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Radiology

Case of the Month

Case No. : 06
Month : June
Year : 1999
Contributor : Dr. Hrishikesh Kale

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Clinical Profile | Radiological findings | Differential diagnosis | Diagnosis | Discussion | Radiological features

Clinical Profile :

A nine-year-old boy presented with recurrent episodes of pain in the left loin and hematuria. There were of red blood cells with epithelial casts in the urine . All hematological investigations were normal.

The plain film of the abdomen and pelvis did not reveal any abnormality. An ultrasound of the abdomen showed normal sized kidneys with the left ureter dilated down to the uretero-vesical junction. An intravenous urogram (IVU) was performed.

Fig 1 Fig 2
Fig. 1 Fig 2.

Radiological findings :

The IVU shows bilaterally prompt nephrograms . Both kidneys are normal in size shape position ,axis and contour. There is no dilatation of the pelvicalyceal system.There is mild to moderate dilatation of the left ureter in its middle and distal thirds.The oblique micturating film shows a smooth tapering narrowing of the distal one centimeter of the left ureter. The urinary bladder and the urethra are normal.

Differential diagnosis :

  1. VU reflux
    a)Primary megaureter
    b)Prune belly syndrome
  2. Obstruction
    a)Primary obstruction
    - Intrinsic ureteral obstruction
    - Ectopic ureter
    - Ureterocele
    b)Secondary obstruction
    - Retroperitoneal fibrosis
  3. Nonreflux non obstructed megaureter
    a)Congenital primary megaureter
    b)Polyuria -diabetes insipidus
    c)Infection
    d)Postobstructive dilation

Diagnosis :

Discussion :

Primary megaloureter is defined as an intrinsic congenital dilatation of the lower juxta vesical orthotopic ureter. The principal pathology lies in the distal ureter immediately proximal to its entry into bladder. An aperistaltic juxta vesical segment secondary to faulty development of the muscle layers of the ureter (functional, non- mechanical obstruction) leads to the wave of peristalsis being not preceded by a wave of relaxation so that contrast medium fails to pass freely downwards .

Presentation may either be by ante-natal diagnosis or by urinary tract infection The condition is seen at all ages - much more0 frequently in boys It is the second most common cause of hydronephrosis in the fetus and the newborn. Associated disorders include contralateral pelviureteric junction obstruction, reflux, ureterocele, ureteral duplication, renal ecopia, renal agenesis. With marked dilatation of the ureter differentiation between a mega ureter and a ureterocele may be difficult or impossible. Association with reflux is well known. On a micturating cystourethrogram, the cardinal feature seen is dilution of contrast medium as it passes from the bladder to the dilated segment with a non dilated segment between the bladder and the megaureter

Radiological features :

  1. Dilataton of ureter most marked in pelvic segment and less or absent in upper ureter.
  2. Normal calibre of the just above uretero vesical junction which allows easy passage of a catheter.
  3. Localised dilatation of lower segment of lower segment with gradual tapering undulated terminal segment.
  4. Dilatation may involve entire ureter but pelvicalyceal system is not proportionately dilated.
  5. Aperistaltic terminal segment.
  6. Delayed ureteral emptying.
  7. Though dilated ureter is not tortous.
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