Case report 133. Hemophilic pseudotumor of ilium and soft tissues.
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Biomedical subjects
Publications and source records attributed to M A Riaz.
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Successful embolisation of active bleeding from the superior gluteal artery seen in two patients within the last 12 months is described. Both patients had extensive abdominal and pelvic injuries. One patient eventually died from renal failure and a perforated colon. The other patient is mobile and has been periodically seen in the out-patient department over the past nine months. In both instances, haemorrhage was at the sacrosciatic notch. Early angiography, in patients with extensive pelvic trauma and major blood requirements, with intent to embolise any identifiable bleeding source would appear to be the best initial manoeuvre to prevent exsanguination.
We describe two patients with extensive pelvic and lower limb angiodysplasias, in whom hemodynamic complications subsequently developed. These have been treated by selective angiography and multiple percutaneous transcatheter embolizations with satisfactory results (1 1/2 to four years of follow-up). One patient had had three previous operations with no improvement; amputation was the only surgical alternative. In the other patient, hip disarticulation and hemipelvectomy was seriously considered because of cardiac failure not responding to medical therapy. We review the literature and use our cases to illustrate points of technique and reemphasize the essential role of therapeutic embolization in the management of extensive angiodysplasia.
A recent publication showed the earliest signs of renal osteodystrophy in patients on maintenance hemodialysis (MHD) to occur in the tufts [1]. We present three patients on MHD, in two of whom the earliest unequivocal radiographic improvement was seen in the tufts. The third patient had been on MHD and, following subtotal parathyroidectomy, showed significant osseous improvement in the hands with relatively equal improvement in the hands with relatively equal improvement in the tufts and middle phalanges. It appears that, with the use of routine primary or secondary magnification, the tufts are radiographically a highly sensitive site for both the early occurrence and improvement of osteodystrophy in patients on MHD. We are not aware of any previous publication pointing out exclusive improvement in the tufts in patients on MHD with virtually no change in the mid-phalanges. Two of these three cases illustrate that renal osteodystrophy is reversible by maintenance hemodialysis alone.
Computed tomography was used for preoperative localization in 12 patients with undescended testes. Because three patients had bilateral involvement, 15 absent or undescended testes were studied. Surgical confirmation of the CT findings was obtained in 12 instances. Confirmation was not obtained in one patient who refused operation and it was considered incomplete in another due to limited surgical exploration. There was one incorrect localization. The procedure is quick, simple, noninvasive, and can be performed at all ages. The testicular radiation exposure was considered acceptable on the basis of phantom measurement. The lowest possible exposure factors were used on all patients. CT findings assisted planning of operative procedures and in some cases enabled more limited and shorter operations.
Direct magnificaiton of the hands of 44 patients on maintenance hemodialysis showed that the earliest unequivocal changes of renal osteodystrophy occur in the tufts. Some workers made a similar observation, but no previous objective study confirmed or refuted the sensitivity of the tufts in the diagnosis of renal osteodystrophy. The macroradiograph is consistently reproducible and serves as an excellent visual record of subtle changes.
In 19 cases, a correct diagnosis of intraabdominal abscess was made by CT body scanning. There was one false-positive diagnosis and initially one false-negative diagnosis. CT proved to be an efficient imaging method for diagnosis, for planning of therapeutic procedures, and in monitoring response to operative or conservative treatment. It has advantages over ultrasound and gallium scanning especially in severely ill, postoperative, and obese subjects. In addition, needle aspiration under CT control is readily performed and can be undertaken at the same examination. Confirmation of the diagnosis and therapeutic aspiration with or without introduction of a drainage catheter can then be undertaken.
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