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Old 06-17-2011
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Kidney Flank Pain, Anitmigrain Rx, and an IVP!

A 31-year-old man visits his primary care physician with complaints of flank and back pain. The pain began 6 weeks ago and seems to be worsening. There are no other complaints. He has chronic migraine headaches, which are currently well controlled with medication. Investigation of the patient’s symptoms culminates with an intravenous pyelogram (IVP) (see figure). Which of the following is most likely associated with the patient’s clinical findings?

Flank Pain, Anitmigrain Rx, and an IVP!-ivp-1.jpg
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A. Adult polycystic kidney disease
B. Amyloidosis
C. Bladder cancer
D. Ergotamine
E. Homocystinuria
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Old 06-17-2011
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Default RPF!

D. Ergotamine induced retroperitoneal fibrosis.

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Old 06-17-2011
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D. Ergotamine induced retroperitoneal fibrosis.

Good one!

but I can see PCK ,, would you explain more !!
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Old 06-17-2011
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Retroperitoneal fibrosis is a rare disease (estimated incidence of the idiopathic form of the disease is 0.1-1.4 per 100,000 person-years. The disease presents insidiously, often making the diagnosis difficult. Early symptoms may include a vague, poorly localized pain over the flank, lower back, and abdomen, or nonspecific systemic complaints, such as malaise, anorexia, weight loss, moderate pyrexia, nausea, and vomiting. Acute-phase reactants such as erythrocyte sedimentation rate and C-reactive protein levels are commonly elevated. Encasement of the ureters by the retroperitoneal mass may also cause obstructive uropathy and renal insufficiency.

A variety of secondary causes of retroperitoneal fibrosis have also been identified.

Drugs - ergot-derivatives, methysergide (which, in the past, was widely used for the prevention of migraine headaches), bromocriptine, beta blockers, methyldopa, hydralazine, analgesics

Malignancy - carcinoid, Hodgkin's and non-Hodgkin lymphoma, sarcomas

Infections - tuberculosis, histoplasmosis, actinomycosis

Radiation therapy for testicular seminoma, colon, pancreatic cancer

Surgery - lymphadenectomy, colectomy, aortic aneurysmectomy

Regarding IVP:

Although previously commonly performed, intravenous urography is now rarely used. However, it may be useful in a few cases to fully assess the extent of ureteral involvement and guide therapeutic decisions (eg, ureteral stent placement).

Intravenous urography in patients with retroperitoneal fibrosis may demonstrate proximal hydroureteronephrosis, medial deviation of the ureters, and extrinsic compression of the ureters. Encasement of the ureters prevents dilatation of the middle and distal ureteral segments. Medial deviation of the ureter typically begins at the level of the third and fourth lumbar vertebrae.

However, these classic findings are not observed in all patients with retroperitoneal fibrosis, and medial deviation of the ureter may be found in some normal subjects. One study, for example, found that almost 20 percent of patients with normal urograms had medial displacement of the ureters without evident urologic disease.

More commonly used modalities include ultrasonography, excretory urography, CT scanning, and magnetic resonance imaging. CT scanning is the examination of choice to visualize the extent of fibrosis, and to assess the presence of lymphadenopathy and tumor.

Source: UpToDate

A similar question was discussed in the following thread.

IV pyelogram in a case of back pain
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Old 06-17-2011
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Quote:
Originally Posted by dr-ahmed View Post
but I can see PCK ,, would you explain more !!
But the question is still unanswered.....i agree wid dr ahmed.......wat abt the PCK on the right ?
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Old 06-17-2011
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I agree that retroperitoneal fibrosis does not explain the PKD on the right. Perhaps the medicated migraines are simply a distractor. ADPKD is far more common than RF (ADPKD is found in approximately 1 in every 400 to 1000 live births) and statistically would be the more likely explanation for recent onset of flank and back pain.
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So, the correct answer is APCKD...........?
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Old 06-18-2011
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I will like to put my 2 cents on retroperitoneal fibrosis.. aka ergotamine given in the options...

APKD is possible, but if you read the literature this is not how it usually presents.. In adults they are usually asymptomatic or present at a very late stage
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Option D (Ergotamine) is correct. The IVP (see figure) shows bilateral hydronephrosis due to ureteral compression; note how the ureters are tapered and characteristically drawn medially by the fibrotic process. This characteristic medial deviation of the ureter at the L4–L5 vertebral level is a classic radiographic picture of retroperitoneal fibrosis. Given a likely drug associated with this condition, ergotamine for the treatment of migraine this diagnosis is the most likely of the available answer choices.

Option A (Adult polycystic kidney disease) is incorrect. There is dilation of the renal pelvis but no sign of cysts. The IVP (see figure) shows bilateral hydronephrosis due to ureteral compression; note how the ureters are tapered and characteristically drawn medially by the fibrotic process. This characteristic medial deviation of the ureter at the L4–L5 vertebral level is a classic radiographic picture of retroperitoneal fibrosis.

Option B (Amyloidosis) is incorrect. The IVP (see figure) shows bilateral hydronephrosis due to ureteral compression; note how the ureters are tapered and characteristically drawn medially by the fibrotic process. This characteristic medial deviation of the ureter at the L4–L5 vertebral level is a classic radiographic picture of retroperitoneal fibrosis. Amyloidosis conceivably could also cause this appearance, but there is no other reason to expect this diagnosis in this patient.

Option C (Bladder cancer) is incorrect. This could explain the patient’s symptoms and the appearance of the IVP (see figure), but the patient is young for bladder cancer, and the mimicking of a classic IVP appearance for retroperitoneal fibrosis would be very rare.

Option E (Homocystinuria) is incorrect. There is no evidence of any stones in the IVP image (see figure). The IVP shows bilateral hydronephrosis due to ureteral compression; note how the ureters are tapered and characteristically drawn medially by the fibrotic process. This characteristic medial deviation of the ureter at the L4–L5 vertebral level is a classic radiographic picture of retroperitoneal fibrosis.

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20. Is ergotamine helpful therapy for migraines?

Ergotamine derivatives can be helpful in patients who have migraine with a clear-cut prodrome. Ergotamine is available in oral, sublingual, suppository, injectable, and inhalation forms. Because of the extreme nausea and vomiting seen with some migraines, the suppository and sublingual preparations are the most useful and tolerable. When using sublingual or suppository form, the usual dosage is 2 mg. The patient may take 3 doses per headache, separated by 1½ hours, up to 9 doses per week.
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