systems was negative. The physical examination was within normal limits. A computed tomography (CT) scan was obtained; an excretory phase image is shown.
The CT scan demonstrated a vermiform filling defect in the left renal pelvis and proximal ureter (seen on this coronal reconstruction). There was also mild fullness of the left renal collecting system. Urine culture and cytology were performed and found to be negative.
Which of the following may cause a filling defect in the ureter/renal pelvis?
A. Calculi
B. Blood clots
C. Malignancy
D. Parasitic infection
E. All of the above
Answer: E. All of the above
A retrograde pyelogram was performed, demonstrating a tortuous and kinked proximal ureter. Attempts at passage of a wire and flexible fiberoptic ureteroscope to visualize the area of concern were unsuccessful. Attention was then directed towards an antegrade approach with interventional radiology obtaining percutaneous access to the collecting system. A wire was placed into the renal pelvis to gain access into the collecting system (shown).
A balloon dilator was used and a 30-Fr sheath was then placed over the balloon. Renoscopy was performed with a flexible cystoscope and a rigid nephroscope. This image depicts how access is obtained percutaneously. A similar method is used in extraction of renal calculi.
What is the most common malignancy of the proximal ureter?
A. Adenocarcinoma
B. Transitional cell carcinoma
C. Renal cell carcinoma
D. Metastatic disease
Answer: B. Transitional cell carcinoma
At this point, the mass was seen bulging from the ureteropelvic junction into the renal pelvis (shown). Rigid nephroscopy was then used and grasping forceps extracted the mass down to the stalk. A 9-French electrode was then used to cauterize the base of the lesion. An antegrade nephrostogram was performed to ensure no further filling defects and no strictures/extravasation. Next, a double-J ureteral stent was placed in an antegrade fashion. The mass was sent to pathology where it was determined to be a fibroepithelial polyp.
A fibroepithelial polyp is a benign nonepithelial tumor of mesodermal origin. Hematuria is found in up to 88% of patients, with pain, infection, and voiding problems being less common. Ureteral fibroepithelial polyps can measure up to 12 cm. Histologically, they have a loose vascular fibrous stroma with overlying benign transitional epithelium (shown). They can be found in concordance with transitional cells[1] and have been shown to grow on serial CT examinations.[2]
Fibroepithelial polyps are most commonly found in what region of the urinary tract?
A. Renal pelvis
B. Ureter
C. Ureterovesicular junction
D. Bladder
Answer: B. Ureter
Fibroepithelial polyps are found within the ureteropelvic junction and upper ureter in 62% of cases. Approximately 15% are found in the renal pelvis and a much smaller percentage are found in the bladder and posterior urethra.[3] Polyps are most commonly found in adults aged 20-40 years old, with a male to female ratio of 3:2. For this patient, a retrograde ureteropyelogram demonstrated a long filling defect in the distal ureter.
This intravenous pyelogram demonstrates filling defects in the right ureter (arrowheads) and a large filling defect in the bladder (arrow) from a large fibroepithelial polyp. Imaging modalities must be optimized to evaluate the ureters. Ureteropyelogram and intravenous pyelogram can adequately evaluate the ureters. CT scans must be performed in the excretory phase to identify filling defects, although in standard portal venous phase imaging they will be able to detect hydronephrosis. A few studies have reported ultrasound detection of ureteral fibroepithelial polyps, describing them as mildly echogenic structures with polypoid projections extended into the right renal pelvis.
This large transitional cell carcinoma extends from the renal pelvis into the proximal ureter on a retrograde pyelogram. In general, differential considerations for ureteral lesions include malignant and benign tumors, nonneoplastic filling defects, and infections. The most common malignant tumors are transitional cell carcinomas. Benign mesenchymal tumors are very rare.
In addition to fibroepithelial polyps, which of the following nephroureteral stones also appears radiolucent on noncontrast CT scan?
A. Uric acid stones
B. Calcium oxalate stones
C. Struvite stones
D. Indinavir stones
E. Cystine stones
Answer: D. Indinavir stones
A struvite stone is shown. Indinavir, a protease inhibitor used in the treatment of HIV, produces stones that are radiolucent on noncontrast CT scan. Uric acid stones appear radiolucent on radiographs only.[4] Other nonneoplastic etiologies of filling defects include blood clots, sloughed papillae, and fungus balls.[5]
Which disease process classically produces multiple filling defects, ulcerations, and strictures?
A. Tuberculosis
B. Transitional cell carcinoma
C. Ureteritis cystica
D. Papilloma
Answer: A. Tuberculosis
Tuberculosis classically produces multiple filling defects, strictures, and ulcerations. This retrograde pyelogram reveals a right-sided midureteral stricture. The treatment of choice for a fibroepithelial polyp is complete excision. Accurate preoperative diagnosis may help guide treatment towards a less invasive endoscopic resection rather than more radical surgery, such as a nephroureterectomy.[1,6]
This polypoid mass emanates from the left ureteral orifice into the bladder. In some cases, retrograde ureteroscopic resection can be done, but is usually difficult in patients with long, large polyps. It may be difficult to access the base of the stalk because the pedunculated body usually hangs inferiorly and obstructs the lumen of the ureter. Visualization can also be poor and working space is limited, which makes it difficult to differentiate the ureteral wall from the polyp itself. This can lead to incomplete polyp resection or ureteral perforation.
Holmium lasers may also be useful for polyp removal, especially for polyps with a fibrous stalk. The thickness and strength of the stalk may make it difficult to remove polyps with a percutaneous approach via the graspers that are typically used. However, lasers can easily vaporize the stalk. Holmium lasers allow for simultaneous shallow cutting and hemostasis and can be inserted via a fiberoptic cable during endoscopic surgery (shown). They may also be used for lithotripsy.[7]
Fibroepithelial polyps have no potential for malignant transformation.
A. True
B. False
Answer: B. False.
The fibroepithelial polyp was successfully removed from the patient; this gross pathology image demonstrates the long filiform nature that allowed extension into the bladder. Although rare, fibroepithelial polyps have been reported to have malignant transformation. They have also been rarely associated with calculi, Peutz-Jeghers syndrome, ureteral intussusception, and retrocaval ureter. Usually there is no significant risk of recurrence.[8] No malignancy was found in this specimen. On follow-up, no recurrence was found and no bleeding had occurred. The patient was advised to follow-up only as needed.
Authors
Lanna Cheuck, DO
Director of Minimally Invasive Urological Surgery
Department of Surgery
South Nassau Communities Hospital
Freeport, New York
Disclosure: Lanna Cheuck, DO, has disclosed no relevant financial relationships.
Christopher Atalla, DO
Intern
Nassau University Medical Center
East Meadow, New York
Disclosure: Christopher Atalla, DO, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
House Staff
Department of Diagnostic Radiology
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Bradley Fields Schwartz, DO, FACS
Professor of Urology
Director, Center for Laparoscopy and Endourology
Department of Surgery
Southern Illinois University School of Medicine
Springfield, Illinois
Disclosure: Bradley Fields Schwartz, DO, FACS, has disclosed no relevant financial relationships.
An Elusive Cause of Severe Recurrent Flank Pain
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Vague Symptoms Belying a Possibly Severe Condition
An Unusual Diagnosis in a Young Woman With Abdominal Pain
