Correspondence

Ching-Hsing Lee MD

235

Post-computed tomography of the kidney, ureter, and

Department of Hyperbaric oxygen Therapy Center and Department of Emergency Medicine Chang Gung Memorial Hospital

and Chang Gung University College of Medicine

Taoyuan, Taiwan, ROC E-mail address: [email protected]

doi:10.1016/j.ajem.2010.10.002

Reference

[1] Lee SH, Ryu S, Lee JW, Kim SW, et al. Hyperthermia occurred after hyperbaric oxygen therapy for carbon monoxide poisoning. Am J Emerg Med. 2010;28:845.e5-6.

Hyperthermia occurred after hyperbaric oxygen therapy for carbon monoxide poisoning

To the Editor,

I want to thank the reader for his/her response to my article. I would like to point out the situation encountered that was described in this article. Hyperthermia occurred after Hyperbaric oxygen therapy was administered to a CO poisoning patient. We used the ideal gas law to explain this case; however, this did not explain our findings entirely. However, the body temperature was normal after HBO therapy ceased without any interventions. I think if any causes were present, hyperthermia would have been steady until those causes were treated. Also, the temperature within the chamber (monochamber) itself might not reach above normal body temperature as the reader cited. No study cites a situation when a human is within the chamber. I think there would be some differences between the standard chamber and a human within the chamber in terms of hormones, metabolism, convection, and so on. Therefore, my colla- borators and I are currently investigating the relation of standard chamber and the body temperature within HBO

chamber (monochamber).

Seung Han Lee MD Seung Ryu MD

Jin Woong Lee MD Seung Whan Kim MD In Sool Yoo MD YeonHo You MD

Department of Emergency Medicine

College of Medicine Chungnam National University Hospital Daejeon 301-721, South Korea

E-mail address: [email protected] doi:10.1016/j.ajem.2010.10.001

bladder diagnosis of urinary extravasation

To the Editor,

We read with great interest the paper by Lien et al who reported 3 cases of spontaneous urinary extravasation (SUE), secondary to ureteral rupture caused by impacted stones at ureterovesical junction (UVJ) [1]. All three of the authors’ cases well demonstrated contrast leakage from ureteropelvic junction (UPJ) on enhanced computed tomographic scans. In this article, we present a case of SUE due to an impacted UVJ stone. abdominal CT scans revealed perirenal fluid accumulation, hydronephrosis, and an impacted UVJ stone, but did not identify contrast medium extravasation. However, the diagnosis was confirmed by a subsequent post- CT radiograph of kidney, ureter, and bladder (KUB). We suggest that a post-CT KUB radiograph might be a choice of imaging modality for the diagnosis of SUE.

A previously healthy, 51-year-old man presented to the emergency department with complaints of sudden onset of severe left upper quadrant pain concomitant flank pain. Physical examination revealed left flank knocking pain. Laboratory evaluation disclosed an elevated WBC count (10980 cells/mm³) with 94% segmented neutrophils and a normal urinalysis. abdominal radiography showed no calcifications. Ultrasound disclosed left hydronephrosis with perirenal fluid collection. An abdominal CT with and without enhancement was obtained to differentiate the cause of hydronephrosis and perirenal fluid accumulation. Unen- hanced CT scans demonstrated a small UVJ stone (Fig. 1A). Enhanced CT scans showed hydronephrosis of left kidney and perirenal fluid accumulation without excretion of contrast medium into the fluid (Fig. 2B). The KUB obtained 23 minutes subsequently after the enhanced CT scan was remarkable for contrast medium extravasation from UPJ and around left renal pelvis and ureter, consistent with ureteral rupture (Fig. 2). The patient was hospitalized and managed conservatively with analgesics, intravenous anti- biotics, and fluids. A follow-up ultrasonography performed on the fourth day revealed resolution of left hydronephrosis and disappearance of the fluid collection. He had an uneventful recovery.

Extravasation of urine secondary to ureter rupture may be responsible for some of the acute abdomen-like cases in ED that can be managed with conservative treatment and careful monitoring [1,2]. The major clinical manifestation of SUE is sudden-onset abdominal and concomitant flank pain on the ruptured side. In previous reports, Ureteral stone disease was the most common etiologic cause associated with ureteral rupture [1-4]. Ultrasound is an essential screening modality to detect perinephric fluid in patients with features of renal colic and is easily accessible for serial evaluation. Enhanced CT scans may play a role in determining the site of rupture, although intravenous urography (IVU) is considered as the radiologic method of choice [1,2]. In our case, contrast-