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A 71-year-old woman presented at the outpatient clinic for the first time in 1973 with diffuse bone pain mainly in both wrists, shoulders and the spine. Clinical examination showed limb deformities (genu varum of the left leg, genu valgum of the right leg) and short stature (142 cm). At that time, she had already experienced multiple spontaneous fractures of the right and left femur. There was no family history of bone disorders (mother and father as well as seven brothers and sisters were healthy). Laboratory tests at that moment showed: sodium 141 mmol/L (normal range 133–145), potassium 3.9 mmol/L (3.5–5.1), chloride 104 mmol/L (95–108), bicarbonate 23 mmol/L (23–29), calcium 9.8 mg/dL (8.4– 10.2), phosphate 1.7 mg/dL (2.4–4.5), serum creatinine 0.72 mg/dL and alkaline phosphatase 120 U/L (53– 141). Hyperparathyroidism was excluded. Urine analysis showed a daily phosphate excretion of 597 mg (300– 1300), a daily calcium excretion of 39 mg (100–250) and a daily creatinine excretion of 852 mg (660–2200), corresponding to a fractional renal excretion of phosphate of 67%. At that time, the diagnosis of a congenital disorder with hypophosphataemia due to renal phosphate wasting, resulting in osteomalacia was considered. Treatment with oral phosphate and vitamin D replacement was initiated, resulting in a normalization of her serum calcium and phosphate. The following years, a few episodes of symptomatic hypoand hypercalcaemia (with nausea and vomiting) could not be prevented. Figure 1 shows the evolution over the years of the serum calcium and phosphate levels. Figure 2 shows the evolution of the daily urinary excretion of calcium and phosphate.

ObjectivePeritoneal dialysis (PD) patients frequently suffer from dyspeptic complaints such as nausea, vomiting, abdominal distension, early satiety, and anorexia. Gastroparesis might be, at least partially, a source of dyspeptic complaints in PD patients. The aim of the present study was to determine the influence of the presence and composition of dialysate on gastric emptying in PD patients.DesignProspective study.SettingRenal Division, Department of Internal Medicine, Ghent University Hospital, Belgium.PatientsSixty-one PD patients using different dialysate solutions, and 27 healthy volunteers.Main Outcome MeasureGastric emptying of solids was assessed by the13C-octanoic acid breath test.ResultsGastric emptying was impaired in PD patients, regardless of the composition of dialysate and even if tested with an empty peritoneal cavity. Gastric emptying was significantly slower when glucose-containing dialysate was compared to an empty peritoneal cavity, or when glucose-containing dialysate was compared to icodextrin dialysate. No difference in gastric emptying could be demonstrated between glucose-containing dialysate and dialysate containing a mixture of glycerol and amino acids as osmotic agent.ConclusionsThese findings suggest that the delay in gastric emptying demonstrated in the presence of peritoneal dialysate is not the consequence of a mere volume or pressure effect, but of the absorption of substrate substances with caloric and/or metabolic activity, such as glucose or glycerol and amino acids.

We report the sonographic, CT, and clinical findings in a patient presenting with clinical sepsis and multiple Staphylococcus aureus hepatic microabscesses. Although contrast-enhanced CT has had a higher sensitivity than sonography in detecting hepatic microabscesses in some studies, this examination was negative in our patient. On sonography, numerous small hypoechoic lesions were present. Some target-like lesions had a striking similarity to Candida albicans microabscesses. The hepatic lesions were believed to be pyogenic liver microabscesses, as several blood cultures were positive for S. aureus. Following prolonged intravenous antibiotic therapy, all the hypoechoic hepatic lesions disappeared, along with the clinical and biochemical signs of sepsis.

Lymphocytic gastritis is a recently described gastric inflammation, characterized by an increased intraepithelial lymphocytic infiltrate mainly composed of T-lymphocytes. Endoscopically it correlates mainly with diffuse varioliform gastritis. Ménétrier's disease is a hypertrophic gastropathy with enlarged gastric folds. The histological picture is that of foveolar hyperplasia and glandular cysts of the mucosa. A few small series of lymphocytic gastritis with microscopic and endoscopic features of Ménétrier's disease have been published previously. We describe a similar case associated with a gastric adenocarcinoma.

The value of axillary sonography in 144 consecutive patients was prospectively studied. Abnormal lymph nodes were demonstrated in 72 axillae, only half (36 of 72) of which were clinically detected. In comparison with intraoperative findings in 47 patients with breast carcinoma, the sensitivity of sonography in detecting malignant nodes was 92%, the specificity 95%, and the positive and negative predictive value 96% and 91%, respectively. In 42 patients a sonographically guided node puncture was performed. Evidence of malignancy was found in 38 (90.5%). In 14 (33%) of them, cyto-histology pointed to a clinically undetected primary malignancy.

We describe the case of a 71-years-old man in chronic hospital hemodialysis who was admitted to the hospital because of symptomatic hypoglycemia. We discovered that this was due to a documented intoxication with cibenzoline, an antiarrhythmic drug , used to treat (supra-)ventricular tachyarrhythmia. In addition we made a short review of the literature concerning cibenzoline intoxication.

The diagnosis Wegener's granulomatosis was made in a 42-year-old man. Occupational history revealed prolonged exposure to large amounts of silicon dioxide in dust during work in a foundry. The illness was stabilized with immunosuppressive treatment, but after one year the patient developed aseptic necrosis in both hips, which ultimately led to essential total hip arthroplasty on the left side. The patient was unable to work since the diagnosis. Similar case reports have been described, as well as a limited number of case-control studies. These indicate an association between Wegener's granulomatosis and exposure to silicon. There is growing evidence for a causal role of silicon dioxide in the pathogenesis of auto-immune disease.

In a patient treated for a non-Hodgkin's lymphoma, a lung abscess caused by Hormographiella aspergillata (stat. anamorph. Coprinus cinereus) was diagnosed using an ultrasound-guided puncture of the lesion. The patient appeared to respond to amphotericin B, but at the same time was also recovering from her neutropenic episode. The extent to which each of these two factors explains the complete resolution of the infection is unclear. Expert classical morphological examination and molecular typing methods were needed to identify this filamentous basidiomycetous fungus.

We report the sonographic, CT, and clinical findings in a patient presenting with clinical sepsis and multiple Staphylococcus aureus hepatic microabscesses. Although contrast-enhanced CT has had a higher sensitivity than sonography in detecting hepatic microabscesses in some studies, this examination was negative in our patient. On sonography, numerous small hypoechoic lesions were present. Some target-like lesions had a striking similarity to Candida albicans microabscesses. The hepatic lesions were believed to be pyogenic liver microabscesses, as several blood cultures were positive for S. aureus. Following prolonged intravenous antibiotic therapy, all the hypoechoic hepatic lesions disappeared, along with the clinical and biochemical signs of sepsis.

We performed a US-guided aspiration of the gallbladder in 27 patients with an acute cholecystitis and severe concurrent disease, not responding to IV antibiotics and supportive therapy. Twenty six of the 27 patients improved after the procedure. One patient died 7 days after the procedure due to multi organ failure; in the others immediate surgery could be avoided. Three patients experienced local pain after the procedure; no other puncture related complications were encountered. Long-term results (mean follow up 18 months; range 2-36 months) were excellent in 20/26 survivors with no biliary complications or need for elective cholecystectomy. Six of the 26 patients needed subsequent cholecystectomy for relapse or incomplete cure.

The value of axillary sonography in 144 consecutive patients was prospectively studied. Abnormal lymph nodes were demonstrated in 72 axillae, only half (36 of 72) of which were clinically detected. In comparison with intraoperative findings in 47 patients with breast carcinoma, the sensitivity of sonography in detecting malignant nodes was 92%, the specificity 95%, and the positive and negative predictive value 96% and 91%, respectively. In 42 patients a sonographically guided node puncture was performed. Evidence of malignancy was found in 38 (90.5%). In 14 (33%) of them, cyto-histology pointed to a clinically undetected primary malignancy.

Eight cases of hepatobiliary invasion of Ascaris lumbricoides into the hepatobiliary tract are presented. In the presence of nonspecific symptoms and biochemical test results, the diagnosis was made in seven patients by sonography. In the remaining patient, in whom the adult roundworm was not visible on sonography owing to the presence of aerobilia, the diagnosis was made at ERCP. Sonography revealed typical tubular, echogenic, filling defects along the long axis of a dilated common bile duct, sometimes exhibiting slow movements and containing a central sonolucent line. Repeated sonographic examinations accurately predicted treatment success.

Diagnostic criteria of analgesic nephropathy with well-defined sensitivity and specificity are not available. During a 2-year period all new patients (n = 273) starting renal replacement therapy in 13 Belgian dialysis units were investigated aiming to select diagnostic criteria of analgesic nephropathy with acceptable performance. Using several interview techniques, a history of analgesic abuse was found in 31% of the patients. Analgesic abusers presenting a clear non-analgesic-related renal diagnosis were excluded from analysis (n = 25). Comparing the remaining abusers (n = 60) and patients without a history of analgesic abuse (n = 188) it was found that renal imaging investigations (sonography plus tomography), showing a decrease in length combined with bumpy contours of both kidneys, presented a sensitivity of 90% and a specificity of 95%. The additional finding of signs of renal papillary necrosis resulted in an overall sensitivity of 72% and a specificity of 97%, giving a positive predictive value of 92%. Other signs frequently mentioned in the literature (hypertension, anaemia, sterile pyuria, bacteriuria, proteinuria) showed insufficient sensitivity and/or specificity to be of help for diagnosing analgesic nephropathy in end-stage renal failure (ESRF) patients starting renal replacement therapy.

Postmenopausal bleeding and nipple congestion heralding ovarian metastases of a primary colonic adenocarcinoma

In 95 consecutive patients with proven colonic carcinoma, the tumor was detected by routine sonography in only half of the patients. However, in 22 out of 23 tumors of the right colon, a correct diagnosis was suggested by sonography (sensitivity 95.5%). Although not suitable as a first choice screening procedure for colorectal cancer, routine abdominal ultrasound can detect even non-suspected colonic tumors, especially in the ascending colon. Since the specificity of ultrasound is probably low, diagnosis must be confirmed by X-ray and/or endoscopy.

In a prospective study of 123 patients with clinical signs of acute intestinal inflammation, the sensitivity of ultrasonography in diagnosing acute colonic diverticulitis was 84.6% and the specificity 80.3%. The predictive value of a positive and a negative sonogram was 76.0% and 87.7%, respectively. Of the 52 patients with subsequently proven acute colonic diverticulitis, 44 presented sonographically with a thickened (greater than 4 mm) hypoechoic bowel wall. In 15 patients, enlarged fluid-filled bowel loops were also present. Air-containing diverticula were demonstrated in 3 patients, abscesses in 8 patients, and colovesical fistulae in 2 patients. Eight large abscesses were successfully treated without emergency surgery by percutaneous sonographically guided evacuation. The described sonographic abnormalities strongly suggest acute colonic diverticulitis, particularly when localized in the left lower abdomen.

This paper has reviewed experience in Belgium with 99 patients on CAPD. They represent 6-7% of all dialysis patients in this country. The principle reasons for selecting CAPD were old age, problems with vascular access and major cardiovas cular complications. Hemoglobin and hematrocrit values increased in all patients but preliminary measurements of red cell volume in some of them showed no change. Most patients showed moderate increases in serum triglycerides. In three non-diabetic patients with marked elevation in triglyceride levels, insulin, given intraperitoneally, prevented further increases. The frequency of peritonitis was still high; the average rate was one episode every 7.6 patient months. Other major complications included hypotension, which improved after the substitution of dialysate with a higher sodium concentration, severe respiratory disease and gangrene of the legs. After a mean follow-up of seven months, the death rate was 18% and the rate of technical success was 70%. The fact that most of our patients were in the high-risk category should be kept in mind when comparing these results with those obtained with other modes of treatment. At the end of 1978, a total of 1195 patients with end-stage renal disease (ESRD) were treated on either home or hospital dialysis in Belgium. There were 50 dialysis centers for a total population of 9.8 million. Of these 1195 patients, only seven were treated with either continuous ambulatory peritoneal dialysis (2-4) or intermittent peritoneal dialysis. Since then and until July 1, 1980 the number of patients treated with CAPD in Belgium has increased to 99 and this paper describes our experience with these patients.

SummaryTwo adult cases with the hemolytic uremic syndrome are reported. The first patient died and this illustrates the often bad prognosis of this disease in the adult. The simultaneous occurrence of the familial and recurrent variant of this syndrome in the second patient is highly remarkable. The differential diagnosis with for example thrombotic thrombocytopenic purpura is discussed. A high antibody titer against Coxsackie B, virus was measured in the serum of our first patient, while a rise in antibody titer for mononucleosis infectiosa was observed in the second patient. The role of viral infections, of intravascular coagulation and of immunological phenomena in the pathogenesis of the hemolytic uremic syndrome and the therapy with heparin and platelet inhibitors arc discussed.

The complications related to the use of subclavian catheters for hemodialysis were prospectively studied in 257 consecutive acute and chronic renal failure patients. Using 394 catheters, 3006 single needle dialyses were performed. Indications for starting catheter dialysis were mainly the absence or disappearance of an adequate vascular access. Most hazardous complications were sepsis (9), malposition (6), hemothorax (3), bleeding (2), vena cava thrombosis (2) and pneumothorax (2). A number of mechanical problems occurred, where the obstructed catheter could easily be replaced by a modified Seldinger technique. No mortal complications occurred. Patient tolerance was excellent. It is concluded that single needle subclavian hemodialysis is a valuable alternative vascular access method in acute situations. It enables the continuation of hemodialysis on an ambulatory basis.

A simple method of plasma exchange is presented that uses a hollow-fiber plasma filter together with conventional unipuncture dialysis equipment. The procedure was well tolerated for eight biweekly sessions in a patient with metastatic breast cancer.

Les auteurs rapportent un cas d’epaississement sous-muqueux et diffus de l’antre gastrique, detecte par l’echographie abdominale. Une infiltration maligne de la paroi gastrique a ete suggeree par l’endoscopie et par la radiographie barytee. Le diagnostic histo-pathologique final fut celui de gastrite a eosinophiles (variante sous-muqueuse). Ce cas demontre la necessite de macro-biopsies gastriques, meme en presence d’une muqueuse apparemment normale, chez les patients presentant une paroi gastrique epaissie lors de l’examen echographique de l’hemi-abdomen superieur.

In a prospective study of 1000 consecutive patients, abdominal sonography added diagnostic information to that available by history and physical examination in 8.9%. The yield ranged from a high of 27.4% in patients with acute abdominal symptoms to a low of 2.7% in screening sonograms of patients without abdominal symptoms. Sonographically guided biopsy-proven diagnoses were obtained in 6.6% of the patients and were clinically not suspected in 4.4%. The percentage of false-positive and false-negative sonographic studies was 0.5% and 1.1%, respectively. Sonography shortened the duration of hospitalization in 15.3%.

SummaryAmyloidosis is a relatively rare complication of Crohn’s disease. This paper reviews 29 previously reported cases and describes three additional patients. All three presented a nephrotic syndrome and one of them died of renal failure. Observation on one of these patients showed a clinical remission of his nephrotic syndrome with the preservation of a normal renal function over a period of seven years, although in a second biopsy amyloidosis could still be demonstrated.

A primary malignant melanoma of the gallbladder, metastatic to the common bile duct, is reported. Both tumor sites were first visualized by abdominal sonography. The presence of the common bile duct metastasis was confirmed by endoscopic retrograde cholangiopancreatography. Histologic evidence is presented that the primary tumor did arise in the gallbladder and that the metastasis to the common bile duct most likely occurred as a consequence of mucosal implants from tumor cells that were shed in the bile.

A hemodialysis patient developed hepatic cirrhosis with subsequent portal-systemic encephalopathy. Switching from hemodialysis to CAPD prevented the recurrent episodes of hepatic coma. This observation suggests that, in combined chronic renal and hepatic failure with portal-systemic encephalo pathy, CAPD may be the treatment of choice. This paper presents evidence to support this assumption. Chronic hemodialysis patients frequently develop hepatitis B, which sometimes results in hepatic cirrhosis. Portal-systemic encephalopathy (PSE) may ensue. We describe a patient in whom mild PSE repeatedly progressed to full hepatic coma during hemodialysis sessions. Switching the patient from hemodialysis (HD) to continuous ambulatory peritoneal dialysis (CAPD) prevented the recurrent hepatic coma.

A 61-yr-old woman presented with acute severe pain in the upper abdomen. Within a few hours after admission, diagnosis of partial splenoportal and superior mesenteric venous thrombosis was made by ultrasonography. This thrombosis appeared to be the first sign of a previously unsuspected essential thrombocythemia. Early sonographic diagnosis made possible the prompt institution of conservative treatment. Total thrombosis of the splenoportal system could be prevented. Major surgery was avoided and the outcome was uneventful.

• Localization of hyperfunctioning parathyroid glands is difficult. We examined 16 patients with biochemically proven primary or secondary hyperparathyroidism, using a 5-MHz 90° real-time sector transducer. In those 16 patients, ultrasonographically guided fine-needle aspiration biopsy of 26 hypoechogenic retrothyroid nodules was performed. Hyperplastic parathyroid tissue was obtained from 24 retrothyroid nodules in 14 patients. In the other two patients, normal thyroid tissue was obtained. Both specificity and sensitivity of the aspiration biopsy technique were 100%. No complications occurred. We concluded that this technique is safe, simple, and very helpful in the localization of parathyroid tumors before surgery or before alcoholization. ( Arch Otolaryngol Head Neck Surg 1986;112:1069-1073)

Bone mineralization is impaired in alcoholic non cirrhotics admitted to hospital for withdrawal. The defect is more marked in women than in men. Low 25-OH vitamin D plasma values may be observed in these patients and seem to be related to malnutrition. The degree of bone demineralization is not statistically correlated to 25-OH vitamin D plasma level.

The complications related to the use of subclavian catheters for hemodialysis were prospectively studied in 257 consecutive acute and chronic renal failure patients. Using 394 catheters, 3006 single needle dialyses were performed. Indications for starting catheter dialysis were mainly the absence or disappearance of an adequate vascular access. Most hazardous complications were sepsis (9), malposition (6), hemothorax (3), bleeding (2), vena cava thrombosis (2) and pneumothorax (2). A number of mechanical problems occurred, where the obstructed catheter could easily be replaced by a modified Seldinger technique. No mortal complications occurred. Patient tolerance was excellent. It is concluded that single needle subclavian hemodialysis is a valuable alternative vascular access method in acute situations. It enables the continuation of hemodialysis on an ambulatory basis.

Three cases of dilated abdominal left paraaortic lymphatic duct are described. The diagnosis was established by means of sonography and confirmed with lymphography in all three patients. A sonographically guided puncture of the lymphatic duct was performed in one patient. Dilatation of these lymphatic ducts was possibly the consequence of previous upper abdominal surgery in two patients and a coronary bypass operation in one.

During a five year period (January 1975 - September 1980) 33 patients, in a population of 262 chronic hemodialysis patients, were treated for uremic pericarditis. They all underwent a pericardiostomy either through a lateral (15 cases) or through a subxiphoid approach (18 cases). Immediate clinical relief occurred in all but one patient who showed a progressive cardiac failure even after drainage. Operative mortality was absent and complications were minimal. There were two recurrences of pericardial effusion after an initial lateral approach through thoracotomy. A subsequent partial pericardectomy was successful in both cases.

We report 3 patients on maintenance hemodialysis who developed a fulminant, disseminated and fatal form of mucormycosis. The diagnosis was made by microscopy and culture in 1 case, yielding Rhizopus rhizopodiformis, and by post-mortem microscopy in the two other cases. These patients were receiving desferrioxamine (DFO) for aluminum overload and had no iron-overload. Ten similar patients, all (with only one possible exception) receiving DFO, have been reported from American centers. The mechanism by which DFO could precipitate mucormycosis is unsettled. The explanation might be that DFO acts as a siderophore to the Mucorales fungi. High serum levels of DFO in renal failure could enhance this mechanism. Epidemiological data, provided from an inquiry in 25 Flemish dialysis centers, support the association between DFO treatment and dialysis-associated mucormycosis.